A case study coauthored by:
Emma Ungureanu, George Voicu, Andrei Ismail
Troy Medicare, an HMO Medicare Advantage Plan from the United States, works with multiple partners to ensure quality for enrolled members. Troy Medicare is striving to achieve its goal of transparent and fair pricing with the help of data: by monitoring, reviewing, and tracking information from numerous sources about beneficiaries, care providers, and pharmacies.
To accomplish this, Troy Medicare partnered with Vitamin Software to build a data exchange system. Through this system, data from all partners in all sizes and formats is processed, cleaned, and stored in a data warehouse. The data warehouse is then used by Troy Medicare staff to generate reports, analyses, and statistics in a user-friendly and meaningful way. This process helps the company achieve their mission of ensuring members get the right care at the right time with the right provider, and drives down medication costs.
About Troy
Troy Medicare is a healthcare insurance company active in the United States. It enables its members to access services covered by an HMO Medicare Advantage insurance plan funded by the federal government.
Troy Medicare collaborates with multiple entities to manage services offered to insured beneficiaries, while complying with HIPAA and federal reporting requirements.
Troy Medicare is committed to continuously monitor and improve their healthcare delivery, by making sure the members get the right care at the right time with the right provider and increasing the adherence to medications by driving down the cost of medications.
“We will meet these goals by:
Customer Challenge
At the core of the multi-trillion dollar American healthcare industry is a complex system where a myriad of entities provide healthcare services under strict HIPAA regulations.
As a consequence, Troy Medicare’s technology needs revolve around two main topics: (1) having a secure, HIPAA-compliant infrastructure to store and process data transferred between Troy Medicare and their providers, third party administrators (TPAs), pharmacy benefit managers (PBMs), and the Centers for Medicare & Medicaid Services (CMS); and (2) optimising data to enable an ever-improving experience for insured beneficiaries.
Our goal was to design and operate a data warehousing solution to support operational excellence in its very first year functioning, in a rich, heterogenous, strictly-regulated ecosystem with low tolerance for errors.
Specifically, Troy Medicare Required:
a HIPAA-compliant infrastructure
data integrations to exchange various types of data with partners, such as daily transaction reports, pharmacy and healthcare claims, monthly membership information, member enrollments, prescription drug events, care plans, lab results, and Part C risk adjustments
data cleaning and processing using EDI data format standards like X12 - 834, FHIR, and HL7v2 for fixed format data files like DTRR, FEFD, HCCMODD, PDE, and P2P
monitoring partner operations for correctness
alerts for events where human intervention or supervision are needed
Failing to meet these goals could result in missed operational deadlines key to facilitating multi-party collaboration. In addition, low data quality or human error would hinder Troy Medicare’s ability to provide quality service to its members.
Why AWS
Due to the nature of its business, Troy Medicare has very specific infrastructure security needs, namely:
all data storage and processing must be done on US territory
Protected health information (PHI) must be encrypted both at rest and in transit
users must be uniquely identified in the system
access and user actions must be logged every step of the way and logs must be saved in a secure location for audit
access to ePHI must be logged for inspections
only HIPAA-compliant vendors and systems that are willing to sign a business associate addendum (BAA) can be used
data recovery procedures must be in place to comply with HIPAA retention requirements
The AWS emphasis on data security aligned with Troy Medicare’s strict requirements. In particular, AWS is willing to sign a BAA and provides HIPAA-eligible services to process, maintain, and store protected health information. Moreover, the pay-as-you-go pricing model that AWS offers is a good fit for a growing company like Troy Medicare.
“Healthcare providers around the world are using AWS to deliver improved care to their patients. AWS reduces the time and effort required to run existing workloads, and also provides access to powerful new analytics capabilities, all while meeting the security and privacy requirements that you expect.”
It was only natural for Troy Medicare to choose AWS and benefit from the vast spectrum of highly available and reliable services.
Why the Customer Chose the Partner
To identify the technologies and platforms that would help achieve their mission, Troy Medicare brought in the experts at Vitamin Software, an AWS Partner Network (APN) Select Consulting Partner.
“Since day one, we at Vitamin Software have been collaborating with AWS to deliver custom software and infrastructure for our partners. Together, we offer a complete services and management portfolio that provides customers fast, flexible access to the cloud.”
