Architects of Reform: Enterprise architecture plays an essential role in establishing Oregon as a leader in healthcare reform.
by David Baum
Signed into law by President Barack Obama in 2010 and upheld by the U.S. Supreme Court two years later, the Patient Protection and Affordable Care Act is the principal healthcare reform legislation of the 111th United States Congress. Among other things, the legislation requires each state in the U.S. to build a health insurance exchange to broker and manage insurance plans, measure eligibility, automate enrollment, and transfer healthcare information electronically between participating organizations. These state exchanges must be online by January 2014.
Logistically, the health insurance exchanges are a massive IT challenge. These are huge projects with the potential for serious complications, from system incompatibilities to cost overruns. Each exchange must integrate with a great number of existing social services systems and handle myriad details related to billing, collections, reconciliation, taxation, reporting, and customer service.
Despite the risks, leaders at the State of Oregon Department of Human Services (DHS) saw this federally mandated project as an opportunity to modernize their entire information enterprise.
“We’ve used the insurance exchange to rethink how we can best deliver services across our IT environment,” says Carolyn Lawson, chief information officer for the DHS and the Oregon Health Authority (OHA). “We’re not building the insurance exchange in a silo. It’s a catalyst for organizational transformation.”
When the healthcare reform legislation was signed, IT staff at Oregon DHS was already modernizing several agency delivery programs, such as Temporary Assistance for Needy Families (which supplies cash assistance to indigent American families with dependent children) and the Supplemental Nutrition Assistance Program (which provides financial assistance for food to low-income families). Lawson had identified a short list of potential technology suppliers, including Oracle, and asked if they could create the new insurance exchange as well.
In conjunction with the exchange, Oregon DHS leadership wanted to modernize fundamental business processes for determining Medicaid eligibility and receiving payments—which were, at the time, being handled by cumbersome legacy systems. They also needed systems to accommodate new types of healthcare providers. For example, the healthcare reform legislation requires providers to change from managed care organizations (MCOs) to coordinated care organizations (CCOs)—networks of doctors, dentists, mental health specialists, and other providers who have agreed to work together to support patients who will receive insurance benefits through the health insurance exchange.
“In a project of this magnitude, with these kinds of expressed timelines, we knew that if we didn’t take an enterprise approach, not only would there be collisions, but we’d tie ourselves in knots,” Lawson admits. “Neither the insurance exchange nor the CCOs had ever existed before. Without the right enterprise approach, we might end up with the same technology silos we were moving away from.”
Further complicating the process was the 2011 transition of DHS and other Oregon health and human service programs into two distinct agencies—DHS and OHA. While the modernization efforts remained with DHS, responsibility for the health insurance exchange project fell under the new OHA. However, the agencies determined that the projects should work jointly to develop the automated Medicaid eligibility and enrollment foundation they both require.
To keep both initiatives in sync and arrive at a cohesive future-state architecture, Lawson and her team decided to engage Oracle’s enterprise architects and apply their enterprise architecture (EA) process.
“The Oracle team helped us see the issues philosophically before we approached the practical aspects of the project,” she recalls. “Then they supplied the structure and personnel we needed to execute the required tasks. Oracle gave us a new perspective on the challenges at hand. Their support has been invaluable.”
Without our dedication to enterprise architecture, we wouldn’t have been able to
pull off a project of this magnitude.
Today the joint Oracle/Oregon task force includes application specialists, middleware specialists, database specialists, hardware infrastructure specialists, analysts, and project managers—nearly 200 people in all. Project managers and executives from both Oracle and Oregon state government are steering the program.
Several large technology initiatives must intersect so the various systems work in harmony when the health insurance exchange goes live in 2014. To structure these technology initiatives, the state of Oregon has been using the Oracle Enterprise Architecture Framework and the Oracle Architecture Development Process. These artifacts and processes provided a structure for defining the current-state architecture, developing the future-state architecture, and working in an iterative fashion to flesh out the design into working systems.
According to Bob Ladouceur, information systems applications manager at Oregon DHS/OHA, one of the leading benefits of EA is its ability to coordinate multiple activities within a multifaceted project to help a large development team stay on track. “Enterprise architects are tasked with envisioning a trajectory between the current-state architecture and a future-state architecture that, in this case, is not well established,” Ladouceur says. “They help us move coherently forward as they mitigate potential conflict points between the new systems, the legacy systems, and the modernized information systems that are evolving in tandem.”
