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Care Management Software

Features, Architecture, Costs

In healthcare IT since 2005, ScienceSoft builds robust, regulatory-compliant software to let managed care organizations (MCOs) efficiently supervise the delivery of high-quality care and control care costs.

Custom Care Management Software
Custom Care Management Software

Contributors

Gala Batsishcha

Healthcare IT Consultant, ScienceSoft

Andrey Dzimchuk

Senior Solution & Integration Architect, ScienceSoft

Care management software is used by managed care organizations (MCOs) to oversee and coordinate patient care delivery across the provider network, track service utilization, ensure diagnosis correctness and relevance, and more.

Note: This page describes care management software intended for managed care organizations (MCOs) such as health maintenance organizations (HMOs), exclusive provider organizations (EPOs), preferred provider organizations (PPOs), and point-of-service plans (POS). If you are interested in a solution for synchronizing the efforts of care teams, healthcare institutions, and other entities involved in patient care, feel free to explore our dedicated guide on care coordination software.

According to IMARK Group, the care management software market is expected to reach $46 billion by 2033. The major market drivers include the increased percentage of chronic diseases, the rising shift toward value-based care, the increasing adoption of ML/AI techs, and the promotion of digital health tools by government organizations.

Custom care management software development is an optimal choice when diverse data exchange formats and protocols used by the involved providers need to be standardized. Custom solutions also provide more flexibility in the choice of ML/AI-powered features, such as analytics for identifying care gaps and assessing provider performance.

Popular Features of Care Management Software (CMS)

Provider network management

CMS should maintain a database of all the in-network and partner providers and a catalog of their services. It should also support provider contract management, credentialing (tracking licenses and certifications), and onboarding. The system must support the relevant data exchange standards (e.g., HL7, FHIR) to enable interoperability with provider systems and secure data exchange.

Utilization management

Utilizing provider claim data (e.g., services rendered, costs), the system can help track service utilization across providers (e.g., types of delivered services, frequency of visits to a particular facility) and generate case review alerts (e.g., on possible exceeding of service utilization). CMS can also have automation capabilities for handling pre-authorization requests from providers.

Checking treatment correctness

Analyzing data on the provided services, the system can assess diagnosis correctness and procedure relevance by checking whether diagnostic codes (e.g., from ICD-10) align with corresponding procedure codes (e.g., from CPT).

These can be tools for collaborative care plan development and editing, referral management, discharge planning, readmission risk assessment, preventive care management, and more.

Care management analytics

CMS can include analytics tools to monitor provider performance (e.g., health outcomes, utilization rates) and identify inefficiencies such as care gaps or overutilization of services. CMS can also help assess provider profiles (e.g., availability, capacity) and pinpoint high- or underperforming providers. Such software can also feature predictive analytics capabilities (e.g., to forecast care costs) and create automated reports for submission to regulatory bodies (e.g., to CMS in the US) in compliant formats.

CMS can have dedicated patient portals and apps to facilitate communication with patients. These tools can be used to notify patients of claim status, send reminders about appointments and follow-up activities, and more. Patient engagement can also offer educational healthy lifestyle content (e.g., self-check guides, videos, articles) and provide personalized recommendations on preventive care services (screenings, check-ups, vaccinations, etc.) or lifestyle changes.

Planning to Develop Care Management Software or Already Launched the Initiative?

Our healthcare consultants are ready to share their experience in building care management software solutions and provide insights on making the solution suit your particular care management workflows and business model.

Sample Architecture of Care Management Software

Below, our solution architects provide a sample architecture of a care management solution that lets managed care organizations oversee care delivery and control service utilization and costs across the provider network. You can also explore a sample architecture of a custom care coordination solution intended for synchronizing the efforts of care teams within healthcare institutions.

Architecture of Care Management Software

The software gets data from the hospital information systems (HIS) of providers. HIS incorporates data from various back-office software, including EHR/EMR, revenue cycle management software (RCM), laboratory information systems (LIS), and more. The means of integrating CMS with HIS may include data exchange protocols and standards such as FHIR and HL7 or custom APIs.

The software backend is built using a multi-provider model where each provider’s data is managed independently. This can be achieved through dedicated database schemas within the data storage, dedicated or serverless data processing pools, customizable operational database templates, tools for tracking provider-specific usage metrics (e.g., API calls), and more.

Data from HIS is automatically ingested and preprocessed via a data ingestion engine on a scheduled and event-driven basis and is fed into the long-term data storage or sent to analytics layer and data processing engine for further processing and analysis.

The business logic layer features the workflow automation service that automates workflows across provider systems e.g., updating a patient medical history after a corresponding record was updated in the provider’s EHR. The event-driven service acts locally, in the providers’ systems. In the scenario above, a notification would be sent to the employees involved in managing care of a particular patient.

