Digital offers the ability to deliver behavioral health care, support a patients’ spiritual coping, and maximize their benefits (e.g., financial navigation, social needs, spirituality and mindfulness, behavioral health resources)

Whole person patient care

Digital offers the ability to create a more seamless and personalized experience for patients to engage in administrative transactions and clinical interactions (e.g., provider search and match, appointment coordination, virtual visits and remote monitoring, patient payments)

Core patient interactions

Stakeholders can more easily connect with leading experts for second opinions and expand patient access to clinical trials (e.g., virtual/video second opinion consultations, simplified scheduling, records and specimen sharing, digital concierge services)

Oncology Navigation

Providers can supplement care with symptom management between clinic visits, efficiently manage complex care plans, and engage in shared decision-making with patients and their loved ones (e.g, virtual check-ins, reminders and notifications, patient education, care coordination documentation, metrics collection, actionable insights, population-level reports and analytics )

Oncology Treatment management

Cancer providers can leverage digital to develop effective programs to support the needs of survivors, while survivors can connect with others and enjoy a supportive community (e.g., follow-up care planning and data collection tools, survivor discussion boards and chat rooms)

Oncology Survivorship

Digital capabilities allow caregivers to meaningfully and actively participate in the cancer care journey (e.g., Caregiver skills training, education, community resources, coping resources, emotional and grief counseling)

Caregiver Support

Digital capabilities to optimize care team workflows and improve care team experience (e.g., Care coordination, remote monitoring, virtual tumor boards, clinical decision support, clinical and quality analytics, care team communication)

Care Team Workflow Optimization

Ability for patients to generate specific details on cost including out-of-pocket expenses for visits, providers, etc. Includes consumer criteria and generate specific detail on cost (including out-of-pocket expenses) based on the patient’s eligibility and preferences.

Self-service out-of-pocket estimator

Ability for consumers to receive their statements digitally based on their communication preferences (text, email, etc.). Ability for consumers to go paperless in their receipt of statements and to set the preferred frequency and modality.

Digital statementing

Ability for guarantors to review and consolidate billing information across a household and demonstrate balance totals and charge detail. Ability to render a single balance for the guarantor with breakdown of costs.

Statement consolidation

Ability for consumers to automatically reconcile their health system statements with their EOB information and flag the discrepancies for guarantor review.

EOB reconciliation

Ability for patients to configure their payment for healthcare expenses using the method of their choosing, including multiple payment options such as IVR, credit card, HSA, PayPal, etc.

Post-service patient payment

The ability for individuals to use digital technology to share biometric and other health data in real-time from outside a hospital or clinic with their care team as a part of an ongoing provider-directed program of care

Data Collection

The ability to identify patients who are at risk of a worsening condition/potential hospitalization

Analytics

The ability to synchronously and/or asynchronously communicate between the patient and care team 24/7

Bidirectional Communication

The ability to reach and engage any eligible patient, including those with limited technical skills, health literacy, and language skills

Accessibility & Equity

The ability to use ready-made, condition-specific, customizable care plans and pathways for clinical decision support and patient engagement

Pre-Built Care Plans

The ability to seamlessly fit within IT infrastructure to improve the user experience

Integration & Interoperability

The ability to support patients and care team with frictionless logistics management, staff training, and patient onboarding, and ongoing tech support, enhancing and not exacerbating the clinician experience

Operational Support

The ability to leverage AI and/or live coaches with specialized training to educate and engage patients by providing tracking, goal-setting and incentives to support behavior change

Patient Education & Coaching

Manages the entire revenue cycle from patient scheduling to final payment
Complements existing practice management systems to streamline financial operations
Provides a unified platform for all revenue cycle functions
Example: An RCM ecosystem that handles scheduling, eligibility verification, coding, billing, and collections within a single integrated platform.


End-to-End Coverage

Utilizes AI and machine learning to automate routine tasks
Employs robotic process automation (RPA) for repetitive, rule-based processes
Reduces manual data entry and associated errors
Example: An RCM solution that automatically codes encounters based on clinical documentation and updates claims in real-time.


Intelligent Automation

Offers real-time financial dashboards and key performance indicators
Provides predictive analytics for denials management and cash flow forecasting
Enables drill-down capabilities for detailed analysis of revenue cycle performance
Example: A system that predicts which claims are likely to be denied and suggests preemptive actions to prevent denials.


Advanced Analytics and Reporting

Offers clear, upfront cost estimates and explanations of benefits
Provides multiple payment options and flexible payment plans
Enables self-service portals for patients to manage their accounts
Example: A patient portal that allows individuals to view their bills, set up payment plans, and make payments online or via mobile app.



