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Health Insurance Industry Reference Architecture

Capability maps, value streams, and strategy maps for health insurance organizations.

  • Health insurers require a unified and validated view of their capabilities that aligns product development, distribution and underwriting, policy management and servicing, and claims management to provide value to patients and stakeholders.
  • Health insurance organizations, including Medicare providers, are a central component of the healthcare system and interact with providers and other points of care across the healthcare continuum.
  • Health insurers are focused on developing products and services that facilitate the payment of health costs related to illness or injury.
  • Depending on where you live, health insurance may be provided as single payer, private, public-government payers, or through a combination of private insurance and public-government payers.
  • The business and IT often focus on a project, ignoring the holistic impact and value of an overarching value stream and business capability view.

Our Advice

Critical Insight

Using an industry-specific reference architecture is central, and has many benefits, to organizational priorities. It’s critical to understanding, modeling, and communicating the operating environment and the direction of the organization, but more significantly, to enabling measurable top-line organizational outcomes and the unlocking of direct value.

Impact and Result

  • Demonstrate the value of IT’s role in supporting your health insurance organization’s capabilities while highlighting the importance of proper alignment between organizational and IT strategies.
  • Apply reference architecture techniques such as strategy maps, value streams, and capability maps to design usable and accurate blueprints of your health insurance operations.
  • Assess your initiatives and priorities to determine if you are investing in the right capabilities. Conduct capability assessments to identify opportunities and to prioritize projects.

Health Insurance Industry Reference Architecture Research & Tools

1. Accelerate the strategy design process

Leverage a validated view of the hospital’s business capabilities to realize measurable top-line business outcomes and unlock direct value.


Health Insurance Industry Reference Architecture

Business Capability Maps, Value Streams, and Strategy Maps for the Health Insurance Industry

Analyst Perspective

In the age of disruption, IT must end misalignment and enable value realization.

An industry reference architecture helps accelerate your strategy design process and enhances IT’s ability to align people, process, and technology with key business priorities.

Health Insurers require a unified and validated view of their capabilities that aligns product development, distribution and underwriting, policy management and servicing, and claims management to provide value to patients and stakeholders.

Health insurance organizations are a central component of the healthcare system and interact with providers and other points of care across the healthcare continuum.

Health insurers are focused on developing products and services that facilitate the payment of health costs related to illness or injury.

Depending on where you live, health insurance may be provided as single, private, or public government payers, or through a combination of private insurance and public government payers.

Jennifer Jones

Research Director, Healthcare

Info-Tech Research Group

Executive Summary

Your Challenge

  • You are a CIO, head of EA, or chief architect who needs to improve your organization’s understanding of business capabilities and how IT can provide support.
  • You work for an organization that wants to sharpen its alignment and focus on organizational outcomes and value by using architecture to better inform innovation, stakeholder management, and IT strategy capabilities.
  • Before executing any strategic initiatives, use this guide to understand how the organization creates value and the underlying capabilities and processes of the organization.

Common Obstacles

  • You don’t know where or how to begin, or how to engage the right people, model the business, and drive the value of an architecture.
  • The business and IT often speak in their own languages without a holistic and integrated view of mission, strategies, goals, processes, and projects.
  • The business and IT often focus on a project, ignoring the holistic value of an overarching value stream and business capability view.

Info-Tech’s Approach

  • Build your organization’s capability map by defining the organization’s value stream and validating the industry reference architecture.
  • Use business capabilities to define strategic focus by defining the organization’s key capabilities and developing a prioritized strategy map.
  • Assess key capabilities for planning priorities through a review of business processes, information, and application and technology support of key capabilities.
  • Consolidate capability gaps for incorporation into priorities.

Info-Tech Insight

Using an industry-specific reference architecture is central and has many benefits to organizational priorities. It’s critical to understanding, modeling, and communicating the operating environment and the direction of the organization, but more significantly, to enabling measurable top-line organizational outcomes and the unlocking of direct value.

Reference Architecture Framework

Overarching Insight

Using an industry-specific reference architecture is central and has many benefits to organizational priorities. It's critical to understanding, modelling, and communicating the operating environment and the direction of the enterprise, and more significantly, to enabling measurable top-line business outcomes and the unlocking of direct value.

Determine your organizational priority.

Many organizational priorities are dependent on an understanding of how the organization creates value and the organization's capabilities and processes.

Examine organizational opportunities through the lens of business, information/data, applications & technology

Your understanding of your organization's business capabilities, processes, (rules & logic), information/data, and architecture will identify organizational opportunities to create value through reduced costs or increased revenues and services.

Follow Info-Tech's methodology to enable organizational outcomes and unlock direct value.

Your approach indicates the scope of your modernization initiatives.

Build your organization's capability map by defining the organization's value stream and validating the industry reference architecture.

Use business capabilities to define strategic focus by defining the organization's key capabilities and developing a prioritized strategy map.

Assess key capabilities for planning priorities through a review of business processes, information, applications, and technology support of key capabilities.

Sustain capability-based strategy planning through ongoing identification and roadmapping of capability gaps.

The image is a graphic with concentric circles. At centre is Value (Revenue, Margin, Assets). The next level is separated into 4 sections: 1. Build, 2. Define, 3. Assess & Prioritize, 4. Sustain. The next level is also 4 sections: Business; Information/Data; Applications; and Technology. The next level includes a number of sections, connected to the previous areas: Governance & Risk; Business Context; Business Strategy; IT Strategy; Innovation; IT Budget; Digital Transformation; Core Application Rationalization & Modernization; IT Service Mgmt; Requirements; Data; Org Design/Operating Model. The outermost layer includes the title Industry Context.

Industry Overview: Health Insurance

Health Insurance organizations operate in an interconnected web of products and service providers that create opportunities for people to have healthy lives.

The cross-integration of healthcare is driven by the complexity required to maintain good health. Healthcare payers such as insurance companies and government institutions often pay for a portion of or all products and services. Health insurance organizations are a key component of the healthcare system and interact with hospitals, medical, dental, vision and other points of care across the healthcare continuum. Finally, both providers and patients use healthcare products to manage health.

Health insurers are focused on developing products and benefits for the payment of health costs related to illness or injury. The primary activity of health insurers is to underwrite a variety of claims and develop products and services that create opportunities for patients. Increasingly, health insurers are focused on preventative care of patient outcomes, reducing healthcare costs using predictive analytics, and early intervention data models.

Depending on where you live, insurance may be provided as single payer, private insurance, public government funds, or through a combination of private insurance and public government payers. Insurance services vary by policy holder and polices are often based on pre-defined selections by employers.

Product Development → Distribution & Underwriting → Policy Management & Servicing → Claims Management

Figure above: Value Chain for the Healthcare Industry

Business Value Realization

Business value defines the success criteria of an organization as manifested through organizational goals and outcomes, and it is interpreted from four perspectives:

  • Profit generation: The revenue generated from a business capability with a product that is enabled with modern technologies.
  • Cost reduction: The cost reduction when performing business capabilities with a product that is enabled with modern technologies.
  • Service enablement: The productivity and efficiency gains of internal business operations from products and capabilities enhanced with modern technologies.
  • Customer and market reach: The improved reach and insights of the business in existing or new markets.

Business Value Matrix

Outward
Improved capabilities Customer and market reach Profit generation Financial benefit
Service enablement Cost reduction
Inward

Value, goals, and outcomes cannot be achieved without business capabilities

Break down your business goals into strategic and achievable initiatives focused on specific value streams and business capabilities.

Business Goals & Desired Outcomes Business Initiatives Level 1 Business Capabilities Level 2 Business Capabilities
Achieved Through → Create or Improve →

Health Insurance and healthcare business capability map

The image is a business capability map, with the following categories: Product Development; Distribution & Underwriting; Policy Management & Servicing; and Claims Administration.

Business capability map defined…

In business architecture, the primary view of an organization is known as a business capability map.

A business capability defines what a business does to enable value creation, rather than how. Business capabilities:

  • Represent stable business functions.
  • Are unique and independent of each other.
  • Typically will have a defined business outcome.

A business capability map provides details that help the business architecture practitioner direct attention to a specific area of the business for further assessment.

Glossary of Key Concepts

A business reference architecture consists of a set of models to provide clarity and actionable insight and value. Typical techniques and terms used in developing these models are:

Term/Concept Definition
Industry Value Chain A high-level analysis of how the industry creates value for the consumer as an overall end-to-end process.
Business Capability Map The primary visual representation of the organization’s key capabilities. This model forms the basis of strategic planning discussions.
Industry Value Streams The specific set of activities an industry player undertakes to create and capture value for and from the end consumer.
Strategic Objectives A set of standard strategic objectives that most industry players will feature in their corporate plans.
Industry Strategy Map A visualization of the alignment between the organization’s strategic direction and its key capabilities.
Capability Assessments Based on people, process, information, and technology, a heat-mapping effort that analyzes the strength of each key capability.
Capability An ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and typically require a combination of organization, people, processes, and technology to achieve.

Tools and templates to compile and communicate your reference architecture work

The Health Insurance Industry Reference Architecture Template is a place for you to collect all the activity outputs and outcomes you’ve completed for use in the next steps.

