Technology is essential for today's care management operations, yet it's important to recognize that technology can either help or hinder the business. At its best, technology offers a reduction in the basic cost of doing business through streamlined workflows, automation and digital processing of administrative functions. But, at its worst, improperly designed technology can cause wasted man hours, rework, increase the likelihood of human error, and create job dissatisfaction—all of which creates staffing issues and distracts clinicians from the primary mission of caring for members.

Listen in to learn more about how innovations in workflows for case management and utilization management are solving common healthcare and business problems for health plans.  

Host: Welcome to Episode 11, How Technology Workflows Influence Quality of Care with expert, Laura Franklin. Laura has over 15 years of clinical nursing experience and 8 years with healthcare technology platforms guiding clinical informatics. Welcome, Laura.  

Laura: Hi, I’m happy to be here.

Host: It’s interesting to think about how much the industry has evolved when it comes to the management of chronic conditions today versus even just 10 years ago. In part, it’s due to the shift towards the value-based care model, but it’s only possible because of technology and how we’re able to coordinate and delegate different aspects of care across a team of clinicians. From what you’ve seen, what kinds of problems in care management are able to be solved with technology?  

Laura: First, I think it’s helpful to define care management. Care management platforms deal with two main product lines. Case management and utilization management. Case management is really all about nurses reaching out to members—the members with chronic conditions, the cases that cost the system the most. Nurses can help with preventative care. If there are barriers to care, such as transportation, nurses can help coordinate to remove the barriers. Nurses can also find gaps and ensure the tests and medications needed are received. So that’s case management. The second part is utilization management, UM. This is the process of getting authorization before a service or medical equipment is distributed to make sure it’s a covered benefit, it’s medically necessary and that the plan will pay for it. Providers are usually submitting these authorization requests to the plan. They can do it by phone, fax, or through a portal if it’s available. There’s a lot of analysis that goes into the process, with a nurse reviewing the documentation to determine if the request meets clinical criteria. If it’s not approved, the request will move on to the medical director for further review. It’s really important that authorization requests are responded to in a very timely manner. There are turnaround times that are part of service-level agreements that are required by regulatory bodies like CMS. So, that’s utilization management. Care management platforms deal with both case management and utilization management.  

Host: OK, that really helps to level-set the discussion. So, when we’re talking about solving problems in care management with technology, what kind of problems exist in these processes for case management and UM?  

Laura: Good question. The basic cost of doing business is a problem that can be solved with technology. Think about the processes involved with administrative work and processing claims—streamlining and automating these processes is huge for reducing costs. This one is more obvious for most people. Less obvious but extremely impactful are staffing costs and the costs associated with human error.  

With staffing, it’s all about productivity, how much each type of staff member can do in a given day, and how much time is required for training, retraining, or oversight, or how much time is required to rework something that was done in error. For care management, this relates to how many members a nurse can handle and how many interactions their schedule allows. You know, like how many phone calls can they do, or assessments, and how many gaps can they close?  And this can be directly effected by the simplicity or complexity of the system to document all the care or create care plans.  It’s also worth exploring: is there anything in the nurse’s workload that maybe a less expensive staff member can execute? Are we making use of the technicians or nurse’s assistants? For UM, it’s all about how many authorizations they can process in a day, which is often based on how difficult it is for staff to follow complex processes. Are there a lot of edge cases to learn about or details to meet regulatory requirements? How much support is needed for them to do it all correctly? Is the staff constantly having to look up certain things, do they have to go outside of the system to find answers, or are they not really sure which choice to make and do they either have to guess or have to go ask somebody—there’s a cost associated with making the wrong choice. How long does it take staff to document the care of a member or to document the authorization request? These are areas that can benefit from being streamlined or automated to make the business more accurate and efficient. So, the rule is that anything that can be automated should be automated. This saves the cost of human time and prevents human error.  

Host: Let’s talk about some examples of how this plays out in the CM/UM world.  

Laura: Yeah, a good example of this is that only certain items need prior authorization before the service is completed. It’s a very specific list depending on the health plan. Every health plan is different in what it requires for prior authorization. Clinicians can’t memorize these lists for every health plan they interact with. So they have to look it up every time. You know, does this require a prior auth or not? And this is a time cost that needs to be factored in. Of course, there’s human error in the process as well. This is a perfect use case for technology—to have the system automatically check if a prior authorization is needed and send it in a different direction if it doesn’t. Another use case is checking for duplicates. If a provider enters an authorization request, the system can identify if another provider has already asked for the same thing for the same member. This is the value of duplicate checking to prevent unnecessary work. Another area where technology can help is auto-approvals. If you’ve got authorization requests coming in with certain elements, then health plans say, “Well, in these circumstances, it’s always going to be approved.” So, let’s just automate the decision-making process. Afterward, the system can automatically send out letters of notification to the members and providers. This is a huge win for efficiency.  

Host: Let’s circle back and talk more about staffing. How is technology impacting this aspect of the business?  

