Transforming the Health & Human Services Enterprise: The Promise of Using Modern Technological Solutions

Transcription

1 Transforming the Health & Human Services Enterprise: The Promise of Using Modern Technological Solutions May 21, 2015 James Weaver, Deputy Chief Information Officer, Pennsylvania Department of Human Services Dr. Mark Allen, Chief Technology Officer, Decision Management, Progress Megan Lape, Senior Policy Associate, APHSA American Public Human Services Association. All rights reserved.

2 What s Shaping Our Path Forward Integrated Policy Modern Platforms Innovation Labs Investing in Outcomes Science Co-creation Six Agents of Change American Public Human Services Association. All rights reserved.

3 H/HS ENTERPRISE: COMMON GOALS & SHARED PRINCIPLES Business-driven transformation Reuse & interoperability Governance ensuring accountability Incremental development and evolution/maturity over time Privacy & security standards American Public Human Services Association. All rights reserved.

4 Business Components & Services Qualifying Under the A-87* Exception Level 1: Front Door -Document Imaging/Digitization of Case Records -Client Portals -Notices -Customer Services -Workflow Management Tools -Interfaces to Community Assister Orgs *OMB Circular A-87 now a part of OMB Omnibus Regulation found at 2 CFR, Part 225 and the HHS 45 CFR Part American Public Human Services Association. All rights reserved. Level 2: Foundational System Components -Business Rules Engine -Automated Account Creation and Case Management Tools -Enterprise Service Bus -Interfaces to State & Fed Verification Services Level 3: Heart & Soul of the System -Identity Management -Master Client Index -Data Warehouse -Analytical Tools/Decision Support

5 Agenda Introduction What is Business Rules Management The Challenge in Rules Management The Corticon Solution Successes in Health & Human Services The Corticon Difference Citizen Self Service Vision for the Future of HHS 5

6 What Is Automated Decisioning? Software to help make the Right Decision at the Right Time with Business Agility Is this family eligible for Medicaid? What insurance options are available? Is this prescription accurate? 6

7 Automated Decisioning and Business Rules Management Decisions are governed by business rules DECISION Is this family eligible for Medicaid? RULE Families in poverty are eligible. LEGISLATION & POLICIES BRMS Business Rules Management Systems (a.k.a. rule engines) externalize decision logic from applications and represent as business rules Case Management System BRMS Rule Rule Rule Rule Rule 7

8 The Problem: Automating Business Rules Traditional approach is programming-based Simple rules difficult to automate, sophisticated ones impossible Single change can impact hundreds of rules/processes Clinical Practice Guideline Hospital Policies Consumer Behavior That change requires 2 years & $5M Regulations Market Shifts New Technologies There is a Better Way 8

9 The Solution: Progress Corticon Business Rules Management System Separate decision logic from code Empower business users Ensure performance & scalability Enable fast, safe changes Model Rules with Integrity Execute as Open Standards Decision Services Decision Modelers Enterprise Systems Enterprise Data Sources 9

10 Agenda Introduction What is Business Rules Management The Challenge in Rules Management The Corticon Solution Successes in Health & Human Services The Corticon Difference Citizen Self Service Vision for the Future of HHS 10

11 Progress Corticon: 500+ Customers INSURANCE FINANCIAL SERVICES GOVERNMENT HEALTH & HUMAN SERVICES ecommerce FBI OPM DIA State Department 11

12 Corticon HHS (Health & Human Services) Customers 24 states have chosen Progress Corticon as their Business Rules solution. CHALLENGE Keeping pace with ever-changing regulations, such as HIPAA and the Affordable Care Act ( Obamacare ) SOLUTION Use Progress Corticon BRMS to modernize legacy and deliver new systems EXAMPLES Eligibility for Benefits Health Insurance Exchange Benefits Administration Medicaid Claims Needs Assessment, Care Mgmt Electronic Prescriptions 12

13 HP SOLUTIONS USING CORTICON Interchange MMIS Medicaid Management Information System Metavance commercial benefits admin solution eprescribe electronic prescriptions system Atlantes care management PASARR needs assessment Eligibility Medicaid-only & Integrated Eligibility 13

14 Agenda Introduction What is Business Rules Management The Challenge in Rules Management The Corticon Solution Successes in Health & Human Services The Corticon Difference Citizen Self Service Vision for the Future of HHS 14

15 Progress Corticon BRMS is a Recognized Market Leader Corticon has breakthrough tools for business analysts. Corticon positioned as Leading Innovator in Gartner Magic Quadrant Corticon has developed breakthrough technology in the BRMS market. 15