Download the Health Insurance Industry Reference Architecture Template

Info-Tech’s methodology for a reference architecture

1. Build your organization’s capability map 2. Use business capabilities to define strategic focus 3. Assess key capabilities for planning priorities 4. Adopt capability-based strategy planning
Phase Steps

1.1 Define the Organization’s Value Stream

1.2 Develop a Business Capability Map

2.1 Define the Organization’s Key Capabilities

2.2 Develop a Strategy Map

3.1 Business Process Review

3.2 Information Assessment

3.3 Technology Opportunity Identification

4.1 Consolidate and Prioritize Capability Gaps
Phase Outcomes
  • Defined and validated value streams specific to your organization
  • A validated level 1 business capability map
  • Identification of level 1 cost advantage creators
  • Identification of level 1 competitive advantage creators
  • Defined future-state capabilities
  • Identification of capability process enablement
  • Identification of capability data support
  • Identification of capability application and technology support
  • Prioritization of key capability gaps

Info-Tech offers various levels of support to best suit your needs

DIY Toolkit

"Our team has already made this critical project a priority, and we have the time and capability, but some guidance along the way would be helpful."

Guided Implementation

"Our team knows that we need to fix a process, but we need assistance to determine where to focus. Some check-ins along the way would help keep us on track."

Workshop

"We need to hit the ground running and get this project kicked off immediately. Our team has the ability to take this over once we get a framework and strategy in place."

Consulting

"Our team does not have the time or the knowledge to take this project on. We need assistance through the entirety of this project."

Diagnostics and consistent frameworks are used throughout all four options.

Guided Implementation

What does a typical GI on this topic look like?

A Guided Implementation (GI) is a series of calls with an Info-Tech analyst to help implement our best practices in your organization.

A typical GI is between six to nine calls over the course of one to four months.

Phase 1

Call #1: Introduce Info-Tech’s industry reference architecture methodology.

Phase 2

Call #2: Define and create value streams.

Call #3: Model level 1 business capability maps.

Phase 3

Call #4: Map value streams to business capabilities.

Call #5: Model level 2 business capability maps.

Call #6: Create a strategy map.

Call #7: Introduce Info-Tech's capability assessment framework.

Phase 4

Call #8: Review capability assessment map(s).

Call #9: Discuss and review prioritization of key capability gaps and plan next steps.

Phase 1

Build your organization’s capability map

Phase 1

1.1 Define the Organization’s Value Stream

1.2 Develop a Business Capability Map

Phase 2

2.1 Define the Organization’s Key Capabilities

2.2 Develop a Strategy Map

Phase 3

3.1 Business Process Review

3.2 Information Assessment

3.3 Technology Opportunity Identification

Phase 4

4.1 Consolidate and Prioritize Capability Gaps

This phase will guide you through the following activities:

  • Identify and assemble key stakeholders
  • Determine how the organization creates value
  • Define and validate value streams
  • Determine which business capabilities support value streams
  • Accelerate the process with an industry reference architecture
  • Validate the business capability map
  • Establish Level 2 capability decomposition priorities
  • Decompose Level 2 capabilities

This phase involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Step 1.1

Define the organization’s value stream

Activities

1.1.1 Identify and assemble key stakeholders

1.1.2 Determine how the organization creates value

1.1.3 Define and validate the organization’s value streams

Build your organization’s capability map

Step 1.1 → Step 1.2

This step will guide you through the following activities:

  • Identify and assemble key stakeholders
  • Determine how the organization creates value
  • Define and validate the organization’s value streams

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Outcomes of this step

  • Defined and validated value streams specific to your organization

1.1.1 Identify and assemble key stakeholders

1-3 hours

Input

  • List of who is accountable for key business areas and decisions
  • Organizational chart
  • List of who has decision-making authority

Output

  • A list of the key stakeholders
  • Prioritized list of decision-making support needs

Materials

  • Whiteboard/flip charts
  • Healthcare Industry Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Build an accurate depiction of the business.

  1. It is important to make sure the right stakeholders participate in this exercise. The exercise of identifying capabilities for an organization is very introspective and requires deep analysis.
  2. Consider:
    • Who are the decision makers and key influencers?
    • Who will impact the business architecture work? Who has a vested interest in the success or failure of the practice?
    • Who has the skills and competencies necessary to help you be successful?
  3. Avoid:
    • Don’t focus on the organizational structure and hierarchy. Often stakeholder groups don’t fit the traditional structure.
    • Don’t ignore subject matter experts on either the business or IT side. You will need to consider both.

Download the Health Insurance Industry Reference Architecture Template

Define the organization’s value streams

  • Value streams connect business goals to the organization’s value realization activities. They enable an organization to create and capture value in the marketplace by engaging in a set of interconnected activities. Those activities are dependent on the specific industry segment an organization operates within. Value streams can extend beyond the organization into the supporting ecosystem, whereas business processes are contained within and the organization has complete control over them.
  • There are two types of value streams: core value streams and support value streams. Core value streams are mostly externally facing. They deliver value to either an external or internal customer and they tie to the customer perspective of the strategy map. Support value streams are internally facing and provide the foundational support for an organization to operate.
  • An effective method for ensuring all value streams have been considered is to understand that there can be different end-value receivers. Info-Tech recommends identifying and organizing the value streams with customers and partners as end-value receivers.

The image is a graphic, arranged horizontally. It begins on the left with the Industry Value Chain, then arrows point right to the Value Receivers: Customers; Partners. There is another arrow pointing to the right, to the Value Streams. Beneath that, are boxes labelled Capabilities.

Value stream descriptions for health insurance

Value Streams:

Product Development

  • Product development is focused on driving the company's strategy, value proposition, marketing, and long-term competitiveness.
  • It covers activities necessary to transform market opportunities and technical capabilities into products that meet distribution and consumer needs while adding value to the company.

Distribution & Underwriting

  • Distribution is the method by which the company reaches and provides policies to its insurers, such as a direct insurer, company, or government agent.
  • Underwriting involves measuring risk exposure and determining the optimal premium that needs to be charged in order to ensure that risk.

Policy Management & Servicing

  • Policy management deals with understanding customers, making new policies with various risk coverages, document verification, customer relationship management, and risk and compliance management.
  • This process enables new business and cash flow into the company.

Claims Management

  • Claims management is the process that functions bilaterally between payers, patients, and providers in order to process, adjudicate, and pay billing claims for health treatment.
  • They include elements spanning work from the intake to the adjudication of claims, including post-payment processing.

Determine how the organization creates value

Begin the process by identifying and locating the business mission and vision statements.

Corporate Websites

Business Strategy Documents

Business Mission

Business Executives

Business Vision

What is business context?

“The business context encompasses an understanding of the factors impacting the business from various perspectives, including how decisions are made and what the business is ultimately trying to achieve. The business context is used by IT to identify key implications for the execution of its strategic initiatives.” (Business Wire, 2018)

1.1.2 Determine how the organization creates value

1-3 hours

The first step of delivering value is defining how creating value will happen.

  1. Use the organization’s industry segment to start a discussion on how value is created for customers. Working back from the moment value is realized by the customer, consider the sequential steps required to deliver value in your industry segment.
  2. The first step to delivering value is defining how creating value will happen. Consider:
    • Who are your customers?
    • What tasks are your customers looking to accomplish?
    • How does your organization’s set of products and services help them accomplish that?
    • What are the benefits the organization delivers to them?
  3. Avoid:
    • Don’t boil the ocean. Focus on your industry segment and how you deliver value to your partners and customers specifically.

Download the Health Insurance Industry Reference Architecture Template

1.1.2 Determine How the Organization Creates Value

Input

  • Business strategy
  • Financial statements
  • Results of SWOT analysis
  • Info-Tech’s industry-specific reference architecture

Output

  • Health Insurance Industry Reference Architecture Template

Materials

  • Whiteboard/flip charts
  • Health Insurance Industry Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

1.1.3 Define and validate value streams

1-3 hours

Input

  • Business strategy
  • Info-Tech’s industry-specific reference architecture

Output

  • List of organization-specific value streams
  • Detailed value stream definition(s)

Materials

  • Whiteboard/flip charts
  • Healthcare Industry Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Unify the organization’s perspective on how it creates value.

  1. Write a short description of the value stream that includes a statement about the value provided and a clear start and end for the value stream. Validate the accuracy of the descriptions with your key stakeholders.
  2. Consider:
    • How does the organization deliver those benefits?
    • How does the customer receive the benefits?
    • What is the scope of your value stream? What will trigger the stream to start and what will the final value be?
  3. Avoid:
    • Don’t start with a blank page. Use Info-Tech’s value stream definitions as a starting point and customize from there.

