Practical Interoperability. Trust, Workflow, & Value-Based Care Models. HealthCare Executive Group. HCEG. Focus Area Roundtable. health plans, payers. Insurance.

Practical Interoperability Part 2: Trust, Workflow, Value-Based Care Models, & More

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‘Practical Interoperability’ means different things to different healthcare stakeholders. In the HealthCare Executive Group’s first Focus Area Roundtable on Interoperability, leaders associated with health plans, care providers, and organizations supporting the healthcare system discussed what practical interoperability means to them. Addressing barriers to interoperability and use cases with the most potential to increase interoperability was a primary focus of the roundtable with highlights shared in the first post recapping the roundtable titled ‘Discussing Barriers to Healthcare Interoperability, Use-Cases, and More.’ This second post shares additional highlights including increasing adoption of use cases, the importance of trust among stakeholders, interoperability’s increasing impact on value-based arrangements, and workflow considerations – particularly in terms of balancing the amount of information exchanged by payers and providers.

Read Part 1 of the recap of this first Focus Area Roundtable on Interoperability here.

Importance of Establishing & Maintaining Trust to Overcome Barriers to Practical Interoperability

Building on discussion of the importance of health plan-provider collaboration and which stakeholders are best positioned, qualified, and equipped to own specific interoperability use cases, HCEG’s Ferris Taylor noted the abundance of EMR’s, robust data sets that increasingly include structured clinical data, and analytical capabilities that weren’t available 12-15 years ago. These data and analytics, along with mandates on transparency and interoperability – particularly electronic prior authorization and pricing data – are forcing stakeholders to increase trust among themselves and other 3rd parties.

Ferris asked Tim Capstick, Regional Vice President of Health Plans at Surescripts, to frame the discussion of developing trust to unlock the value of increasing practical interoperability.

Developing a Trust Framework to Unlock the Value of Existing Healthcare Data AssetsTransparency in Coverage Mandate. No Surprises Act. health plans, health systems, healthcare providers. compliance-related activities. Data Standards, Data Collection & Operational Considerations

Tim set the context for roundtable comments by sharing how well-defined standards, clearly understood use cases, and trustworthy partners serve as the essential foundation to maximize business model benefits of increased interoperability. Tim emphasized: “We have to be able to trust whoever’s going to sit in the middle – or bring these entities together. We’ll have to be able to trust each other and make sure that we know and trust what each other are going to be doing with this information.

Listen here for more on establishing trust to unlock the value of healthcare data

RELATED: Building Trust is Essential to Transforming the Healthcare System

Establish Trust by Consistently Providing Quality Information That Returns Value

One participant representing a research organization shared that standards – particularly FHIR – will help with advancing practical interoperability once the data content, elements and formats of these standards are better understood.

Participant Denny Brennan, Executive Director and Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium (MHDC), weighed in on the importance of by sharing that MHDC is creating an implementation guide combining DaVinci-compatible payer data and clinical data exchange standards related to prior authorization.

Denny noted that payers and providers have a great deal of work getting their digital house in order and making the necessary data available to accelerate instantaneous or close to instantaneous prior authorizations for services that today are difficult, arduous, and don’t require a huge amount of clinical intervention, if anything, to make the decision.Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Listen here for more on the importance of providing quality data to healthcare providers

See Price Transparency Data Standards & Operational Considerations from a recent roundtable in Price Transparency facilitated by our Focus Area Partner HealthSparq.

Balancing Amount of Data Shared with Providers – Increasing Impact of Value-based Arrangements

Other discussions involved challenges, issues, and opportunities regarding interoperability’s impact on the day-to-day workflow of healthcare stakeholders – particularly in terms of how care providers are accessing information and what information is being presented. The balance between providing too much information that can overwhelm care providers, administratively burdens them, and inhibits their ability to do what they need to do and responding to provider requests for more information to make care decisions were discussed. Participants noted value-based arrangements and risk-based reimbursement models are clearly an impetus for increased interoperability and drive desire from the provider community for more information. Being mindful of the process workflow of care providers, what information is inserted into the workflow, and how that information is inserted and accessed was identified as key considerations.