Vitamin Software has a proven track record as a service provider for customers in the healthcare industry. Moreover, Vitamin Software has extensive experience with manipulating vast amounts of data and protected health information, and is no stranger to implementing data integrations using EDI standards.
Vitamin Software possessed the skills necessary to implement EDI on top of AWS services. In addition to industry knowledge, Troy Medicare’s CEO Flaviu Simihaian chose Vitamin Software because:
“[Vitamin Software] are not just talented developers, but highly effective communicators, which is critical to solving challenging problems at startup speed”.
— Flaviu Simihaian, CEO, Troy Medicare
Partner Solution
A Data Warehouse
First and foremost, Vitamin Software focused on infrastructure security by following the AWS architecting guidelines for HIPAA security and compliance.
Second, Vitamin Software built a user-friendly data warehouse, with Amazon RDS and AWS Elastic Beanstalk at its core. RDS scaled up well, enabling Troy to use MySQL instances to store and process an increasing volume of claims and encounter data ingested from its TPA, PBM, and the CMS. Vitamin Software used Elastic Beanstalk to run Metabase, an open-source tool that provides a graphical interface for data auditing and analysis.
To meet data residency requirements, US-based Amazon data centers were used to deploy the components. Amazon Workspaces were used to connect to remote machines, and an enrollment overview system was designed using Amazon Workdocs Spreadsheets. With the help of the data warehousing system, Troy Medicare was able to reduce the cost of care while offering optimal patient outcomes.
Troy Asks, Data Answers
To transform raw data into usable formats, Vitamin Software used the BOTS framework — an open-source, platform-independent EDI translator — then exposed a REST API to integrate the data into an internal company and plan member dashboard.
Vitamin Software not only used BOTS to expertly process various EDI data formats, but also contributed back to the framework code that decreases processing time.
Troy Medicare staff use the data warehouse built by Vitamin Software in a number of different ways. The most straightforward advantage is that staff are able to download reports, analyse trends, and monitor costs. Aside from basic information — like which members have requested to disenroll or which drugs have members bought — Troy Medicare can use this data to calculate various financial indicators or identify medical claims that need adjustment.
Data Love Story
The main challenge when dealing with huge amounts of data is inconsistency. Vitamin Software processed, parsed and cleaned the data received from all of Troy Medicare’s partners before uploading it into the data warehouse.
As a result, some painful problems were resolved, leading to data that is:
consistent and user friendly, ready to use for accurate reporting and analysis directly in the Metabase application
exportable into popular file formats, like CSV and Excel
portable, as it can be downloaded and used as a source for further tools
All the above outcomes are essential in Troy Medicare’s pursuit to bring the best health care to its community.
Security & Compliance Everywhere
Popular AWS services are at the core of the solution designed by Vitamin Software: Amazon S3 for secure storage and archival of data, Amazon EC2 for data processing. AWS Lambda and AWS Transfer for data exchange, Amazon CloudWatch Logs for logging plus Amazon CloudTrail for auditing, and — last but not least — Amazon RDS instances behind it all. To meet the key security requirement, VPCs, Load Balancers, IAM and security groups were used to manage access to AWS services, and control users and groups by allowing and denying access to AWS resources.
Results & Benefits
Vitamin Software and AWS provided a secure and scalable solution for Troy Medicare. The collaboration successfully steered Troy Medicare through its first year and a half of operation and its first open-enrollment period.
Troy Medicare’s business is highly dependent on partnership with various vendors. The Vitamin Software and AWS solution helped Troy Medicare monitor and evaluate its TPA and PBM activities, supporting operational excellence.
For Troy Medicare’s staff, this collaboration meant a significant reduction in time spent monitoring utilization and care patterns, reviewing claims trends, and tracking medical costs to ensure providers and members experience the best healthcare delivery.
About Vitamin Software
Vitamin Software is an Amazon Web Services (AWS) Partner Network Select Consulting Partner, specializing in building, operating, and maintaining robust and secure data interchange systems that enable predictive analytics and operational excellence.
Solutions built by Vitamin Software empower its customers to comply with healthcare industry standards and facilitate accelerated data interchange. As more organizations move to the cloud and embrace interoperability, Vitamin Software is there to help deliver meaningful improvement in healthcare decisions.
As part of its comprehensive offering, Vitamin Software tackles the infrastructure on which the software runs, from inception to retirement.
Vitamin Software builds bridges: From problem to solution, from difficult to feasible, from impossible to outstanding.
Want to know how?