Download the Health Insurance Industry Reference Architecture Template

Step 1.2

Develop a business capability map

Activities

1.2.1 Determine which business capabilities support value streams

1.2.2 Accelerate the process with an industry reference architecture

1.2.3 Validate the business capability map

1.2.4 Establish level 2 capability priorities

1.2.5 Deconstruct capabilities

Build your organization’s capability map

Step 1.1 → Step 1.2

This step will guide you through the following activities:

  • Determine which business capabilities support value streams
  • Accelerate the process with an industry reference architecture
  • Validate the business capability map
  • Establish Level 2 capability priorities
  • Decompose Level 2 capabilities

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Outcomes of this step

  • A validated level 1 business capability map
  • Deconstructed level 2 capabilities

Develop a business capability map – level 1

  • Business architecture consists of a set of techniques to create multiple views of an organization; the primary view is known as a business capability map.
  • A business capability defines what a business does to enable value creation and achieve outcomes, rather than how. Business capabilities are business terms defined using descriptive nouns such as “Marketing” or “Research and Development.” They represent stable business functions, are unique and independent of each other, and typically will have a defined business outcome. Business capabilities should not be defined as organizational units and are typically longer lasting than organizational structures.
  • A business capability mapping process should begin at the highest-level view of an organization, the level 1, which presents the entire business on a page.
  • An effective method of organizing business capabilities is to split them into logical groupings or categories. At the highest level, capabilities are either “core” (customer-facing functions) or “enabling” (supporting functions). As a best practice, Info-Tech recommends dividing business capabilities into the categories illustrated to the right:

The image shows a grid of blank squares, in three rows. The top row is labelled Defining Capabilities, the middle row is labelled Shared Capabilities, and the third row is labelling Enabling Capabilities.

Business capability map for Health Insurance

The image is the same business capability map from an earlier section.

Legend:

Mid-blue - Level 1 Capabilities

Light blue - Level 2 Capabilities

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

Glossary of capabilities

A business capability is an ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and require a combination of organization, people, processes, and/or technology to achieve. Level 1 healthcare capabilities used in this reference architecture model are:

Capability Definition
Underwriting
Case Management The planning, processing, and monitoring of the healthcare services given to a patient by a coordinated group of healthcare providers. Insurance companies, hospitals, and outpatient care providers may all assign a case manager to monitor a particular patient.
IT Management Providing day-to-day management and operation of IT assets and processes. This is typically divided between operations, application management, and helpdesk management services.
Credentialing Insurance credentialing (or Provider Enrollment) refers to the process of applying to health insurance networks for inclusion in their provider panels. The Contracting phase of enrollment is when the provider has been approved by Credentialing and is extended a contract for participation.
Credentialing A process used to monitor and control key IT capability decisions, to ensure the delivery of value to key stakeholders within an organization.

1.2.1 Determine which business capabilities support value streams

1-3 hours

Deconstruct value streams into their component capabilities.

  1. Analyze the value streams to identify and describe the organization’s capabilities that support them. This stage requires a good understanding of the business and will be a critical foundation for the business capability map.
  2. Consider:
    • What is the objective of your value stream? This can highlight which capabilities support which value streams.
    • What are the activities that make up the business?
    • Segmenting your value stream into individual stages will give you a better understanding of the steps involved in creating value.
  3. Avoid:
    • Don’t do this alone. Make sure the right stakeholders participate. The exercise of identifying capabilities for an organization is very introspective and requires deep analysis. It is challenging to develop a common language that everyone will understand and be able to apply. Don’t waste your efforts building an inaccurate depiction of the business.

Download the Health Insurance Industry Reference Architecture Template

1.2.1 Determine which business capabilities support value streams

Input

  • Value streams from previous activities

Output

  • List of organization-specific capabilities mapped to value streams
  • Reference Architecture Template

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

1.2.2 Accelerate the process with an industry reference architecture

1-3 hours

It’s never a good idea to start with a blank page.

  1. The business capability map on the last slide of this phase can be used as an accelerator. Assemble the relevant stakeholders – business unit leads and product/service owners – and modify the business capability map to suit your organization’s context.
  2. Consider:
    • What are the activities that make up your business?
    • Can these activities be tied to outcomes? If not, they might not apply to your organization.
    • Are there any capabilities on the map that don’t fit the organization? Deselect them if yes.
  3. Avoid:
    • Don’t repeat capabilities. Capabilities are typically mutually exclusive activities.
    • Don’t include temporary initiatives. Capabilities should be stable over time. The people, processes, and technologies that support capabilities will change continuously.

Customize generic capability maps with the assistance of Info-Tech’s industry analysts.

Download the Health Insurance Industry Reference Architecture Template

1.2.2 Accelerate the process with an Industry Reference Architecture

Input

  • Value streams from previous activities
  • Info-Tech’s industry-specific reference architecture accelerator

Output

  • List of organization-specific capabilities mapped to value streams
  • Reference Architecture Template

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

1.2.3 Validate the business capability map

1-3 hours

Input

  • List of organization-specific capabilities mapped to value streams
  • Reference Architecture Template

Output

  • Level 1 business capability map
  • Reference Architecture Template

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Crowdsource the capability map validation.

  1. Validate the capability map with the executive team (those who were not included) and other key stakeholders. Use the validation of your business capability map as an excuse to start a conversation regarding the organization’s overall strategy.
  2. Consider:
    • Are there any sensitive areas of the organization that may take this effort the wrong way? Engage them to get their input as early as possible to ensure they don’t feel left out or alienated.
  3. Avoid:
    • Don’t delay validating the maps with top-level executives. Without their support, your architecture practice won’t be taken seriously.
    • Don’t leave anyone out on the assumption that they won’t be interested. This process will foster alignment between organizational silos.

Download the Health Insurance Industry Reference Architecture Template

Develop a business capability map – Level 2

  • Level 2 business capabilities define individual Level 1 capabilities at a more granular level of detail. Level 2 capabilities typically represent individual stable business and operational functions that, while unique and independent of each other, typically will have a collection of processes that make an overall contribution to, and enable, Level 1 capabilities.

The image is a graphic with 2 rows, and the title Human Resources. The top row is labelled Level 1 capability, and the lower row is labelled Level 2 capability. Level 1 includes: HR Strategy & Planning; Workforce Management; HR Analytics & Reporting; People Relationship Management. Level 2 includes: Recruitment & Hiring; Talent Management; Learning & Development; Compensation & Benefits Management

1.2.4 Establish level 2 capability priorities

1-3 hours

Deconstruct your level 1 capabilities into their component capabilities.

  1. Analyze the level 1 business capabilities to identify and describe at a deeper, more granular level the organization’s capabilities that support them. This stage requires a good understanding of the business and will be a critical foundation for the level 2 business capability map.
  2. Consider:
    • Which level 1 capabilities enable the most critical stages of your chosen value stream?
    • Which level 1 capabilities enable the most stages of the value stream?
  3. Avoid:
    • Don’t try to cut corners. Although it may be tempting to jump right to this step and avoid doing your level 1 mapping, you will run the risk of model pollution. Starting with level 1 helps ensure you have a unified view of your organization’s capabilities and will help you avoid having to re-do work later.

Download the Health Insurance Industry Reference Architecture Template

1.2.4 Establish level 2 capability priorities

Input

  • Level 1 business capability map and a value stream for areas of interest and focus
  • Reference Architecture Template

Output

  • Prioritized list of level 1 business capabilities for deconstruction

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

1.2.5 Deconstruct capabilities

1-3 hours

Input

  • Prioritized list of level 1 business capabilities for deconstruction
  • Reference Architecture Template

Output

  • Level 2 capabilities for your main areas of interest and/or focus

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Deconstruct level 1 capabilities into their component level 2 capabilities.

  1. Using the level 1 capability map as a baseline, hold working sessions with the lines of business represented by each (or your selected) level 1 capability or set of related capabilities and decompose them.
  2. Consider:
    • Will you want to go deeper (to level 3)? If so, then confirm if the team you’re using for level 2 has the necessary knowledge to go to level 3 (or further) and perhaps drill down to level 3 concurrently.
  3. Avoid:
    • Don’t do this alone. Make sure the right stakeholders participate. Identifying level 2+ capabilities for an organization is a very introspective exercise, requiring deep analysis and an understanding of business functions and processes. It’s challenging to develop a common language that everyone will understand and be able to apply here. Don’t waste your efforts building an inaccurate depiction of the business.

Download the Health Insurance Industry Reference Architecture Template

Level 2 capability map deconstruction

The image is the same business capability map from an earlier section.

Legend:

Mid-blue - Level 1 Capabilities

Light blue - Level 2 Capabilities

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

Glossary of capabilities

A business capability is an ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and require a combination of organization, people, processes, and/or technology to achieve. Level 2 capabilities that are used in this reference architecture model are:

Capability Definition
Data Management Health Data Management (HDM) is the methodical organization of health data in digital format, it supports providing quality care, and estimating cost of services offered.
Contracting A document representing the agreement between an insurance company and the insured. Central to any insurance contract is the insuring agreement, which specifies the risks covered, the limits of the policy, and the term of the policy.
Research & Development Involves activities that health insurance companies undertake to innovate and introduce new products and services. It is often the first stage in the development process. The goal is typically to take new products and services to market and add to the company's bottom line.

