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 increasingly
costly 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 increasingly
costly 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 PROCESSES
Advance 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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Operations
Optimization
Enterprise
Clinical
Integration
Healthcare
Interoperability
Enterprise
Health
Analytics
Core Systems
Modernization
Enterprise
Health Plan
Analytics
Research &
Development
Transformation
Supply Chain
Transformation
Sales and
Marketing
Transformation
Business
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 Healthcare
and 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

3 use cases for bpm in healthcare 2

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