Building on its expertise in building artificial intelligence solutions for hospitals, Iodine Software rolled out new AI-based software to tackle the complex healthcare challenge of utilization management.
The Austin, Texas-based company, a major player in healthcare artificial intelligence, says its new solution, called AwareUM, will help hospitals streamline utilization reviews.
As healthcare costs continue to rise and hospitals struggle with weak margins, effective utilization management becomes critical to help health systems capture more revenue.
Utilization management is the process of evaluating and monitoring the use of healthcare services to assess their appropriateness and quality. Streamlining UM can significantly impact the bottom line as healthcare organizations become increasingly conscious of operational costs by eliminating waste. It also can improve the quality of care.
"For providers and hospitals, it is so crucial for them to demonstrate that the care that they're providing to these patients is appropriate care and for that they should be appropriately reimbursed. Without demonstrating and documenting medical necessity, it's going to be pretty much impossible for providers to get reimbursed in a timely fashion from payers," Priti Shah, Iodine Software's chief technology and product officer, said in an interview.
The issue is that clinical staff are often overwhelmed yet must make clinical decisions about what is the most appropriate level of care for each patient based on the clinical record. Poor utilization management can lead to reimbursement issues.
Iodine Software developed artificial intelligence-powered software solutions to address automation for clinical administration and revenue cycle management. The company's AwareCDI Suite identifies and captures mid-revenue cycle leakages, like discrepancies in reimbursement and clinical documentation, to make sure healthcare services are accurately coded and to optimize revenues.
Iodine’s AwareCDI solution has helped more than 900 hospitals capture more than $1.5 billion in earned revenue through more efficient clinical documentation improvement (CDI), according to the company.
Shah saw an opportunity to expand its capabilities to develop an AI-based solution to augment clinical staff decision-making for utilization management.
"We built out these battle-tested, time-tested AI models that have continued to provide value to our customers year over year. It became very clear to us that there was this logical adjacency in this clinical rev cycle because the common thread was sophisticated clinical users needed to have their tasks automated. While there are so many products out there in the market that claim to automate, what we have perfected at Iodine is taking that automation to that next frontier of emulating that clinical judgment for the sophisticated clinical users," Shah said.
"For provider systems, as well as UM nurses and CDI nurses, are now able to use our technology to automate far more complex clinical thinking which other products don't allow for. It was this true natural progression into utilization management from a CDI perspective," she said.
Iodine Software has been able to leverage artificial intelligence to augment scarce clinical resources, streamlining workflows that were once considered resistant to automation due to the indispensable role of clinical, human judgment, according to Shah.
The solution, AwareUM, is powered by Iodine’s AI engine CognitiveML, based on a dataset of 1.5 billion medical concepts, 93 million diagnoses and 18 million procedures. Shah said the company's AI engine is "turbo-charged" by almost a quarter of all U.S. inpatient admissions.
"It is a collection of machine learning models that is constantly trained by 30 million admissions and 450,000 admissions added per month," she said. "That has now translated into really powerful AI models that are able to really predict and emulate clinical thinking and clinical decision-making, which translates into better prediction accuracy."
By intelligently analyzing all clinical data and documentation in the medical record, AwareUM prioritizes cases for review at the right time and provides transparency and reasoning behind predictions, which enables the capture of correct patient status and streamlines the review process, according to the company.
Additionally, AwareUM provides a dedicated hub for all UM work and helps teams communicate effectively with payers to establish medical necessity. The solution also enables clinicians to work at the top of their license, automating important processes and improving overall efficiency.
The software has already been in pilot with multiple hospitals nationwide.
"With one client, we saw a 30% reduction in their inflated observation rates over a 90-day period, which roughly estimated an additional $2.5 million in reimbursements because we were able to accurately give them enough information to give them the confidence to prioritize the right patients and move them from observation to inpatient status," Shah said.
Baptist Hospitals of Southeast Texas also is piloting the new solution.
"AwareUM has transformed our approach to utilization reviews and allowed our nurses to focus more on understanding the patient’s needs by reducing the amount of time required for administrative tasks. With AwareUM, pertinent documentation and patient information is easily obtained, which has cut our review time by half," said Sarah Horner, director of case management at Baptist Hospitals of Southeast Texas.
"In addition, the case prioritization capabilities have helped us identify high-opportunity cases that need to be reviewed first, which has improved our observation rates significantly,” Horner said.
The company also gauges the value of the product on improvements in time and productivity. "On average, prior to using Iodine, UM nurses spent roughly about 15 minutes reviewing a particular patient case. But after using Iodine, they now only take about five to seven minutes," Shah said.
The company also reports a 25% increase in the number of appropriately changed patient statuses across seven months.
As a combined suite of solutions, AwareCDI and AwareUM will bridge the gap in communication between CDI and UM teams, according to William Chan, co-founder and CEO of Iodine Software.
“The debut of AwareUM reaffirms Iodine’s position at the forefront of innovation, signaling the evolution of our business to empower the nation’s leading health systems in navigating the entire clinical revenue cycle,” Chan said.
The company continues to advance its AI capabilities. In June, Iodine Software announced it was collaborating with OpenAI to integrate generative AI and large language models, including GPT-4, across the breadth of its solutions for clinical administration and revenue cycle management.