Glossary of capabilities (continued)

A business capability is an ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and require a combination of organization, people, processes, and/or technology to achieve. Level 2 capabilities that are used in this reference architecture model are:

Capability Definition
Clinical Collaboration Organizations work together in teams (or in small groups of professionals). Each has skills, equipment, and knowledge that compliment their peers and result in effective outcomes for patients.
Partnership Management Partnership management involves bringing together separate organizations to benefit from shared experiences and resources to improve the efficiency and quality of service provision.
Utilization Management Utilization management or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
Case Management The planning, processing, and monitoring of the healthcare services given to a patient by a coordinated group of healthcare providers. Insurance companies, hospitals, and outpatient care providers may all assign a case manager to monitor a particular patient.
Remote Monitoring The use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions.

Glossary of capabilities (continued)

A business capability is an ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and require a combination of organization, people, processes, and/or technology to achieve. Level 2 capabilities that are used in this reference architecture model are:

Capability Definition
Fraud Analysis Detection technique calculates the likelihood or probability of each record to be fraudulent by analyzing the past insurance claims. Examples of health insurance fraud includes activities like falsifying a patient's diagnosis to justify the need for tests, surgeries, or other procedures that are not medically necessary. Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery.
Waste, Abuse, and Fraud Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system. Abuse is any provider practices that are inconsistent with sound fiscal, business, or medical practices, and result either in an unnecessary cost to the federally-funded programs or in reimbursement for services that are not medically necessary or provider practices that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the federally funded programs. Fraud is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Glossary of capabilities (continued)

A business capability is an ability that an organization, person, or system possesses. Capabilities are typically expressed in general and high-level terms and require a combination of organization, people, processes, and/or technology to achieve. Level 2 capabilities that are used in this reference architecture model are:

Capability Definition
Data Quality and Compliance Data quality management is a set of procedures and technologies for effectively integrating and validating data sources, securely collaborating between trusted parties, handling lifecycle systems such as aggregation and deduplication, and safely sharing the results while protecting sensitive customer information.
Relationship Management A strategy in which a health insurer maintains an ongoing level of engagement with its audience. This management can occur between a business and its customers (business to consumer [B2C]) or between a business and other businesses (business to business [B2B]). Relationship management aims to create a partnership between an organization and its patrons, instead of viewing the relationship as merely transactional.
Billing Management The process involves a healthcare provider obtaining insurance information from a patient, filing a claim, following up on and appealing claims with health insurance companies in order to receive payment for services rendered such as testing, treatments, and procedures. The same process is used for most insurance companies, whether they are private companies or government-sponsored programs: Medical coding reports what the diagnosis and treatment were, and prices are applied accordingly.
Benefits Management Benefit: the amount payable by the insurance company to a plan member for medical costs. Benefit level: the maximum amount that a health insurance company has agreed to pay for a covered benefits.

Medicare reference architecture showing capabilities undre the categories of Product, Marketing & Sales, Enrollment & Eligibility, Helath & Wellness, Claims, and Clinical, as well as shared capabilities and enabling capabilities.

Phase 2

Use business capabilities to define strategic focus

Phase 1

1.1 Define the Organization’s Value Stream

1.2 Develop a Business Capability Map

Phase 2

2.1 Define the Organization’s Key Capabilities

2.2 Develop a Strategy Map

Phase 3

3.1 Business Process Review

3.2 Information Assessment

3.3 Technology Opportunity Identification

Phase 4

4.1 Consolidate and Prioritize Capability Gaps

This phase will guide you through the following activities:

  • Determine cost advantage creators
  • Determine competitive advantage creators
  • Define key future-state capabilities
  • Identify the strategic objectives for the business
  • Map strategic objectives to IT programs
  • Validate the strategy map and program prioritization

This phase involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Step 2.1

Define the organization’s key capabilities

Activities

2.1.1 Determine cost advantage creators

2.1.2 Determine competitive advantage creators

2.1.3 Define key future-state capabilities

Use business capabilities to define strategic focus

Step 2.1 →Step 2.2

This step will guide you through the following activities:

  • Determine cost advantage creators
  • Determine competitive advantage creators
  • Define key future-state capabilities

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Outcomes of this step

  • Identification of levels 1 and 2 cost advantage creators
  • Identification of levels 1 and 2 competitive advantage creators
  • Future-state capabilities

Define the organization’s key capabilities

  • A discussion about the key or most-critical capabilities is an excellent opportunity for IT leaders to review, refresh, and even reset expectations from the business as to what value IT should be providing to the organization. There is often misalignment as to whether, or to what extent, IT should be making strategic investments to help the business enhance its capabilities through technology. Some IT leaders believe they should be transforming the organization, while their CEO wants them to focus on operational efficiencies.
  • Depending on the mandate from the business, an IT leader may focus on developing a cost advantage for the organization by directing technology efforts to capabilities that deliver efficiency gains. This is often the case for many IT leaders for whom the primary role for IT is to enable the business to deliver its products/services to the end consumer at the lowest cost possible. These capabilities are known as cost advantage creators.
  • Organizations can develop a competitive advantage over their industry counterparts by creating a differentiated experience for the organization’s customers. Increasingly, this is facilitated and made possible through technology. IT can direct investment into capabilities that will improve their organization’s competitive position in its market by delivering unique or enhanced experiences for the organization’s end customers. IT can focus on developing a competitive advantage by directing efforts onto capabilities that are end-customer facing. These are known as the organization’s competitive advantage creators.

The image is a graphic, with a blank Business Capability Map in the centre. To the left of the template, is the following text: Cost Advantage Creators - Focusing on these capabilities will help the organization derive operational efficiencies. To the right of the template is the following text: Competitive Advantage Creators, Focusing on these capabilities will deliver differentiated end-customer experiences.

Defining key capabilities for healthcare

The image is a business capability map, with the following categories: Product Development; Distribution & Underwriting; Policy Management & Servicing; Claims Administration. The sections of the map coloured in light blue, mid-coloured blue, and dark blue, according to the legend transcribed below.

Legend:

Mid-blue - Cost Advantage Creators

Dark blue - Competitive Advantage Creators

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

2.1.1 Determine cost advantage creators

1-3 hours

Input

  • Value stream and level 0 and level 1 capabilities from previous activities
  • Reference Architecture Template

Output

  • Identified capabilities that create cost advantages

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Focus on capabilities that drive a cost advantage for your organization.

  1. If your organization has a cost advantage over competitors, the capabilities that enable it should be identified and prioritized. Highlight these capabilities and prioritize the programs that support them.
  2. Consider:
    • What is the source of your cost advantage? IT should support the capabilities that drive the cost advantage.
    • Is the industry you operate in sensitive to prices?
  3. Avoid:
    • Don’t focus on capabilities that create an unsustainable cost advantage. Take a long-term perspective and allocate your resources wisely.

Download the Health Insurance Industry Reference Architecture Template

2.1.2 Determine competitive advantage creators

1-3 hours

Prioritize capabilities that give your organization an edge over rivals.

  1. If your organization does not have a cost advantage over competitors, determine if it can deliver differentiated end-customer experiences. Once you have identified the competitive advantages, understand which capabilities enable them. These capabilities are critical to the success of the organization and should be highly supported.
  2. Consider:
    • Are there any products or services your organization provides that customers consider superior to competitors’ offerings?
    • Which capabilities enable the competitive advantage?
    • How easy is it for competitors to neutralize your competitive advantage? Focus on the capabilities that are difficult to replicate by competitors to create a more sustainable advantage.
  3. Avoid:
    • Don’t determine the competitive advantages alone. Incorporate various perspectives from throughout the organization to truly understand how the organization competes in the marketplace.

Download the Health Insurance Industry Reference Architecture Template

2.1.2 Determine competitive advantage creators

Input

  • Value stream and level 1 and level 2 capabilities from previous activities
  • Cost advantage creators from previous activity
  • Reference Architecture Template

Output

  • Identified capabilities that create competitive advantages

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

2.1.3 Define key future-state capabilities

1-3 hours

Input

  • Value stream and level 0 and level 1 capabilities from previous activities
  • Cost advantage creators from previous activity
  • Competitive advantage creators from previous activity
  • Reference Architecture Template

Output

  • Identified enhancements to existing or new organizational capabilities

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Know where you want to go and chart a course to get there.

  1. In addition to the current cost and competitive advantage creators, the organization may have the intention of enhancing new capabilities. Discuss and select the capabilities that will help drive the attainment of future goals.
  2. Consider:
    • Are your competitors doing anything to give them a competitive advantage? Can your organization easily replicate the capabilities needed to neutralize that advantage?
    • How is the external environment (political, economic, social, or technological) likely going to change in the future? How might these changes impact your current key capabilities?
  3. Avoid:
    • Don’t blindly copy your competitors’ strategies. It is important to understand that each organization is unique; before focusing on key capabilities that might neutralize your competitors’ advantages, ensure they fit well with your overall strategy.