Patient-Centric Financial Experience

Ensures adherence to healthcare regulations (e.g., HIPAA, HITECH)
Provides robust data security measures to protect sensitive financial information 
Offers audit trails and reporting for compliance monitoring
Example: An RCM system with built-in compliance checks that flag potential regulatory issues before claims are submitted.



Compliance and Security

Performs instant insurance eligibility checks 
Provides detailed breakdowns of patient benefits and coverage
Updates patient financial responsibility in real-time
Example: An RCM tool that automatically verifies insurance coverage when appointments are scheduled and updates information at check-in.


Real-Time Eligibility and Benefits Verification

Identifies root causes of denials through pattern analysis 
Offers workflow tools for efficient denial follow-up and appeals 
Provides education and training to prevent future denials
Example: A denial management module that categorizes denials, assigns them to appropriate staff, and tracks appeal outcomes.


Denial Management and Prevention

Benchmarks performance against industry standards
Identifies areas for process improvement and cost reduction
Provides ongoing training and support for optimal system utilization
Example: An RCM system that compares an organization's key metrics to peer benchmarks and suggests improvement strategies.


Continuous Performance Improvement

Process to verify the necessity of submitting a prior authorization request is automated. If a prior authorization is required, solution can identify payer-specific rules.

Requirements Identification

Prior authorization requirements knowledge base is continually and automatically maintained. There should be minimal (if any) effort required of health systems to support this function.

Requirements Knowledge Base

Prior authorization forms completion is augmented with automation, populating appropriate fields through leveraging structured and unstructured data from the EHR.

Form Completion

Where necessary, payer-specific forms can be created/maintained.

Forms Library

Necessary documentation can be attached to satisfy the prior authorization request.

Documentation Collection

Prior authorization request can be submitted on behalf of the health system (through e-fax, payer portals, third party sites, etc.).

Request Submission

Prior authorization request status is monitored in near real-time and can be pushed back, along with other relevant information (e.g., tracking numbers, supporting text), into the appropriate work queues and fields within the EHR.

Status Monitoring

Synchronizes with multiple data sources to provide up-to-date provider listings without duplication across sources. Search function should automatically complete terms and returns for mistyped words.


Provider directory and search

Provider reviews from multiple sources with reviews management capabilities, customizable star rating calculations, and analytics to glean insights about potential patient experience improvements.


Transparent information	

Multi-lingual and consumer-friendly, with scheduling enabled directly from provider pages and new patient scheduling options that do not require logging into a portal. EHR-agnostic to create a consistent consumer experience, and call center-enabled.


Online scheduling	

Multi-lingual and omni-channel with the ability to integrate symptom checking functionality into a general chatbot solution. A strong consumer experience should include SEO from non-branded web searches, with capabilities to patients, pass data into the EHR, and integrate with appropriate endpoints.


Virtual triage	

Aggregates inventory of on-demand care options, transitions seamlessly between modes of care, leverages virtual provider pools to manage resources based on demand, leverages ancillary services, and integrates with other digital front door capabilities.


Low-acuity care navigation	

Synchronous and asynchronous virtual visit solutions are multilingual, accessible, and omnichannel; and allow users to alternate between modalities. Capabilities should integrate with existing provider workflows and auto-generate clinical documentation, offer real-time benefits information and auto-generate claims, directly enable orders for ancillary services, and automate follow-ups and referrals.


Virtual visits	

Includes geolocation capabilities to assist with resource navigation, enables self-service transactions, aggregates care options and provides price transparency, and supports consumers with personalized care management and engagement.


Unguided interactions	

Guided consumer interactions should include automated or live bidirectional text and chat conversations that are free text enabled and allow users to find providers, schedule or cancel appointments, review real-time health information, and start synchronous virtual visits.


Guided interactions	

Ability to capture patient behavioral health status, inclusive of substance use disorders, using evidence-based assessments.

Behavioral Health Screening

Ability to coordinate across a healthcare delivery system or network to provide patients with behavioral health services in inpatient and outpatient sites of care.

Behavioral Health Integration

Ability to deploy ED-based interventions for treatment initiation and referrals to appropriate services for individuals with mental health needs across the acuity spectrum.

ED-based Mental Health Interventions

Ability to deploy ED-based interventions for treatment initiation and referrals to follow-up treatment for individuals with SUD.

ED-based SUD Interventions

Ability to provide on-demand services and resources that address diagnosed behavioral health needs across the acuity spectrum, either synchronously or asynchronously.

On-demand Behavioral Health Support

Ability to connect a patient with SUD to individuals with either lived experience or appropriate training to support a patient's long-term recovery.

