HIE & Claims Clearinghouse Integration

Legacy system hangover, stressed resources and impatient customers are a cry for moving to a modern architecture and integration solution. Learn how a Healthcare Claims Clearinghouse and HIE challenged its new integration solution to re-engineer and transition its claims processing architecture in record time with no disruption to existing connections or increase in resources. A small internal team armed with the new tools and PilotFish support met every challenge. As a result, with newfound agility, the organization has responded efficiently to growth and increased transaction volumes.

THE CLIENT

The client is a clearinghouse for healthcare claims data and a Health Information Exchange (HIE) for the communication of clinical data. It provides a secure gateway for the electronic exchange of data and serves large healthcare networks as well as private practices. The client connects to over 4,000 payers nationwide, ensuring that transactions are timely and secure.

THE CHALLENGE

The client struggled with an outdated, unstable infrastructure for the movement, validation, and manipulation of millions of ASC X12 HIPAA claims files. Their existing solution was based on a combination of a large commercial vendor’s ETL software and their own homegrown technology. The new solution needed to replace a legacy system but still needed to retain the old connection functionality with the legacy system. The legacy system was notoriously difficult to troubleshoot and prone to failure. It was too rigid to easily build new features with as well.  Attempting to keep up with evolving new standards and technologies had become impractical. Due to the burden of maintaining the old system, the team also did not have the bandwidth to react in a timely manner to data editing and validation requests from their client base. This resulted in mounting frustration from both their user community and the internal management team.

The client required a new enterprise solution that would be capable of addressing all of these issues. As the organization had very limited financial resources, minimizing the amount of staff required for maintenance and ongoing development was another critical requirement. Additionally, the new system must be implemented transparently, maintaining hundreds of existing endpoints with little to no disruption during the transition.

THE SOLUTION

After vetting the PilotFish solution, the client engaged PilotFish in a Proof of Concept (POC). The POC consisted of a 4-day onsite engagement. During this time, a Pilotfish team (comprised of two Senior Solutions Architects) worked with a small group of experienced client staff members to prototype a new claim processing architecture. In just a few days, the team quickly constructed a framework capable of handling the connectivity, data manipulation and data validation required to effectively replace and enhance the legacy implementation.

After the successful POC engagement, the client officially selected the PilotFish eiPlatform integration engine and eiConsole graphical IDE. With very little formal training needed, the client’s team fully re-engineered their entire claims processing architecture in less than six months. This effort included the implementation of several hundred unique data flows. This impressive feat is even more remarkable when one considers that this effort was completed with a small team of no more than three software engineers who received training and assistance from the PilotFish professional services staff.  The speed and efficiency corroborated the selection team’s decision that PilotFish would optimize both scarce financial and IT resources early in adoption.

THE BENEFITS

With the Phase I implementation of the PilotFish integration middleware, the client has already seen dramatic gains in the manageability and flexibility of their trading partner communications. These technical benefits have been coupled with improvements in team productivity. This allows the organization to deliver better, more personalized and reliable service to their large constituency.

The flexible EDI to XML and XML to EDI transformation technology embedded in the PilotFish solution have allowed the client to dramatically facilitate the design and implementation of solutions to edit and validate customer data when connecting to new endpoints. In turn, this has significantly reduced the time required to onboard new customers and trading partners. The system performance and increased operational visibility of the PilotFish eiPlatform have measurably improved client uptime while reducing the man-hours required for day-to-day system maintenance and monitoring.

For new development, the client has found the eiConsole software to be intuitive and easy to use – thereby minimizing the staff and time it takes to train new staff on the technology. As required, to help meet particularly challenging requirements, the client has been able to call on a PilotFish professional services staff that they have lauded as “one of the best, if not the best, professional services groups” with whom they have had the opportunity to work. They have gone on to say that “the PilotFish professional services team does a great job not just on helping supplement your staff and implementing new technologies, but on empowering your internal staff to be able to maintain, design and implement solutions on their own.”

Lean in both time and resource requirements, the new PilotFish integration solution leverages the strengths of internal teams and positions the organization to succeed quickly, inexpensively, and flexibly.

THE FUTURE STATE

The flexible and extensible architecture of the PilotFish eiPlatform will allow the client to rapidly set up connection methodologies that meet the needs of their existing legacy clients while also allowing them to leverage emerging industry standards, new advanced technologies and best practices with new trading partners.

To further reduce resource requirements, the client may elect to implement another product in the PilotFish suite, the eiTestBed. By implementing the eiTestBed, the client can offer their trading partners a complete self-service facility that automates not only the distribution of interface requirements but also enables complete message testing and validation prior to customers going live. The eiTestBed can be custom configured to define an organization’s data formats, communication methods and validation rules required for electronic data exchange with their trading partners. Trading partners may use the eiTestBed to send asynchronous follow-up messages into their system to test and verify the flow of inbound transactions.

With the eiTestBed, once satisfied with self-testing, the trading partner need only contact the organization’s technical representative for final integration testing and production deployment. By leveraging the eiTestBed, the client will be able to dramatically reduce their resource requirements and costs while onboarding more trading partners and managing increasing transaction volumes.

HL7 is the registered trademark of Health Level Seven International.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.