Digital innovations improve patient outcomes

Health plans are turning to Artificial Intelligence (AI) for member engagement and digital apps to make it easier for members to interact with them.

The COVID-19 pandemic prompted the demand for remote services, particularly in the healthcare industry, which is seeing new improvements in efficiency, quality and patient outcomes driven by technology. For example, Forrester estimates there will be 440M telehealth visits in 20211 , a sign of just how much the healthcare industry has pivoted overnight to doing business digitally.

While traditionally, the industry has focused on leveraging digital transformation more focused on operational efficiency, today, the industry is tapping into digital tools to improve member and provider experiences.

Health plans are turning to Artificial Intelligence (AI) for member engagement and digital apps to make it easier for members to interact with them. In addition, SMART on Fast Healthcare Interoperability Resources (FHIR) is creating new opportunities to build apps integrated with EHRs, health exchanges, health plan data and consumer device data to drive consumer-centric healthcare. With the emergence of 5G networks, consumer devices, remote monitoring delivers, as well as a cloud transformation, the stage is set for healthcare organizations to infuse digital solutions into the overall provider and member experience.

In this white paper, we will address how digital innovation is accelerating transformation in the healthcare industry. We will look at some of the digital macro trends currently affecting the healthcare industry while focusing on member and provider engagement, health and care management, and revenue optimization.

Member and provider engagement

When speaking about digital trends, it’s important to consider how digital tools are impacting member and provider management.

Providers that have adopted digital technologies have achieved a 45% reduction in documentation time2, and well over half of consumers are open to monitoring their ongoing health issues remotely3. Beyond this, more than threequarters of patients think managing their appointments online is important4.

The move to digital is also being supported by increases in venture capital funding. Much of this investment went toward digital technology that supports member and provider experience, including digital therapeutics, telehealth, behavioral health apps, clinical decision support, wearable sensors and wellness.

What this all adds up to is a great opportunity for healthcare organizations to engage with consumers. For example, health plans can turn to mobile health apps to provide a fast convenient way for members to access self-service information such as provider directories, benefit summaries, formulary information and claims information.

How digital tools are transforming operational workflows and driving efficiencies

From an operational standpoint, digitallydriven workflows are positively impacting member and provider satisfaction. However, there is a two-fold challenge facing plans: firstly, the legacy technology that drives much of payers’ and providers’ operations is an obstacle to fully embracing and integrating a pervasive digital strategy.

Secondly, as an industry, we need to move away from a purely linear thought mindset. The digital world is about exponential gains and it brings to life cross-pollination and interoperability within an organization, step by step.

With the right technology and the right mindset, we can transform what have traditionally been inefficient workflows, such as the ingestion of medical records. It’s still common for multiple requests to be sent to a provider for the same record because of different needs within a payer – medical management, gaps in care, payment integrity just to name a few. It not only creates significant abrasion with the provider, but also increases expenditures throughout the process, sometimes by hundreds of dollars for what could be a single transaction.

With smart, digitally-enabled platforms with deep analytics, NLP and RPA, all of these issues could be eliminated. The application of automated processes to handle pre-authorization, claim coding and payment verification could be very successful, especially if run sooner in the process to eliminate rework and denials. AI and NLP could improve the payment integrity process, and we could reduce administrative overhead with better collaboration between payer and provider systems using various digital technologies.

Payer/provider collaboration building on digital trends

Improved interoperability will be essential if plans want to experience better ‘utilization management’. Utilization management is a series of techniques used by or on behalf of purchasers of health care benefits to manage costs by influencing the ‘appropriateness of care’ decision-making.

Appropriateness of care is obtained by healthcare organizations through a prior authorization request, which, when conducted manually, often stands in the way of improved patient care and outcomes.

The solution lies in using standards to support seamless data exchange between providers and payers. For example, if HCOs had systems in place that support seamless electronic communications through standards such as DaVinci, an MRI order could get a an evolving FHIR (Fast Healthcare Interoperability Resources) based response from the payer. The patient would know the next steps of their treatment immediately and leave their provider’s office feeling confident and informed.

Health and care management

Consumers are becoming increasingly interested in managing their health digitally:

But where will telehealth land as a channel of patient and physician interaction post-pandemic? While it’s likely the transformative telehealth revolution will continue, addressing the many challenges associated with telehealth such as security, workflow integration, and the relative effectiveness compared with in-person visits, is essential.