RELATED: How Health Plans Can Best Support Provider Organizations Address Barriers to Practical Interoperability

The Importance of Breaking Workflow to Include Business Partners

Roundtable participants made clear that accommodating care provider information demands – whether under traditional FFS or new value-based payment models – requires a thoughtful change to provider workflows. In addition, compliance with interoperability mandates and realizing practical interoperability’s greater benefits means all stakeholders will need to break their routines and [modify] their workflows to include partners.

“Stakeholders don’t have to do this themselves if they can get out of the adversarial zero-sum game that, if we share data with providers, or we share data with health plans, they are going to use those data against us or whatever scenario comes to mind. There’s a lot of money that’s being swept off the table by IT vendors who are offering niche services that ultimately never get used.” – Roundtable Participant

As shared in the Part 1 recap of the roundtable on interoperability, if providers invested in better collaboration with their payers, they might reduce their investment in the technologies to support processes they thought they were going to do entirely by themselves.

Listen here for more on breaking business partner workflow to reduce overall IT investments

Interoperability Vendors Serving the Healthcare Market – a Darwinian ExperimentDarwinian experiment interoperability-related initiatives, programs, and applications.

Participants shared various comments about increasing the adoption and evolution of interoperability-related initiatives, programs, and applications.

One participant shared his observation that, on the intervention side, increased interoperability is empowering many great third-party companies that are already doing great work around mobile engagement, disease management, and so on.

“There’s a whole bunch of them. There’s been a sort of Darwinian experiment of all these different vendors about what approaches to take and we’re starting to see some rise to the top; to create the ability for them [providers] to sort of socket in a secure way and play on the platform and do things for the benefit of patients.”

Another shared that healthcare stakeholders have a collective obligation to create a competitive environment for the adoption of practical interoperability:

“I think when we talk about interoperability, we have just not a responsibility but really an obligation to create a competitive environment where they can come and play and let the best continue to rise to the top.”

And another shared a suggestion to healthcare providers who think they can avoid sharing their healthcare data.

One of the steps that we have to really focus on in terms of what do payers and providers have to do is: stop thinking you have to do everything yourself. You’re going to have to share data. Forget about arguing about that. Forget about it. You’re going to have to share everything. The deal is done. It’s over. You’re going to have to be transparent, get over it, stop complaining about it.”

And now, healthcare requires payers and providers are going to have to really start thinking about creating new, collaborative business models that engage consumers. And if they don’t do that and each go after the consumer in their own way, they’re just complicating the problem we have today which is: I want to go to one place to get all my health data. The fact that it’s a health plan as envisioned in the regulation should not preclude any progress.

Quality Measures: Data Requirements, Costs, & Impact of Upcoming Changes

A participant from a small health plan noted the number of new hybrid measures related to telehealth services and how interoperability mandates and related initiatives will impact provider collection of quality measures and submission to health plans; particularly as the CMS deadline for transition to all-digital quality measures takes place in 2025 and information currently being collected goes away.

Sharing Information – It’s the Law & The Right Thing to Do

This participant representing a small health plan expressed concern about the number of EMR systems in use at health systems, the overall lack of awareness, understanding and adoption of interoperability mandates among the provider community, and the challenges that present health plans – particularly smaller health plans – with accessing data from health systems.

She mentioned the cost impact of both complying with interoperability mandates and how some providers and health systems charge for access to data housed in their individual EMR’s.

“We’re sitting here knowing that our entire world is going to digital, knowing that we have to get to digital, seeing interoperability as one opportunity for everybody collectively to get to digital. But the adoption rate is The Big Question in my mind.”

