The Role of Rule Engines in Managing Healthcare Protocols and Compliance

Łukasz Niedośpiał
May 21, 2024

US healthcare accounts for $2.8 trillion in spendings with 30% of it being wasted. Expenditures per capita are also rising – currently it's $9,146 per patient.

Healthcare and compliance protocols are necessary, and they exist for a reason. Without it, patients are at risk of being mistreated, and hospitals face the danger of litigation costs. A survey showed that during one year nearly 62,000 medical errors were made with claim costs of $617 million.

The total cost of administrative activities to stay compliant reaches $39 billion, with the average cost of $1,200 per patient admitted, and $47,000 per bed per year.

Regulatory Act Estimated Cost of Compliance
HIPAA (Health Insurance Portability and Accountability Act) $3.5 million - $7 million per year for a large healthcare organization
CHIP (Children's Health Insurance Program) $0.5 million - $2 million per year for a state CHIP program
HITECH (Health Information Technology for Economic and Clinical Health) $1 million - $5 million per year for a large healthcare organization
Medicare $0.5 million - $2 million per year for a medium-sized hospital
Medicaid $0.3 million - $1 million per year for a medium-sized hospital
Electronic Health Record (EHR) $1 million - $10 million for initial implementation, plus $0.2 million - $1 million per year for maintenance

Non-compliance is not an option. University of Michigan Hospital faced a $4.3 million dollars fine for violating the controlled substances act, which meant record keeping violations.

See for yourself how implementing rules engines can untangle the complexity of healthcare compliance, reduce the risk of violating provisions, and speed up the work, resulting in a better care and profitability.

Compliance in Healthcare is More and More Complex

Carthey at. al. pointed out key challenges when it comes to compliance in healthcare industry:

  • sheer volume of the documentation – Understanding and disseminating policies and guidelines is complex and time-consuming, leading to decreased compliance with critical regulations due to an overwhelming influx of information.
  • multiple rules on the same topic – Confusion arises among healthcare professionals when multiple organizations. For example, the American Association of Clinical Endocrinologists and the International Diabetes Foundation, issued comprehensive guidelines on the management of diabetes.
  • naming and accessibility – Accessibility of policies is hindered by their location on hospital intranets or specific departmental drives. It is assumed staff have easy computer access and knowledge of policy names and locations, with confusion compounded by obscure policy titles like the "Acceptable Use Policy," aiming to clarify appropriate internet usage within the trust.
  • length and complexity of guidance – a single document on a single topic can be described in a 400 or more pages document. Staff members cited that they were never able to find controlled drugs list within the policy,
  • trivial policies – some things don't have to be standardized. Yet, authors mention official documents on "wearing of Crocs in theatres, managing adverse weather conditions, how healthcare staff should answer a telephone, and how to politely “meet and greet” visitors to a hospital department"
  • version control – with so many documents it is hard to keep track of which version is the most accurate.

They also mentioned guidance from government bodies – 3000 documents from Department of Health and 1000 documents from NICE.

That's a lot of documents to keep track of. Not to mention, following the guidelines, where the patient's life and health depends on. 

Ensuring Real-Time Compliance in Patient Care

Ensuring compliance with healthcare regulations minimizes the incidence of medical mishaps, incorrect diagnoses, and suboptimal results for patients.

By incorporating comprehensive data from health information exchanges into quality assessments in patient care, real-time compliance brings about a transformative effect that includes:

  • Prompt availability of relevant patient details
  • Rapid enforcement of pertinent healthcare guidelines
  • Boosted safeguarding of patient safety
  • Enhanced outcomes for those receiving care.

Seamless System Integration: A Necessity for Modern Healthcare

In healthcare, seamless integration improves care delivery by minimizing errors and delays in treatment. It allows for quick and safe retrieval of extensive patient information, thereby improving the quality of patient care.

When health information systems are integrated, it leads to:

  • Precise reporting on the quality of services
  • The incorporation of detailed patient data gathered from multiple sources
  • Effortless exchange of data between entities
  • Real-time application of relevant rules and guidelines
  • Immediate access to necessary patient information

Such integration underscores the importance placed on real-time adherence to regulations within patient care practices.

