By Cynthia Young, BSN, MBA, RN, CMCP 

Healthcare leaders are seeking solutions to the challenge of using data in the new era of utilization management automation. Multiple drivers are at play in a compelling change in business processes and procedures to implement new technology and seek analytics solutions that can accommodate the new way of doing business. These drivers include prior authorization burden reduction legislation, “gold card” programs, the transition toward value-based payment, and demands from healthcare consumers. It is essential to gather and deliver information in a way that makes it actionable. It is no longer enough to be able to analyze data. You must articulate the story your data is presenting to you. 

Leaders need to move from a reactive to a proactive mindset. In addition, use cases for data are expanding. Healthcare organizations must use data to determine the return on investments (ROI), compliance, utilization benchmarking, outcomes measurements, performance measurements, identify opportunities, and monitor financials. This can be manageable with the right data management strategy and a plan to connect the dots. Using technology effectively and eliminating outdated processes and tools can help organizations “cost-effectively” to do the right thing. We have all heard the saying, “If you don’t know where you are going, any path will take you there.” A well-thought-out data strategy will set the path. 

Some traditional data sources are often months or years old. Many data sources are captured manually, lending themselves to variability. In the fast-paced environment we are experiencing, utilizing information captured in “real” time is essential to make business decisions. In addition, data must be specific and relevant to the front-line staff, managers, and leadership across the organization. Often, the data sciences area manages all things data, and results are not pushed down to the teams in an actionable format but instead are trying to manage metrics. Tools that are easy to use for these stakeholders and provide timely and actionable data to make better-informed business decisions must be available to these stakeholders. 

A modern data management strategy requires the addition of new metrics beyond Admits/1000, Average Length of Stay, and Bed Days/1000. Current challenges require accessing additional data sources to satisfy complex needs, evaluating provider performance by service and approval percentage, and assessing below a DRG level specific to procedure and service. Using analytics tools to identify provider utilization patterns and employing benchmarks to identify real-time utilization trends is essential to driving toward critical outcomes. 

They have skilled staff who can organize and interpret information from multiple sources, develop a straightforward story, and present the data in a way that illustrates the action case. This is a new skill set. Many organizations are attempting to recruit or secure the services of experienced consultants to develop a new approach to using data to tell their stories. 

Clients are contacting us seeking solutions and a path for complying with new state legislation, explicitly implementing provider “gold card” programs. The initial challenge is identifying providers and specific services that qualify for “gold card” designation. The current manual state of prior authorization programs requires scouring multiple sources to identify retrospective prior authorization approval/denial rates. With an automated prior authorization system, you can pull reports specific to requested services and drill down further to identify approved or denied services. Without an automated prior authorization system, complex data pulled from multiple sources must be developed, causing delays, redirection of IT and analytic resources, and the risk of inappropriately designating or not designating providers and services for this program.  

Ongoing monitoring becomes critical to track utilization trends against the original baseline. New providers may now be eligible, some may fall off eligibility, and monitoring specific services to include becomes more accessible with the right tools and strategy. Fully automating the prior authorization process is essential to capture approval/denial rates at the point of request. By leveraging analytic tools, it is possible to track ongoing utilization patterns using near real-time data presented in a dashboard format intended for utilization management leaders and front-line staff use. Automating the identification and ongoing monitoring of complex government-mandated programs is a challenge that needs a targeted strategic plan that includes tools and resources that leverage data and technology. With robust, specific benchmarking, it is easier to identify provider trends with laborious manual audit processes. This holds for other emerging programs, including value-based contracting and prior authorization burden reduction initiatives. 

Moving to the era of utilization management automation requires healthcare organizations to implement new business processes and remove old manual processes. It requires procuring and employing tools that provide specific data points that are presented in a usable way across the organization. Breaking down silos between departments and sharing of data is essential to being successful in this new automation environment. Focus on the people side of change should include internal and external stakeholders with the mindset of education and collaboration. Having a data strategy that can take data and develop actionable insights – data stories – is necessary to remain competitive, comply with new legislation, and make informed business decisions focused on better patient and business outcomes. 

Now, as you look at your data, what story is it telling you?  


Walken, David. (2020). 10 Steps to Creating a Data-Driven Culture. Harvard Business Review. 

Cote, Catherine. (2021). Data storytelling: How to Effectively Tell a Story with Data. Business Insights Blog. 

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Bio: Cindy has over 35 years of experience, as a Critical Care Registered Nurse, hospital utilization review and case management. Cindy has led clinical program development, case management, and the use of clinical analytics. She holds a Black Belt in Six Sigma, is a Certified Change Management Professional and Certified Change Agent.