3 use cases for bpm in healthcare 2

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3 Use Cases for BPM In Healthcare and Life Sciences

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Inconsistent Quality

Errors in the way medications are prescribed, delivered and taken harm 1.5 million people in the U.S. every year.

Estimated number of patients affected by healthcare-related infections

Number of Americans projected with diabetes in 2050; estimated obesity rate of 42% in 2050

# of Americans projected to gain coverage, putting more pressure on an already stressed supply of Primary Care physicians

Estimated U.S. healthcare spending each year on administrative and clinical waste, fraud and abuse and other waste.

2010-2011 rate of employer-based healthcare cost increase; continues to far exceed CPI

Increasing costs, inconsistent quality and lack of access to timely care are negatively affecting the global healthcare ecosystem

1.5 million

1 in 10

32 million

1 in 3

$475 billion

8.4 percent

Lack of access to timely care

Increasing costs

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Growing Expectations for Value

From increasinglycostly health systems

Mounting Quality and Patient Safety Scrutiny

From increasingly active and demanding stakeholders

Increasing Consumer Responsibility

To make better health and wellness choices

Expanding Resource Challenges

From increasinglycostly health systems

New Health Promotion and Care Delivery Approaches

Driven by changing needs combined with new treatment approaches and technologies

Increasing Cost Sharing

Among public and private health insurers and individuals

Healthcare and Life Science CIOs face a number of challenges

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They are recognizing the need for a patient centric, value based

system, based upon 4 key mandates.Refine business processes and enhance

collaboration

Streamline operations and increase organizational effectiveness

Change the mode of governance through improved relationships

Radically innovate products, services and business models

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How are CIOs addressing these mandates?

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They’re adopting BPM and decision management.

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How are BPM and decision management empowering enhanced healthcare and life sciences?

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BUILDING SUSTAINABLE HEALTHCARE SYSTEMS

Build an efficient, flexible organization that proactively manages cost and regulatory requirements and enables greater transparency and accountability.

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INCREASING CONSUMER ACCESS AND VALUE

Reduce disparities in access and compel individuals to become advocates for their own health.

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COLLABORATING TO IMPROVE QUALITY,OUTCOMES AND PERSONALIZED CARE

Improve the quality and efficiency of care while cultivating patient centricity through engagement and health and care personalization.

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IMPROVING CLINICAL DEVELOPMENT PROCESSESAdvance productivity by end-to-end process simplification and standardization

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ACTING ON INSIGHTS TO DRIVE GROWTH

Leverage insights from patients, payers, and providers to attain market leadership.

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ENHANCING RELATIONSHIPS ACROSS THE ECOSYSTEM Collaborate with healthcare constituents to drive outcomes, personalized solutions, and sustained growth.

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So, what does this mean?Here are 3 practical use cases

• Provider process management• Payer membership / claims management• Life Sciences Governance, Risk & Compliance (GRC)

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Example 1: Provider process management

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Benefits of using BPM and decision management for provider process management

• Accept eligibility requests, adjudicate those requests and produce consistent outcomes

• More efficiently address the eligibility processes that are paper based, ad hoc, inefficient or reliant knowledge workers

• Automate eligibility processes to quickly evaluate and adjudicate citizen and business requests for services

• Reduce process costs• Drive more consistent outcomes

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University Hospital of Antwerp expedites diagnosis, treatment with rules

Challenge: Treat rare diseases (<5 in 10,000) Diagnose and treat these rare diseases quickly and effectively

Why Smart Healthcare?

Rules are generated more quickly and accurately using a predictive model based on known patient data. The solution can serve as an intelligent and dynamic knowledge base on rate diseases, improving the quick diagnosis and treatment of rare diseases. Compared with a pure rule-based system, a combination of rules and data mining tools provides both higher sensitivity and more specificity.

Business Solution: Platform allows for a quicker and more accurate diagnosis by integrating medical expertise and data

mining tools Business rules are generated much faster and more accurately through a predictive model based on

known patient data Solution can serve as an intelligent and dynamic knowledge base on rare diseases

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Example 2: Payer membership / claims management

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Benefits of using BPM and decision management for payer membership / claims management

• Ensure the right information gets to the right people in near-real time

• Enable collaboration, not only up and down the chain, but also across command structures

• Create a common operating picture for all stakeholders

• Shorten the decision cycle, enabling public safety professionals to quickly adapt to changing threats and increase situational awareness

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Challenge:Horizon BCBSNJ was established in a manual, paper-intensive era, and virtually all critical processes had remained manual

until the company launched a business process improvement initiative. Horizon BCBSNJ needed to become more efficient in business process management (BPM) and to drive rapid, automated and continued process innovation.

