Digital Transformation Journey of Healthcare Business

3685 words (15 pages) Essay in Technology

23/09/19 Technology Reference this

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Executive Summary

Digital transformation is an ability to understand the way business operates and adapt change quickly by restructuring operations using latest technologies such as Artificial Intelligence, Machine learning, big data, social and mobility to continuously assess and engage customers to provide the best possible user experience. New technologies are evolving continuously and it is very critical to understand and identify disruptive technologies in health care industry well advance to stay ahead of the competitors, companies invest heavily on research and development departments to ensure that they can identify innovative methods, disruptive technologies, automation, and redundancies well in advance and provide the best customer service

The purpose of this paper is to review optum healthcare’s digital transformation journey and how they are staying ahead of their competitors by continuously identifying innovative solutions


Executive Summary






References and Bibliography


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and the mission is to help people live healthier lives and to help make the health system work better for everyone ( United health group is the top ranking company in the insurance and managed care sector on fortune’s 2017 “world’s most admired companies” list. ‘When you work to better people’s lives, one of those lives will always be yours’. United health group is providing health care to over 90 million people worldwide with lines of business the company is leading the way nearly on every aspect on today’s healthcare system. United health group is a multinational diversified health and well-being company dedicated to helping people live healthier lives and serves entire spectrum of healthcare participants, Individual consumers, Employers , governments, physicians, hospitals, healthcare professionals and Pharmaceutical and medical device manufacturers. The company has around 270,000 employees across the globe and generated $201 billion dollars revenue in 2017. It is leading the way to improving quality, affordability and access to the health system.

United health group is organized in two business units that are uniquely committed to transforming the healthcare in US and throughout the world, those businesses are United Healthcare and OPTUM. United Healthcare has four divisions that deliver health benefits across the full spectrum of healthcare consumers.

  • United Healthcare (Employer & Individual) – This group works with individuals and businesses of all sizes to develop healthcare benefits that works for everyone
  • United HealthCare (Medicare & Retirement) – This is the largest business in US dedicated to serving health and wellbeing needs of individuals aged 50 and older
  • United HealthCare (Community & state) – This group focuses on providing proactive health care resources and solutions to community and government partners to help create a positive change for those who needed the most
  • United HealthCare (Military & Veterans) – This group provide innovative, high quality and affordable healthcare solutions to those who serve US and those who served in the past and their families

OPTUM is dedicated to making health care system work better for everyone and it works collaboratively across the health system to improve care delivery, quality and cost effectiveness to nearly 150 countries, OPTUM focusses on three key drivers. 1. Engaging consumers 2. Aligning healthcare delivery 3. Modernizing health system. Some examples include helping families manage their healthcare dollars, helping doctors and patients inform treatment decisions and develop new technology solutions to enhance accuracy and accessibility of health care system. AS part of OPTUM, OPTUMRX is one of the largest pharmacy benefit managers in United States meeting the needs of 12 million Americans and it specializes in delivery, clinical management and affordability for prescription medications

This assignment will review health care industry, competitive environment, identify challenges with legacy systems and how digital transformation helped united health group to achieve business goals


The United States spends an estimated $3.5 trillion dollars or $10,739 dollars per person on health care expenditure and spending grew by 3.7% in 2017, as per organization for economic cooperation and development (OECD), United States average spending on health care expenses is significantly higher, around two and half times more than other developed countries. United States spent 18.2% GDP (Gross Domestic Product) on health care in 2017 and it is forecasted to consume 20% of GDP by 2026, there is a huge potential in health care industry and it is changing rapidly, with evolution of technology comes with many challenges both for quality of patient care and healthcare regulatory. To address these changing dynamics, most of the key players in healthcare organization in United States specializing in healthcare technology solutions which utilize new technologies and mobile connectivity to assist the industry in regulatory compliance, improve the care delivery process, provide new models for patient care and improve patient satisfaction

National health care expenditure in US as percent of GDP from 1960 to 2025 (CMS)


Health care expenses are growing and take a larger share of United States economy, it is a driver for US debit at federal level, As per Warren Buffet ‘The ballooning costs of health care act as a hungry tape worm on US economy’ (



Pega is a platform that provides customer engagement and digital process automation solutions. UnitedHealth Group and Pegasystems have signed an Enterprise License Agreement (ELA) that allows for “all you can eat” license for the following products:

  • Customer service for Healthcare (Call-center, CRM solution)
  • Pega Product Composer (to build health plans)
  • Care Management (Population Health Management)
  • Sales automation for healthcare (Opportunity, Quote Management, Group & Member enrollment)
  • Pega Healthcare Claims Automation (Claims Repair and Claims Workstation)
  • Healthcare Industry Foundation (FHIR, Member, Provider Data Models, Appeals & Grievances)
  • Pega Core Platform (Case Management & BPM, Workflow, Reports, Service Level Agreements (SLA), Robotic Automation)

This assignment will review on UHG partnered with Pega and rolled out digital process transformation for healthcare claims automation and what was the outcome

The Business Issue

UnitedHealthcare Medicare & Retirement provides health benefits and services to nearly 10 million people. Compliance requirements and the agents’ growing need for easier access to customer information made it necessary to quickly build a new contact center solution.

The Solution

UnitedHealthcare selected Pega BPM technology to wrap and renew its legacy contact center desktop systems. Phase 1 of the project included a common intake platform, an end-to-end issue management platform, and behind the scenes enhancements to the existing agent desktops to enable a better customer experience. This initial phase was fully deployed and rolled out to 5,000 agents in under 10 months.

