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Transaction Accountability
Sarbanes-Oxley and other corporate compliance requirements bring increasing pressure to account for the flow and
processing events related to transactions. Even without compliance requirements, knowing what came in, what went
out and what happened between, is just good business. Original transactions must be maintained and accessible.
Alterations to source transactions must be controlled and follow defined rules.
Visibility on processing changes as transactions move through their lifecycle is required to assure that the
processing of transactions has full accountability. Controls for transaction reporting and legacy data can be
established with Edifecs HTR. Discrepancies between received charge amounts and paid claim amounts as defined
in HTR can be compared to legacy reporting to identify potential discrepancies and help identify the cause of
these discrepancies. The Edifecs Healthcare Transaction Repository provides a critical infrastructure needed
to meet transaction accountability.
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Benchmarking
Benchmarking information across enterprises or even across various systems within enterprises can be a difficult task.
It requires that these disparate systems output to a central repository, facts and aggregations that are consistently
defined or share a common ontology. The Edifecs Healthcare Transaction Repository provides an out-of-the-box solution for
pooling standard healthcare transaction data given the organization is already producing the standard transaction.
Output for benchmarking in this model does not increase the burden on the participants since the standard transaction is
already a mandated requirement.
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Alerts and Notifications
Early notification of key threshold values related to transactions or groups of transactions can add significant
value to an organization by allowing early intervention. Patterns of transaction content such as high dollar charges,
targeted claim types or other indicators can be identified early rather than waiting for a processing load and query
cycle from one or more legacy databases. A number of metrics can only be derived from the inbound and outbound transactions,
since some of the data may never arrive in the legacy databases.
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Error Remediation
Identifying errors and rejecting invalid transactions is necessary, but hardly addresses the real goal of improving
transaction quality resulting from external or internal errors. The Edifecs Healthcare Transaction Repository provides
the information needed to analyze and report on patterns of errors through an extensive set of dimensions so that correction
opportunities can be identified and the impact of interventions can be assessed over time.
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Data Sharing
The data content of the transactions may be of considerable importance to other systems. The canonical presentation of
data in Edifecs HTR provides a reliable way to construct the representative data needed by many systems. Edifecs HTR
data elements are easily accessed by any number of approaches to the database through appropriate connectivity. The
database documentation and data dictionary provide sufficient metadata to accurately share data with other systems,
assuming reasonable definitions in those systems.
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Business Activity Monitoring
Effective business activity monitoring (BAM) from the
transactional perspective requires a near real-time access
to inbound and outbound transaction data content. The
nature of transactions that are entering and leaving the
organization are frequently defined deep within the content
of the transaction rather than at a high “wrapper” level.
Ongoing trends and threshold values may require access
to calculated measures from several elements and comparison
to historical content. The operational data store
and historical database supported by Edifecs HTR delivers
the data needed to provide the appropriate metrics for
BAM regardless of the tools used to display the dashboards
that contain these metrics.
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Business Intelligence
Most organizations rely on their legacy databases to provide
the data for business intelligence needed in a variety of
decision support venues. Unfortunately this data is frequently
incomplete and substantially altered from the original
inbound or outbound transaction. An important part of
decisions support requires a timely, accurate and enterprise
wide view of inbound and outbound transactions. A variety
of OLAP tools that may be placed on top of the Edifecs
HTR can provide a current analytic view of all inbound and
outbound transactions.
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Provider Performance Monitoring
Initiatives such as “pay for performance” require the consistent
collection of information on transactions submitted by
providers. To accurately assess performance of provider
claim submitters, it is important to create reporting and
analysis based on the submitted data. The process of consistently
extracting this information from multiple legacy
systems can be difficult. Each system may process inbound
data differently so that it can be difficult to assure that the
extracted data has not been altered or redefined and that
extracted data elements are consistently represented in the
reported event. Reporting and analysis directly from the
inbound and outbound transactions assure consistent metrics
on what came in the door and what went out. Edifecs HTR
provides the normalized repository of data to support
direct reporting from transactional content without a
dependency on legacy data.
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Transaction Reconciliation
Reconciliation of transactions requires the ability to match
transaction content in one transmission with the content
in another transmission. This could require a simple matching
of control numbers or it could require a more complex
match based on some algorithm using variables in transaction
content. Beyond just matching, reconciliation may require
that values calculated from multiple elements in one transaction
are tested against a value calculated from a different
set of elements in another transaction. Reconciliation at a
transactional level requires access to transaction data
elements in a business-normalized format so that the rules
of matching and reconciliation can be easily applied. The
business-normalized structure of Edifecs HTR and storage
of transaction within a single repository schema allows for
the type of transaction reconciliation that would be difficult
to accomplish through other means.
