decision camp 2014 - carole-ann berlioz-matignon - preparing for exceptional behavior

Preparing for

Exceptional BehaviorBusiness Rules / Decision Management

In Healthcare

Carole-Ann Berlioz-Matignon

cmatignon@sparklinglogic.com

Introductions

Carole-Ann Berlioz-Matignon

Co-founder & CPO

Sparkling Logic

@cmatignon

Case Study

Division of BCBS of TN

Delivers

Wellness programs

to BCBS of TN and

others

Wellness Programs

What are they?

• Offered by Medical Insurance companies

• Complement Insurance policy

• Aim at keeping members healthy, preventing expensive disease down the road

• By promoting / encouraging goodbehavior

Why?

• Healthcare cost skyrocketing

• Few diseases cause major financial burden

• Saves $$$ in claims

• Evolution towards Population Health Management

• Healthier employees are more productive too

• And improves quality of life for member

How it works

Detect At-Risk

Population

Educate / Encourage

Good Behavior

Reward based on Activity / Results

Lots of Decisions

Detect At-Risk

Population

Educate / Encourage

Good Behavior

Reward based on Activity / Results

Who is at risk? Which activity would prevent

disease?

Which incentive would they respond

to?

What reward should they be credited for?

Did they fulfill all the requirements for the reward?

Issue Detection

Victim of our Success

More Members

Æ More Volume

Plan gets updated with every activity reported, lab test received, etc.

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Onlife’s Challenge #1: Velocity

x15

Insurance AInsurance BInsurance CInsurance D

Onlife’s Challenge #2: Diversity

Issue DetectionVictim of our

Success

More Customers

Æ More

Customization

Each program has

its own specificities

Æ Different Rules

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Issue Detection

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Issue Detection

Wellness

Recommendation

Issue Detection

Activity Monitoring

Reward Accounting

Issue Detection

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Issue Detection

Wellness

Recommendation

Activity Monitoring

Reward Accounting

Insurance EInsurance XYZ

Issue Detection

Wellness

Recommendation

Activity Monitoring

Reward

Accounting

Using Decision Management

Data

DataData

Data

DataData

Data

DataData

Data

Data

DataData

Data

Data

DataData

Data

DataData

Data

DataData

Data

Data

Decision

Service

Issue Detection

Wellness

Recommendation

Activity Monitoring

Reward

Accounting

Cascading Business Rules

Decision

Service

Generic

Rules Insurance A

With a twist

Insurance B

With less rules

Insurance C

With more rules

Issue Detection

Wellness Recommendation

Activity Monitoring

Reward Accounting

Key Benefit

Decision

Service

Flexibility & Agility

New rules can be

managed by

domain experts

• Clinical team

• Product team

Before…

Clinical team

Product team

Spreadsheet

Most of the time spent here…

Would have been okay for short term

Development

Testing

Initial Focus…

Solid Architecture

Now…

Clinical team

Product teamDecision

Service

Minimum time spent here…

Initial Rules

Repository

with full

Traceability,

Lifecycle

Management

& Governance

Deployment

on the Cloud

After…

Clinical team

Product teamDecision

Service

Most of the time spent here…

Quick Enrollment

Repository

with full

Traceability,

Lifecycle

Management

& Governance

Deployment

on the Cloud

Skills

Profile of our Rule Writer

• Business Analyst

• Technically savvy

An anecdote…

• Plans to expand to domain experts

Lesson Learned – Skills

• Not as hard as we thought!

• How the learning curve was reduced

• Having a very short cycle (immediate) from rule writing to testing

• RedPen technique for learning the syntax, especially on collections

• Reporting to see all cases by risk/issue helped clinical team

analyze and approve the rules

• Decision Improvement

• Based on analyzing decision results Clinical team now looking at

offering more proactive issues identification for those nearing an

issue identified status

• Rules writing worked well with agile scrum methodology

Rules Design

• Business changes

• Over time

• Per customer implementation

• For example

• From food pyramid

• To food plate

Lesson Learned – Rules Design

• Cascading decisions allow customization per health plan

• Some customers choose to stay on food pyramid rather than move

to food plate

• Ability to add new fields as rules were added increased

productivity since BA’s did not have to rely on IT

• Easy to change decision flow and reorganize decision

steps rules

• Easily refactoring as needed as the number of rules increased

through the sprints

• IT/Rule Authoring team successfully worked in parallel w/

coordination around the data model

Deployment

Architecture in flux at the start

of the project

Complete redesign of the

infrastructure

Made decision to decouple

completely deployment from

rules implementation

And it worked!

Lesson Learned – Deployment

• IT and Rules Teams can work mostly in parallel

• Needs for coordination on the data model

• Mitigated

• Performance is not an issue, even on the cloud

• Peak loads during enrollment Jan-Mar up to 1 million transactions

per hour, 200 pages per min on web portal

Questions?

Thank You!

Carole-Ann Berlioz-Matignon

Co-Founder & CPO

Sparkling LogicCMatignon@SparklingLogic.com

@CMatignon