IBM Healthcare Solutions Healthcare

To support your organization’s objectives

The IBM Health Integration Framework:

Accelerating solutions for smarter healthcare 
The IBM Health Plan edition
2 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Today’s health plan executives and government

health insurers must guide decision making in
what is arguably the most complex IT system in
any industry.
3 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare
Addressing the challenges of a rapidly
changing environment
Healthcare technology has advanced to unprecedented levels,
but dramatic changes in the business and political climate are
making it hard for health plans to keep pace. Today’s health
plan executives and government health insurers must guide
decision making in what is arguably the most complex IT
system in any industry.
Despite significant progress over the past decade, health plan
line-of-business executives continue to focus on ways to
automate the manual processes that drive up administrative
costs and contribute to increasing premiums. To achieve mem-
bership targets, health plans must be able to respond quickly to
opportunities and competitive threats, and they must be able to
comply with significant regulatory requirements and mandates.
For health plan IT decision makers, legacy systems often mean
limited business flexibility. IT resource constraints inhibit the
company’s ability to rapidly introduce and absorb change; the
IT staff cannot code fast enough to keep up with the demand.
Clearly, the point-solution approach no longer works. Adding
to these pressures, evolving regulations and standards present
significant challenges: code set changes, for example, require
periodic system, process and procedure overhauls.
For health plan consumers, buying patterns are changing as a
result of high unemployment and coverage mandates. Rising
premiums are leading employers to shift financial accountabil-
ity to employees. Members and providers are demanding more
transparency of costs. Consumers and politicians are focused
on health insurance firms’ financials.
The solution to these challenges is multi-faceted. In broad
terms, to move toward smarter healthcare, health plans have to
focus on value, core processes and collaboration—concentrat-
ing on what they do best and doing it more efficiently. Health
plans need to exploit opportunities to form new partnerships
and build future capabilities. And they need to act with speed to
institute change, set leadership agendas and manage risk and
performance with transparency.
Most health plans today look at claims or at their environment
from a plan perspective, from an employer perspective, from a
group perspective—almost every perspective except the
member. But that is about to change.
Today’s challenges to health plans call for business
transformation—a shift away from a product business model
and into a service model. The individual healthcare member is
now the customer.
To help you make a successful transition from a product
model to a service model, IBM® and IBM Business Partners
offer solutions built on the Health Integration Framework—
solutions that include enterprise health analytics and core
systems modernization.
4 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

The IBM Health Integration Framework

The IBM Health Integration Framework is a unified software
platform for implementing comprehensive solutions for
healthcare providers, health plans and life sciences enterprises
to improve safety and quality of care, process efficiency and
patient and member satisfaction.

The IBM and IBM Business Partner assets that comprise the
Health Integration Framework reflect more than 10 years of
success in the healthcare industry. The framework offers a
superior approach to the two traditional practices of custom
development and packaged applications use. Custom
development can be both lengthy and expensive, while pack-
aged applications are frequently inflexible, stand-alone, and
require heavy customization.

The framework enables you to choose from a variety of industry

solutions that are pre-integrated on common middleware and
industry-specific extensions. As a result, you can quickly deploy
solutions using your existing health IT investments in your
current environment— and at lower cost—without compromis-
ing flexibility and choice.

The IBM Health Integration Framework delivers:

• Speed: Incorporating a proven software foundation,

healthcare industry-specific extensions, pre-built solution
accelerators and implementation patterns for faster
deployment at lower risk.
• Flexibility: Providing a roadmap that enables customers to
build capabilities over time on their existing environment.
• Choice: Leveraging an ecosystem of industry independent
software vendors (ISVs) and IBM solutions that are built on
industry standards and integrated into the framework.
• Interoperability: Increasing transparency between healthcare
entities for more efficient information sharing, service
coordination and record keeping.
5 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Combining strengths in partnership

