SAP MDM: A Healthcare Use case
Recently, the stork visited one of my friend and his wife. After the initial well wishing, I posed a question to him: what was the most nerve-wrecking moment? I was expecting the routine answer: the wait outside the OT, as the child had been delivered via surgery. Instead, he said, it was the seemingly endless wait for his cashless insurance claim to materialize. It seems, his employer had taken a cashless health insurance cover for all its employees and their families. It covers hospitalization too and he can avail cashless treatment, subject to a co-pay.
He narrated the entire process: His wife has a bar-coded identity card issued by the hospital and her health policy details are on a separate e-card issued by his insurer. Upon hospitalization, her cashless-claim request form was faxed to the TPA, who in turn verified the policy details with the insurer. The insurance firm requested some past medical data. So the relevant info was retrieved from the medical records at the hospital and then faxed back. Finally, an authorization was faxed to the hospital by the TPA after a gap of many hours. During this period, his wife could not be operated upon as the hospital insisted on either a deposit or an insurance authorization, before proceeding with the surgery. All this happened while his wife was in labour.
Suddenly, it struck me, why was this process so time-consuming and error-prone? The employer, TPA, insurer and hospital were all maintaining information about my friend and his wife as the insurance policy was taken a year back and they were regular visitors to the hospital for routine checkups. Although data about them was used for different purposes by different parties involved, it contained some common data elements like: name, age, insurance policy id etc… Then why were these entities playing a game of u-fax-me-I-fax-u? These firms could work together to accurately identify a patient across multiple systems and databases to create a meaningful, trusted system of record. This would not only enable speedier claims settlement but also prevent frauds.
SAP MDM can definitely play a role here. It can provide the community of hospitals, insurers and TPAs, access to a consolidated view of patient data across participating organizations thus enabling community-wide workflows and messaging. It can serve as a critical foundation for accurate matching and linking of patient information across widely dispersed systems.
Once a SAP MDM solution is in place supplemented with a health information exchange, the patient can simple check into the hospital in a planned or unplanned visit. The hospital identity card can be swiped on a bar-code/RFID reader and immediately the patient’s employer, hospital, insurance firm, TPA would be notified and seamless information exchange could take place. The attending doctor’s diagnosis and other details contained in the medical records could be sent to the TPA and insurance firm as and when requested. SAP MDM would form the backbone of such a system feeding accurate master data on patients to all the relevant systems.