This collaboration is particularly evident as Oregon staffers create a multichannel customer service portal based on Oracle’s Siebel Customer Relationship Management (Siebel CRM) solutions. The portal will support a call center that helps Oregon’s approximately 600,000 Medicaid clients make the transition from the MCOs to the CCOs. It will manage a great deal of the communication and interaction to ensure that the transition to Oregon’s future healthcare system is easy, accurate, and efficient. The development of this customer service portal is well under way. Developers are currently populating the system with client data from the legacy systems.
“The Siebel implementation became a test bed project for demonstrating how EA can be instrumental in guiding, facilitating, and fast-tracking IT projects,” says Ladouceur. “We chose an enterprise architect to lead this project because we wanted somebody with a perspective for the bigger picture. We didn’t want to have to re-engineer the CRM system 12 months later when all the other systems started to come online.”
The many related IT projects underway at both Oregon DHS and OHA require extensive design work—not just from a technology perspective but also from a business perspective. Lawson says enterprise architects can’t necessarily lead the business in these instances, but they can help business stakeholders understand where they want to go by guiding the stakeholders through a systematic process of discovery. As the team identifies the types of solutions it needs, enterprise architects help to define and connect the appropriate IT functions.
“We’ve trained enterprise architects to have business discussions without mentioning technology,” says Lawson. “The technology discussion comes later. Once we understand the business context and metrics for success, we come back and say, ‘Here’s how we can apply technology to our business discussion.’”
For the new health exchange, the joint Oracle/Oregon team began by defining business architecture for plan management, eligibility, enrollment, and financial management. This architecture provided a solid foundation for determining which software applications to implement, including Oracle Policy Automation, Oracle Identity Management, Oracle Master Data Management, and Oracle Business Intelligence Enterprise Edition—in conjunction with the Siebel CRM applications.
“The business architecture helped us to determine where each product would fit as well as to identify the specific business functionality we would need, based on the technical requirements,” explains Hamza Jahangir, practice director, enterprise architecture, Oracle Public Sector. “Ultimately we wanted a new platform that better supports citizen-facing services, so everything had to work in sync.”
To accomplish this goal while adhering to a tight schedule from the federal government, the EA team divided the design cycle into a series of three-week increments, broken down by inception, elaboration, construction, transition, and product stages. Ninety days later, they had completed the first set of design blueprints—just in time for a key review by the U.S. Center for Medicaid Services (CMS). This was an important milestone that was necessary to ensure ongoing support and funding.
“The federal team from CMS was very impressed when they visited us in November 2011,” recalls Lawson. “We set a high mark, and then we did everything we could to overachieve. We had our system design, we had our deep architectural diagrams, we had the infrastructure set up, we had it tested end to end—we had some very significant work completed.”
After two subsequent design reviews, CMS continues to be pleased with Oregon’s progress. The state is now on target to meet the CMS requirement to go live in October 2013, and Oregon citizens will be able to purchase health insurance on the exchange in January 2014 at orhix.org.
Lawson says many other states are still working on requirements documents and traditional planning lifecycles—but the Oregon team could demonstrate new functionality relatively quickly. She attributes the progress to Oracle’s agile development methodology, which entails iterative development, small incremental updates, and steady progress toward demonstrable goals. She is especially passionate about the new opportunities this project has afforded to her staff. She says Oregon’s reliance on EA has given the state an opportunity to maximize the abilities of its employees, use them more effectively, and help people be excited about coming to work (see Upside for Employees).
Once we understand the business context and metrics for success, we come back and say, ‘Here’s how we can apply technology to our business discussion.’
All of the DHS and OHA systems are becoming more cohesive, which means Oregon citizens will be able to answer a single set of questions to determine what types of assistance the state can provide them—even when multiple agencies are involved.
By the time the project is complete, the State of Oregon will have spent as much as US$200 million on the exchange and related information systems. However, Lawson believes that if Oregon staff had hired a systems integrator to install a packaged exchange application and integrate it with its legacy DHS systems, as many other states are doing, they would have had to spend even more money than that, and engage more people overall. “We’re taking the money that many states are spending on just the insurance exchange and rebuilding our entire enterprise,” she notes.
Public servants, from Oregon Governor John Kitzhaber on down, have been thrilled with the team’s progress, as well as with the example that Oregon is setting for other states. Lawson credits the Oracle EA methodologies and frameworks for keeping the project on track.
“Without our dedication to enterprise architecture, we wouldn’t have been able to pull off a project of this magnitude,” Lawson emphasizes. “EA provided a structure for moving forward, from designing the business architecture to mapping the various functions to the technologies that we needed. The State of Oregon has not received any more funding, magic pixie dust, or anything that makes us different from any other state,” she adds. “We walked in with the same needs, the same challenges, the same funding.
David Baum is a freelance business, technology, and lifestyle writer in Santa Barbara, California.