The IBM Health Integration Framework includes an ecosys-
tem of independent software vendors and systems integrators to
provide a wide range of healthcare applications that are proven
to run on the framework. This means faster deployment, easier
integration, lower cost of operations, and an ever-expanding
partner community. Industry-specific extensions and accelerators
Service oriented architecture (SOA) is a business-
centric IT architectural approach that supports
With the help of IBM solutions, leading health plans are
integrating your business as linked, repeatable
improving the ways services are administered and operations
business tasks, or services. With the Smart SOA
are organized. IBM solutions are contributing to smarter, more
approach, you can find value at every stage of the
efficient and effective healthcare operations in two important
SOA continuum, from departmental projects to
categories: enterprise health analytics, with solutions for health
enterprise-wide initiatives.
plan analytics and consumer health information; and health
plan core systems modernization, with solutions for model-
driven architecture and business process re-engineering, health On top of the IBM SOA foundation, the framework’s
plan customer service modernization, and electronic data healthcare-specific assets, called extensions and
interchange (EDI) modernization. accelerators, add industry relevance and open stan-
dards, integrate faster with legacy systems, build
new services and provide new capabilities. These
assets include:

• IBM InfoSphere™ Clinical Analytics:

An integrated data warehouse platform that
provides a single source of trusted administrative,
clinical and research information throughout the
healthcare enterprise to help improve operational
efficiency and outcomes.

• IBM WebSphere® Message Broker with support for

HL7: An advanced Enterprise Service Bus providing
connectivity and universal data transformation
for assured delivery and message interchange
between multiple applications.

• IBM WebSphere Transformation Extender Industry

Pack for Healthcare: Capabilities to help integrate
a range of industry-standard data formats with
your enterprise infrastructure; supports HIPAA
EDI (including 5010, HL7 and NCPDP), leveraging
predefined templates, tools, and conversion and
validation maps to reduce risk.
• IBM WebSphere Healthcare Content Pack:
Rich set of assets for enrollment, case management,
employer and group management, claims
management, and provider collaboration solution
areas.
6 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

IBM industry-specific software, accelerators and Enterprise health plan analytics