Download the Health Insurance Industry Reference Architecture Template

Step 2.2

Develop a strategy map

Activities

2.2.1 Identify the strategic objectives for the business

2.2.2 Map the strategic objectives to the IT programs that support them

2.2.3 Validate the strategy map and program prioritization

Use business capabilities to define strategic focus

Step 2.1 → Step 2.2

This step will guide you through the following activities:

  • Identify the strategic objectives for the business
  • Map the strategic objectives to the IT programs that support them
  • Validate the strategy map and program prioritization

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Portfolio manager (PMO director)
  • Departmental executive and senior managers

Outcomes of this step

  • Identification of the business’s strategic objectives
  • Defined and validated strategy map and goal cascade

Develop a strategy map

  • A strategy map is a tool to help narrow the focus onto what matters most. With ever-changing resources, business strategies, and external environments, the strategy map can ensure IT is consistently providing value through the enhanced prioritization of IT programs.
  • Strategy mapping is a technique that helps the executive suite communicate the business strategy to other levels of the organization by visually representing the organizational strategic objectives and mapping each of them to value streams, business capabilities, and ultimately, to specific IT programs. There are five layers to a strategy map: strategic business goals, business initiatives, value streams, business capabilities, and IT programs.
  • Strategic business goals are the targets and outcomes that the organization is looking to achieve.
  • Value streams enable an organization to create and capture value in the market through interconnected activities that support strategic objectives.
  • Business capabilities define what a business does to enable value creation in value streams, rather than how.
  • IT programs are actionable descriptions of how the IT department will enable one or multiple business capabilities in its target state.

The image is a graphic of a strategy map. The left-hand section of the graphic is the same business goals/strategic and achievable initiatives map from a previous section. The right-hand section of the graphic add IT capabilities, initiatives, and goals.

2.2.1 Identify the strategic objectives for the business

1-3 hours

Knowing the key strategic objectives for the business will drive business-IT alignment.

  1. It is important to make sure the right strategic objectives of the organization have been identified and are well understood. Engage the right stakeholders to help identify and document the key strategic objectives for the business.
  2. Consider:
    • Who are the decision makers and key influencers?
    • Who will impact the strategic objectives for the business?
    • Are there external forces that will impact the current strategic objectives?
  3. Avoid:
    • Don’t simply go with the existing documented strategic objectives for the business. Ensure they are up to date and interview the decision makers to get the most updated objectives if needed.

Download the Health Insurance Industry Reference Architecture Template

2.2.1 Identify the strategic objectives for the business

Input

  • Business strategy
  • Executive stakeholder interviews
  • IT project portfolio

Output

  • Business goals
  • Business context information

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Portfolio manager (PMO director)
  • Departmental executive and senior managers

Illustrative example of strategic goals and outcomes for Health Insurance

Health Care Insurance

  1. Effective Support
    • We are committed to aligning IT initiatives with the business strategy to support providers in delivering exceptional patient care.
  2. IT Excellence
    • We demonstrate respect for our patients and providers and assist in delivering the most exceptional patient care possible, resulting in positive outcomes .
  3. Innovation
    • We will ensure that IT is pursuing innovation opportunities to demonstrate leadership and improve internal processes.

2.2.2 Map the strategic objectives to the IT programs that support them

1-3 hours

Input

  • List of IT projects, initiatives, and capabilities
  • Business goals

Output

  • IT Initiatives
  • Goals cascade

Materials

  • Whiteboard/flip charts
  • Capability maps
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Portfolio manager (PMO director)
  • Departmental executive and senior managers

Communicate the business strategy to other levels of the organization visually.

  1. Starting with strategic objectives, map the value streams that will ultimately drive them. Next, link the key capabilities that enable each value stream. Finally, map the IT programs supporting those capabilities. This process will help you prioritize IT programs that deliver the most value to the organization.
  2. Consider:
    • Focus on the value streams that truly drive the strategic objectives.
    • Are there any capabilities that are not tied to outcomes?
    • Are all strategic objectives supported with IT programs?
  3. Avoid:
    • Don’t be too granular. The audience for a strategy is interested in a higher-level understanding of what IT is doing. As such, keep things at the program level as opposed to the individual projects that programs are composed of.

Download the Health Insurance Industry Reference Architecture Template

Illustrative example of a strategy map

The image is a graphic of a strategy map. The left-hand section of the graphic is the same business goals/strategic and achievable initiatives map from a previous section. The right-hand section of the graphic add IT capabilities, initiatives, and goals.

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

2.2.3 Validate the strategy map and program prioritization

1-3 hours

Crowdsource the strategy map validation.

  1. Validate the strategy map in layers. Start with IT and confirm which IT programs enable capabilities. Next, work with the business departments to validate the capabilities that support the value streams. Finally, validate the strategic objectives of the organization with the C-suite and communicate the value streams that support them.
  2. Consider:
    • Are all strategic objectives equally important? If not, get a prioritized list of strategic objectives.
    • Do any of the programs have critical dependencies that influence sequencing?
    • If there are strategic objectives that do not have any IT programs mapped to them, consider adding new programs. Conversely, reconsider upcoming programs that do not have a connection to strategic objectives.
  3. Avoid:
    • Don’t delay validating the strategic maps with top-level executives. A proactive approach will save you time in terms of rework and will maximize alignment.
    • Don’t leave anyone out on the assumption that they won’t be interested. It is easy to miss key stakeholders – be careful and organized.

Download the Health Insurance Industry Reference Architecture Template

2.2.3 Validate the strategy map and program prioritization

Input

  • IT Initiatives
  • Goals cascade

Output

  • Validated strategy map and goals cascade

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Portfolio manager (PMO director)
  • Departmental executive and senior managers

Phase 3

Assess key capabilities for planning priorities

Phase 1

1.1 Define the Organization’s Value Stream

1.2 Develop a Business Capability Map

Phase 2

2.1 Define the Organization’s Key Capabilities

2.2 Develop a Strategy Map

Phase 3

3.1 Business Process Review

3.2 Information Assessment

3.3 Technology Opportunity Identification

Phase 4

4.1 Consolidate & Prioritize Capability Gaps

This phase will guide you through the following activities:

  • Assess process support for capabilities
  • Evaluate user adoption of processes for key capabilities
  • Prioritize key capabilities process refinement
  • Assess how well information supports capabilities
  • Evaluate accessibility to data for key capabilities
  • Prioritize data improvements for key capabilities
  • Assess technology support of capabilities
  • Uncover value opportunities for applications
  • Compare results with industry research to determine plan of action

This phase involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Step 3.1

Business process review

Activities

3.1.1 Assess how well processes support capabilities

3.1.2 Evaluate user adoption of processes for key capabilities

3.1.3 Prioritize process refinement for key capabilities

Assess key capabilities for planning priorities

Step 3.1 → Step 3.2 → Step 3.3

This step will guide you through the following activities:

  • Assess how well processes support capabilities
  • Evaluate user adoption of processes for key capabilities
  • Prioritize process refinement for key capabilities

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Outcomes

  • An assessment of how well current processes support capabilities
  • A prioritized list of processes to be refined

Business process review

Use process analysis and assessment to drive collaboration and integration.

  • Organizations undergoing growth, either organically or through mergers and acquisitions, tend to develop in a piecemeal and short-sighted fashion to preserve their view of agility. This can lead to the following pains:
    • Duplicated or conflicting business activities
    • Processes that create bottlenecks by involving too many business units
    • Manual rekeying of data into multiple systems
    • Inefficient process for producing standard reports
  • These organizations are driven by the desire to effectively manage existing business processes while recognizing the need for a faster ability to share data, information, and insight across multiple systems and business units to support increasing demands for more rapid responses.
  • A primary goal of a strategy is to provide a framework that enables the current business environment to function as seamlessly as possible, allowing for flexibility when processes need to evolve.
  • Through effective strategy design, IT can provide integration across business units by performing an analysis of how well the organizational capabilities are supported by processes. Specifically, IT should analyze and assess processes based on adherence, enforcement, and overlap and on the presence of effective monitoring measures.

Assess how well processes support capabilities

Legend

NONE: No documented process exists.

LOW: Processes have been documented but have not been effectively communicated and may be in conflict.

MEDIUM: LOW + processes are explicitly defined and have been formally communicated. There is minimal overlap between processes.

HIGH: MEDIUM + processes are enforced and regularly monitored for deviations. Employees typically adhere to the process.

Figure above: Process Assessment Legend

Business process support of key capabilities

The image is a graphic with boxes of key capabilities, in the following categories: Product Development; Distribution & Underwriting; Policy Management & Servicing; Claims Administration (across the top); and Defining Capabilities; Shared Capabilities; and Enabling Capabilities (along the left hand side of the grid). The capabilities are colour-coded according to the legend transcribed below. In the None section are: Claims Registration & Validation; Claims Adjudication; Research and Development; Communication Management. In the Low section are: Product Risk Valuation; Sales & Lead Management; Relationship Management; Billing Management; Marketing & Sales Management. In the Medium category are: Policy Issues; Policy Alteration; Fraud Analysis; Waste, Abuse, and Fraud; Accounting; Quality Management; Risk Management; Security. In the High category are: Underwriting; Data Management

Legend:

Red - NONE: No documented process exists.

Yellow - LOW: Processes have been documented but have not been effectively communicated and may be in conflict.

