While the healthcare industry has made some significant strides toward the goal of achieving true interoperability among healthcare stakeholders, there is still a great deal of work to be done – especially under the current challenges all aspects of the healthcare ecosystem are facing during the COVID-19 pandemic.
Federal rules and policies released by CMS and ONC such as the CMS Interoperability & Patient Access Rule and 21st Century Cures Act, growing adoption of new electronic data standards like HL7 FHIR®, and the application of new innovative technologies represent great progress, but these are just the first steps. The overall goal remains – to foster the healthcare industry’s ability to combine all aspects of the patient experience (e.g., claims, clinical, social determinants of health) to create a more comprehensive, complete patient profile capable of driving better decision making about which patients require intervention, how and when to address those needs, and, ultimately, deliver better outcomes.
The Payer and Provider Perspective on Establishing “True” Interoperability
In today’s health data interoperability landscape, organizations already engaging in the bi-directional exchange of data are experiencing the greatest success. However, standardized clinical data exchange is not yet rapidly scalable, and variations in provider connectivity are a common obstacle.
“Healthcare is being digitized; however, little of it is interconnected.”
– Yolangel Hernandez Suarez, MD, MBA, FACOG, Vice Provost, Population Health and Well-Being Associate Dean for Clinical and Community Affairs
How did we get here? With payers and providers/health systems continuing to feel the top down pressure from federal, state and other regulatory bodies to improve outcomes and quality while reducing avoidable costs, the quest for a functional, timely and accurate approach to sharing data among each other and with patients (i.e., consumers) remains challenging for most. There remain very real questions for both payers and providers around how best to overcome the obstacles that have plagued the payer-provider relationship over the years, including how to best break down any barriers of mistrust, build transparency, ensure data accuracy, completeness and timely delivery, and foster technical interoperability capabilities among both payers and providers.
Challenges certainly remain. Different performance measures and varying coding and reporting requirements that must be navigated pose significant hurdles. However, the benefits of payer-provider data sharing outweigh existing obstacles. For instance, data sharing among payers and providers supports medical and pharmacy prior authorization requests, care management programs and quality gap closure. Key payer processes are better informed by the latest patient clinical data found within their provider’s EHR data, which is accurate, complete and timely.
Data Sharing Challenges
We know that payers still struggle in many instances to get the complete, timely, accurate data they need. But properly integrated data can help solve care management challenges and support effective resource allocation while ensuring payers and providers have the right information on the right members at the right time – a critical step forward.
While it is easier to assume that some things like data storage, data mapping, differences in system languages or finding unique identifiers for patients across EHR systems would be the impediments to smoother transactions, it is a lack of data standards, formatting and tools to measure those data standards that appears to be affecting the efficacy of data exchange more robustly. When payers and providers attending Inovalon’s RISE National Virtual Conference 2020 speaking session, Connecting Healthcare: The Future of Clinical Interoperability, were polled, the biggest challenge identified by payers was the lack of data and measure standardization.
What would you identify as your biggest payer/provider data sharing challenge?
Payers of all sizes and providers face daily challenges of data sharing. Hence, a robust, shared infrastructure or data-exchange network will allow users to not just access but also use and share data effectively with other healthcare entities.
To support this infrastructure and free and multi-directional flow of accurate patient data, all parties bear the burden for maintaining data accuracy and completeness, which by far have the biggest impact on the ability of payers and providers to effectively share data and positively impact care.
CMS Interoperability Final Rule – Background and Impact to Payers
From a regulatory perspective, the changes we’ve seen in interoperability over the past decade are largely driven from an advocacy lens. In the past decade, top-down federal government regulations (e.g., HiTECH, Meaningful Use) have mandated many of the changes we’ve seen in interoperability. What’s been the impact on healthcare stakeholders? The industry now has hundreds of electronic health record (EHR) systems, which amplifies the challenge of bi-directional data exchange given that each EHR has slightly different variations of how it implemented the “standards.”
When asked to identify the biggest obstacle to complying with the CMS Interoperability Final Rule, health plans attending Inovalon’s session at RISE National overwhelmingly identified lack of clarity in requirements as their biggest challenge.
What would you identify as your biggest obstacle complying with the CMS Interoperability final rule?
As we look forward to broader FHIR adoption across the industry as a key driver of clinical data exchange in the United States, it’s important to consider where we are seeing progress and carefully think through the next steps to best support providers on this journey. Disparate, overlapping regulations need to coalesce around one standard piece of guidance. We also must ensure we are sharing data bi-directionally and that the data we do share is in the same format, establishing clarity among different entities within shared networks to arrive at desired outcomes.
We set different targets each time we examine healthcare interoperability. Moving toward a single, consolidated document of thousands of data elements is a monumental task, but if multiple standards exist, there is no standard.
“Standards alone are not the answer for interoperability.”
-John Halamka, Life as a Healthcare CIO Blog
What Does the Future Hold?
Payers and providers are partnering on initiatives focused on accelerating the achievement of interoperability. The gap and resistance to interoperability still exists in the healthcare provider space, but with emerging regulations and the development of data lakes in the industry, stakeholders can reconcile complex, disparate clinical data and gain insight to make informed business and clinical decisions. We are moving away from an era of “how do I get more information” on my member (or patient) to “how do I make sense of all this data,” and “what insights really matter?”
We know that payers, providers, hospitals and health systems are all seeking innovative and yet practical approaches to work across organizational boundaries to improve patient care and experience. Intelligent organization of claims, clinical, social determinants of health and other patient (member) insights using the latest artificial intelligence technologies will further make this effort a reality.
Current circumstances are requiring us to accelerate this transformation – the nation’s nimbleness and ability to respond to COVID-19 provides evidence to the industry’s ability to accelerate advancement in interoperability. Health data interoperability and real-time data exchange of relevant healthcare information between payers and providers improves not only the quality of care provided, but also the efficiency with which it is delivered in value-based healthcare ecosystems. FHIR®-based data standards are also providing greater opportunities for data sharing across the care continuum and enabling organizations to leverage their existing systems to improve care delivery and patient outcomes.
Healthcare interoperability will continue to evolve and improve as new technological advancements are made, requiring organizations to pace themselves in order to succeed in the new interoperability-driven generation in healthcare.