This is the "heart and brains" of a provider network. Each provider runs their own system and collects their own data. This remains local unless that provider chooses to make it available to inSync. These providers do not need to be using Profile, although there are many advantages to this.
InSync then delivers a series of capabilities to those seeking to manage the network of providers to deliver maximum health benefits within defined resources. This document highlights some of these capabilities, but it is not exhaustive - with its clinical rules and flexible clinical repository, inSync is capable of being extended almost without limit.
A number of inSync's capabilities are "iterative". That is, a series of inSync's could be run across various network managers and then the outcome aggregated up to a next level (eg. from various MDO or MAPO up to a regional or Ministry of Health level).
InSync is intended to support these sorts of initiatives:
Population enrolment
Population health and outcomes
Disease management programs
Integrated care programs and activities (eg. early discharge)
Centralised case management across providers
Resource utilisation
Referrals management
Clinical Quality Assurance
Decision support
Notifications and Authorities
Standardising interfaces to community and primary care providers
Population Enrolment
By collecting a list of enrolled patients each month from providers, inSync can build a managed population register across all these providers. This includes grouping duplicate entries and data cleaning. This process does not require an NHI number, and improves with each month cycle as the system 'learns' about the population. This provides an analytical resource and can be compared against census and council data to identify areas of deficits and gaps.
Provider Enrolment
Providers participating in the network are recorded onto the system. They are grouped in a number of ways, including being in one or more peer review groups ("cells"). In being grouped, this provides a reporting and comparison framework for any number of key performance indicators (KPIs), but also for other characteristics such as demographic profiling and so on.
Contracts
Providers have contracts for the provision of health services with the network manager. These are entered into inSync and can include specific elements for agreed care delivery and services, such as places of service, modifiers, disease states, specific providers and so on. Contracts have periods of validity and one or more specific service lines. Services have adjudication rules, written with Intrahealth's rules engine that can specifically assess a service for validity beyond the presence of a contract or approved provider. For example, a diabetic claim may not be permitted unless the patient is already known by inSync to be a diabetic.
Claims Processing
In order to motivate health interventions by associated providers, inSync allows the network managers to create "programs". These are typically service bundles aimed at achieving a health gain for an amount of money; examples include the nation wide Immunisation benefit, or more local efforts such as the Hepatitis B program in Auckland. This could be extended to pay for other state screenings, or programs of care, such as COPD, Asthma, Diabetes and Mental Health. Profile systems can submit claims for these electronically, which are received and processed without manual intervention by inSync. An Explanation of Benefit (EOB) is sent back to Profile systems automatically. Rejected or otherwise deferred decision claims can be temporarily placed into suspense within inSync. This might have relevance where the notification of diabetes has not yet been received; the claim can be held for two weeks. At this time, if the notification of enrolment in the diabetes program has been received, then the system will automatically pay the account; if not, the claim will be rejected.
Capitation
InSync is able to undertake capitation calculations based on the enrolled population and those that are seen. Although the system is capable of running any number of capitation protocols, only the Midland model is currently supported (the Ministry protocol will be implemented once confirmed).This process takes account of mobile patients and allows auditing and description of any "eliminations" from a provider's expected claim. InSync creates vendor invoices on behalf of the providers and sends payment advice both to the provider and to a payment system (external to inSync).
Case Management
InSync includes integrated case management, with either manual or automatic creation of cases based on characteristics of the claim. Cases are routed to case managers and load management tools are included. Cases can have approved care plans which permits invoices submitted with the appropriate pre approval number to be automatically paid.
Disease and Risk Registries
Based on information provided by providers, inSync is capable of generating disease registries and if necessary, reporting these in the provider reporting framework. Thus, relative rates of diabetes, asthma and other disease, disability and health states can be reported. Equally, risk factors such as obesity, smoking and so on can be similarly tracked and reported.
Screening
InSync can undertake large-scale population screening, based on Clinical Rules defined by users. This can be used to drive "call and recall" systems such as mammography, cervical smears and so on. Screen rules are limited only by the scope of information delivered to inSync by Providers.
Tasks and other triggers
Based on various clinical rules and activities, inSync can generate a variety of activities and outputs, ranging from task lists across the provider network to email and even potentially paging or other electronic outputs.
Pharmaceuticals
Clinical rules can be used to test appropriateness of pharmaceuticals against the clients covered. This can include monitoring for poly pharmacy, interactions and contraindications, based on the Medibase formulary.
Referrals
Rather than direct provider to provider referrals, these can be routed through inSync. InSync is then capable of testing the referral against various rules and making appropriate referral responses, from declining the referral to passing it on.
Clinical Quality Assurance
Run clinical processes and rules against clinical audit and quality control metrics, generating action steps or output as required.
Notifications and Authorities
InSync is able to run processes against a variety of data, checking for issues or special triggers and task action. It can also act as a generator of special approvals or authorities.
Standardising Interfaces
With inSync's flexible data routing and queuing structures, it can receive data and messages in a variety of formats, repackage and redispatch in a common final format. This can be used to simplify the "local loop" connection to primary care based providers.
