Balaji Krishnamoorthy, Horizon BCBS NJ
John Bair, Ajilitee
Tuesday, September 27
10:45 - 11:30 am
Driving Immediate Value
from a Phased MDM Program
September 25 – 28, 2011
Biographies
Balaji Krishnamoorthy
Director Data &
Information Architecture
Horizon BCBSNJ
Information Management
Strategy and Architecture
(Office of the CTO)
John Bair
Chief Technology Officer
Ajilitee
Content
The data challenge
Business drivers of MDM initiative
Approach and timeline
Data governance
Key data architecture decisions
MDM tool selection
MDM pilot
MDM implementation (in progress)
Outcomes
Success factors and key insights
The Information Challenge We Face
Data Governance
?
Customer
Service Health Exchanges Consumerism & Compliance Sales Marketing Medicare Advantage Medical Claims Provider Data
Management Dental Medicaid
Medicare PPO/HMO Medicaid Dental Physicians Ancillaries Hospitals Pended Claims Incorrect
Contact Info No View of
Consumer
Joseph Braverman,
M.D. Kate Smith Dr. Joe Braverman
450 Second Street HMO
Katlyn Smith 452 2nd St
Newark, NJ-07105
PPO 20/150/40 Kate Smith
Medicare B
Portals
Jbraverman@email .com
What is Master Data?
ENTERPRISE DATA
UNSTRUCTURED
Images
Text
STRUCTURED
Master
Control/Reference
Transactions
MET
AD
A
TA
REPOR
TING
Master Data
Provider
Member
Product
Employees
Customer/Group
6Control/Reference
Data
Specialty
Provider Type
Member Type
Country/State ISO Codes
ICD / CPT / DX Codes
Master Data in Context
Birthdate
Gender
Patient name,
address, phone
Insured name,
address, phone
DX
CPT
TIN
Billing provider
Relationship
Transactions pull together the different types of data:
–
Master
–
Control/Reference
–
Transactional (values)
CONTROL / REFERENCE DATA Generally controlled through Approved Lists of Values (LOVs)
State
MASTER DATA (Who, what, where)
TRANSACTIONAL DATA (How many, how fast, how much)
Charges
UnitsWhere
INFERRED through the Master Data Provider Type
Strategy – Our Key Thoughts
Approach
Registry style migrating to Hub
MDM progression
Why we selected the tool
Single instance – flexible data
model that aligns with enterprise
data model that we are building
Precursor to EDW and BI
strategy
Strategy
Big data analytics – an appliance
by
itself does not solve the
problem
We need to first fix the data
MDM is key, once you have
conforming data, then you can
use big data and parallel
processing
Therefore our strategy is
first
Provider and Member MDM Business Value
Proposition
Unified view of Provider and Member Data across enterprise applications and lines
of business, improving collaboration and quality of care and reducing costs
Member & Provider
Collaboration
Claims
Reimbursements
Authorizations
Referrals
Customer service
Network management
Case Management
Care Management
Pricing
Portals
Marketing
Segmentation
CRM Strategy
Service & Billing
ACO
Enabling a unified, consistent, accurate, and timely view of Master Data
Member Profile
Provider Profile
Contracting
Demographics
Networks
Capitation
Provider Types
Physicians
Groups
Hospitals
Diagnostics & Labs
Durable Medical
Dental & Vision
Retail Health Clinics
Delegates
Subscribers
Patients
Contacts
Preferences
Segmentation
Additional Benefits
Standardize data services
Deliver consistent information to members and providers across channels
Decouple and insulate downstream systems from changes to upstream systems
Retire obsolete components from infrastructure
Reduce the cost of maintenance
Reduce data inconsistencies across systems and improve business and IT
operational efficiencies
Increase agility with faster time to implement new business functionality
Enable portals and self-service administration
Implement necessary workflows to authorize changes
Improve operational efficiency, customer satisfaction and regulatory
compliance
Enable reporting and analytics
Unified view of providers and members across all plans, lines of business and
Leading with Data Governance
Data Governor
B.Krishnamoorthy
Data Governance Council
(Business, IT, and Administrative)
IT
Administration
Membership
& Benefits
Claims
Provider
Strategy Planning
Security
Service
Product &
Marketing
Healthcare
Management
•Network Management •Relationship Management •Provider Profiling •Provider Contracting •Portfolio Mgt •Product Development •Product Instantiation •Product Selection •Brand Marketing •Marketing Campaign •Campaign Mgt •Sakes Membership & Benefits Provider
•Account Set-up & Maintenance •Group Enrollment •Verify Member •Manage Membership •Underwriting •Account Impl. •IT Strategy •Application Development •Product Support •Infrastructure •System Strategy Planning •Blue List •Healthcare Act •Human Resources & Finance •Mandates •ePMO •Process Management •Actuarial •Legal •Auditing •Compliance •Regulatory •Risk Management •Security •PHI •PI •ISO/IEC •NCPDP •HITECH •HIPAA •Inquiry Mgt •Manage Service Protocols •Contact Center •Call Center Mgt •Provider •HCM •Claim •Product Explanation •Marketing •Producer Product
