HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
BlueHourTHE FIRST BLUEHOUR HEALTHCARE DEMONSTRATION

One MRI. Three Operating Models.

A physician orders an MRI. The Provider sees a diagnostic procedure. The Payer sees medical necessity, authorization, network rules and economics. The Patient brings her health, her time, her money, her constraints and her preferences. Each can make a rational decision inside its own Operating Model. Follow one order to see who is operating the whole.

The objective is Positive Patient Outcomes and Experiences. Every interaction produces an outcome; the aim is to raise the probability that it is a positive one, clinically and as the patient experiences it.

PATIENTJane Smith
PROCEDURELumbar MRI without contrast
CLINICAL URGENCYRoutine, set by her physician
LOCATIONDemonstration market
INSURANCEDemonstration PPO
DEDUCTIBLEIllustrative: already met
SYNTHETIC DEMONSTRATION DATANo real patient. No real provider, payer, price or schedule. No medical recommendation. Clinical judgment stays with licensed professionals.
Designed with Physics. Deployed with Economics. Determined by Humans.
BlueHourHEALTHCARE OPERATING MODEL
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 1 · WHAT HAPPENS WHEN A PHYSICIAN ORDERS AN MRI?

One order, fifteen steps, three Operating Models

The operating flow of a routine lumbar MRI. Choose a lens below the flow.
The operating flow of one MRI order across three lanes, Patient, Provider and Payer: patient, physician, MRI order, scheduling, prior authorization, payer review, network, imaging facility, MRI, radiologist, results, physician, patient, claim, payment. Six handoffs cross between participants. PATIENTPROVIDERPAYER123456PatientPhysicianMRIorderSchedulingPriorauthorizationPayerreviewNetworkImagingfacilityMRIRadiologistResultsPhysicianPatientClaimPaymentPatient portalEHREHR orderSchedulingPA systemPayer platformNetwork dataRISMRI systemPACS · AIEHREHRPatient portalBillingPayer platform Who is operating the whole? No participant is assigned this.
LENS

Fifteen steps, three Operating Models. A seemingly simple order becomes a multi-party operating system. Each participant generally does its job well within the system it has been given. Read across the lanes to see the whole flow.

BlueHourHEALTHCARE OPERATING MODEL
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 2 · THREE OPERATING PERSPECTIVES

The same MRI, seen from three Operating Models

Three active participants, each entering the decision with different information, economics, responsibilities and priorities. Their authority differs. All three shape the outcome.
PATIENT
My health. My time. My money. My experience.
  • Do I need this MRI?
  • Where should I go?
  • How quickly can I get it?
  • Is the facility appropriate for my clinical needs?
  • Is it in network?
  • What will it cost me?
  • Has it been authorized?
  • How far do I have to travel?
  • What happens after the MRI?
  • When will my physician receive the results?
  • When will I know what those results mean?
SHE ALSO BRINGS TO THE DECISIONClinical circumstances, personal preferences, time, location, transportation, financial responsibility, risk tolerance, scheduling constraints, previous diagnostic history, and the ability and willingness to act.
OBJECTIVE INSIDE ITS OWN OPERATING MODELPositive Patient Outcome + Positive Patient Experience
PROVIDER
A diagnostic procedure, inside clinical responsibility, capacity and quality.
  • Clinical appropriateness
  • Diagnostic requirements
  • Urgency
  • Imaging capability
  • Available capacity
  • Scheduling
  • Quality
  • Network considerations
  • Prior authorization
  • Existing diagnostic information
  • Physician workflow
  • Results delivery
  • Follow-up care
  • Administrative cost
  • Asset utilization
  • Continuity of care
OBJECTIVE INSIDE ITS OWN OPERATING MODELThe right diagnostic information for the patient, with capacity, quality and economics sustained
PAYER
Medical necessity, authorization, network rules and economics.
  • Medical necessity
  • Appropriate utilization
  • Prior authorization
  • Network status
  • Contracted rates
  • Alternative facilities
  • Duplicate procedures
  • Quality
  • Patient benefit design
  • Patient out-of-pocket exposure
  • Total medical cost
  • Downstream cost
  • Administrative expense
OBJECTIVE INSIDE ITS OWN OPERATING MODELAppropriate care at appropriate cost, within the member’s benefit
ov

Authorization, network, cost, quality, timing, results and site appear in more than one Operating Model. That shared ground is where interests can be made to reinforce one another.

