Success stories
Healthcare Industry: Unifying Member Data
Health insurance organization develops Web-enabled services to provide online health plan and claim status information
Scenario:
In order to maintain its leadership position, a health insurance company aggressively pursued the eHealth market by developing Web-enabled services. These services provide members with online health plan and claim status information. Providing online information resulted in improved customer satisfaction and lower customer-service costs.
Objectives:
A member who uses the system expects to see unified and accurate coverage information. The carrier's information system needed to identify like-member records throughout the multiple member databases and link them through an online matching system. The matching system would interface with existing legacy systems to select critical information and display the information in order to assist in making the linking determinations. All links needed to be tracked and recorded to meet legal requirements.
IBM WebSphere Business Integration Modeler solution:
A custom-built workflow management system, WebSphere MQ Workflow, and reporting solution, WebSphere Business Integration Monitor, were used to meet all the client's business requirements. WebSphere Business Integration Modeler provided expert support in business process modeling, workflow integration, screen design, and monitor development and implementation services.
Overview and results:
The insurance carrier needed to overcome a large database-administration hurdle in order to display a unified-coverage screen for members. The client had been struggling with multiple-member databases that did not interact and/or automatically update each other when changes were entered into one of them. This lack of database linkage required employees to access multiple individual systems to handle customer service inquiries. The corrections of inconsistent and inaccurate data also required updates to individual databases. The client needed to solve these issues without having to rebuild the existing information infrastructure.
First, the WebSphere Business Integration Modeler-lead project team developed a representative list of questions and issues for which members and providers would most likely request online assistance. Process models were built from the list that outlined responses to each expected customer-service request. The process models showed what information was critical, what system housed that information and what handoffs occurred between departments. Differences in regional organizational structures led to significant model changes and a completed model validation. This information provided expanded insight into the project's scope and what additional development had to be done outside the workflow system.
Conservative-matching criteria were used to ensure that no two members were linked incorrectly, which prevented the display of incorrect, inappropriate or inaccurate information. Records that came close to matching, but did not meet the necessary criteria, were sent to a queue for manual review. WebSphere MQ Workflow managed these queues and displayed these work items to the client's staff. Once a work item was selected, APIs accessed numerous legacy systems to select and display critical information for the researcher.
WebSphere Business Integration Modeler worked with the project team to build To-Be business process models that supported the eHealth environment and the data clean-up effort. Screen mock-ups were developed to provide clarity to the project participants' display requirements. This aided in the decision-making process that determined if WebSphere MQ Workflow would be the chosen application.
The WebSphere Business Integration Monitor was customized to provide an accurate, real-time view of work items in process. Reports generated by WebSphere Business Integration Monitor provide managers with an accurate representation of the system's efficiency and effectiveness, which allows them to make needed changes that keep the system running smoothly.
Implemented technology:
The technology used to provide this solution was the WebSphere Business Integration Workbench, WebSphere Business Integration Monitor, WebSphere MQ Workflow, WebSphere MQ, and WebSphere Application Server. WebSphere Business Integration Modeler performed all screen development using WebSphere Business Integration Workbench's Xform Designer. The client's internal IT department developed the API wrappers that access the database hosted on an IBM OS/390 mainframe.
Customer benefits:
This new system helps collate like-member data. It provides industry-leading customer service, reduces costs and enables future database transformations.