& Marketing Service
•Medical Policy •Utilization Management •Complex Case Management •Chronic Care Management •Health Program Management Healthcare Management Security Administration Information Technology
Data Governance Council Coverage
•Claim Acquisition •Claim Adjudication •Claim Pricing •Advise Claim Outcome Claims
2
1
How We Phased the Implementation
Provider data governance and stewardship
Definitions and identifiers
Individuals, groups and organizations, provider types
Member, subscribers, dependents and patients
MDM tools selection
Determine needs and MDM style (Integration, Registry, Hub)
Single-domain versus multi-domain
MDM pilot
Focus on how provider data is used in the business
Engage Data Stewards to prototype match/merge and trust rules
Initial rollout – Provider directories, Member and Provider portals and
communications
Individuals, groups, organizations
Service and billing locations
MDM Tool Selection Evaluation Criteria
MDM Business Value Categories
Third party data service integration
Data Stewardship support
Workflow and rules
Multi-domain and Payer data models
Match/merge technology
Training and professional services
Total cost of ownership
Health plans/Blues customer success
MDM Technical Value Categories
Extensible data models
Integration with enterprise applications
Change and release management support
Pre-canned web services
Supports common MDM styles
Integration with infrastructure services
Integration with BPM tools
MDM Evaluation Activities
Written questions
Demonstrations
Technical deep-dive sessions
Use case run-throughs
Single-Domain versus Multi-Domain
Multi-domain solutions versus Single-domain
We chose to leverage and reuse a single tool to master
Provider, Member, and reference data
Eliminates cost of buying multiple tools and creating
competencies around multiple, domain-specific tools /apps
Multiple MDM instances versus Single MDM instance
We chose to integrate provider and member master using
a party model that aligns with the enterprise data model
we are designing
Key value of having a single instance is the ability to
identify and manage relationships
Multi-Domain MDM Hub as a Solution
Data Governance
Customer
Service Health Exchanges Consumerism & Compliance Sales Marketing Medicare Advantage Medical Claims Provider Data
Management Dental Medicaid
Joseph Braverman, M.D. [email protected]
Portals
Provider Customer Employee Member Product
Enterprise Master Data Hub
Broker … ICD-10 NPPES Kate Smith 452 Second Street, Newark, NJ-07105 Pri: Medicare B Sec: PPO 20/150/40 Third Party Data
ETL Server Provider Data Management Internal DATA SOURCES NPPES (CSV Flat File) ETL Server Integration and Data Quality Services Credentialing Dental MDM Pre Processing Batch/Real Time ODBC Batch/Real Time ODBC
Share Point Site 1. Ancillaries 2. Hospitals 3. Radiology 4. Imaging 5. Vision Batch/Real Time ODBC External DATA SOURCES Batch/Real Time PWX Provider Portal CAQH Master Data Standardize Master Master Data
Services Consumers Internal
Other Sources Application Server Integrated Workflow Services Provider Web Services External Consumers Business Partner Provider Data NDM Provider Batch Services Online Provider Directory Data Stewards Provider Data Management Tasks Lookups Resolution Approvals ETL CDC Cleanse Data flow Interaction Output Staging Batch/Real Time Batch/Real Time MDM Server FTP Pull / Batch Batch/Real Time Transform to Common Record Format Maintain Model Configure Hub Generate Web Services
Conflict Resolution Approval Workflows Dashboard Match/Merge Survivorship Golden Record
ETL Server Membership System Internal DATA SOURCES
Third Party Data
ETL Server Integration and Data Quality Services Claims System New Membership System MDM Pre Processing Batch/Real Time ODBC Batch/Real Time ODBC External DATA SOURCES Batch/Real Time PWX Master Data Standardize Master Master Data
Services Consumers Internal
Active Directory Application Server Integrated Workflow Services Member Web Services External Consumers Member Batch Services e-Business Data Stewards New Membership System Tasks Lookups Resolution Approvals ETL CDC Cleanse Data flow Interaction Interface Hub FTP Pull / Batch/Real Time Batch/Real Time Email 1. Sales 2. Cust Service Transform to Common Record Format MDM Server Maintain Model Configure Hub Generate Web Services
Conflict Resolution Approval Workflows Dashboard Match/Merge Survivorship Golden Record
Third Party Data Selection Criteria
Evaluation Criteria
Evaluation QuestionsCost What is the pricing model (Geography, Type, Frequency, etc)? What are the contract
lengths and terms? What are the costs for the offered menu of data and/or services?
