I started on the payer side, as a systems analyst at a health plan, and the first thing I learned was that healthcare runs on files. Enrollment files. Claims files — the 837, in professional and institutional flavours. Eligibility inquiries and their responses. Everything a member experiences as a card in their wallet is, underneath, a set of records moving between systems on a schedule, and when a record does not arrive, nothing tells you. Database queries, interface tests and mapping specifications help make those records and handoffs visible.
At a pharmacy benefit manager I saw the same plumbing from the other side — formularies, rebates, the drug identifiers that let two systems agree they are talking about the same product. The next question is how to make information useful within a clinician’s workflow.
Consider an illustrative clinical decision-support workflow: consultation notes and lab reports are read through optical character recognition, relevant information enters the electronic health record, and three treatment options are presented with confidence scores. The oncologist reviews the options and provides feedback. The workflow illustrates a design approach; it is not a delivered-project result.
Three principles follow from that illustrative workflow. Useful information belongs inside the clinical workflow, not in a separate tool the clinician has to go and find. The licensed human is the final authority — the engine advises, the physician decides. And a model without a feedback loop is a model that gets worse while everyone assumes it is getting better.
Years later, during enterprise platform work in 2018–2022, I made a Salesforce date-of-birth field mandatory without impact analysis. Sales calls were disrupted, and I restored the prior version the same day. Subsequent Salesforce changes went through user-acceptance testing with sales executives. A one-line validation change is still a workflow change.
Tools and standards referenced in this chapter SQL · SOAP UI · EDI 837 / 834 · 270/271 eligibility · OCR · Salesforce · data-mapping specifications