Users interact with the software via dedicated apps and portals. For example, primary care physicians (PCPs) at clinics communicate with MCO coordinators via provider portals; MCO coordinators can track service utilization via a care management interface and exchange data with providers via an interoperable data exchange solution. Communication with patients is enabled via patient portals and apps.

By integrating their systems with care management software, payors can access data on service utilization and reimbursement and take preventive or corrective measures to optimize care costs.

Security mechanisms for care management software typically include data encryption at rest and in transit, identity and access management, role-based user access control (RBAC), audit trails and logs, and more.

How to Develop Care Management Software

Care management software development is needed to let MCOs benefit from the smooth integration of software systems across multiple healthcare providers. Below, our healthcare consultants provide a general overview of key steps for developing a custom care management system. In the actual project, some of the steps may differ depending on your organization’s needs.

1.

Business analysis and requirement engineering

At this stage, business analysts communicate with the stakeholders (e.g., MCO coordinators, payor administrators) to elicit the details required for shaping functional and non-functional software requirements. The specialists find out the types and number of healthcare organizations the CMS solution will cover, care management use cases it will support, regulations it should comply with, and the solutions it will integrate with (e.g., providers’ EHRs by Epic or Cerner).

ScienceSoft

ScienceSoft

2.

Integrations and architecture design

At this step, solution architects decide on the integration strategy. They define the relevant data exchange standards and protocols (e.g., HL7, FHIR, DICOM). The specialists also analyze providers’ software (e.g., EHRs, LISs) that the CMS should integrate with and see if there are ready-made APIs (e.g., either offered by software vendors or cloud service providers) or if custom API development is needed.

The experts analyze system requirements for scalability, elasticity, performance, availability, and other parameters, and choose technologies that can satisfy these requirements at an optimal cost-to-benefit ratio.

ScienceSoft

ScienceSoft

3.

UX/UI design

UX and UI designers create workflows and visual elements that enhance the solution’s usability and streamline the completion of tasks for the defined user roles. For instance, MCO coordinators may benefit from dashboards that give a 360-degree view of service and resource utilization with the capability to drill down into details. If an accompanying mobile app for on-the-go care management is planned, UI designers create simplified interfaces for smaller screens.

ScienceSoft

ScienceSoft

4.

Development and testing

Development and testing teams often work in parallel to better coordinate efforts and fix defects as soon as they are detected. The specialists can also go for QA automation when feasible. Infrastructure engineers implement DevOps practices.

In ScienceSoft’s experience, combining ready-made components from reputable cloud providers (e.g., AWS, Microsoft, Google Cloud) with custom elements can speed up development by 2-20 times and cut development costs by up to 50%. For example, Microsoft Cloud has pre-built elements designed specifically for care management. They include templates for care plans and patient profiles that can be either fully reused or enhanced with custom elements to accommodate unique patient conditions, care plan activities, or organizational requirements. Furthermore, Microsoft offers a ready-made patient portal that can be directly incorporated in the solution instead of developing one from scratch.

Senior Solution & Integration Architect, ScienceSoft

5.

Deployment and support

The development team deploys the care management software and monitors its performance. Developers also deliver exhaustive software documentation, including maintenance guides, instructions on API usage, and user training materials.

ScienceSoft

ScienceSoft

How Much Does It Cost to Develop Care Management Software?

The costs of care management software development may range from $600,000 to 5,000,000*. The major cost factors include the complexity and range of its features, the number of targeted institutions and supported users, and integration capabilities.

*The range is for CMS designed for managed care organizations (MCOs). If you're planning to build a system for synchronizing care within medical institutions, check care coordination software costs.

Core solution

Advanced solution

Features
  • Provider network management.
  • Utilization tracking and alerting.
  • Basic care coordination tools (e.g., for care plan development).
  • All the features of the basic tier.
  • Automated pre-authorization.
  • Checking diagnosis and procedure relevance.
  • Advanced care coordination with referral management, readmission risk assessment, and other capabilities.
The number of organizations that will be using the software

Up to 100

Up to 500

The number of supported users
?

E.g., PCPs, MCO coordinators, payor administrators.

Up to 10,000

Up to 100,000

A patient portal

Up to 1,000,000 patients

More than 1,000,000 patients

Analytics and reporting complexity
  • KPI monitoring (e.g., provider performance, service utilization metrics).
  • Role-specific dashboards.
  • All the capabilities of the basic tier
  • Predictive analytics (e.g., to forecast care costs).
  • Automated reporting to authorities in regulatory-compliant formats.
Software costs

$600,000–$1,500,000

$1,500,000–$5,000,000

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Why Develop Your Care Management Software With ScienceSoft