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In the healthcare sector, leaders are increasingly aware of the importance of a data-centric strategy to enhance member satisfaction. A significant number have embarked on their transformative journey to adopt a member-first philosophy and consolidate various data silos. They understand that the path towards a unified system is strategic and will yield considerable benefits once accomplished.

However, the intricacies of outdated healthcare applications, coupled with a lack of expertise in crafting, implementing, and managing advanced solutions, compel them to reassess their methodologies. The demand for swift delivery of strategic initiatives often forces organizations into a tactical, point-to-point approach for exchanging member information across healthcare systems.

This short-sighted method can lead to applications gradually morphing into a complicated system that is tightly integrated and incredibly challenging to oversee. This scenario generates multiple issues, including elevated maintenance costs, weakened application security, and fragmented governance surrounding sensitive member data. Such architectural compromises can adversely affect broader digital transformation efforts.

Relying on a tactical approach to address today’s challenges may cause organizations to neglect the foundational requirements for the future.

Understanding a System of Record

Healthcare organizations utilize various applications to manage information related to their members’ demographics, claims, wellness, plan affiliations, primary and critical care, call center interactions, and self-service engagements. The primary issue with these individual systems is their disconnection and reliance on outdated information for decision-making.

A system of record integrates all aspects of a member’s profile into a centralized repository, drawing from disparate data silos. This hub-and-spoke model establishes a system of record for both upstream and downstream systems. By leveraging a system of record as the backbone, organizations can compile quality member data to create a comprehensive view known as Member360. This Member360 view allows for a seamless experience across various systems for healthcare payors.

Creating a 360° View of Member Information

Top healthcare organizations have recognized that a system of record represents a strategic next-generation architecture. To achieve this, there are three actionable steps to follow:

Define your business objectives and understand the benefits of this architecture.
Acknowledge that establishing a system of record necessitates a series of iterations.
Select the appropriate technology platform that facilitates smooth digital transformation and modernization without unnecessary complexity.

Functional Objectives and Benefits

A common misconception about developing a system of record is the belief that immediate business value is absent and that it can only be assessed in the long run. It’s vital to design business deliverables that demonstrate value promptly, rather than waiting until the end of the project. Defining the full scope of business objectives for large initiatives, such as a system of record, can be challenging.

The key is to isolate smaller problems and iterate, ensuring that the underlying architecture and platform evolve accordingly, without waiting for long-term outcomes. Achieving true business value quickly—within 3 to 6 months—can help justify the project.

Adopting an agile approach to deliver incremental business value allows organizations to adapt as they continue to iterate. This method enables the establishment of a long-term initiative based on short-term efforts, applicable to various business use cases, particularly with the top three industry trends:

Real-time Integration
Operational Reporting
Enterprise Analytics

Real-time Integration

Applications like Customer Relationship Management (CRM) systems, Claims Management Systems (CMS), and Member Portals greatly influence members’ digital experiences for payors. Members engage with healthcare core systems through call centers, chatbots, and self-service options. Implementing near real-time service level agreements across these channels enhances the customer experience. These systems can connect directly to the system of record to access Member360 data with minimal latency, leading to expedited claims processing, improved self-service, and a more personalized digital experience.

For instance, consider Jane Smith, a 65-year-old with type 2 diabetes, who contacts customer service to check the status of her recent outpatient claims. Upon review, the customer service representative finds that her address in the CRM system is outdated, leading to the claims check being sent to the wrong address. Such situations can easily be avoided if the CRM system is integrated with a system of record, serving as the source of truth.

Operational Reporting

Internal healthcare systems including audit and compliance, financial oversight, and claims processing depend on accurate member information. Operational reporting, in various formats such as delimited files and fixed-width files, is a common method for periodically exchanging member data. A system of record can streamline integrations with downstream systems, allowing them to utilize a comprehensive view of member information from a single point of entry.

By enabling version control within the system of record, healthcare organizations can create detailed reports for audit, compliance, and third-party requirements. Internal data science teams can also conduct data mining on reliable member information without traversing multiple siloed systems.

Enterprise Analytics

Healthcare executives can make informed strategic decisions based on analytical insights derived from historical datasets within a system of record. The trusted member-centric data contained in the system will assist organizations in predicting healthcare outcomes and developing personalized strategies to boost member engagement in preventive care. This approach ultimately leads to improved outcomes for members. For example, using Jane Smith’s member profile, payors can identify care gaps and proactively reach out to her to schedule overdue visits.

As organizations learn from each iteration, they can implement improvements to enhance the member experience. AI and machine learning models can be applied within systems of record to automate claim workflows, forecast premiums, and detect fraud and abuse, clarifying the functional objectives and advantages of the system.

Non-Functional Objectives and Advantages

Non-functional objectives pertain to the technical system requirements that ensure the system of record adheres to the principles of a well-architected framework. These requirements are just as critical as functional ones. Neglecting non-functional requirements can compromise security, reliability, performance, and scalability, ultimately increasing costs.

Selecting the right platform and data strategy for your system of record is vital for its success. Key non-functional requirements for crafting a reliable system of record include ensuring security, scalability, and maintainability.

For more insights on workplace dynamics, consider reading this article on office etiquette. Additionally, SHRM provides valuable resources on the impact of inclusion and diversity changes on equity in employee benefits. For further information, this video on effective onboarding is an excellent resource.