Peer Support Services

Ability to virtually deliver psychiatry (i.e. telepsychiatry) and/or therapy (i.e. teletherapy) and prescribe medication as applicable.

Telemental Services

Ability to virtually deliver medication-assisted treatment (MAT).

Tele-MAT Services

Multimodal delivery options that allow patients to choose how to engage. Options include desktop, mobile apps, text messaging, and other connected devices.

Multimodal delivery options

Personalized care plans that deliver customizable treatment. Leading solutions offer libraries of evidence-based medical and psychosocial intervention pathways. Content is delivered in accessible, personable language to meet patients where they are.

Personalized care plans

Connected FDA-approved devices as needed to monitor specific conditions. Devices should support automatic and/or patient-triggered data upload.

Connected FDA-approved devices

Real-time data collection and response with AI-driven coaching. In addition, health systems must work with solution companies to determine where this data flows and the associated care pathways.

Real-time data collection

Integration and interoperability with EHR and other relevant software. Leading solutions are accessible to providers in their native workflow and easily exchange data with other solutions, such as prescribing software.

Integration and interoperability

Off-the-shelf repository of clinical pathways and order sets

Content library

Ongoing, thorough review of the content library against the latest medical literature and evidence

Evidence-based review

Ability to update content to reflect local conditions, e.g. availability of supplies, practice patterns, workflows, clinician preferences

Customization

Ability to draw on existing pathways, order sets, and best practices from other users of the platform

Continuity content sharing

Tools that seamlessly enable the development of new pathways and the customization of existing ones

Authorship tools

Functionality that supports governance and maintenance (e.g. permissions, approvals, updates) of clinical pathways

Governance tools

Ability to draw on medical evidence and literature to identify and address gaps in current pathways and other sets

Care gap identification

Ability to seamlessly integrate new pathways and updates to existing pathways with EHR workflows and leverage EHR data to inform triggers and alerts

EHR Integration

Configurable analytics and reporting encompassing a broad range of categories and metrics (e.g. utilization/compliance, cost of care, outcomes)

Analytics & Reporting

Ability to provide multilingual and omni-channel options. No app download or authentication required for patients/members. Navigation and scheduling through existing channels, with provider launch from the EHR. Allow for patient link distribution to family members. Proxy support is provided.

Access & Scheduling

Ability to handle digital form upload & intake. Integrated symptom checking.  Waiting room accessible to patients, providers, and staff. Patient/member queueing. Patient can share images or videos. Integration with connected devices for vitals collection. Patient/member contact/chatting. Content for patients to interact with in the waiting room. Notify patient when provider is ready to start visit. Tool for patient to test tech feasibility 

Intake & Virtual Waiting Room

Ability to provide high-resiliency, high-latency video with ability to toggle to phone/audio and support for multi-party video. Patient education that can be annotated. Enable a consumer to alternate between modalities (text/chat/in-app messaging/secure portal). Asynchronous interview (including integrated symptom checking/virtual triage). Ability to “step up” to video visit or in person care if needed. Integration with connected devices, support for file sharing, screen sharing, and group chat. Notification for patients when provider has responded and vice versa. Ability to obtain patient feedback post encounter

Virtual Encounter

Ability to leverage existing patient demographic/medical info. Support for documentation within the EHR. Auto-generation of clinical documentation. Review, confirm, or revise diagnosis, treatment options (including escalation to a higher acuity care setting), and care plan in a timely manner and within existing provider workflow tools. Photo integration, recording integration, and ability to push AVS to patient portal.

Diagnosis & Documentation

Ability to support eligibility, prescription, lab, order, and referral integration with core, host systems. Ability to provide access to real-time benefits and eligibility, show pricing options based on RTE or self-pay, and apply discounts or differential pricing. Ability to generate claims and collect patient payment. Ability to offer automated follow up & referrals on treatment, adherence, or re-engagement. Care handoffs for consumers hitting escalation or exit points (i.e, direct scheduling)

Billing, Orders, & Follow Up

Ability to provide phone-based support for patients/members and providers. Ability to provide chat or text-based support for patients/members and providers.

Technical Support

Ability to guide to relevant providers based on coverage. Queuing to meet SLAs for 3rd party providers. Analytics on provider utilization/ productivity. Flex staffing based on supply and demand. Provider pooling to fill underutilized capacity.

Flexible Staffing

Ability to provide robust analytics such as provider utilization/productivity, average time per visit, most commonly treated conditions, resolution vs. escalations, volume by day and time, and patient feedback / where patient would have gone.

Content is accurate, in the best interest of the patient, and without commercial bias by provider, insurer, or supplier. Content is continuously updated to reflect the latest studies or findings, and reviewed by appropriate standards boards so patients feel confident in their decision-making. Content is relevant and pinpointed to meet a patient’s immediate needs.

