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Developing A Business Model and IT Foundation For Digital Healthcare v4
Developing A Business Model and IT Foundation For Digital Healthcare v4
Healthcare
Michael Ali and Eric Plummer
April 2016
I.
Introduction
The business case for digital healthcare derives from the need to continually deliver
better value at lower cost. The healthcare industry is migrating toward measuring
value by using objective measures of beneficial results for the patient, which BCG
calls competing on outcomes [BCGa]. There are a number of case studies
demonstrating that outcomes-based healthcare works for the patient, the provider,
and the payer [BCGb]. The Gartner Group [Gartnera] states The successful
transformation of the industry to a consumer-centric, value-based delivery model
depends upon healthcare digitalization,and the means to leverage IT to achieve
quality outcomes at lower cost. This paper proposes an approach to creating the
business model and enabling IT infrastructure that can serve as a foundation for
achieving digitalized healthcare.
II.
The business case for digital healthcare derives from the need to continually deliver
better value at lower cost. The healthcare industry is migrating toward measuring
value by using objective measures of beneficial results for the patient, which BCG
calls competing on outcomes [BCGa]. Competing on outcomes requires the
following business capabilities:
a. 360 view of the patient: ideally, every interaction with a patient is
captured, from prevention and wellness, to diagnosis, to intervention and
therapy, to treatment and monitoring. Interactions include the various
channels such as the pharmacy, in- and out-patient care, emergency room,
self-service (perhaps via mobile), etc.
b. Analytics: identification of patterns and trends, modeling and decisionsupport, ideally with the option of leveraging machine learning
c. Low-friction interface between partners: patient data needs to be
accessible across 1st, 2nd, and 3rd level service providers, payers, suppliers,
etc.
There are a number of case studies demonstrating that outcomes-based healthcare
works for the patient, the provider, and the payer [BCGb]. However, achieving the
enabling capabilities requires that each of the players in the value chain have a
vision, strategy, and plan for creating a digital business model and the aligned
III.
A. Context Model
The first step in laying out the business model is to create a context model. The
context model puts a boundary on what we are calling our enterprise vs their
enterprise. For this paper, we will take the position of the healthcare provider. The
context model (Figure 1) shows the entities which interface to the enterprise.
B. Structure Model
We need the structure of the Provider. In this case, we assume that the provider is a
large healthcare group with divisions consisting of hospitals, labs, pharmacies, etc.
These are shown in Figure 2.
D. Core Diagram
The last step is to create a Core Diagram, which captures the functional model of
the enterprise. This diagram will consist of major processes and key interfaces.
While process reference models (ex: APQC) exist, in practice, this model is businessspecific as it needs to capture how business leaders think of their enterprise, using
their terminology. The Core Diagram for this example is shown in Figure 4 below.
As a check, we confirm that the Core diagram provides interfaces for the external
entities in the Context Model (Figure 1) via the Channels, API Services and Payor
Integration functions. Two key processes are Analytics and Medical Records.
Medical Records provides the master data capability needed for the operating
model in Section C. The Analytics function serves as a center of excellence for
coordination and support of analytics capability that is distributed within each of the
other functions. As an example, we have incorporated Episode Analytics [iHTT] in
the model.
Episode Analytics uses an episodedefined as a patient care event that crosses
care settings and timeframes including pre- and post-care, as the unit of analysis.
An episode includes enough services to allow treatment choices and intensity to
be measured and analyzed. Aligning care episode data with traditional and
historical payor data creates standard profiles form comparing costs and outcomes
of various care options. The profiles and comparisons create a framework for valuebased outcome analysis over time [Plummer]. As shown in Figure 4, episode data is
captured at the point(s) of patient care (InPatient, OutPatient, Emergency, Lab,
Pharmacy). This data is integrated with other data, such as Payor data, in Medical
Records. The integrated data is then available to Analytics.
IV.
Enabling IT Model
A. Application Architecture
The enabling IT model starts with an application architecture (Appendix B and the
right side of Figure 5, example applications from [MITb]).
The application
architecture mirrors the Core Diagram (Figure 4 and the left side of Figure 5), as the
applications enable and enhance the processes expressed in the Core Diagram. Of
course, there are other elements to enterprise architecture (information, servers,
network, security, etc.), however the application architecture has the most direct tie
to the business model, which is why it is the starting point. The applications in the
architecture can be on-premise or cloud-based. For sharing medical records, a
NoSQL database management system is proposed in addition to any legacy or
traditional databases. Per Gartner [Gartnerb, Gartnerc], use cases that involve
combining data from different databases along with real-time data are best
addressed with NoSQL-type databases.
that work within one layer of the architecture (ex: with one or two applications) but
also teams that can work across multiple layers/applications to create complete
solutions.
Infrastructure & Operations:
responsible for the day-to-day running of
applications, desktops/laptops, mobile, servers, storage, and the network.
V.
Summary
Capability
360 view of the patient
2
.
Analytics
3
.
How achieved
The model captures interactions with the
patient via the various channels (in-person and
digital). The data is captured in the underlying
applications as shown in the application
architecture, and shared via a master data
construct.
Analytics capability is specifically called out in
both the Core Diagram and the application
architecture.
There is a portal channel provided as well as a
partner API for sharing medical records.
References
[BCGa] Competing on Outcomes: Winning Strategies for Value-Based Health Care,
Boston Consulting Group, January 2014.
[BCGb] Alternative Payer Models Show Improved Health-Care Value, Boston
Consulting Group, May 2013.
[Gartnera] Business Drivers for Healthcare Provider Information Technology
Decisions, 2016. Gartner, January 2016.
[Gartnerb] Match Use Cases and Capabilites for Operational DBMSs, Gartner, August
2015.
[Gartnerc] A Tour of NoSQL in Eight Use Cases, Gartner, February 2014.
[iHTT] Episode Analytics: Essential Tools for New Healthcare Models, Institute for
Health Technology Transformation, 2014.
[MITa] Enterprise Architecture as Strategy: Creating a Foundation for Business
Execution, Harvard Business School Press, 2006.
[MITb] Trinity Health: Using Digitization, Unification, and Data Analytics to Tame the
Quality and Accessibility Problems of Healthcare, MIT Sloan School Working Paper
4960-11, December 2011.