Data Exchange and Patient Safety: A Symbiotic Relationship

The reciprocal relationship between data exchange and patient safety is vital within the healthcare sector. The swift access to updated patient information and current treatment guidelines, made possible through effective data sharing, enhances the safety of patients. 

Key in facilitating this are:

  • Merging of Electronic Health Record (EHR) systems
  • Optimization of clinical workflows
  • Advancement in data interchange capabilities
  • Adherence to regulatory health compliance standards.

Exchanging clinical information via networks such as electronic health records has a profound impact on ensuring the well-being of patients. 

When patient records are complete and readily accessible, it significantly bolsters identification protocols for high-risk medication usage, which mitigates potential adverse effects on health. 

Streamlining Compliance: The Role of Healthcare Rule Engines

Rule engines in the healthcare industry have become pivotal, greatly enhancing operational efficiency, precision, and adaptability. By automating decision-making processes and policy enforcement, these advanced systems liberate healthcare professionals from tedious manual tasks. This focus shift enables clinicians to devote more attention to patient care. 

Consequently, healthcare organizations benefit by being able to:

  • Quickly and effectively respond to regulatory changes
  • Enhance the accuracy of their decision-making process
  • Boost overall operational productivity
  • Minimize mistakes thereby bolstering patient safety

The agility of rule engines within health care is rooted in their unified structure that addresses the increasing complexity found in managing protocols and ensuring compliance with regulations—a sophisticated task made simpler through this technology. 

The functionality of these rule engines is grounded on three integral elements: 

  • a Rule Repository for storing rulesets, 
  • a Rule Execution Engine that applies them, 
  • a Rule Editor which allows users to create or modify existing rules.

Centralized Rule Repository: Simplifying Access and Management

The Rule Repository serves as the foundational infrastructure for the healthcare rule engine, operating as a central hub where an array of healthcare rules are stored. These include clinical guidelines and various regulatory stipulations that health professionals must adhere to. 

By concentrating these resources in one place, it allows for simplified acquisition and control over such information for those providing patient care.

Healthcare providers benefit from this centralized repository by being able to:

  • Effortlessly traverse through intricate healthcare regulations
  • Consolidate their management protocols
  • Promptly adjust to evolving guidelines and legal mandates
  • Elevate the standards of patient treatment

Facilitated access granted by this system is crucial in empowering medical practitioners with the capability to administer superior care effectively. This stands particularly true for patients who fall under protection via children’s health insurance programs facilitated by agencies focused on both health and human services while leveraging aspects like health insurance portability.

Rule Execution Engine: Powering Clinical Decisions

The core component of a healthcare rule engine is the Rule Execution Engine. It serves as an instrumental system for interpreting and applying healthcare rules to patient data, significantly assisting clinicians in providing informed decisions that contribute to quality patient care.

Rule Editor: Customizing Care Protocols

The Rule Editor plays a vital role as a key feature of any healthcare rule engine, providing an interface for healthcare professionals to undertake actions such as:

  • Tailoring and adjusting rules according to unique requirements
  • Building and amending various rules
  • Fortifying the autonomy of healthcare professionals by granting them increased authority over protocols related to patient care.

Through the use of the Rule Editor, personalization is brought into focus when devising individual patient care strategies. It allows for both natural language and specialized domain-specific languages in crafting or altering healthcare rules so that each plan addresses particular needs and situations relevant to the patient. This tailored approach greatly improves patient safety while simultaneously elevating the level of care patients receive.

Health care compliance – Summary

In the complex arena of healthcare, adherence to compliance is paramount. Healthcare organizations need to proactively employ rule engines and cultivate a culture that prioritizes regulatory adherence to guarantee patient safety. As this field continues to evolve, keeping abreast of legislative updates and engaging in risk management are essential strategies for preparation against unforeseen challenges. The integration of cutting-edge technologies with innovative compliance methodologies clearly indicates that technology interwoven with compliance will shape the future trajectory of healthcare systems.

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