Light green - MEDIUM: LOW + processes are explicitly defined and have been formally communicated. There is minimal overlap between processes.

Dark green - HIGH: MEDIUM + processes are enforced and regularly monitored for deviations. Employees typically adhere to the process.

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

3.1.1 Assess how well processes support capabilities

1-3 hours

Input

  • Reference Architecture Template
  • Standard operating procedures
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Standardization breeds efficiency.

  1. Begin by assessing whether each key capability has documented processes supporting it. Then evaluate whether the documented processes have been communicated and the extent to which there is process overlap.
  2. Consider:
    • What processes are documented?
    • Have the documented processes been communicated to the business users?
    • Are some of the processes redundant? Has that been done on purpose, or can you optimize them?
    • Are there key capabilities that lack processes altogether?
  3. Avoid:
    • Don’t waste time. Only evaluate processes that are documented and communicated, then evaluate them for exclusivity.
    • Don’t do this in a vacuum. Validate that you have captured all existing processes by speaking to other employees.

Download the Health Insurance Industry Reference Architecture Template

3.1.2 Evaluate user adoption of processes for key capabilities

1-3 hours

Input

  • Reference Architecture Template
  • Standard operating procedures
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Having processes is one thing, but are they being adhered to?

  1. The next level of analysis involves assessing whether defined processes are being adhered to. Confirm if the organization enforces adherence and that regular monitoring for deviations is occurring.
  2. Consider:
    • Is there regular monitoring for deviations from the defined process? Is this recorded and acted upon?
    • Are there certain groups of users that are not following the processes in place? Why?
  3. Avoid:
    • Don’t think the lack of process adherence is simply the employee’s fault. In some cases, the processes might be poorly designed or outdated and need refinement.

Download the Health Insurance Industry Reference Architecture Template

3.1.3 Prioritize process refinement for key capabilities

1-3 hours

Use process to drive collaboration and integration.

  1. Key capabilities should be well supported by processes. If there are any capabilities that scored level medium or below, prioritize delivering effective process support, improving user adoption, and establishing effective process governance.
  2. Consider:
    • Is business process management in your mandated area of influence, responsibility, or accountability? If not, consider who you may need to recruit for support from the business side to drive refinements.
    • Communicate any new processes or changes to existing ones through a variety of mediums. Make it easy for the users/employees to reference them if needed.
  3. Avoid:
    • Don’t create redundant processes. Ensure there is minimal overlap with existing processes if you are creating a new process.
    • Don’t forget to think about user adoption and governance when creating new processes. This might be more challenging, but it will ultimately ensure long-term success.

Download the Health Insurance Industry Reference Architecture Template

3.1.3 Prioritize process refinement for key capabilities

Input

  • Reference Architecture Template
  • Standard operating procedures
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Step 3.2

Information assessment

Activities

3.2.1 Assess how well information supports capabilities

3.2.2 Evaluate accessibility to information for key capabilities

3.2.3 Prioritize data improvements for key capabilities

Assess key capabilities for planning priorities

Step 3.1 → Step 3.2 → Step 3.3

This step will guide you through the following activities:

  • Assess how well information supports capabilities
  • Evaluate accessibility to information for key capabilities
  • Prioritize data improvements for key capabilities

This step involves the following participants:

  • Enterprise/Business architect
  • Data architect
  • Organizational planning & analysis staff
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Outcomes of this step

  • An assessment of key capabilities and the information that supports them
  • A prioritized list of necessary data improvements

The Data, Reporting & Analytics Diagnostic helps identify information gaps

Assessing how well information supports capabilities is nearly impossible to perform without an honest and thorough understanding of end user sentiment.

Develop data-driven insights to help you decide which business capabilities require new or improved reporting and analytics, what opportunities exist to improve business processes, and by extension enable the capabilities of the business.

Info-Tech’s Data, Reporting & Analytics Diagnostic program will help you:

  • Assess data quality and reporting satisfaction at a glance
  • Evaluate data quality across nine dimensions
  • Evaluate reporting across ten dimensions of satisfaction
  • Determine which areas are the most critical
  • Determine the effectiveness of analytics tools

Critical insights to extract from your Data, Reporting & Analytics Diagnostics Report

Begin by understanding the perception of the information in use in your organization. Then assess the effectiveness of information in supporting your key business capabilities.

The image is a screen capture of the Data, Reporting & Analytics Diagnostics Report, with the categories: Clarity, Accuracy, Currency, and Completeness. The text transcribed below points to the Currency section.

Data and reports that are deemed to be of low accuracy, currency, or completeness could hamper strategic business capabilities. These should be investigated further regarding their effectiveness of supporting key business capabilities.

Information assessment

Assess the availability and quality of data in providing information as a business asset.

  • Information is central to every organization’s success and ability to realize its goals. Too often organizations experience the following pains:
    • Duplicated or conflicting data residing in disparate databases
    • Inadequate controls or edits on data
    • Manual rekeying of data into multiple systems
    • Inability to provide executives with reliable and easily accessible information for decision making
    • Inability of business units to assume “ownership” of data
  • These organizations are driven by the desire to effectively manage existing business processes while recognizing the need for a faster ability to share data, information, and insight across multiple systems and business units to support increasing demands for more rapid responses.
  • A primary goal of a strategy is to provide a framework that enables information to be viewed as a critical business asset across organizational boundaries and accessed as seamlessly as possible.
  • Through effective strategy design, IT can provide integration of data across business units by performing an analysis of how well the organizational capabilities are supported by information. Specifically, IT should analyze and assess data on the basis of quality, integrity, and ownership and on the presence of an effective data governance framework.

Assess how well existing information supports capabilities

NONE: Data is unavailable, unreliable, duplicated, or not of sufficient detail

LOW: Data is available but not subject to adequate integrity or quality controls. Data ownership is undefined.

MEDIUM: LOW + Data is available but not fully automated. Data ownership is mostly defined.

HIGH: MEDIUM + Data is available, of high quality, and fully automated with clear ownership.

Figure above: Information Assessment Legend

Information support of key capabilities

The image is the same key capabilities map that appeared in a previous slide, but with different capabilities highlighted according to the legend. In the None category are: Claims Adjudication; Communication Management. In the Low category: Product Risk Valuation; Sales & Lead Management; Claims Registration & Validation; Research and Development. In the Medium category: Policy Issues; Policy Alteration; Waste, Abuse, and Fraud; Relationship Management; Billing Management; Accounting; Quality Management; Risk Management; Security; Marketing & Sales Management. In the High category: Underwriting; Data Management; Fraud Analysis.

Legend

Red - NONE: Data is unavailable, unreliable, duplicated, or not of sufficient detail.

Yellow - LOW: Data is available but not subject to adequate integrity or quality controls. Data ownership is undefined.

Light green - MEDIUM: LOW + data is available but not fully automated. Data ownership is mostly defined.

Dark green - HIGH: MEDIUM + data is available, of high quality, and fully automated with clear ownership.

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

3.2.1 Assess how well information supports capabilities

1-3 hours

Input

  • Reference Architecture Template
  • Data dictionary
  • Key reports
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Information is a key business asset.

  1. Begin by assessing whether each key capability has data available to support it. Then evaluate the quality and integrity of the data and the extent to which there is clear business unit ownership of it.
  2. Consider:
    • What data exists to support the capability?
    • Does the same data exist in various databases?
    • What controls exist to ensure quality and integrity?
    • Are there key capabilities that lack automated information altogether?
  3. Avoid:
    • Don’t waste time. Only evaluate information holdings that are central to the capability.
    • Don’t do this in a vacuum. Validate that you have captured all existing data by collaborating with other IT and business unit employees.

Input

  • Reference Architecture Template
  • Data dictionary
  • Key reports
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Information is a key business asset.

  1. Begin by assessing whether each key capability has data available to support it. Then evaluate the quality and integrity of the data and the extent to which there is clear business unit ownership of it.
  2. Consider:
    • What data exists to support the capability?
    • Does the same data exist in various databases?
    • What controls exist to ensure quality and integrity?
    • Are there key capabilities that lack automated information altogether?
  3. Avoid:
    • Don’t waste time. Only evaluate information holdings that are central to the capability.
    • Don’t do this in a vacuum. Validate that you have captured all existing data by collaborating with other IT and business unit employees.

Download the Health Insurance Industry Reference Architecture Template

3.2.2 Evaluate accessibility to information for key capabilities

1-3 hours

Input

  • Reference Architecture Template
  • Data dictionary
  • Key reports
  • List of your key systems of records and/or transactional data source system inventory
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Having data is one thing, but is it easily accessible and available in a format suitable for decision making?

  1. The next level of analysis involves assessing whether data is easily accessible to the main users of the information.
  2. Consider:
    • Is data well integrated so executives do not have to access more than one source for the information they need? Is there a data warehouse capability to bring together data from disparate databases?
    • Is there an end-user business intelligence (BI) capability? Are users sufficiently trained in its use?
  3. Avoid:
    • Don’t think that the lack of information is the fault of any one IT unit or application. In most cases, there is a lack of a comprehensive approach to enterprise and data architecture at the core of the problem.