Factors such as lack of awareness of telehealth offerings, education on types of care needs that could be met virtually and understanding of insurance coverage will also need to be addressed.

If telehealth adoption is going to continue to grow, reimbursement will have to remain favorable for the long-term. Many payment policy changes were temporary and only tied to the emergency status of the pandemic.

Many more providers will seek to turn the cost-efficiency and quality improvement potential of their virtual care investments into real revenue using expanded value-based payment arrangements. For example, a capitation payment for primary care could encourage providers to use virtual care visits when clinically appropriate. So, virtual care might end up accelerating the industry’s transition to value-based payments.

While telehealth has emerged as a popular option, whether or not it will become the preferred mode of care delivery remains to be seen.

Fraud, waste and abuse also need to be addressed as we move forward with virtual care. In 2019, federal law enforcement charged 35 defendants from more than 25 telemedicine and cancer genetic testing laboratories in connection with a $2.1 billion Medicare fraud scheme. With many more examples similar to these, telehealth has become a key enforcement priority for federal and state agencies.

The importance of the “Digital Front Door’ in healthcare

More consumers want digital entry into the healthcare system via mobile or online apps, allowing them to gain access to care and manage that care across the continuum.

A variety of tools such as patient portals, scheduling assistants, navigation resources, and virtual care assistants are available that could help build this new electronic entryway. With these tools, patients could efficiently take care of everything digitally, from scheduling appointments with primary care physicians, to requesting x-rays or prescription refills.

Payers also need to develop digital front doors to meet burgeoning consumer demand. A digital front door could provide a strong first point of virtual contact for member interactions, establishing healthcare payers as a trusted resource to purposefully direct provider productivity while guiding member care decisions and wellness behaviors.

Integrating clinical and non-clinical data for true whole-person health management

Integrating Clinical and Non-Clinical Data for True Whole-Healthcare organizations are increasingly finding that they must integrate clinical and non-clinical data to get a holistic understanding of the individuals who make up the populations being served. It requires an understanding of social determinants of health such as race, ethnicity, financial stability, employment status, availability of food, affordability of housing, and access to healthcare.

This whole-person view can specifically help payers better engage with members, identify which members need help, increase member compliance with care plans, and select the right engagement tools. With a whole-person view, heath plans can concentrate their energies on the most impactable/intervenable members and patients so they can get the best results.

Payers will need to broaden their focus to include a full range of physical, behavioral, and social health needs. Underlying the shift is a growing recognition that managing the health of members more holistically, which will likely lead to better outcomes and greater financial efficiency over time.


“The digitization and codification of contracts with a pervasive NLP and deep analytic layer for content extraction can be used to support clinical and payment outcomes. This will vastly improve payment accuracy and cut down on the back and forth of denials and payment recoveries ”

Kurt Anderson,
Senior Vice President & General Manager, Payment Services, EXL Health


Revenue optimization

As healthcare organizations have dealt with the reduced demand for care during the pandemic, they’ve felt increasing pressure to optimize revenue. They are all dealing with shrinking margins and need to find a way to succeed in this environment.

Digital applications can provide the opportunity for payers to be more successful in how they operate and establish new revenue models such as content and retail-based subscriptions. They have significantly more access to information about their members, specifically their healthcare status – with which they could create a “direct to consumer” experience. Meal delivery, nutrition advice & weight loss, wearable devices, exercise equipment, virtual exercise classes, health & beauty goods, are just some examples. Deep analytics and learning models can help to fine-tune benefits to payments, aligning outcomes.

Ultimately, health plans and providers need to manage compressed margins, and digital innovations can help mitigate this by providing members with the tools to access healthcare, understand their options and their costs.

Digital innovation can also help to develop positive provider relationships which can drive better patient outcomes, supported by clinical data and insights with reimbursement models that align the incentives and needs for the provider and patient.

For payers, digital tools may help to reduce administrative expense and lower the cost of care while maintaining or improving quality while ensuring provider and patients have a positive experience.


1. Forrester’s 2021 Prediction: Watch Out In-Person Care, the Telehealth Surge Will Continue (

2. Patient Engagement: Digital selfscheduling set to explode in healthcare over the next five years,” Accenture, 2016

3. Notification of Enforcement Discretion for Telehealth |

4. Telehealth: A post-COVID-19 reality? | McKinsey

5. i 2021 Healthcare Consumer Trends Report - NRC Health

6. i What to expect in 2021 and beyond? IDC offers 10 healthcare predictions | Healthcare IT News