Benefits Reduces processing time for standard claims by 20 to 30 minutes each

Generates an average ROI of 300% for each internal process improvement project

Increases customer and provider satisfaction by freeing claims processors to focus on more complex claims

Solution:Horizon BCBSNJ teamed with IBM® and IBM Premier Business Partner Prolifics to deploy a suite of IBM BPM and BRMS tools. The company worked with Prolifics to create a BPM center of excellence to provide Horizon BCBSNJ with methodologies, best practices and design patterns for the lifecycle of process improvement projects regarding enrollment, claims processing and coordination of benefits.

Horizon Blue Cross Blue Shield of New Jersey optimizes agility and ROI

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Example 3: Life Sciences Governance, Risk & Compliance

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Benefits of using BPM & decision management for Governance, Risk & Compliance

• Proactively prevent inaccurate benefits from being paid, keeping unnecessary strain from the system

• Identify instances of fraud automatically, reduce improper payments and eliminate the waste of rework

• Ensure all regulatory compliance needs are met

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Challenge:

To meet Federal legislative requirements, the client needed a solution to keep track of worldwide spend on USA physicians. Several of its divisions were using legacy systems to house spend data. They needed to consolidate to a central solution for year-end compliance reporting.

Solution:

The client engaged IBM Global Business Service (GBS) to implement an aggregate spend solution named Shine360. Shine360 consisted of

• IBM Business Process Manager (BPM) v7.5

• WebSphere Operational Decision for Management (WODM)

• Cognos

• WebSphere Application Server

Benefits:

• Delivered a 360 degree view of all spend by individual recipients across the organization

• Enabled seamless, automated, auditable, accurate and thorough governmental and internal compliance reporting

• Ability to comply with aggregate spend legislation

• A better understanding of spend by product, division, healthcare professional and organization

Pharmaceutical company deploys a unique solution to meet aggregate spend reporting requirements

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OperationsOptimization

Enterprise Clinical

Integration

Healthcare Interoperability

EnterpriseHealth

Analytics

Core Systems Modernization

EnterpriseHealth Plan

Analytics

Research & Development

Transformation

Supply Chain Transformation

Sales and Marketing

TransformationBusiness

Model Transformation

And there are even more use cases…

Core system re architecting per SOA Member enrollment and plan management Enrollee/insured case/record management Claims adjudication/payment Member/provider/plan sponsor services Evidence-based actuarial analysis Waste, fraud and abuse prevention/detection Agent portal for quotes and contracts Member/enrollee portal for wellness management,

benefits selection and coverage status

Patient/case management BPM incorporating legacy IT Medical common body of knowledge

management Care delivery organization process

automation/optimization Diagnostic and therapeutic

determination and monitoring Patient admission/transfer/discharge Medication order management Waste, fraud and abuse

prevention/detection Protected health information privacy

and security management Human resource management Medical staff credentialing

Promotional spending monitoring and management

Clinical trials management Research and development support Marketing and sales management Subcontracting operations management Contract management Product management, pre- and post

approval for sale

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Putting BPM and decision management into practice at your organization

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Smarter Process is…

is IBM’s approach to Business Process and Decision Management.

We’re focused on helping your business put the customer first, all while driving efficiency and optimization into end-to-end processes.

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Why IBM?

Experience. Our install base includes over 5,000+ active implemented customers and 800+ business partners.

Market Leadership. We are a Leader in Gartner’s Magic Quadrant for Intelligent Business Process Management Suites and in the Forrester Waves for BPM Suites and Dynamic Case Management

Expertise. Our Global Smarter Process Center of Competency puts more than 650+ experts at your disposal

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Smarter Process is reinventing Healthcare and Life Sciences operations, saving lives.

“We have everything we need to make judgments more quickly, so we can get checks out the door that much faster. And the sooner we can fund successful programs, the more lives we can help save.”

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Learn more about Smarter Process for Healthcareand Life Sciences

Video Series: Smarter Process in healthcare and life sciences http://ibm.co/1K45G5h

Whitepaper: Smarter Process in the Age of the Customer ibm.co/1Dy8gJQ

eBook: Smarter Process for Dummies: http://ibm.co/1zbo4T1

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