The Results

Customers and agents alike are thrilled with the new platform, and it is also delivering bottom-line benefits:

  • Reduced compliance errors
  • Cost savings
  • Call agent empowerment
  • Customer focused
  • Fast agent adoption
  • Reduced training 75%
  • Quickly adapts to the changing market


-          R&D

Agile & Devops

The Optum Scalable Agile Method (OSAM) is a new methodology, built on agile principles and values, that provides a streamlined and simplified framework, to take Optum development groups to the next level of agile maturity. OSAM has been created for the people, by the people, to guide (not inhibit) groups in developing Optum products. It is a scalable, lean, metrics-driven approach to software delivery that fosters engineering excellence and agile maturity.

OSAM provides a blueprint for “agile done well” at any scale. The goals of OSAM are to:

•Raise the quality of our solutions

•Improve the predictability of our releases

•Increase the productivity of our organization

•Provide transparency into project health

•Increase employee engagement

OSAM brings together industry best practices and Optum’s continuous improvement efforts. The OSAM initiative is supported by training, both live and virtual, and a library of guides that describe the activities in each phase of the framework. The Hub Connect portal also provides a community for everyone involved in OSAM to share knowledge.


Application hosting

There are many hosting options available to application developers at Optum. Many options are Platform as a Service, or PaaS. Cloud Computing Platforms give customers the ability to quickly spin up modern application platforms in seconds leveraging runtime containers like Docker. Rapid prototyping, development and testing environments can be started and stopped in seconds. Production workloads can automatically scale out and in based on varying demand. At Optum, several PaaS platforms are available for internal and externally-facing applications:

Lastly, Optum still offers non-cloud related hosting options such as Legacy NGIS, Bare Metal, and Optum FISMA environments.

  • Legacy NGIS – an on-premise managed hosting service.
  • Bare Metal – an on-premise, dedicated physical server.
  • Optum FISMA – an on-premise, virtual machine that meets Federal Information Security Management Act (FISMA) guidelines for use in government data applications.


Big data

Big Data Platform as a Service (BDPaaS) brings several best-of-breed Big Data technologies in a highly scalable, cost-effective, enterprise-grade analytics platform. BDPaaS is a multi-tenant Hadoop platform built on a MapR Converged Data

The UnitedHealth Group (UHG) Data Lake is an organized and managed repository of various UHG data. As one of the major components of the Optum big data platform, it’s a big data repository hub framework on Hadoop.

A separate big data tenant volume has been created for Machine Learning enthusiasts who want to get some hands-on experience with Optum Big Data Machine Learning tools.

Data science

Data Science is a field that bundles computing, analytics, machine learning, and subject matter expertise.

Machine Learning (ML) : ML expands the opportunity of traditional predictive analytics by processing large amounts of data much faster than humanly possible. ML is a subfield of computer science and artificial intelligence, which deals with building systems that can learn from data, instead of explicitly programmed instructions. ML starts with the outcome to automatically uncover the factors that are driving the outcome. These relationships may be incredibly complex, including hundreds of possible causes, interactions, and non-linear responses that might not be realized by traditional methods. With ML we can teach a system to organize, learn, describe, and generate predictions so that we can offer multiple solutions that will best serve our customers’ needs.

UnitedHealth Group has an enormous amount of unstructured and structured healthcare data. By aggregating a healthcare member’s records across a continuum of data sources and applying machine learning methods Optum can begin to transform raw data into meaningful, actionable insights.


Emerging Tech


UHG has several different iOS Developer Enterprise Program accounts. In general, we break this down into two basic account types; one account to develop with and to distribute apps in-house with (private distribution, testing, etc.) and another account to only create apps for the AppStore (public distribution). The first type of account is referred to as the In-House account type while the second type of account is referred to as the Company/Organization account type.

The In-House account type is not allowed to publish apps to the Apple AppStore. The Company/Organization account, on the other hand, is specifically intended to allow Apple AppStore submissions. The control mechanism for all of this resides in the types of certificates that Apple issues for both of these accounts.

Within the UHG organization, we have several brands/organizations that we promote. Consequently, we have different Company/Organization accounts for some of these to ensure that when an app is publicly distributed, the correct name of the publisher and branding is applied in the Apple AppStore.

Open Source

The Open Source Platform is a strategic initiative aimed at changing Optum’s approach to architecting and developing solutions. A sample application illustrating the recommended approach is the end product.

The approach must meet the following high-level non-functional requirements:

  • Physical architecture assumes the use of commodity hardware with little or no resiliency provided.
  • Software solution must focus on resiliency and scalability.
  • Open source software must be used throughout the software stack.
  • NO commercial products can be used in the solution of the end product.
  • The application musct be able to withstand failure of multiple components and continue to perform with acceptable response times.
  • The application should be capable of automatic horizontal scaling up and down to handle increases in load.
  • The application should be portable so using capacity from public and private clouds is as “seamless” as possible.
  • The application should use the principles of the 12 Factor App as much as possible.
  • The application should be designed according to latency, failure, resource awareness principles as well as using event-driven, parallel, and secure architecture principles.
  • The application should assume a DevOps model and employ automation wherever possible.


United health group had several acquisitions from past few decades, the main reason behind acquiring companies is to focus on diversifying UHG businesses and ensure that it stays ahead of the competitors in United States health care industry by providing best services to customer using the latest technologies, here is the list of acquisitions since 1993

The acquisitions helped united health group to reevaluate their long term strategies to address the challenges caused by operational silos, technology silos, company culture, high cost to integrate these silos and lack of technologies to match human intelligence. The emergence of robotic process automation (RPA) for operational digital transformation helped organizations to

-          Eliminate redundant work and automate any manual work

-          Engage customers through ‘chat bot’, ‘voice’ or any media

-          Provide real time metrics and change management capabilities



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