best practices can help you manage costs, improve IBM enterprise health plan analytics provide aggregation
safety and quality of care, achieve operational and analysis of information from disparate systems throughout
efficiency, and improve member satisfaction. the enterprise. These solutions detect patterns in sales, mem-
bership, claims and providers. With this data, health plans can
Solutions built on the IBM Health Integration Framework
create and modify products and services, minimize fraud and
include:
improve profitability. For health plans, the data provide the
ability to:
• Health plan analytics – Detects patterns in sales, membership,
claims and providers to create and modify products and
• Find and mine sales and prospect information for
services, minimize fraud and improve profitability.
cross- or up-selling to existing or new corporate and
• Consumer health information hub – Consolidates information
individual customers.
from disparate sources to build a single view of a member or
• Consolidate member information siloed in multiple
provider, delivering member-centric services and improved
applications.
member retention.
• Unlock valuable insights from unstructured clinical data
• Core systems modernization – Transforms core health
by gathering, analyzing and structuring content and
insurance systems through integration and process
transforming it into actionable information.
orchestration to increase worker productivity, improve
• Leverage unstructured text analytics to streamline medical
deployment of new services and enhance customer service.
review and transform unstructured clinical data into
• HIPAA 5010 and ICD-10 conversion - Speeds conversion
quantifiable coding, providing deeper insight into provider
to HIPAA 5010 and ICD-10 code sets and modernizes
quality measures and automated review of evidence-based
transaction handling.
protocol compliance.
• Health plan portals – Provides members and employees
• Predict and deliver needed services to optimize costs
with access to information and self-service to reduce costs
and wellness.
for customer service, facilitate collaboration and increase
• Improve the costly, error-prone process of entering member
satisfaction.
information into multiple transaction systems.
• Manage evolving business relationships with members (such
as births, retirements) for improved member retention.
7 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare
Case study: Major U.S. health plan gains
competitive edge
A not-for-profit managed care provider serving more than
two million members needed targeted offerings to help
differentiate itself from competitors and win new business.
The health plan provider offers PPO and traditional indemnity
health insurance plans. The company wanted to respond
efficiently to the growing information needs of customers and
providers. To achieve this goal, the plan provider needed a sin-
gle view of information across their multiple lines of business,
with business intelligence capabilities.
According to the company’s chief information officer, informa-
tion management was critical to the company’s ability to serve
customers—a real differentiator in the marketplace. “We must
have the right information in place for people to be able to make
the best choices for their own healthcare.”
To gain a competitive edge, increase productivity and improve
quality of service to customers and healthcare providers, the
plan provider turned to IBM to help deliver timely and seamless
access to information.
The solution included:
• IBM InfoSphere Information Server to profile, transform,
and load data to their enterprise data warehouse.
• IBM DB2® for AIX® and IBM InfoSphere Warehouse to
accommodate 1TB of raw data and 100 concurrent users.
• IBM Cognos® BI for multidimensional analytics and
client reporting.
• IBM OmniFind® and IBM DB2 Content Manager for
unstructured data.
Smarter business outcomes
The scalable enterprise data warehouse solution provided
powerful multidimensional analytics and access to structured
and unstructured information. The solution:
• Improved customer and provider satisfaction by enabling
them to run their own analytics and better manage their
healthcare costs.
• Reduced risk with improved tracking of data movement to
comply with healthcare regulations.
• Reduced time to load data into the data warehouse
and improved performance for high-volume data
transformations.
• Provided access to structured and unstructured data—
historical and real-time.
“By lowering our internal costs in the reporting area and
giving us additional capabilities, the IBM solution has offered
us a competitive edge, enabling us to go after prospects that we
couldn’t bid on in the past,” says the company’s director of
client management.
The chief data architect concurs: “We needed a set of integrated
tools that would provide a seamless interaction with our
customers. IBM’s Information on Demand tools provide access
to both structured and unstructured data, both historical and
real time. IBM’s vision for Information Management is very
important to us.”
Key technologies
IBM Information Server DataStage® Enterprise Edition
IBM DB2
IBM DB2 Content Manager
IBM OmniFind Enterprise Edition
8 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Case study: Health plan improves operational

