Business Intelligence for Healthcare: A Prescription for Better Managing Costs and Medical Outcomes

Business Intelligence for Healthcare: A Prescription for Better Managing Costs and Medical Outcomes

Jack S. Cook (SUNY Brockport, USA) and Pamela A. Neely (SUNY Brockport, USA)
DOI: 10.4018/978-1-4666-8756-1.ch076
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Abstract

Using an interpretive case study approach, this chapter describes the data quality problems in two companies: (1) a Multi-Facility Healthcare Medical Group (MHMG), and (2) a Regional Health Insurance Company (RHIS). These two interpretive cases examine two different processes of the healthcare supply chain and their integration with a business intelligence system. Specifically, the issues examined are MHMG's revenue cycle management and RHIS's provider enrollment and credentialing process. A Data and Information Quality (DIQ) assessment of the revenue cycle management process demonstrates how a framework, referred to as PGOT, can identify improvement opportunities within any information-intensive environment. Based on the assessment of the revenue cycle management process, data quality problems associated with the key processes and their implications for the healthcare organization are described. This chapter provides recommendations for DIQ best practices and illustrates these best practices within this real world context of healthcare.
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Background

Healthcare: As defined by the U.S. Department of Health and Human Services, a healthcare provider is “a provider of services as defined in §1861(u) of the Act (Social Security Act), a provider of medical or health services as defined in §1861(s) of the Act, and any other person or organization who furnishes, bills, or is paid for healthcare services or supplies in the normal course of business.” (U.S. Department of Health and Human Services, 2001) Until recently, healthcare providers were paid when sick people sought treatment. Quality and outcomes were not rewarded, but rather providers were paid based on how much was done to treat the patient. In the future, healthcare providers will be given financial incentives to keep people well, and quality, not treatment, will matter a great deal. This shift from volume to value will require a rethinking of treatment plans and a shift towards preventative care.

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