Author: Dinesh Raman
Electronic Health Records (EHR), as the name suggests, is a digitized version of the patient’s health records that contains aggregated healthcare touchpoints from several healthcare providers. The use of EHR is well known for healthcare organizations, especially payers (health insurance firms) and providers (hospital networks). But disability insurers have also identified ways to leverage EHR.
There are two broad areas where insurers have found value in using EHR.
2. Disability Claim Management
Both life and disability insurers have included attending physician (APS) statements as a part of the application to understand applicant health and other factors that may be used to assess applicant risk during the underwriting process. The APS provides a report of the applicant’s medical condition from the perspective of a physician. One of the key features which APS provides is the unstructured physician notes in addition to visit and test summaries that may be available to a physician at that time. While some of the early Electronic Health Records implementations may not have captured physician notes accurately, recent instances/implementations of EHR have the ability to not only contain unstructured physician notes but also provide a more comprehensive and long-term view of the applicant/patient health records. Because of these advancements in EHR, disability insurers have started to look at EHR more closely to make underwriting decisions.
2. Claim Management
Claim management is an important area to optimize for disability insurers. Insurers have invested in efforts to predict disability based on Electronic Health Records and other internal data. At the same time, they are focused on triggers/underlying factors that contribute to disability and work proactively with the employers to develop several wellness programs to either prevent disability or to facilitate a faster return to work(RTW). Also, a lot of efforts are made to understand how various health factors, such as diagnosis, comorbid conditions, medications, therapies, and treatments, impact RTW duration. These can, in turn, help create personas that help with targeted and customized intervention programs.
Tiger Analytics recently partnered with a leading provider of group life and disability insurance to evaluate external EHR for several use cases. Through this initiative, several pilot studies were conducted that enabled the following:
1. Claimant healthcare journey map provided an understanding of leading/lagging indicators of disability
2. Disease and treatment progression pathways helped assess diverse medication pathways for claimants
3. Claimant personas helped create targeted intervention programs to impact RTW duration positively
Electronic Health Records hold a lot of promise to improve several areas within claims management significantly. However, insurers need to avoid pitfalls concerning the acquisition and the eventual use of health records in internal processes. Insurers need to be compliant with HIPAA and other regulations that govern the use of patient health records. Besides, insurers need to get alignment with multiple teams/functions to ensure that the use of Artificial Intelligence (AI) and Machine Learning (ML) on health records is successful.
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