Listen here to the leader of a small health plan share insight on accessing data

Information Blocking – Serious Consequences for Non-Compliance

Information Blocking. Section 4004 of the 21st Century Cures Act. Electronic Health Information (EHI). USCDI Version 1. Regulations. Interoperability

Source: Office of the National Coordinator for Health Information Technology (ONC)

Existing regulation concerning Information Blocking (Section 4004 of the 21st Century Cures Act) was raised with one participant noting that charging fees for accessing, exchanging, or using Electronic Health Information (EHI) – with exception per 45 CFR § 171.302 – is a felony.  He noted that while a smaller subset of EHI data (elements defined in USCDI Version 1) is currently subject to Information Blocking through October 5th, 2022, regulations expanding those data elements to USCDI version 2 are quickly approaching and the regulated community should make all EHI available as if the scope of EHI were not currently limited to Version 1.

Patience for Non-Compliance with Information Blocking Regulations is Decreasing

This topic of discussion was ended with this participant saying:

“And CMS and the [Biden] Administration have shown absolutely no patience whatsoever with that stance. So, I think health plans who were finding themselves running up against EMR’S who are trying to monetize data and the availability of data from their records, have the weight of the law behind them. Providers who try to monetize their data exchanges with health plans directly is not okay unless it’s purely at cost or something very close to at cost if it’s an extraordinary effort. And going forward it’s not going to command a very high premium to get data from the provider who’s treating a member.”

Listen here to a healthcare data expert on provider reluctance to share data with health plans

Learn More About Practical InteroperabilityPractical Interoperability. Electronic pre-authorization. Surescripts. HealthCare Executive Group. HCEG. Focus Area Roundtable. health plans, payers.

On September 8th, 2021, leaders of health plans, health systems, and provider organizations will have the opportunity to discuss the real-life initiatives, programs, applications, and technologies their organizations are considering, implementing, or currently using to address the challenges, issues, and opportunities recapped here and in the first post of this two-part series.  Leaders of health plans, health systems, and provider organizations are encouraged to request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities presented on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

Barriers to Interoperability. Health plans, payers, care providers. Mandates. data transparency, information blocking, HIPAA regulations. Surescripts. Use Cases. Prior Authorizations. Electronic prescribing. Medications. Surescripts

Discussing Barriers to Healthcare Interoperability, Use-Cases, and More – Part 1

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‘Interoperability’ – particularly between health plans and care providers – has been a high priority of healthcare executives for years. It ranks #6 on the 2021 HCEG Top 10+ list and has an impact on almost every area of healthcare. And recent, still evolving mandates regarding data transparency, information blocking, changes to current HIPAA regulations, and interoperability have placed significant challenges upon the health plans, provider organizations, and the technology partners serving the healthcare industry. Forward-thinking stakeholders are not considering mandates as barriers to healthcare interoperability but rather viewing compliance with mandates as opportunities for ensuring the ongoing viability of their healthcare business models.

In our first Focus Area Roundtable on Interoperability held Tuesday, July 20th, and facilitated by our Focus Area Partner Surescripts, leaders from health plans, health systems, and healthcare provider organizations shared their experience, insight, and information in a roundtable fashion on the topic of Interoperability. Surescripts Tim Capstick and Ashley Clark served as industry thought leaders providing their perspective on these interoperability-related topics, in particular from a health plan point of view.

This post presents the first part of a 2-part series sharing highlights of this first roundtable on interoperability. Leaders of health plans, health systems, and provider organizations are encouraged to participate in upcoming Focus Area Roundtables including the 2nd Interoperability roundtable on September 8th, 2021.

Read Part 2 of the recap of this first Focus Area Roundtable on Interoperability here.

Barriers to Healthcare Interoperability Payers & Providers are Encountering

HCEG’s Executive Director Ferris Taylor kicked off the roundtable by asking participants: What are the barriers to healthcare interoperability that health plans and health systems are encountering with respect to the broad topic of interoperability?

Consent Management – One of the Barriers to Healthcare Interoperability

One participant noted that when deploying interoperability solutions, one of the biggest challenges involves consent management for members and patients. Appropriately managing patient data and providing individuals the ability to weigh in on the sharing of their data is both a technical and policy problem. He noted while their organization is addressing consent management largely on their own, he expects the evolution of privacy laws in California and Europe will likely have a national impact across the United States.

