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requirements:use-cases:use-case-medical-insurance_claims [2018/05/03 11:23]
youssef gaigi
requirements:use-cases:use-case-medical-insurance_claims [2018/05/03 11:57] (current)
youssef gaigi
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 ==== Current Solution ==== ==== Current Solution ====
  
-There'​s a general agreement in the healthcare industry that further streamlining claims processing will have considerable benefits on the the industry and reduce costs. In the US, there are several government agencies and professional groups working on healthcare administrative simplification among them the Centers for Medicare & Medicaid Services (CMS), the Office of the National Coordinator for Health Information Technology (ONC), and the American Academy of Family Physicians (AAFP). In 2009, a coalition was formed to address the administrative costs of healthcare, the Healthcare Administrative Simplification Coalition (HASC), which brought together various players in the industry, but it seems extinct since then. The latest press release ​of AAFP titled ​“AAFP sustains fight to reduce administrative burden for family medicine” (Aafp.org, 2018) describes the current atmosphere in the healthcare ecosystem and the tensions between various players around the administrative burden of healthcare professionals. ​+There'​s a general agreement in the healthcare industry that further streamlining claims processing will have considerable benefits on the the industry and reduce costs. In the US, there are several government agencies and professional groups working on healthcare administrative simplification among them the Centers for Medicare & Medicaid Services (CMS), the Office of the National Coordinator for Health Information Technology (ONC), and the American Academy of Family Physicians (AAFP). ​ 
 + 
 +In 2009, a coalition was formed to address the administrative costs of healthcare, the Healthcare Administrative Simplification Coalition (HASC), which brought together various players in the industry, but it seems extinct since then.  
 + 
 +Under the umbrella of the CMS and the ONC there are various initiatives to simplify administrative procedures, AAFP has also made recommendations and elaborated a framework for administrative simplification. In 2009, the Health Information Technology for Economic and Clinical Health Act, known as the HITECH Act, was enacted with the aim of promoting widespread adoption of information technology in the healthcare system. Large budgets were allocated for the implementation of the HITECH act with various incentives and penalties. This led healthcare professionals to launch IT projects under strict deadlines. "The rush was on for vendors to create electronic health record (EHR) systems and for providers to choose—and pay for—complicated,​ expensive, and sometimes insufficiently tested systems."​ (fojp service corporation,​ 2013). 
 + 
 +But since the start these initiatives faced several barriers: fragmented markets, lack of coordination,​ insufficient leadership, undefined milestones, and unproven concepts. This has left the industry far from achieving interoperability and continue to face challenges integrating the healthcare ecosystem. (Institute of Medicine US, 2010).  
 + 
 +In 2013, the The Quarterly Journal for Health Care Practice and Risk Management describes the situation: "The idealistic goals have now been tempered by frustration as shortcomings become apparent—especially documentation issues, lack of standardisation,​ and poor communication among systems. Unforeseen safety, privacy, and liability issues have emerged. And some naysayers contend that the move to EHRs has exacerbated medical costs."​ (fojp service corporation,​ 2013). 
 + 
 + 
 +In 2018 the AAFP published a press release entitled: ​“AAFP sustains fight to reduce administrative burden for family medicine” (Aafp.org, 2018). This describes the current atmosphere in the healthcare ecosystem and the tensions between various ​governmental and private ​players around the administrative burden of healthcare professionals, leaving patients in limbo with processes that do not meet their expectations. 
 + 
 + 
 +The complexity of the healthcare system makes it difficult to achieve seamless and frictionless experience for all parties. This is essentially rooted in the large number of players in the healthcare industry who have to share patient information and interact with each other. With three members in a clinical team, three separate conversations could take place between any two individuals. If we increase the size of the team to five individuals,​ the number of possible conversations increases to 10, and for a team of 10 the number of possible conversations blows out to 45. (Coiera, 2018) [Insert image: https://​www.ncbi.nlm.nih.gov/​core/​lw/​2.0/​html/​tileshop_pmc/​tileshop_pmc_inline.html?​title=Click%20on%20image%20to%20zoom&​p=PMC3&​id=1579411_cbr27_2p089f1.jpg]
  
-Under the umbrella of the CMS and the ONC there exists various initiatives to simplify procedures, AAFP has also made recommendations and elaborated a framework for administrative simplification,​ however these initiatives are facing several barriers: fragmented markets, lack of coordination,​ insufficient leadership, undefined milestones, and unproven concepts. This has left the industry far from achieving interoperability and continue to face challenges integrating the healthcare ecosystem. (Institute of Medicine US, 2010). ​ 
  
-In 2009, the Health Information Technology for Economic and Clinical Health Act, known as the HITECH Act, was enacted with the aim of promoting widespread adoption of information technology in the healthcare system. Four years later, the The Quarterly Journal for Health Care Practice and Risk Management describes the situation: "The idealistic goals have now been tempered by frustration as shortcomings become apparent—especially documentation issues, lack of standardisation,​ and poor communication among systems. Unforeseen safety, privacy, and liability issues have emerged. And some naysayers contend that the move to EHRs has exacerbated medical costs."​ (fojp service corporation,​ 2013). 
  
-The complexity of the healthcare system makes it difficult to achieve seamless and frictionless experience for all parties. This essentially rooted in the sheer number of players in the healthcare industry who have to share patient information and interact with each other. With three members in a clinical team, three separate conversations could take place between any two individuals. If we increase the size of the team to five individuals,​ the number of possible conversations increases to 10, and for a team of 10 the number of possible conversations blows out to 45. (Coiera, 2018) 
  
 Aafp.org. (2018). AAFP Sustains Fight to Reduce Administrative Burden for Family Medicine. [online] Available at: https://​www.aafp.org/​media-center/​kits/​aafp-sustains-fight-to-reduce-administrative-burden-for-family-medicine.html [Accessed 3 May 2018]. Aafp.org. (2018). AAFP Sustains Fight to Reduce Administrative Burden for Family Medicine. [online] Available at: https://​www.aafp.org/​media-center/​kits/​aafp-sustains-fight-to-reduce-administrative-burden-for-family-medicine.html [Accessed 3 May 2018].
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 Institute of Medicine, (2010). [online] Available at: https://​www.ncbi.nlm.nih.gov/​books/​NBK53909/​ [Accessed 3 May 2018]. Institute of Medicine, (2010). [online] Available at: https://​www.ncbi.nlm.nih.gov/​books/​NBK53909/​ [Accessed 3 May 2018].
  
-FOJP Service Corporation. (2013) . [online] Available at: https://www.ncbi.nlm.nih.gov/books/NBK53909/ [Accessed 3 May 2018].+FOJP Service Corporation. (2013) . [online] Available at: http://www.fojp.com/sites/default/files/​Infocus_Summer2013_EHR.pdf ​[Accessed 3 May 2018].
  
 Coiera, E. (2018). Communication Systems in Healthcare. [online] PubMed Central (PMC). Available at: https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1579411/​ [Accessed 3 May 2018]. Coiera, E. (2018). Communication Systems in Healthcare. [online] PubMed Central (PMC). Available at: https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1579411/​ [Accessed 3 May 2018].
requirements/use-cases/use-case-medical-insurance_claims.txt · Last modified: 2018/05/03 11:57 by youssef gaigi