Care Delivery Model Succeeds with PilotFish

HIMSS defines health and care as the sum of three domains: social care, behavioral health care and medical care. Today companies and social determinants of health (SDOH) services can span administrative services (network management, analytics, risk adjustment services, etc.), care services (care management, care coordination, disease management, patient education, etc.) and financial services (health plan administration, member services, claims processing, PBM, benefits management, etc.). Payers, providers and service partners struggle to navigate the proliferation of disparate processes, standards and systems. This transformative high-growth leader across domains partnered with PilotFish to tame complexity and ensure frictionless data interoperability.

THE CLIENT

This forward-thinking and innovative company built extraordinary technology solutions and offerings. Its healthcare platform is designed to improve patient outcomes by facilitating the sharing of secure patient information, optimizing coordinated services and ensuring payment. It works with networks of state and regional Health Information Exchanges (HIEs), community-based organizations and information exchanges, state all-payer claims databases and regional health improvement collaborations, as well as federal agencies and programs. Its impressive technologies, networks and products drive a new population health and policy model for impactful change in healthcare delivery.

THE CHALLENGE

The company was in a major push to build out the resources and knowledge to support an ever-growing number of data resources and analytics. Integrating disparate data sources and analytics is always complex when there are several stakeholders. As with any data collection and sharing process, ensuring data security was paramount and even more so with state and federal-level contracts. The client searched for a new architectural framework and system to tame complexity and guarantee data accuracy, quality and security.

Building on an existing system, the new integration processes could not disrupt established workflows. New data feeds needed to be quickly added to existing live feeds with no problems.

Scalability was another factor that had to be considered relative to their aggressive expansion plans. The client needed a solution that could scale to match accelerated growth in services and products, data sources and analytics – all dedicated to improved patient experience and care delivery.

In addition to all their other criteria, the client wanted an integration product suite proven to seamlessly exchange clinical, pharmacy, EHR, lab, imaging, monitoring devices, SDOH, administrative and claims data. 

The client emphasized that efficient payment and healthcare reimbursement processing was critical to success and cost controls as well. For example, the Centers for Medicare & Medicaid Services (CMS) published new rules for 2020 that allow insurers to offer supplemental, SDOH-related benefits for Medicare Advantage (MA) plans. CMS also worked with states seeking to integrate SDOH into their contracts with Medicaid managed care organizations. Yet, while insurers have taken advantage of this, they aren’t generally changing benefit designs, reimbursement policies or other business practices. 

To deal with these inconsistencies, the client required exceptional capabilities in the bi-directional data exchange of HL7 FHIR and X12 EDI. Timely and accurate data validation had to be part of the solution.

The client understood that frictionless interoperability was absolutely necessary and sought a single, consistent approach to integrations through:

• Easy and efficient electronic exchange between internal systems as well as with external data and information sources and services. 
• No-problem syntactic interoperability, semantic interoperability and workflow interoperability.

Before selecting PilotFish (a leader in healthcare integration), the client undertook an extensive evaluation process of all the major interface engines in the industry. PilotFish stood out as the clear winner.

THE SOLUTION

One of the critical selection factors for this investment was long-term viability. Importantly, PilotFish supports every major healthcare standard and source – X12 EDI, NCPDP, HL7, CDA, FHIR, XML and data sources outside of healthcare. PilotFish is fully extensible to support virtually any new standard or format that emerges (e.g., CMS SDOH-related ICD-10 Z codes ranging from Z55-Z65). PilotFish is experienced with all health-related information expressed in terminologies such as LOINC, SNOMED, CPT, HCPCS, ICD-10, RXnorm, etc.

The decision makers were impressed by the PilotFish integration engine’s built-in capabilities for incoming data validation and translation, outgoing transaction construction, acknowledgment generation, process orchestration and scheduling. 

The engagement kicked off along two critical paths – PilotFish’s lightweight HL7 FHIR and API capabilities, plus implementing PilotFish’s X12 EDI integration solution. The starting EDI set for automating transactions included 837, 835, 270/271, 276/277 and 275. PilotFish’s eiConsole for X12 EDI incorporates deep expertise in EDI structures and data mapping to ensure the highest data quality and reliability.

PilotFish delivered a complete solution of integrated components that includes a graphical automated interface assembly line process and visual drag & drop data mapping. Easy reuse of components and interfaces is a distinctive PilotFish advantage, saving time and money throughout.

The PilotFish Data Mapping component generates XSLT transformations that transform any data format to any other. PilotFish transforms any standard industry format and all interpretations of the standard, proprietary formats or a company’s common model – anything to anything.

PilotFish’s graphical automated interface assembly line process and visual drag & drop Data Mapper also quickly negated the company’s need for custom coding and scripting. Early on, the team could demonstrate this money and time savings to management.

With PilotFish’s short learning curve and ease of use, the client’s adoption of EDI and improved FHIR capabilities was on firm footing and moved forward fast. Every metric of the new system was verified during the real-life performance.

THE BENEFITS

The evolution of population health and value-based care both disrupts and improves care delivery. The capability to reconcile:

1. Inconsistent use of data across different healthcare settings.
2. Inconsistent implementation across health information and technology systems is critical to healthcare IT infrastructure. With PilotFish, the client’s information and IT systems were now armed to address these conflicts and inconsistencies always looming from disparate domains.

Today, clinical systems continue to require and maintain mapping capabilities using clinical standards. On the other hand, social and behavioral service providers need to employ standards more usable to them. Semantic interoperability needs a built-in capability to map terms from these disparate domains, with appropriate translation guides and functionalities. As these integration challenges grow, PilotFish is uniquely designed to adeptly handle these ongoing crossovers of domains of new and legacy systems.

With the PilotFish Integration Solution and its built-in expertise and experience, the organization was immediately able to build on rapid test-and-learn cycles. From the start of the engagement, the time and cost savings in taming this complexity were confirmed repeatedly for the client.

PilotFish’s expertise and experience architected into its exceptional product suite was proven in:

1. The self-sufficiency achieved by the client from the start after just a short training course.
2. The range of applications and teams utilizing PilotFish’s Integration Solution. 

The PilotFish solution, built-in tools and elegant architecture are being adopted by the organization’s developers for strategic and mission-critical projects as well.

The client highly valued how PilotFish works with clients in ways that make sense for the client and their integration challenges. With PilotFish, the company is set to meet its current and new integration requirements enterprise-wide with one easy-to-learn and use tool for non-programmers and developers alike.

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.
HIMSS: Healthcare Information and Management Systems Society, Inc.