Applying technology to getting medical tests right

One of the major targets of enabling health care to be more efficient is making sure patients get the right kind of medical testing done, and that no unnecessary or repetitive testing is done. HealthHelp, a Houston-based organization, provides radiology benefit management intended to streamline the process of getting the right test done first and avoiding unnecessary procedures.

The benefits of controlling medical tests are multiple, said Steve Spar, executive vice president of information technology at HealthHelp. Not only does it help control costs by avoiding unnecessary tests, but it also helps reduce unnecessary exposure to medical radiation and speed the process of getting to the right diagnosis.

HealthHelp applied technology to this issue by developing a clinical data repository that can handle the multiple types of queries required to determine the best radiology solution for a given patient and diagnosis.  Over the last year, the company has teamed with Qwest Communications’ Business Markets Group to go one step farther in automating the process, creating an interactive voice response system that is available 24-7 and doesn’t require a live operator. After working with professional services experts from Qwest with specific IVR expertise, HealthHelp also now hosts and services most of the application on its own servers, maintaining its own software.

Diagnosis necessary
Participating physicians and medical offices contact HealthHelp to get approval for the radiology procedure such as Xrays, CAT scans and MRIs. They provide basic information: The patient’s insurance ID and date of birth, the referring physician’s national provider number and the diagnosis or CPT – the Current Procedural Terminology codes, which are numbers assigned to every task and service a medical practitioner provides, as established by the American Medical Association.

“From that, we then are able to ask a series of clinical questions that [the caller] responds to that are specific to the situation indicated,” Spar said. “If you are looking at the viability of an MRI for the brain for headaches, for example, we will ask you specifically about that situation. If your answers meet our Tier 1 criteria, the case is immediately recognized and approved and an authorization code is generated for the case and it is automatically faxed to you. If case doesn’t meet the clinical criteria, then is escalated to a nurse or a radiologist to discuss with the physician.”

Until recently, HealthHelp took in information directly via its call center agents or via an online form, which participants filled out. The interactive voice response system is a third option that, among other things, enables HealthHelp’s clients to get what they need on a 24 by 7 basis, and not just during the working hours of its Houston-based call center.

“We want to make the process as convenient and workable for each one of the physicians’ offices,” Spar said. “We have many thousands of offices who interact with us every day, so we offer multiple channels for what works best for each office. Some like to go online, some like to interact with agents, others want to key it in as fast as possible and be done.”

Complex application
Creating a customized IVR option meant incorporating the high degree of interactivity required to properly match the diagnosis or procedure with the proper testing.

“One of our concerns was that this process is complex and data-intensive,” Spar said. “The system has to look up one of the millions of data IDs to identify the member or the doctor. Then the person calling has to interact with the IVR and provide domain-specific information – it wasn’t just a case where you were asking questions and getting answers from a short list, there was tremendous interactivity.”

HealthHelp maintains “a very robust clinical data repository” that would provide the back-end information, Spar said. What Qwest did was build an application for HealthHelp that translated their business rules into an application that could run on servers hosted within Qwest’s data center, said Martin Capurro, director of product management for Qwest’s Business Markets group.

“What they wanted required us to understand what type of menu prompting was needed, and how to tie into the database to seek actual intelligence and data,” Capurro said. “It’s doing the voice recognition part but also getting to the data the doctor’s office needs and providing that data real time without human involvement. We wrote the application for them, deployed servers on their behalf to host the business rules, and set up the relationship between the Web application server and our call center platform so the rules can be honored within our platform, which is a large multi-tenant Genesis [IVR] platform.”

The Qwest process uses secure Web services in addition to the specific code that was programmed onto the Qwest server, to enable a series of secure Web calls back into the HealthHelp clinical data repository for database query and business rule lookups, Spar said.

“They collect the member ID via the IVR and pass it to us in Web service, we look that up and say that’s good member ID, keep going, or, it’s not valid,” Spar said. “There were two teams of expertise working on this – their team for the IVR development and ours for the health-specific business knowledge and database queries. That left our databases on our infrastructure and the middle tier at Qwest.”

Bringing it home
Initially, Spar said, HealthHelp knew it didn’t have the in-house expertise to handle IVR programming, although it could provide the Web services side.

“Writing the Web services side was a pretty good task in itself, never mind that other part which was very specific to their industry and expertise,” Spar said. “They had application development group that worked with that.”

Initially, HealthHelp paid up front for the development work and paid Qwest monthly hosting charges as well, Spar said. Then HealthHelp took the next step of moving that middle tier from Qwest’s data center, where it was a hosted application, to its own facilities.

“Over the course of a year after the initial development, we absorbed the technology into our development team,” Spar explained. “Our developers were able to make changes to the software and expand it. We set up an applications server in our own data center and gladly paid the capital costs to move that over to our side, so we are able to self-service the application.”

Qwest still hosts the basic IVR function on its Genesis system, and its professional services team provided the support required to enable HealthHelp to move the software application to its own servers, Spar said.

“There were a couple of times that we had had to go to their professional services team to make changes, and they were a really good partner, but my general philosophy is that I want to own the code,” Spar said. “Over time, we evolved to where we were comfortable we could make the changes and add components, add functionality to that middle tier. We went from where we had paid them a lot of money to write whole program, then to maintenance support, then to a bank of hours to talk to the developers that we had relationships with. We could call them up and say, ‘Look at this code why doesn’t it work?’”

Technology resistance
Qwest has done some similar work for large medical organizations, but was particularly under the gun to meet some aggressive timelines for HealthHelp, Capurro said. “It was a little bit of a pleasant surprise – how quickly we could write the application and go through their beta, we were able to make up some ground that they had lost,” he said. “I can’t say it’s an easy process – you have to go through the testing, the software development, the load testing. The good thing for us is that we have the platform and the back-end engine pre-built. It’s the business rules and adapting to the application that is custom every time.”

The health care industry poses a particular challenge because many of the end-users are smaller medical offices that are scattered all over the country, Capurro said. “Part of the design characteristics for a medical application is making sure it is very easy to do,” he said. “Many of the doctors’ offices tend to shy away from technology, especially those doctors who are well-established. Newer doctors will be more likely to embrace technology as a way, but many others will be resistant.” 

In HealthHelp’s case, the new system has been operating nine months and is handling about 3000 calls a day, proving many of HealthHelp’s customers like this approach, Spar said. At any point, callers can opt out of the automated process and talk to an agent, who can pick up a call in process, but HealthHelp is finding that this channel is growing, which has enabled the company to slow the rate at which it is adding people to its call center.

“That’s still growing as well, but since this process is handling procedures that would have been done by the call center, I think it’s fair to say it has slowed the growth rate of hiring – there would have been more agents needed without this,” Spar said.