Another participant shared that addressing consent management is key to the future of interoperability – not just between members/patients and their health plan and providers but also when providers are sharing information with other health systems/healthcare providers.

Listen here for more on the importance of consent management in advancing interoperability

Other Barriers to Interoperability for Health Plans and ProvidersHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability poll

Participants were presented with a list of potential barriers to interoperability and asked to select two barriers from the perspective of a health plan and a provider.

For health plans, Access to and Integrating Data Sources ranked first followed by Complex Privacy and Security Concerns.

For providers, Internal Challenges with Technology and a Lack of Knowledgeable Resources were identified as key barriers to healthcare interoperability.

Impact of Proposed Modifications to HIPAA’s Privacy Rule on Interoperability

Surescripts Ashley Clark shared that data rights are an issue her organization takes very seriously and that they’re currently looking at CMS legislation regarding expanding the definition of treatment under HIPAA and what information can be shared as medical treatment versus non-treatment. Ashley shared that pending regulation changes will likely open up a lot of doors in terms of information that can be shared on things like medication history.

Another participant shared his perspective on barriers to healthcare interoperability for payers and providers by sharing that from his vantage point he’s seeing tremendous reticence on the part of providers to address interoperability and data transparency in any deep way vis-à-vis their health plan partners; with the exception of some relationships forced by the COVID pandemic.

Who Owns Health Plan Member and Provider-Patient Data?

Health Plan Best Positioned to Own Data - HCEG-Industry Pulse Research Survey 2020

Data Ownership – 2020 Industry Pulse Report

The recent announcement by the Biden Administration to increase penalties on providers who are not making their pricing information available was identified as the first step toward breaking the long-held, culturally ingrained notion that patient care and the information generated from that critical activity belongs to the health system and to the provider community alone.  It was noted cultural acceptance – on the part of both payers and providers – that their existing business models are built on a largely zero-sum game is a large barrier that must be overcome in order for practical interoperability to be widely adopted.

Note: Respondents to the 2020 Industry Pulse Report shared their take on data ownership between payers and providers. See survey results in the graphic on the right.

Listen here to a roundtable participant discuss data ownership among health plans and providers

“Culture eats technology. Culture eats strategy. Culture eats operations. Culture even attempts to eat policy for lunch.” – Roundtable Participant Denny Brennan – Executive Director & Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium

Health Plans as Primary Connection for Patients & Healthcare Consumers

The concept of data hoarding by providers and payers was discussed along with the idea that it’s easier for health plans to surface data than it is for providers to do so. January of 2023 – just over two years away – was noted as a deadline for providers to share almost all of ‘their data’ with health plans. Per the Interoperability and Patient Access final rule (CMS-9115-F), providers will have to send the entire patient medical record to a patient’s current health plan because that health plan is responsible for moving that to the patient’s next health plan.

“I know a lot of regulators and a lot of providers around the country have not yet internalized the idea that the primary connection for the patient is going to be the health plan and that providers are responsible for providing the health plan all the clinical data that’s necessary to maintain that connection. And to inform the patient and make it possible for payer-to-payer connectivity to work.”

RELATED: Key Interoperability, Health Information Technology, and Transparency Policies

How Health Plans Can Best Support Provider Organizations Address Barriers to Healthcare Interoperability

“If I were running a medical group or a community hospital, one of the first things I’d be thinking is:

  • How do I sit down with my major payers and figure out what I can upload?
  • What am I doing that I don’t have to do that payers can pick up with me?
  • How do I cement that partnership by taking over pieces of the business that they insist on taking over that I’m better equipped to do like delivering care to the patient?

I’m the one who’s going to engage the patient. Give me tools, help my staff get trained so that the doctor doesn’t have to talk to the patient about SDOH or the doctor doesn’t have to talk to the patient about their financial exposure.”

