Module C: Electronic Information Technology in UM

CE Credits: 1.75


This module explores how utilization management can improve electronic tools—namely, electronic health records (EHR) and other information technology (IT). The module first looks at the relevant data accessed through such tools, such as medical necessity information and discharge plans, and the vital role that EHRs play in preventing unnecessary errors, such as wrong medications or even wrong surgeries. Next, the module looks at the realm of medical necessity—the decision that a patient’s treatment, test or procedure is necessary for the member’s health—which can be measured by both intensity of service (IS) and severity of illness (SI), and tracked by using software that compiles such data. Then, the module looks at software to track and monitor readmissions, adverse events and avoidable delays; it also offers some guidance on how to find the right program for one’s healthcare organization, and how certain federal and state databases can complement the data that CMs and patients need.

Learning objectives: After completing this module case managers will be able to:
» Choose appropriate tools for improving quality
» Discuss medical necessity and criteria for determinations
» Review case management software, including key components
» Identify federal and state use of electronic data


Advance your professional practice: While the bad news may be that our healthcare system needs to be more efficient and effective, the good news is that tools exist that can help—a lot. By embracing new technology, we can troubleshoot for our patients and streamline communications among team members.

Improve organizational performance: The best technology is beneficial only if everyone on the team commits to using and understanding it. By using the best data and technology at our disposal, we can offer more effective and efficient care for patients while reducing wasteful spending and the number of medical errors.