Download the Health Insurance Industry Reference Architecture Template

3.2.3 Prioritize data improvements for key capabilities

1-3 hours

Use data to institute information as an asset.

  1. Key capabilities should be well supported by data. If there are any capabilities that scored medium or below, prioritize establishing an effective data governance framework. Leverage the Build a Data Architecture Roadmap blueprint and the Data Quality Scorecard.
  2. Consider:
    • Is data management fully in your mandated area of influence, responsibility, or accountability? If not, consider who you may need to recruit for support from the business side to drive refinements.
    • Effective data governance will require close collaboration between IT and the data owners on the business side.
  3. Avoid:
    • Don’t create redundant data. Ensure there is minimal overlap with existing data elements if you are creating a new application or database process.
    • Don’t forget to think about end-user access and reporting tools when creating new data holdings. This might be more challenging, but it will ultimately ensure long-term success.

Download the Health Insurance Industry Reference Architecture Template

3.2.3 Prioritize Data Improvements for Key Capabilities

Input

  • Reference Architecture Template
  • Standard operating procedures
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Data architect
  • Organizational planning & analysis staff
  • Business analysts
  • Business unit leads
  • CIO
  • Departmental executive and senior managers

Step 3.3

Technology opportunity assessment

Activities

3.3.1 Assess how well capabilities are supported by applications

3.3.2 Uncover opportunities for applications to create value

Assess key capabilities for planning priorities

Step 3.1 → Step 3.2 → Step 3.3

This step will guide you through the following activities:

  • Assess how well capabilities are supported by applications
  • Uncover opportunities for applications to create value

This step involves the following participants:

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers

Outcomes of this step

  • Identify the ways technology and applications can better support business capabilities

The Application Portfolio Assessment Diagnostic helps identify application gaps

Application portfolio management is nearly impossible to perform without an honest and thorough understanding of end user sentiment toward IT software.

Develop data-driven insights to help you decide which applications to retire, upgrade, re-train on or maintain, to meet the demands, and by extension enable the capabilities of the business.

The Application Portfolio Assessment program will help you:

  • Assess the health of the application portfolio
  • Understand the business’s perception of the application in use throughout your business
  • Identify and build core IT processes that automate IT-business alignment
  • Create a plan to address alignment gaps impeding business growth
  • Deliver your plan to demonstrate IT value and progress

Here are some critical insights to extract from the Application Portfolio Assessment report

Begin with understanding the perception of the applications in use in your organization to assess the effectiveness of supporting key business capabilities.

The image is a screen capture of the Application Portfolio Assessment Report. The note transcribed below is connected to the At Risk Applications section.

At-Risk Applications: Applications that are deemed as unleveraged, questionable or contentious should be investigated further regarding the effectiveness of supporting key business capabilities.

Technology opportunity assessment

New technologies can create opportunities for business agility and help develop resilience to changing market conditions.

  • Business agility is essential to staying competitive. However, the application portfolio of many organizations cannot sufficiently support the flexibility and efficiency the business needs because of legacy challenges.
  • Organizations experience application sprawl over time, caused by many factors, that can end up costing more for licenses, operational resources, and maintenance.
  • Organizations are looking for ways to modernize their applications, but they want to develop options without introducing additional risks. Adopting a capability-based approach to assessing applications will enable the IT department to identify opportunities to:
    • Automate tasks through the strategic selection and implementation of applications
    • Integrate applications that have cross-capability implications
    • Rationalize the application portfolio
    • Eliminate redundant or legacy applications that don’t deliver enough value
  • The market availability for software applications dedicated to supporting a specific capability (or set of capabilities) can serve as an indicator of the presence of legacy challenges. Where there is a lack of application availability, it may be a signal of either custom developed, ad hoc, and makeshift solutions or shadow IT.

Availability of software applications that support each capability

NONE: Capability is typically unsupported by applications. The likelihood of legacy applications supporting these capabilities is high.

LOW: Capability is somewhat supported by applications. There is typically a mix of legacy and purchased applications supporting these capabilities.

MEDIUM: Capability is moderately supported by applications. Organizations do not have to build their own applications; however, there aren’t many solutions to choose from.

HIGH: Capability is well supported by applications. Organizations can choose from a variety of solutions that will meet or exceed their needs.

Figure above: Technology Opportunity Assessment Legend

3.3.1 Assess how well capabilities are supported by applications

1-3 hours

Input

  • Reference Architecture Template
  • Listing of key system of records/transactional system inventory
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers

Determine how well key capabilities are supported by applications.

  1. Perform an application rationalization exercise on the key capabilities to determine how well they are being supported by applications. Applications should be assessed on the basis of flexibility, ease of use, and integration.
  2. Consider:
    • How flexible are the applications?
    • How well do the applications integrate?
    • How easy are the applications to learn and use?
    • Are there overlap, unplanned redundancy, or data quality issues?
  3. Avoid:
    1. Don’t perform a complete overhaul. Consider continuity in delivering business services before you rip and replace everything.
    2. Don’t forget about shadow IT. Ask around to get an accurate understanding of what applications are being used to support business capabilities.

Download the Health Insurance Industry Reference Architecture Template

Application support of key capabilities

The image is the same key capabilities graphic from previous sections, with the capabilities highlighted according to the legend (transcribed below). In the None category are: Claims Adjudication; Communication Management. In the Low category are: Product Risk Valuation; Sales & Lead Management; Claims Registration & Validation; Research and Development. In the Medium category: Policy Issues; Policy Alteration; Waste, Abuse, and Fraud; Relationship Management; Billing Management; Accounting; Quality Management; Risk Management; Security; Marketing & Sales Management. In the High category are: Underwriting; Data Management; Fraud Analysis

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

Legend

Red - NONE: Capability is typically unsupported by applications. The likelihood of legacy applications supporting these capabilities is high.

Yellow - LOW: Capability is somewhat supported by applications. There is typically a mix of legacy and purchased applications supporting these capabilities.

Light green - MEDIUM: Capability is moderately supported by applications. Organizations do not have to build their own applications; however, there aren’t many solutions to choose from.

Dark green - HIGH: Capability is well supported by applications. Organizations can choose from a variety of solutions that will meet or exceed their needs.

3.3.2 Uncover opportunities for applications to create value

1-3 hours

Input

  • Reference Architecture Template
  • Listing of key system of records/transactional system inventory
  • Capability maps

Output

  • Heat mapped capability map

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers

Make sure the business is leveraging applications wherever it should.

  1. Unsupported key capabilities are areas in which IT can deliver high value for the business. The key capabilities that score “none” or “low” in the technology assessment are the ones that require the most attention.
  2. Consider:
    • Prioritize which unsupported key capabilities to focus on based on their importance.
  3. Avoid:
    • Don’t focus on unsupported key capabilities that will require too much investment.
    • Don’t build an application just because you can. Research existing solutions before deciding to build in-house.

Download the Health Insurance Industry Reference Architecture Template

Phase 4

Adopt capability-based strategic planning

Phase 1

1.1 Define the Organizations Value Stream

1.2 Develop a Business Capability Map

Phase 2

2.1 Define the Organizations Key Capabilities

2.2 Develop a Strategy Map

Phase 3

3.1 Business Process Review

3.2 Information Assessment

3.3 Technology Opportunity Identification

Phase 4

4.1 Consolidate and Prioritize Capability Gaps

This phase will guide you through the following activities:

  • Assess capability gaps via a MoSCoW analysis

This phase involves the following participants:

  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers Portfolio manager (PMO Director)

Step 4.1

Consolidate and prioritize capability gaps

Activities

4.1.1 Assess capability gaps via a MoSCoW analysis

Adopt capability-based strategic planning

Step 4.1

This step will guide you through the following activities:

  • Assess capability gaps via a MoSCoW analysis

This step involves the following participants:

  • Enterprise/Business architect
  • Project managers & business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers

Outcomes of this step

  • Consolidated and prioritized capability gaps

Consolidate and prioritize capability gaps

  • Direct your strategic IT investments based on the collective output of your capability assessments.
  • When combined with a solid understanding of the business’s priorities and IT’s mandate, a capability assessment can be the driving force that informs a unified perspective on the sequencing of an organization’s strategic IT initiatives.
  • Assessments should be based on how well a capability is supported by people (via an organizational analysis), process (via a process review), data (via an information assessment), and technology (via application, infrastructure, data, and security improvements). This will inform the overall health of a capability or, in other words, the size of a capability gap. This information, when contrasted with the concept of a MoSCoW-based effort-to-value analysis, forms an enhanced decision-making framework that can be used to determine initiative sequencing on a strategic roadmap.
  • If a capability has a large gap (i.e., it’s poorly supported by people, process, data, or technology), it should be considered as high effort (or high difficulty) to address. When the capability is well aligned with the business’s priorities and IT’s mandate, the capability gap should be considered as high value to address.
  • Review the figure on the right. IT leaders should focus their efforts on the lower right quadrant (high value, low effort). In the top-right quadrant (high value, high effort), IT should seek business support to drive the initiative. Capability gaps on the right side of the quadrant are good candidates for capability outsourcing overall.
Effort

Won't Address

HE/LV

Should Address

HE/HV

Could Address

LE/LV

Must Address

LE/HV

Value

Figure above: MoSCoW Analysis for Business Capabilities

MoSCoW capability gap analysis

Effort

Won't Address

HE/LV

Should Address

HE/HV

Could Address

LE/LV

Must Address

LE/HV

Value

We are looking to act on low effort, high value initiatives

Value to Effort Impact Ratio

  • HE = High Effort
  • LE = Low Effort
  • HV = High Value
  • LV = Low Value

4.1.1 Assess capability gaps via a MoSCoW analysis

1-3 hours

Input

  • Reference Architecture Template
  • Capability maps

Output

  • Shortlisted assessment of capability gaps in a 2x2 matrix

Materials

  • Whiteboard/flip charts
  • Reference Architecture Template

Participants

  • Enterprise/Business architect
  • Business analysts
  • Business unit leads
  • CIO
  • CTO, VP Applications, and VP Infrastructure
  • Departmental executive and senior managers

Elevate your focus from the IT level to the organization level.