Data Coverage What is the provider or member match rate? What data elements are offered?
Data Model Fit How well does the vendor’s data model map to the Horizon’s use cases and Data Model?
Data Quality Lift What quality improvements and enhancements have been measured?
Data Sourcing Which data elements are sourced a) by the vendor b) from public sources c) from third
parties?
Metadata and trust
rules What metadata is provided for defining trust and usage rules?
Reporting and
analytics What analysis does the vendor provides around the data?
Data Security The vendor must completed a BAA and Horizon’s Vendor Information Security Risk
Assessment Survey. Horizon IT Security and Legal approval are required before sample data can be sent to the vendor.
Batch Data Publishing Details around a unidirectional vendor to Horizon data feed for NJ, NY, PA and DE.
Batch Data Matching Details around providing a bidirectional data feed with a data service to match and append
Horizon supplied data.
Online Lookup Details around vendor offered portal, web site or application so that Horizon staff can
perform ad-hoc lookups.
Real-time Web
Organizing the Team to Manage Risks
MDM was a new tool and discipline at Horizon
Although the tool has been used extensively in Pharma,
this is the first implementation of the tool at a Payer
Onboarding the right resources at the right time was key
Staffed people with experience and depth in:
Enterprise data architecture
Provider and Member data
Prior success with the MDM Tool
Prior success with big data integration
Showing Early Value through MDM Pilot
Validate the capabilities of Informatica Master Data Management (MDM) solution
specific to Horizon BCBS Provider and Member domains, data sources and consumer
systems
Data Integration: Integrate Provider and Member data for a subset of attributes from
multiple selected sources
Data Quality Improvement: Demonstrate data enrichment using Third Party data
Data Governance: Demonstrate the use of workflows to support data stewardship
Consolidated outputs: Produce data extracts to demonstrate “full lifecycle” MDM value
21
Making Tough Pilot Choices
Not included in scope
Party to Party Relationship
Employer Group/Plan/Network
Language
Degree (Qualifications)/Credentialing
Par/Non Par (depends on Plan/Network)
In scope with limitations
Active Providers/Members only
One Primary Specialty per Provider per source
One Address, Telephone Number and Email per Provider/Member per source (regardless of
type)
Latitude, Longitude populated only if available in data source
NPPES Providers only included for NJ, NY, PA, DE
External identifiers: SSN, TIN, NPI, Medicare Number (depending on source)
Cleansing limitations
Testing if the Multi-Domain Model Works
Dependent Member Role
Credentialed Provider Specialty
Individual Provider Type
Member Role
Network
Party Qualification Person Marital Status
Person Ethnicity
Subscriber Member Role
Specialty Marital Status
Organization Provider Role
Person Gender
Provider Type
Individual Provider Role Party Role Relationship
Provider Network
Provider Specialty
Person
Party Role Contact Mechanism
Organization
Party Identification
Party
Provider Role
Party Role
Group Organization Provider Role Institutional Organization Provider Role
MDM Pilot Results
Data profiling analysis of Provider and Member data sources
Preliminary match/merge and trust rules
Performance metrics
Master Data metrics (Totals, # Golden Records, # Overlaps)
Institutional Providers
Counting noses and belly-buttons
–
Individual Providers and Members
–
Individual intersections
–
Members who are also Providers
–
Dependents who are also Subscribers
Postal and email addresses
Refined trust rules based on analysis of results
Total Individual Providers
12.7%
Total Individual Subscribers
43%
Total Individual Dependents
44.3%
< 1%
< 1%
< 1%
1.8%
Individual
Subscribers
41.1%
MDM Pilot Results for Individuals
Counting Noses & Belly Buttons…
Individual
Providers
12.6%
Individual
Dependents
42.4%
13% unusable Member emails
50.29% Provider email duplicates
13.28 % Provider duplicates
Additional Metrics:
% Names cleansed
% SSNs and TINs
cleansed
% Addresses cleansed
Values demonstrated:
Unified Enterprise view
Identity Resolution
Centralized Email Mgmt
2011
2012
2013
2014
Reference Code Mapping and ICD-10
MDM Provider MDM Membership DG Member MDM Member DG Membership MDM
Product, Customer, Group, Plan DG
Product, Customer, Group, Plan MDM Other Data Domains DG Customer , Identity MDM
2015
DG & MDM Foundation Provider DG MDM Pilot MDM Platform Deployed Provider MDM Version 1.0 (Supports OPD and PDR)Golden Record for Member(Includes Email)
Onboard Consumers:
DG & MDM Multi-year Program Roadmap
ICD-10 MDM Platform Deployed
Provider MDM Version 2.0 (Supports Source System and 3rd Party Integration) Provider MDM Version 3.0 (Supports Real Time Web
Service Integration) Membership Hierarchies
Membership and Product Integration Version 1.0)
