The following was first published on The TIBCO Blog.
We can expect significant changes ahead in healthcare as a surge of digitized data becomes available to healthcare providers and insurance payers alike. The data sets will be large and diverse, requiring filtering, analysis, and a way to deliver information to the right place or person in the moments when decisions need to be made. Only with real-time capabilities can an organization make proactive moves, like stopping payments before reimbursements when fraud is discovered or catching a patient safety issue the first time it happens and not the nth. This will play out in three key areas:
Sifting through data to find exceptions is an old science, but always associated with small groups. In today’s real-time, data-rich environment, the volume and velocity of information allows outliers to emerge more easily and earlier. Identifying treatment that goes off course, showing up as a complication or readmission to hospital, is much easier and faster. Crunching real-time data at scale essentially puts every instance of treatment into a virtual, immediate clinical trial.
Large scale data capability is very promising for finding financial exceptions as well. For starters, fraud is often found in aggregate data and not in any one invoice. Looking across a practice or a network, payers can more easily see patterns for waste and fraud. Secondly, payers can look across structured and unstructured information to see identity patterns and other ways information aligns that were never visible before. Lastly, the combination of geographic and other data allows payers to spot when people have traveled long distances for prescriptions, over-utilized services in an area, or are using doctors and hospitals that don’t match their geography. And it isn’t just fraud… error rates can be discovered and addressed, especially as we move toward the increased specificity of the ICD-10 coding standard.
Once you have better pattern recognition, putting that information to use is what some call the Big Lever… what do I “pull” in my organization to act on what I know? For one, there is a tremendous opportunity for health insurance payers to become information partners with providers and patients. By sharing information that perhaps can only be seen in aggregate, payers using real-time analytics have the ability to see more effective treatment methods and to spot trends across regions and demographics. Doctors can treat with confidence that the facts “have their back.” Patients armed with information can make better choices about travel when seeing the spread of the flu.
The new level of understanding that Big Data provides to healthcare is perfectly suited to cutting costs while improving outcomes. And it doesn’t have to be done with a stick approach… insurance payers can offer financial incentives to doctors who more often bill for procedures that are statistically shown to be more successful. This same information in the hands of patients can help them participate in shortening stays, avoiding readmission and generally reducing their cost of care.
Going after new business
As we move away from analog models of healthcare, we can expect greater consumer choice on the payer and provider sides of the equation. Health insurance exchanges offer a new marketplace that requires the kinds of information that other consumer markets have managed for a long time and are very suited to real-time analytics. Hospitals and physicians can demonstrate the quality of their care by benchmarking against competitors and regional standards.
This is an exciting time for healthcare as it fights to be more successful and cost effective. Real-time sense and response capabilities are at the center of the stage.
If you happen to be at AHIP in Salt Lake City today or tomorrow, please stop by the TIBCO Booth and say hello!