efficiency
A U.S. health plan needed to improve the functionality and
reporting capabilities of its enterprise data warehouse. As part
of this strategic priority, the organization wanted to consolidate
data from four claims engines into a single database manage-
Enterprise health plan analytics—a foundation
ment system (DBMS) environment. They also wanted to
for quality care
improve the reporting process for major accounts.
Our enterprise health plan analytics solution embeds
accelerators that are part of the IBM Health
Integration Framework, creating operational flexibility, To achieve their goals, the health plan brought in IBM Business
helping to accelerate solution deployment and ensur- Intelligence consulting to assess and then implement the
ing healthcare solution integration. The solution uses evolution to new architecture. Initial milestones included
building blocks such as: creating a common claim operation data store (ODS) and pro-
vider credential ODS which comprised the integral part of the
enterprise data warehouse architecture for claim management
• IBM Cognos 8 BI
and provider management. The team also established an
• IBM WebSphere Portal UI
• IBM InfoSphere server efficient reporting environment for major accounts.
• IBM InfoSphere Information Server
• IBM InfoSphere Data Architect Smarter business outcomes
• IBM InfoSphere Balanced Warehouse® The solution enabled the health plan to:
• IBM InfoSphere Clinical Analytics • Increase flexibility in the dynamic healthcare environment.
• Initiate Payer Data Management • Improve response and capability for internal and external
• Health Plan Data Model information customers.
• DB2 Data Warehouse • Enhance the company’s operating efficiency.
• Medical Records Text Analytics (MRTA) • Continue to build an information foundation to support
more efficient and cost effective medical care.
• Enhance analytic comparison across the enterprise.
9 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare
Health plan core systems modernization
IBM health plan core systems modernization provides the
transformation of core health insurance systems.
Transformation is achieved through integration and process
orchestration to increase worker productivity, enhance
customer service, and improve overall efficiency and flexibility
in creating and deploying new services—for example, claims
process transformation or member enrollment.
Case study: Health plan improves time-to-market,
reduces costs
A major health plan serving more than six million members
nationwide needed to improve their management of large
volumes of documents, both in electronic and in paper formats.
The storage, indexing, retrieval and workflows of these docu-
ments did not follow a standard process or technology platform
throughout the firm. As a result of the company’s growth
through acquisitions, there were various information silos
with multiple, non-integrated technologies.
Smarter business outcomes
Now, with business process modernization, the company is
better able to control costs through improved integration and
efficient use of imbedded data compression. Thanks to IBM
FileNet ® Lab Services and IBM Global Business Services,
the company can now use advanced data mining for medical
management to help control the cost of care.
Key technologies
IBM FileNet P8
Case study: EDI modernization helps solve
performance issues and improve provider relations
A large health plan that serves more than 3.2 million members
needed to prepare for new HIPAA regulations mandating
migration to the ANSI 5010 format for EDI, which was also
required for another regulatory mandate, ICD-10. To comply
with these mandates, the company would need major upgrades
to their existing infrastructure.
The IBM Lab Services team, along with IBM Global
Technology Services infrastructure team, demonstrated deep
understanding of the health plan’s EDI needs and regulatory
requirements, including mandated HIPAA transactions and
ICD-10 requirements. IBM worked with a Business Partner,
Edifecs, Inc., to create the solution architecture and roadmap.
IBM performed a pilot that validated the architecture and dem-
onstrated the capabilities and integration of the EDI solution.
Smarter business outcomes
Modernization of the company’s EDI gateway delivered a
foundation for streamlining and improving the reliability of
the company’s EDI processes and workflows, helping solve
performance issues and improve provider relations. The
solution also delivered a foundation to comply with HIPAA
5010 and ICD-10 mandates.
Key technologies
WebSphere Transformation Extender with HIPAA Pack
WebSphere Partner Gateway
WebSphere Application Server ND
WebSphere Message Broker
IBM Tivoli® Composite Application Manager for SOA
10 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Core systems modernization—the way Case study: Modernized EDI gateway lays the
to flexibility foundation for compliance
Core systems modernization enables business leaders A large health plan that serves more than 2.8 million members
to define business processes and use enabling tech- was faced with an aging EDI infrastructure and needed to
nology that will drive the metrics and business results comply with HIPAA 5010 and ICD-10 mandates.
required by a health plan. Solution components for
core systems modernization include: Smarter business outcomes
IBM Business Partner, Edifecs, Inc. modernized the company’s
• Health plan data model EDI gateway and channel architecture, laying the foundation
• Data warehouse and management services for compliance with HIPAA 5010 and ICD-10 mandates. The
• Single view (member health) new infrastructure prepares for migration to stream based
• Healthcare analytics/business intelligence transactions, such as HL7.
• IT and infrastructure optimization
• Member-centric operations integration Key technologies
WebSphere Message Broker
IBM skill sets include: WebSphere Transformation Extender with HIPAA Pack
WebSphere Partner Gateway
• Core systems operations and process redesign
• Business information requirements definition
• Information architecture and integration to
business
• Application management and maintenance
11 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Why IBM
IBM’s deep industry expertise provides the foundation for
solving the most complex problems in the delivery of healthcare
and health plans. A leader in working with and transforming
healthcare organizations through service oriented architecture
(SOA) and information management, IBM employs dedicated
technology research professionals, including the largest clinical
consulting staff in the United States. With its long-term
commitment to industry standards, IBM has developed proven
business transformation and health analytics methodologies
and global delivery capabilities.

For more information

To learn more about the IBM Health Integration Framework,
contact your IBM representative or visit:

ibm.com/software/industry/healthcare/
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Produced in the United States of America
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