Information systems architecture to support managed care business processes

Abstract Escalating costs have forced dramatic changes in the healthcare industry, with a move towards managed care. Managed care seeks to integrate healthcare delivery processes and continuously improve them through feedback based on evaluation of care outcomes. The success of managed care depends critically on the collection, analysis and seamless exchange of information within and across organizational borders. This paper examines the business processes unique to managed care, and identifies its architecture requirements. We find that in addition to interorganizational networking, the architecture must provide sophisticated decision support capabilities. Historically, the emphasis of decision support in healthcare has been on clinical applications. Our examination shows that in the new managed care environment, it is equally important to also provide decision support for (i) specific nonclinical aspects of care delivery (ii) outcome analysis and (iii) continual refinement of care protocols to enhance cost-effectiveness.

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