  1. Gather and synthesize the priorities from the information, people, process, and technology assessments you have completed to develop a consolidated view of IT’s planning responsibilities.
  2. Consider:
    • How big is the difference between your current needs and the assessment of the factors that support each capability?
    • Are there any groups of capabilities that have low scores from the assessments? Consider performing a root-cause analysis to determine what could be impacting these capabilities.
  3. Avoid:
    • Don’t forget about healthy capabilities. Enhance the green (low-gap) capabilities once you have resolved the issues with the red and yellow (large-gap) key capabilities.

Download the Health Insurance Industry Reference Architecture Template

MoSCoW analysis for business capabilities

Effort

Won't Address

HE/LV

Research and Development

Should Address

HE/HV

Claims Registration & Validation

Could Address

LE/LV

Product Development

Must Address

LE/HV

Claims Adjudication

Value

Note: This is an illustrative example. To edit and customize this visual, please download the corresponding template.

Ranked list of IT implications

MoSCoW Rank IT Implication Value Stream Impacted Comments/Actions
M [Implication] [Value Stream]
M [Implication] [Value Stream]
M [Implication] [Value Stream]
S [Implication] [Value Stream]
S [Implication] [Value Stream]
S [Implication] [Value Stream]
C [Implication] [Value Stream]
C [Implication] [Value Stream]
C [Implication] [Value Stream]
W [Implication] [Value Stream]
W [Implication] [Value Stream]
W [Implication] [Value Stream]

Address key capability gaps

Reference Architecture

As part of your next steps checklist, leverage this reference architecture for priorities that drive measurable, top-line organizational outcomes and the unlocking of direct value.

Summary of Accomplishment

Problem Solved

Upon completing this research, you have:

  • Accelerated the building of your organization’s capability map by defining the organization’s value stream and validating the industry reference architecture.
  • Used business capabilities to define strategic focus by defining the organization’s key capabilities and developing a prioritized strategy map.
  • Assessed key capabilities for planning priorities through a review of business processes, information, and application and technology support of key capabilities.
  • Consolidated capability gaps for incorporation into priorities.

If you would like additional support, have our analysts guide you through other phases as part of an Info-Tech workshop.

Contact your account representative for more information.

workshops@infotech.com

1-888-670-8889

Additional Support

If you would like additional support, have our analysts guide you through other phases as part of an Info-Tech Workshop.

Contact your account representative for more information.

workshops@infotech.com 1-888-670-8889

To accelerate this project, engage your IT team in an Info-Tech workshop with an Info-Tech analyst team.

Info-Tech analysts will join you and your team at your location or welcome you to Info-Tech’s historic Toronto office to participate in an innovative onsite workshop.

The following are sample activities that will be conducted by Info-Tech analysts with your team:

Model Level 1 business capability maps.

Using the business capability map as an accelerator, Info-Tech analysts will work with relevant stakeholders to modify and validate the business capability map to suit your organization’s context.

Review capability assessment map(s).

Info-Tech analysts will work with relevant stakeholders to review the various capability assessment maps and identify value opportunities within your organization.

Bibliography

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Ahlquist, Gary D., Minoo Javanmardian, and Sanjay B. Saxena. “A Better Model for Health Care.” strategy+business. 27 Aug. 2009. Web.

Atluri, Venkat, Jenny Cordina, Paul Mango, and Sri Velamoor. “How Tech-Enabled Consumers Are Reordering the Healthcare Landscape.” McKinsey & Company. Nov. 2016. Web.

Aue, Gerardo, Stefan Biesdorf, and Nicolaus Hanke. “How Healthcare Systems Can Become Digital-Health Leaders.” McKinsey & Company. Jan. 2016. Web.

Bales, Thom, Casey Le Jeune, Gil Irwin, and Pier Noventa. “A Low-Cost Strategy for Health Plans: Winning in a Revenue-Constrained Environment.” Booz & Company. 8 May 2012. Web.

Barella, Leo. “Business Value Measurements and the Solution Design Framework.” Blue National Summit. 2015. Web.

Bartlett, Chris, Sarah Butler, and Chris Rogan. “Australia’s Healthcare System: An Opportunity for Economic Growth.” Strategy&. 22 June 2016. Web.

Biesdorf, Stefan, and Florian Niedermann. “Healthcare’s Digital Future.” McKinsey & Company. July 2014. Web.

Bueno, David, Brian Milch, and Adesh Ramchandran. “Sources of Value from Healthcare IT.” McKinsey & Company. February 2016. Web.

“Building Value-Based Healthcare Business Models.” ATKearney. September 2013. Web.

Business Architecture Guild. A Guide to the Business Architecture Body of Knowledge, V4.6. BIZBOK® Guide, 2015. Web.

Chahine, Gabriel, Jad Bitar, and Nikhil Idnani. “Harnessing the Power of Public-Private Partnerships in Healthcare: Imperatives for GCC Governments.” Booz & Company. 26 February 2013. Web.

Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/. Accessed 21 Oct. 2021. Web.

Chilukuri, Sastry, and Steve Van Kuiken. “Four Keys to Successful Digital Transformations in Healthcare.” McKinsey & Company. April 2017. Web.

"Define the Business Context Needed to Complete Strategic IT Initiatives: 2018 Blueprint." ResearchAndMarkets.Com. 1 Feb. 2018, Web.

“Health Insurance Terms Glossary.” Medical Mutual. Accessed 21 Oct. 2021. Web.

“WPS Health. Common Health Insurance Terms and Definitions.” WPS. 10 Oct 2021 . Web.

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Nelson, Jacqueline. “Great-West to cut 1,500 jobs, take charge amid restructuring plan.” The Globe and Mail. 25 April 2017. Web.

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nCred. “What Is Insurance Credentialing – the Process of Credentialing.” National Credentialing Solutions, 14 Nov. 2017, Web.

Osunyomi, Babasile D., and Sara (Saartjie) S. Grobbelaar. “Integrating eHealth in HIV/AIDS Intervention Programmes in South Africa.” SA Journal of Information Management 17.1 (2015): 10 pages. Web.

“Patient Experience Scores Drive Clinical Quality.” Deloitte. n.d. Web.

Patrick, Margaret. “The 5 Major Entities of the Hospital Industry Value Chain.” Market Realist. 6 November 2014. Web.

Stephan, Jean-Pierre, Brian Kalis, Michael Brombach, and Janessa Nickell. “Winning the Trust of Highly Digital Healthcare Consumers.” Accenture. n.d. Web.

“Taking health care data analytics to the next level.” Deloitte. n.d. Web.

The Business Architecture Guild. BIZBOK® Guide. 2021. Web.

TOGAF Version 9.2. The Open Group. 16 April 2018. Web.

van Biesen, Tim, Josh Weisbrod, Michael Brookshirre, Julie Coffman, and Andy Pasternak. “Front Line of Healthcare Report 2017.” Bain & Company. 11 May 2017. Web.

Viljoen, Sarina. “Reference Models: A Healthcare Case Study.” Real IRM. n.d. Web.

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Capability maps, value streams, and strategy maps for health insurance organizations.

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Get the help you need in this 4-phase advisory process. You'll receive 9 touchpoints with our researchers, all included in your membership.

Guided Implementation #1 - Build your organization’s capability map
  • Call #1 - Introduce Info-Tech’s industry reference architecture methodology.

Guided Implementation #2 - Use business capabilities to define strategic focus
  • Call #1 - Define and create value streams.
  • Call #2 - Model level 1 business capability maps.
  • Call #3 - Map value streams to business capabilities.
  • Call #4 - Model level 2 business capability maps.

Guided Implementation #3 - Assess key capabilities for planning priorities
  • Call #1 - Create a strategy map.
  • Call #2 - Introduce Info-Tech's capability assessment framework.

Guided Implementation #4 - Adopt capability-based strategy planning
  • Call #1 - Review capability assessment map(s).
  • Call #2 - Discuss and review prioritization of key capability gaps and plan next steps.

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Jennifer Jones

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