Listen here for more on how health plans can help healthcare providers enhance interoperability

Use Cases with Most Potential to Increase Interoperability

Ferris asked participants to share their insight on which use cases might best advance interoperability and improve payer-provider-patient/consumer collaboration.

Increasing Consumer Ownership & Assisting Stakeholders Serve Their Members/Patients

A health plan participant shared that the use cases he sees that have the most impact potential are ones that lead to an increased amount of consumer ownership and activation of the health system to serve the member/patient. He noted that the process of effecting these use cases requires healthcare organizations to face some level of deconstruction. He explained that addressing barriers to interoperability in healthcare means that everyone has to have a relationship with everyone else when it comes to data – and some organizations are uncomfortable with that. So, we have more work to do.

Automating High Friction Activities & Improving Patient Engagement

Another participant shared that his organization separates use cases into two major buckets. One in the realm of automating high friction activities between payers and providers. Frequently occurring activities that can be automated and that are happening in every other industry. And the other in the realm of interventions, population health, or value-based care efforts that actually improve care like patient engagement, chronic disease management, telemedicine, etcetera.  For each bucket he emphasized the importance of each use case:

  • Being capable of being rolled out on their own and in a stepwise fashion to get to some ideal future state.
  • Having deployable value on its own and being able to stand on its own.

As an example of the bucket on the automation side, one of the first things healthcare organizations should address is auto eligibility because something like three-quarters of the calls from providers to their payers is some flavor of eligibility. And, except for a long tale of rare cases, a lot of that is totally automatable.

In a recent Focus Area Roundtable facilitated by HealthSparq, participants discussed how new price transparency mandates will likely help drive opportunities for increased engagement between providers and their patients. Read more about this potential in Payer-Provider Collaboration Critical to Meeting Price Transparency Mandates.

Reshaping Patient Relationships with Providers

Another participant shared that their personal experience is that the patient-provider relationship is typically a transactional relationship – often a negotiation on a chargemaster – and that increased interoperability seems to have the potential at least to change that quite dramatically.

Most Impactful Use Cases Identified by Focus Area Roundtable Participants

After discussing interoperability-related use cases, participants responded to a poll on ‘Which interoperabiliHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability Use Cases pollty use cases offer the most opportunity to advance patient-payer-provider collaboration?’ This question was asked from the perspective of both health plans and providers and the following were equally ranked for both health plans and providers:

  • Shortening or Automating Prior Authorizations
  • Providing Pricing Data to Patients & Providers

Electronic Prior Authorizations – Webinar on August 25th at 2:00 PM ET

Automating the processing of prior authorizations via ‘electronic prior authorization’ (ePA) – particularly in settings like the pharmacy where a patient may be waiting – can significantly enhance patient/member engagement by reducing the time between a request being made and a patient receiving care. To learn more about the Fast Prior Authorization Technology Highway (Fast PATH) initiative launched by AHIP and several health plans, consider attending Electronic Prior Authorization: The Fast PATH Towards Better Patient Care on August 25, 2021 at 2:00 PM – 3:00 PM ET.

Cutting Through Administrative Chaos by Focusing on Specific High-Value Use Cases

Surescripts Ashley Clark shared some actions that can be performed to cut through the chaos of everything that’s going on administratively at health plans and provider organizations. These included:

  • Driving adoption and usage of a limited set of use cases by getting very specific about those use case
  • How achieving success with a limited set of use cases can lead to bigger decisions across the board.
  • Being very detailed about the information that is being shared back and forth so that it’s not seen as if irrelevant information were overlooked

Listen here for more from Surescripts Ashley Clark on cutting through administrative chaos

Plans and Providers Working Together to Avoid Duplicative Efforts

One participant whose organization is closely engaged with supporting provider organizations shared that when meeting with providers and health plans they talk regularly about “You both are doing the same things, you call them the same things. They’re a little bit different but why are you both doing Population Health Management?” He commented: “I don’t understand why people who are battling it out on engaging the patient are battling it out on collaboration at the level of administering clinical process.”