Accurate & Relevant

Captures and tracks what information has been provided to the patient, what education they did or did not understand, whether they are reading the tools, etc. Recording dates of when education materials were received helps ensure they don't repeatedly get the same information. Historical context prompts clinicians to reinforce critical messages to ensure the patient sticks to their care plan.

Records Historical Context

Delivered via a variety of formats (e.g. video, audio, print, etc.) and modalities (e.g. website, mobile apps, etc.) to capture patient attention and improve comprehension. Drag-and-drop type functionality allowing patients to visualize their own medical conditions. In-the-moment reminders through augmented reality helps steer patients to make the right changes or choices. Interfaces that are as easy to use (such as YouTube) so patients can find videos around topics they're interested in and quickly get to them.

Interactive & Multimodal

Guided journeys for a specific condition helps providers understand what stage of behavior change the patients is in to better personalize, inform, and guide the next steps in the care plan and whether there is a need for targeted intervention. Personalized materials enable patients to learn about the risks and benefits of different options, form preferences, and share in the decision-making on treatment options.

Guided & Personalized

Tailors content based on comprehension checks and health literacy level. Medical illustrations that simplify concepts, and easy-to-understand text regardless of reading level. Applies the latest health literacy principles to help clarify diagnoses, support shared decision-making, and build a trusted physician-patient relationship. Translatable to other languages based on patient’s preferred language to ensure accuracy and comprehension.

Easy & Simple to Understand

Reduces steps for physicians prescribing education to patients and aligns with existing workflows (e.g. content suggestions per the patient's health history, favorites tagging, and folder access). Care managers can easily access content, while marking their favorites and organizing it into folders shared across the team and so they can easily see what other managers have shared with patients too. Care coordinators can find and use relevant health information in real-time, in preparation for a call, during an encounter, or to send as follow-up.

Seamless Care Team Workflows and Accessibility

Uses the patient’s medical record and diagnosis to provide a list of health education specific to the patient’s needs. Efficiently recommends content based on the patient's profile, visit history, and current clinical encounter. Content can be shared directly through patient portal before, during, or after a visit. Supports mix of traditional and custom orders and results interfaces; integrations include but are not limited to HL7.

The solution should understand and respond to patient inputs in a manner that takes the context into account, providing relevant and accurate information or advice.

Contextual understanding

Conversational AI solutions should seamlessly integrate with the EHR and other existing systems, databases, and digital channels.

Interoperability

Solutions must protect patient privacy and comply with HIPAA and all other applicable regulations.

Data security and privacy

The user experience should mimic human conversation and include an easy, intuitive interface.

Naturalistic interaction

The solution should be capable of handling increasing volumes of interactions as use cases expand and adoption grows.

Scalability

A good solution should keep pace with rapidly evolving AI technology and continuously improve over time.

Adaptability

Virtually monitoring patient safety to prevent patient falls


Virtual sitters	

Performing virtual assessments for low-acuity patient conditions


Providing virtual visits to support patient access, for a variety of medical conditions


Providing virtual visits to support access, chronic care management, and remote monitoring


Care coordination: PCP and specialist	

Assisting with discharge planning to enable a smooth and timely transition


Care coordination: care transitions	

Providing virtual, hospital care at home for complex patients, creating inpatient capacity


Health at home	

Providing bedside nurses with virtual support, mentoring, and education


Virtual bedside support	

Providing critical care services to patients and nurses at the bedside


e-ICU	

Driving system capacity and throughput via a centralized hub


Command center	

Fixed room displays that display information in an easy-to-read format for patients and families

User-Friendly Interface

Unit-specific requirements, layout, and display can be customized to surface the most relevant information to patients and care teams with configurable health system branding

Customization and Personalization

Integration with EHR, in-room devices, and software to provide care teams with updates and alerts in real-time

Automated Integration

Contact-less sensors and/or monitors that provide continuous monitoring with predictive algorithms that analyze collected and historical data to enable real-time intervention and optimization of care delivery

Real-time Data Collection and Analysis

Precision and dependability in the collection and transmission of data to ensure precise measurements and fail-safes to minimize the risk of errors, data loss, and false positives or negatives

Accuracy and Reliability

Allow patients to easily adjust and manage their room environment in real time according to their preferences and comfort levels

User-Centric Interface

Seamlessly integrate with other hospital systems and devices to allow for automated adjustments and coordination with clinical workflows that align with patient vitals and care regimens

Integration and Automation

Prioritize energy efficiency and sustainability and monitor the environmental impact and resource consumption of the facility

Alpha II - Healthcare RCM

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