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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 3 · THE MOM EVALUATES THE ALTERNATIVES

This is not a price-shopping engine

Price is one variable. It is not the objective function. Rank by one variable, then by the whole operating context.
Three imaging alternatives for Jane Smith, evaluated on eleven dimensions
A · Hospital Imaging Department$3,200 total · $640 patient · 11 days · 6 milesB · Independent Imaging Center$780 total · $156 patient · 2 days · 9 milesC · Open MRI Clinic$610 total · $366 patient · 1 day · 4 miles
Clinical needmeets: Protocol metmeets: Protocol metfails: Lower field strength than the ordering protocol specifies
Qualitymeets: Accreditedmeets: Accreditedtradeoff: Accredited for open MRI
Timetradeoff: 11 daysmeets: 2 daysmeets: 1 day
Locationmeets: 6 milesmeets: 9 milesmeets: 4 miles
Capacitytradeoff: Scanner also serves inpatient and emergency demandmeets: Open capacity this weekmeets: Open capacity tomorrow
Authorizationmeets: Confirmedmeets: Confirmedfails: Not authorized at this site
Networkmeets: In networkmeets: In networkfails: Out of network
Economicstradeoff: $3,200 total · $640 patientmeets: $780 total · $156 patienttradeoff: $610 total · $366 patient
Patient preferencemeets: Where her physician practicesmeets: Within her travel limitmeets: Closest to home
Riskmeets: Lowmeets: Lowfails: A repeat scan is more likely
Downstream consequencesmeets: Results in the shared recordmeets: Results sent electronically to the ordering physiciantradeoff: Report by fax
✓Meets~Tradeoff to weigh✕Fails a requirementClinical need, authorization and network govern before anything is weighed.
BlueHourHEALTHCARE OPERATING MODEL
How the numbers workSynthetic case
HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 4 · THE OPERATING DECISION

A recommendation the Physician, Payer and Patient can see and explain

The MOM assembles the operating context, applies the governing rules and recommends. People decide.
RECOMMENDED OPERATING DECISION
Independent Imaging Center
  • Clinical requirements satisfied
  • Prior authorization confirmed
  • In network
  • Earlier appointment: 2 days, not 11
  • Required imaging capability available
  • Quality requirements satisfied
  • Travel acceptable: 9 miles
  • Lower patient responsibility: $156, not $640
  • Lower total system cost: $780, not $3,200
  • Results sent electronically to the ordering physician
PATIENT SAVINGS$484Jane pays $156, not $640
SYSTEM SAVINGS$2,420$780 total, not $3,200
TIME SAVED9 days2 days to appointment, not 11

Illustrative synthetic data, comparing the recommended site with the hospital imaging department. Not a clinical recommendation, not a price quote and not a result from any real Payer or Provider.

WHAT THE PHYSICIAN, PAYER AND PATIENT CAN EACH SEE
  • What was recommended
  • Why it was recommended
  • What information influenced it
  • Which tradeoffs were made
  • What economics were involved
  • Where human judgment remains
BlueHourHEALTHCARE OPERATING MODEL
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 5 · CONSTRUCTIVE INTERFERENCE

Multiple participants benefit because the Operating Model optimized the whole

The objective is not to optimize Patient, Provider and Payer independently. It is to find decisions where their interests reinforce one another.
Three waves for Patient, Provider and Payer. Out of phase, they cancel and the whole system barely moves. In phase, under one governed decision, they reinforce each other. PatientProviderPayerThe wholesystem
SHOW

One governed decision: the same participants, aligned on one site. Their interests reinforce one another, and the whole system produces more than any participant could alone.

BlueHourHEALTHCARE OPERATING MODEL
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 6 · SHOW THE TRADEOFFS

Lowest cost does not necessarily produce the highest-value outcome

Case 2, also synthetic. Thomas Reed, lumbar MRI without contrast. His physician has documented a change in his condition and marked the order urgent.
CASE 2

The MOM does not set urgency. Had the physician marked the order routine, the imaging center’s date would have been weighed against cost like any routine order.

Imaging center
Total cost
$700
Patient pays
$140
First appointment
14 days
Meets the 3-day window the physician set
No
Hospital-based imaging
Total cost
$2,100
Patient pays
$420
First appointment
Tomorrow
Meets the 3-day window the physician set
Yes
RANKED BY LOWEST COSTThe imaging center is selected at $700. Its first appointment is 14 days out, against a 3-day window set by the ordering physician. The cheapest choice fails the clinical timing requirement, and nothing records why it was chosen.

Operating Architecture makes the tradeoff visible, explainable and governed. Interests do not always align. When they do not, someone accountable decides, and the reason is kept.

BlueHourHEALTHCARE OPERATING MODEL
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
STEP 7 · OPERATING LEVERAGE

One MRI is small. Multiply the decision across healthcare.