Who’s Best Positioned, Qualified, and Equipped to Own Specific Interoperability Use Cases

After discussing interoperability-focused use cases, roundtable participants shared their take on additional considerations regarding involvement and ownership. The following points were raised:

  • Health plans are much better equipped to do population health management.
  • Providers are much better equipped to deal with care requirements and patients in real-time.
  • Everybody is investing in systems that are enormously expensive.
  • Providers are spending a lot of money on tools that if they had better collaborative relationships with payers, they wouldn’t have to invest in.

Payers and providers each need to ask: What does practical interoperability mean for our business and how do we design our businesses?

Listen here for more from roundtable participants on interoperability-related use cases

Informing Care Decisions & Providing Insights to Either Side of the Network

As an individual who works directly with payers and who has colleagues working directly with providers, Tim Capstick shared that Surescripts tends to focus on informing care decisions, providing insights across the network to both sides of the network, and enhancing the prescribing process for providers.

Tim shared that on the payer side there is a lot of concern and issue around the consistency in which providers are utilizing enhanced prescribing services, what providers are getting out of prescription services enhanced by interoperability and the overall return on investment? And on the provider side: what is the quality of this information that’s being presented? Is data consistently being presented and can the data be trusted?

Listen here for more from Surescripts Tim Capstick on informing care decisions and increasing the adoption of interoperability use cases.

Additional Interoperability-related Topics of Discussion – Coming in Part 2

The first Focus Area Roundtable on Interoperability facilitated by Surescripts covered a lot of areas of interest to participants – way more than can be reasonably shared in a single post. In the second part of this two-part recap, information on the following will be shared:

  • Trust, quality, and scarcity as a mechanism for increasing adoption of interoperability use cases
  • The importance of balancing the amount of information payers share with providers
  • Interoperability’s increasing importance and impact on value-based arrangements
  • The importance of workflow
  • An interesting comment about charging for access to healthcare data and how another participant responded

Come Learn More & Share Your Insight

Our second Focus Area Roundtable on Interoperability takes place on Tuesday, September 8th at 10:00 AM PT / 2:00 PM ET and will build upon the topics shared in the first roundtable. In addition, our Focus Area Partner Surescripts will share information on and respond to participant challenges, issues, and opportunities regarding interoperability collected in advance of the roundtable.  Leaders of health plans, health systems, and provider organizations can request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

Webinar: The Care We All Strive For: The Impact of Interoperability

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Has 2020 given you webinar fatigue? The seemingly endless run of virtual events and webinars would certainly justify it. And while moving everything to the digital world has its challenges, society is embracing technology and making the most of the situation. Healthcare is no exception. With the expanded use of technology, healthcare has been reminded of the importance of being able to communicate with each other quickly, efficiently, and easily.

In our October Webinar Series event, The Care We All Strive For: The Impact of Interoperability, we will help fight that webinar fatigue by taking a break from the traditional webinar structure and take time to revisit our shared purpose – to make healthcare run better for everyone.

Please join us on Wednesday, October 28th at 11:00 am PT / 2:00 pm ET to hear the story of what it feels like to be a patient, provider, pharmacist, and payer in a world where interoperability is a reality.

Our sponsor Surescripts will be joined by four healthcare stakeholders who will share their take on the difference interoperability makes on the experience of a patient, provider, pharmacist, and payer. The panelists will examine how sharing information across stakeholders can reduce administrative burden and improve member experience.*:

Carlos Garcia Dr. Natalie Pinter Keisha Wright, RPh Oscar Gustafsson
Patient with Rheumatoid Arthritis & Hypertension Provider Pharmacist, Specialty Pharmacy Vice President of Pharmacy, Payer

Over the next four weeks leading up to the live webinar on October 28th, we’ll be sharing more information on how patients, providers, pharmacists, and payers all benefit from enhanced interoperability of data and systems. In the meantime, learn more about how Surescripts addresses healthcare interoperability challenges here.

* These are imaginary personas whose role in this webinar will be performed by employees of our sponsor Surescripts.