Humana Inc.: Keeping a Watchful Eye on Patients

Computerworld - Humana Inc.'s business intelligence application recently sorted through claims to flag one particular member: a 44-year-old man hospitalized for a ruptured appendix. He had shown up as a "high utilizer" of health care services, prompting a call from one of Humana's personal nurses.

The nurse discovered that the man also had cancer and was struggling with social issues. She learned that he was having difficulty paying medical bills. She helped him better understand his medical condition and referred him to several agencies for financial help.

"Medical Metrics has allowed us to find a lot of folks who have not been identified for our disease management or personal nurse programs, folks who are high-cost, high-need members," says Gary Thompson, vice president of clinical programs.

N. Venkatraman, a professor and chairman of the information systems department at the Boston University School of Management, says BI is particularly important for health-care- related organizations because of increasing costs and competitive pressures.

Moreover, he says, BI is indeed identifying these high-cost patients who "might have fallen through the cracks."

Humana started the first phase of its BI implementations with Medical Metrics in 2003, says Bruce Sterpka, vice president for corporate information management. Louisville, Ky.-based Humana opted to develop its own BI tools because workers didn't find "an off-the-shelf solution that delivered all that our business asked for."

The company also wanted more flexibility than it could get with commercial products, says Marcus Bourke, Medical Metrics product manager, because it has to rapidly adjust to changes in the health care market.

In addition, Bourke says, Humana wanted a tool that was easy to use. "We want someone to be able to come in the door and, with an hour-and-a-half training session, be up and running with this tool," he explains.

Clinical staff members use Medical Metrics to identify high utilizers. Underwriters use it when developing rates for groups, and actuaries use it to help identify trends.