Small improvements per decision, applied to every decision of its kind. Illustrative assumptions, set deliberately below Jane’s case.
ROUTINE IMAGING DECISIONS THAT HAVE A BETTER-GOVERNED SITE
Illustrative effect at three volumes of imaging decisions
10,000 IMAGING DECISIONS50,000 IMAGING DECISIONS100,000 IMAGING DECISIONS
Decisions with a better-governed site2,00010,00020,000
Total medical cost avoided$1.8M$9.2M$18.4M
Patient out-of-pocket avoided$360K$1.8M$3.6M
Days to diagnosis returned to patients8,00040,00080,000
Administrative hours released2,50012,50025,000
Duplicate scans avoided50250500
Hospital scanner slots preserved1,0005,00010,000

Each redirected decision is valued at $900 of medical cost, $180 to the patient and 4 days, against $2,420, $484 and 9 days in Jane’s case. Every decision saves 15 minutes of authorization and scheduling effort.

Illustrative. Not ROI, not a forecast and not a result from any Payer or Provider. The assumptions are listed under How the numbers work.

HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
THE FIRST BLUEHOUR HEALTHCARE DEMONSTRATION

What other healthcare operating problems could we solve this way?

The MRI is the demonstration, not the definition of the MOM. The underlying operating problem may prove to be Diagnostic Imaging Decisioning, Diagnostic Decisioning, Site-of-Care Decisioning or something else. The MRI demonstrates the architecture. It does not constrain it. We will name the operating problem after Payers, Providers and other healthcare executives tell us where the real friction is. The objective stays the same: Positive Patient Outcomes and Experiences.

A POSSIBLE HEALTHCARE TRAY · POTENTIAL MICRO OPERATING MODELS, NOT EXISTING PRODUCTS
Imaging DecisioningPrior AuthorizationSpecialty Drug DecisioningSurgical Site-of-CareEmergency Department UtilizationReferral ManagementDischarge & TransitionChronic Care CoordinationClaims & PaymentRevenue CycleProvider CapacityPatient Access
INSIDE THE BLUEHOUR OPERATING ARCHITECTURE
MOM-001Capital Disciplinebluehourbusiness.comMOM-303Enterprise Workforce Modernizationbluehourworkforce.comMOM-304Complexity Ceiling Managementbluehourcomplexity.comMOM-305Operating Riskbluehourrisk.com
MOM-405Truth Preservation and VerificationIn design
MOM-505Governance and AccountabilityIn design
MOM-510Enterprise ValueIn design
BRING US A HEALTHCARE OPERATING PROBLEM.

We will show you what it looks like as a Micro Operating Model.

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Designed with Physics. Deployed with Economics. Determined by Humans.
AI × IT × Human Intelligence × Operating Architecture = Governed Positive Outcomes
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HEALTHCARE DEMONSTRATION · SYNTHETIC DEMONSTRATION DATA · NOT MEDICAL ADVICE
REFERENCE · THE DEMONSTRATION ASSUMPTIONS

How the numbers work

Written down before the demonstration was built. Synthetic cases, illustrative figures.
S1
Synthetic dataJane Smith and Thomas Reed are fictional. Every facility, payer, plan, price, schedule and distance is invented for this demonstration.
S2
Plan designDemonstration PPO. Deductible already met. The patient pays 20 cents of each dollar in network and 60 cents out of network.
S3
Case 1 alternativesCosts, days and miles as shown. The open MRI clinic’s scanner is below the field strength the ordering protocol specifies, and the clinic is out of network and not authorized.
S4
Governing rulesClinical requirement, authorization and network must be met before anything is weighed. Among eligible sites: earliest appointment, then lower patient cost, then lower total cost. The patient may choose any eligible site.
S5
Case 2The physician sets a 3-day window. Imaging center $700, 14 days. Hospital-based $2,100, next day. No lower-cost site has capacity inside the window.
S6
DifferencesPatient savings, system savings and time saved compare the recommended site with the hospital imaging department in Case 1.
S7
TechnologyThe demonstration shows where existing systems could contribute intelligence. It does not claim that any integration exists, or any partnership with a technology provider.
L1
Better-governed siteExists for 1 in 10, 1 in 5 or 1 in 4 routine imaging decisions. You choose.
L2
Value when it does$900 medical cost and $180 patient cost avoided, 4 days returned. Set below Case 1 on purpose.
L3
Administrative effort15 minutes saved on every decision through fewer authorization and scheduling reworks.
L4
Duplicate scans1 decision in 200 avoids a duplicate scan costing $780.
L5
Hospital scanner slotsHalf of redirected decisions would otherwise have used a hospital scanner.
L6
A million decisionsAn improvement of $10, $25 or $50 a decision, and 5 minutes of administrative effort.