Document Type : Promotional-Science Article
Authors
1 Department of Information Technology Management, Faculty of Management and Economics, Tarbiat Modares University, Tehran, Iran
2 Department of Information Technology Management, Faculty of Management, Vali Asr University, Rafsanjan, Iran
3 Department of Information Technology Management, Faculty of Management, Payam Noor University, Tehran, Iran
Abstract
BACKGROUND AND OBJECTIVES: Without an effective monitoring system, organizations cannot successfully accomplish their missions and properly allocate their resources. Millions of health insurance transactions are conducted every month. These transactions should be examined from both a "real" and "scientific" perspective. Investigating this volume of transactions, detecting errors and misconduct, and preventing misconduct requires intelligent monitoring. A model that enables intelligent monitoring for health insurance holistically and taking into account the main beneficiaries has not yet been presented. This research focuses on developing a model for smart monitoring in basic health insurance.
METHODS: A detailed action design research (ADR) methodology consisting of two diagnostic and four design cycles within the Iranian Health Insurance Organization was applied in this research. This model proposes four separate ADR cycles for the diagnosis, design, implementation, and evolution of the artifact development solution, and in each cycle it goes through the activities of problem formulation, artifact creation, evaluation, reflection, and learning. The required control patterns for the organization's interaction in a business network were identified using agency theory. The concepts and problems of supervision in health insurance were categorized in the first cycle of diagnosis and conceptualization of the problem using systematic mapping. In the second cycle, 24 interviews were conducted using the snowball method to identify the current situation of the organization as well as the issues and problems. Finally, a system model that provides smart monitoring in health insurance was presented based on the components of smart monitoring.
FINDINGS: The proposed model for smart surveillance in health insurance includes five levels. First, the data resource layer includes internal and external organizational systems that provide the data resources required for surveillance. Second, the data storage layer includes the data warehouse where data is extracted, transformed and loaded from various sources. Thirdly, the data presentation, analysis and knowledge capture layer provides monitoring reports, analysis tools and data mining techniques for knowledge extraction. Text mining methods extract knowledge from the texts available in the company's knowledge portal. The fourth layer, the knowledge storage layer, involves loading the extracted knowledge into the knowledge repository. Finally, the knowledge utilization and presentation layer provides a system for searching, displaying and using knowledge that is linked to the knowledge portal and the company's transaction systems.
CONCLUSION: This research provides a framework of process and outcome criteria for basic health insurance, control, and monitoring based on the organization theory and the monitoring process. By adding the knowledge warehouse and data warehouse, the current research model enables the coverage of all types of knowledge and includes various monitoring criteria. The advantage of the presented model is that by combining the concepts of data warehouse, knowledge extraction, knowledge warehouse and knowledge portal, it creates a framework for better decision making in all organizations. For health insurance companies in particular, the model presented provides a framework of outcome criteria and a process based on health insurance beneficiaries that can form the basis for the work of the monitoring department.
Keywords
- Agency theory
- Elaborated action design Research
- Health insurance
- Intelligent control
- Intelligent monitoring
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