16 Corticon Differentiation Easiest to Use Most Reliable Fastest Model-Driven Development Automate rules without coding Guaranteed Rules Integrity Ensure safe rules changes DeTI Engine Market-best performance & scalability

17 Agenda Introduction What is Business Rules Management The Challenge in Rules Management The Corticon Solution Successes in Health & Human Services The Corticon Difference Citizen Self Service Vision for the Future of HHS 17

18 Vision for Citizen Self-Service Self-Service Results: Improved Compliance Decrease Utilization & Costs Faster, Better Customer Service Citizens Citizen Portals Encounters BRMS Rule Rule Rule Rule Rule Case Workers Core Systems 18

19 Sitefinity Web Content Management System One system of engagement connected to all your systems of record to deliver personalized one-on-one conversations with your customers, no matter where they are. 19

20 Using a Business Rules Engine to Deliver Value from an Enterprise Perspective May 21, 2015

21 Evaluating and Selecting a Business Rules Engine As part of technology incremental renewal planning, leading business rules engines were evaluated. Leading Business Rules products were evaluated based on business criteria and technical criteria Demo, Proof of Concept, Sandbox, and Load Tests were performed Corticon was selected as the Business Rules Engine enterprise standard for DHS Business Factors Ease of rule modeling/training Ability and ease of testing the rules within product Identifying conflicting rules Finding incomplete rules Versioning rules What If Analysis Cost Technical Factors Ease of configuration and installation Integration with.net applications Adaptability with multiple applications Performance real time and batch Scalability Technical support 21

22 Delivering Value Across the Enterprise DHS has over 40 core decision services, integrating with 5 enterprise systems. Each day there are more than 250,000 rule executions, performing a diverse set of functions both in real time and batch across Health and Human Service programs. Medicaid, CHIP Eligibility Child Care Enrollment Funding Program Eligibility Eligibility rules for Medicaid and CHIP programs (over 1,500 business rules) Child care eligibility and enrollment rules Client Notices Rules for triggering client notices based on eligibility outcomes Managed Care Assignment Enrollment rules to assign individuals to managed care plans Pending Verifications Determining what information is pending verification based on program policies Data Exchange Targeting Identifying data match results that may impact benefits Childcare & Supervisor Provider Review Automated Individual Support Plan Approval Identifying Child Care providers requiring additional review/inspection Rules for headquarter approval of individual support plans for individuals receiving Long Term Care services 22

23 Interoperability and Reuse in Practice With the implementation of MAGI Medicaid and CHIP eligibility, we sought to maximize reuse of rules across the organization. With ACA, we have a single MAGI eligibility service that is consumed by three applications maximizing reuse and consistency. MAGI rules developed by New Mexico were leveraged to jump start the implementation in PA (60-75% reuse). IE Caseworker Portal Enterprise MAGI Eligibility Service Self-Service Portal CHIP Eligibility System Enterprise Applications MAGI Medicaid & CHIP SOA Servers 23

24 Corticon Integration Patterns There are two ways Corticon is accessed in the DHS environment: In-process: Invoking using.net APIs (messaged via.net objects or XMLs) Web Services: Using messages via XML Benefits of In-Process Server Superior performance by eliminating XML translation overhead Flexibility in custom orchestration between multiple Corticon files Enterprise Applications Corticon Rules Engine Decision Services Web Servers SOA Server 24

25 The Value of Corticon IT Value Reducing Application Development Time: single MAGI eligibility service eliminated the need for online and batch application code in three separate applications. By isolating business logic in Corticon services, coding complexities are reduced Maintainability of Business Rules: by isolating business rules to Corticon, modifications are isolated. Minor changes can be supported with a limited deployment footprint Reducing Defects: because Corticon rule modelling more closely mirrors business process flows, fewer defects are introduced and found earlier in the testing cycle Business Value Improving Efficiency & Productivity: by reducing the manual processing by case workers, especially the elimination of unnecessary work Assuring Compliance with Legislation: By providing greater transparency and traceability of the rules to the legislation. Better Citizen Service: faster eligibility determination, self-service screening 25

26 Future Opportunities With each technical upgrade or significant business rule modification, an analysis is completed for migrating/developing business logic to Corticon. Below are some identified opportunities that are in-flight or in consideration for runway planning. Eligibility Determination for additional Social Service benefit programs Batch rules processing logic Automated Case Actions What If Analysis Rules to further support operational efficiency such as dynamic office and worker routing and automated prioritization of work Health Insurance Exchange 26

27 Questions? Jim Weaver: Dr. Mark Allen: Megan Lape: American Public Human Services Association. All rights reserved.