Payment and Interoperability in Healthcare
Interoperability is the backbone of quality care in the modern healthcare world and has been a staple of the health information management conversation for decades.
At first, this conversation focused on the clinical data exchange within a health system. Then interoperability rapidly expanded between enterprises with the meaningful use era. Over the past few years, the dawn of the value-based care era has ushered new stakeholders into the interoperability space. Population health, connected devices and consumer-mediated exchange became new buzzwords around interoperability in healthcare. And on the sidelines, payers began to quietly exchange clinical data with their contracted providers.
When a healthcare payer contracts with a provider for reimbursement based on the quality of care, measurements of the outcomes of this care are required for payment. This includes items like lab results, admission and discharge information, body mass index, vital signs and results of screening procedures and preventative health assessments.
Just knowing that the provider had performed the procedure/test/assessment was enough for payment under a fee for service contract. However, under a value-based contract, the healthcare payer also needs to know the results to measure the quality outcomes of the care. This brings exchanging clinical data between a provider and payer under the Treatment, Payment, and Operations section of HIPAA, and makes it possible for payers to utilize the power of clinical data to improve the health of the populations they serve.
Importance of Healthcare Payer Interoperability to a Patient
I am not only the manager of the enterprise data acquisition team; I am also a chronically ill, high-cost patient/member. I have Type 1 Diabetes (T1D) and have struggled with the complications of this disease for more than 20 years. Diagnosed with T1D in 1995, I have lived through the electronic medical records (EMR) and the boom of interoperability in healthcare as a patient. I watched the transition from paper medical records I had to bring from provider to provider to EMR records that were difficult to transmit and for which I had to pay to acquire copies. I watched providers not read or not trust the records from other providers.
I desperately need all of my providers to be on the same page with my care plan. I see between five and 10 different providers over the course of a year (primary care provider, endocrinologist, cardiologist, nephrologist, pulmonologist, neurologist, ophthalmologist, OB/GYN, hospitalists, nurse practitioners, urgent care providers, etc.). In my experience, it is highly unlikely that these providers will know visits with the others have occurred, much less the outcomes associated with those visits, while my payer already has a record of the claims from each of these providers that shows a more complete picture of my care.
With the addition of clinical data, such as my lab results, vital signs, results of procedures and even the fact that I had a flu shot or an eye exam, my holistic care plan comes into sharper focus. The payer is a one-stop shop for all of the data required to catch up any provider with what has been happening with my care. This is how healthcare payer interoperability is important to an individual patient.
Importance of Payer Interoperability in the Healthcare Industry
The goal of the industry is to improve the health of the populations we serve, while making enough money to remain open. The shifting payment models and regulations make interoperability in healthcare a key factor in accomplishing that goal. The industry is focusing more and more on the health of populations.
Without both clinical and claims data on groups of people with similar traits, this type of population analysis cannot be completed. Payers already perform population health analytics using claims data. With the addition of clinical data from providers, population health analytics have grown into predictive and even prescriptive analytics very quickly. Payers then share the information gleaned from all of this data with the other players in the space.
RELATED: Interoperability Takes a Village
Once the industry is on the same page, the true magic can begin. Emergency department and hospital stays decrease, repeat tests and procedures decrease, management of chronic conditions tracks seamlessly between providers, patients feel more engaged in their care and trusting of their providers, network/accountable care organizations/group leakage is avoided, population needs are identified and met, and it all starts with healthcare payer interoperability.
The power of data is a reality in healthcare. No one entity can generate enough data single-handedly to meet the needs involved in population health, predictive analytics and alternative payment models. This fact forces healthcare entities, including payers, to become interoperable.
There are many instances of healthcare payer interoperability in existence. There is power in interoperable claims and clinical data. Through participation in HIMSS, healthcare standards (such as HL7) and other industry organizations, the industry can evangelize the importance of payer interoperability. We can bring payers to the table when interoperability is being discussed. Every stakeholder in healthcare is important to this discussion; patients, providers, vendors and payers.
The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.
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Originally posted January 8, 2019