Providing injured workers with the best level of recovery and the most effective return to work programme is vital to the economic and social welfare of every Australian community.  WorkCover in South Australia have long pursued increasingly effective ways of optimizing their role in managing and rehabilitating injured workers, and began looking at ways of automating the transfer of claims data directly into their line-of-business systems about four years ago.  The result was a vision of an organization that would migrate itself into a fully-integrated systems environment.  Implicit in the vision was a redesign of the line-of-business systems, and a review of IT strategy. 

 

The organisation required a solution that would incorporate a range of systems, software products and platforms, and the preferred acquisition path was to build a solution from off-the-shelf components, rather than from scratch.  “We were looking to build a system from ready-made components and achieve a fully-integrated, functioning environment that could manage our line-of-business activity, our CRM and Knowledge Management systems.  Whatever we looked at, we wanted to automate and integrate,” says Kit Black, Project Director at WorkCover.

The analysis focused on the current systems and workflow from a business perspective, aiming to set priorities for automation in the first instance.  A review of workers compensation claim activity revealed a series of forms that were required to start a claim.  The most critical of these was the Prescribed Medical Certificate, or PMC.  “Our first view was that we could get information from medical certificates into our organisation more quickly using the web, but there were a range of other forms that we wanted to get online as well,” Black says.  A key aim of the automation process was to get data into WorkCover more effectively/quickly so that early intervention could be implemented, and workers returned to the workplace more quickly.  “With a need to maintain certain manual processes, and the fact that a claim has a number of different workflow components to it before it gets approved, an interface between systems was always going to be a critical component.  The aggregation of a complete claim takes time, and if we are not finding out about it until three weeks after the incident  we miss a significant opportunity to intervene and get workers back on the job,” he adds.

The first step towards the ePMC system was a fax service with an incentive paid to practitioners for information received by WorkCover within 24 hours of an incident. The next move was to an online system of web forms. It became clear that this method didn't work efficiently, as doctors were rarely online during consultations, and would therefore have to key in patient information twice.

When questioned about the system, medical practitioners asked if it was possible to integrate the data entry component of the process into their existing clinical software, and an interface was designed to achieve this.  General Practitioners who currently use the Medical Director application are able to transfer a patient's claim details directly into the ePMC format and email the details directly to WorkCover.

Adelaide-based Microsoft Certified Gold Partner, Strategic Data Management (SDM), recommended that BizTalk Server 2000 be used as the integration engine behind the solution, connecting internal systems and integrating with medical practitioners.  The workflow was divided into process-to-process communication and manual tasks, with BizTalk passing the data between the components of the system.  Exchange 2000 listens for the ePMCs to arrive, then starts a process to decrypt the encoded ePMC.  BizTalk reads the document and decides whether the XML content meets validation requirements.  If it is a valid PMC, BizTalk checks to see if the claim is already on the file by calling components that query the legacy database. The system can then initiate manual workflow alerts. “BizTalk fits in well with the architecture and direction of WorkCover as we have moved from a Tandem platform across to Windows 2000.  With BizTalk we have focused on providing much greater enterprise integration, as well as extending our systems to the outside world.  Now WorkCover can communicate more effectively with our customers and partners,” says Black.  

BizTalk is the facilitator of a range of processes that are implemented as COM objects.  By interfacing components together, BizTalk creates a workflow system that goes through a number of stages.  BizTalk checks that the XML schema of the PMC is valid, and if not, rejects the message.  Rejected messages trigger an alert to a manual operator who assesses the problem and returns the data to the medical practitioner for correction if necessary. 

 

BizTalk is based on a SQL Server 2000 database, which applies the business rules of the legacy system to the data to check the integrity and validity of the data.  BizTalk communicates with WorkCover staff by interfacing with the document management and workflow systems and raising an appropriate flag.  BizTalk maintains data in a system database, and after validation, can trigger the process for a payment to be made to the medical practitioner from WorkCover's legacy system. The ePMC system is able to identify if the PMC is associated with an existing claim and if so, send the information directly to the applicable claims agent automatically.  Alternatively, if there is no previous claim, the details can be sent via post from WorkCover to the Claims Agent.  This activity occurs within 24 hours of the injured worker visiting their medical provider. Future versions are envisaged that will deliver all ePMCs electronically to claim agents.  

 “One of the critical problems with the hand-written PMCs is that many doctors do not write legibly.  With the ePMC system we have already seen improvements in data quality, and we are getting the information in a more complete format,” says Mal Watt, Program Manager of Business Systems at WorkCover.  Prior to implementation it was necessary to return the PMC to the medical practitioner if it was incomplete, adding to the cost and timeliness of the process.  The ePMC solution has almost eliminated this issue.

ePMC is secure, confidential and convenient, and is a leading edge Australian product for the South Australian WorkCover Corporation. WorkCover is currently in discussions with other software providers with a view to incorporating the ePMC interface into more medical practices across South Australia. MedTech is used by the Work Health Group which works primarily with injured workers. The incorporation of the ePMC interface into the MedTech software will provide access to the ePMC interface in more medical practices across the State.  “The whole thing is about faster, more accurate processing; and we are also getting quality data entering the system, which results in less administration time.  Now that we rarely have to ask doctors for more information, our follow-up costs have come down,” Watt says. 

One of the key features of the solution is a BizTalk process that matches the PMC to an existing claim when it is loaded into the ePMC system.  This means that there is single keying of data at the medical practice.  Approximately 13% of the electronic PMCs match up to existing claims in this manner.

A key strategic issue being tackled by the Corporation is to effectively risk-manage its liabilities incurred through the payment of entitlements to injured workers and other costs of outgoing claims. If these injuries are notified early in the life of the claim then their associated costs can be significantly reduced.

Scheme Sustainability
If the amount of time that an injured worker is on income maintenance is reduced because of action on their needs much sooner, the long term viability of such a scheme can be sustained.

 
Alerts Flag Risk Situations
Additionally, there are alert processes based on triggers for certain transactional activities.  By combining information from the ePMC and invoices located on other systems, an alert can be raised in a case that has a high risk of an expensive outcome. 

Reduced Processing Times
The solution has reduced processing times on system and manual processes, and led to increased data quality and accuracy, as there is no longer a component of manual handling involved. 

Reduced Error Rates
Reduced error rates have resulted from the application of mandatory fields in both the desktop and web-based forms, and a simple to use workflow structure ensures that there is no double handling of data.

Reduced Human Intervention
Reduced human intervention has resulted from integration into the Medical Director application. Uptake by the doctors has improved, as payment of invoices occurs sooner.  

Improved Worker Outcomes Anticipated
Improved worker outcomes anticipated in the long term due to better and more timely treatment of workers.