Laura: Yeah. We were just talking about how technology can help the business. But, it’s important to realize that technology can also hinder the business. On one hand, it can make the business more efficient and effective. But on the other hand, it can create barriers or waste time if it is confusing to the user. Staffing turnover is a big issue right now.  Most people don’t consider it, but technology can be a primary cause of work dissatisfaction and a deep source of frustration if technology processes cause staff to have to go through a lot of repetitive processes, which creates boredom. Processes that are cumbersome create feelings of frustration. Or maybe the choices are unclear, and it creates feelings of not being capable. Or it’s just clunky, which can be wearisome over time.  None of these feelings are going to foster a highly satisfied staff, and that can lead to higher turnover rates, which can cost the business in many ways – with increased training costs, loss of knowledge and expertise, and lower productivity.  It’s a huge win for staff to work with technology that supports them and that they feel empowered by. The technology should streamline processes. We want it to be easy for the user to do the right thing. Language is clear; choices are simple and intuitive—it should make the next step obvious. Another consideration is that clicks should be minimized. If the user is looking for information, it should be easy to get to. A click or two away.

Host: I’m envisioning one of those memes that say, "I got into healthcare because I love clicking through software systems,” said no healthcare worker ever.” But really, regardless of the skillset, healthcare workers want to work at the top of their license and not spend time on routine tasks or clicking through the abyss of some software system.

Laura: Exactly. That’s such an important point—you want to make the best use of highly skilled and highly paid practitioners. You don’t want them to be wasting time because of poorly designed technology or by doing something that can be done by administrative staff. A platform can really help support a technician to enact complex processes rather than requiring it to be done by a higher-paid staff member.  This is a big advantage of smart platforms, which can provide decision-making support with branching logic so that a non-clinician can work through the algorithms and do the correct steps without needing to rely on clinical judgment for it. Technology can also keep track of outstanding work. In case management, that could mean having the system notify a case manager to complete a member’s annual assessment. In UM, that could mean reminding the clinician to finish a review before the deadline or making sure that the fax that comes in doesn’t get lost in the system. Coordination between various members of the care team is also another benefit. You’ve got to keep track of the back-and-forth communication that occurs within the care team. In today’s world of remote working, you’re no longer going next door to your teammate or walking over to the medical director and asking about something real quick. Now, cases need to be more coordinated, they need to be tracked in a clear manner and passed along for the next step to another clinician. That handoff needs to be streamlined. Along those same lines, plans need to have the support of their providers, and that means making the system easy and straightforward for the providers to submit an authorization request. Staff turnover is an issue in provider offices as well, so it’s important to make sure there’s an intuitive nature to the system to keep training minimal.  

Host: That makes sense. You mentioned earlier that technology can either help or hinder the business. What are the potential consequences of poorly designed workflows?  

Laura: Yeah. There are a lot of consequences to different stakeholders, including the members, the staff, and the plan itself.  A poor workflow where something doesn’t get a follow-up can result in delayed care, gaps that aren’t filled, and tests that aren’t completed or ordered.  This can have a huge impact on the very real health of the member and may have financial implications as well. Also, don’t forget the impact to the clinician. They need easy access to the information they need to make informed decisions and an intuitive process so it doesn’t detract from their work. For clinicians working directly with members, the technology should support and maximize the time between the clinician and the member, so it’s a meaningful time. The clinician shouldn’t be bogged down in the technology and navigating the software but rather focus on the person and the care they’re giving. This is the difference that good technology can have on not just member care but member satisfaction. At the health plan level, we’ve talked about staffing and efficiency costs—costs for mistakes, cost of training, frequent turnover, there’s a lot of downstream impact. There’s also the impact of the claim’s system. If authorization requests aren’t processed correctly, there are costs for incorrectly paying those claims. There’s the implication on strategic choices if you’re dealing with inaccurate data; it’ll skew reporting and impact decision-making.  Incorrect reporting can also lead to regulatory issues and result in fines or negative ratings.  So, there are some really important consequences for a poorly designed system.

Host: As a clinician, what were some of your greatest frustrations with the technology of the time? And what inspired you to pivot from a clinician to specializing in technology workflows?

Laura: Yes, I have a background as a clinician. I’m a clinical nurse specialist and a clinical informaticist, but I started out as a bedside nurse in the ICU and then went into case management.  I’ve done a lot of documentation for case management and bedside nursing, and the technology was often a battle. It would take so much of my day to document, paying attention to the technology instead of the people I was trying to care for. It can be very, very frustrating and complicated, where a lot of energy is spent navigating weird processes to make things work. So, as a clinician, I wanted to practice at my highest level and not have to stumble through a ton of steps that didn’t feel meaningful, like clicking through a bunch of screens to get to one little thing I wanted at the very end. It’s the frustration that inspired me to want to contribute to making the overall process better and more streamlined and to put the joy back into a clinician’s work so they can have meaningful interactions and provide the best care possible.  

Host: Laura, I think we can all identify with cumbersome processes in some aspect of our lives, and then to think about having to deal with that day after day, we can really empathize with clinicians. It’s really important work you’re doing, and it’s important to realize the effects that technology can have on all the parties involved—from the health plans and providers all the way down to member care and satisfaction. Thanks so much for your insight today.

Laura: Thank you for having me.  

Host: Thanks to our listeners. If you enjoyed this episode, follow and share it with your colleagues.