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Interoperability Challenges and Recommendations 

Introduction

The U.S. Department of Health and Human Services (HHS) aims to have an interoperable health IT ecosystem by 2024.

This ecosystem would make the right data available to the right people at the right time across products and organizations.

Centers for Medicare & Medicaid Services (CMS) has been regulating data exchange schematic and syntax standards using 1500, 1450 Forms, HIPAA 5010 X12 EDI Messages, and NCPDP D.0 Messages.

Clearing houses, infomediaries and plan portals require connectivity across disparate systems and organizations to exchange data.

Leveraging an interoperable health IT system, patient data would be shared seamlessly among authorized practitioners and individuals. This would help all parties make more informed decisions, improving the healthcare quality and lowering costs.

Not all types of healthcare data exchanges are as in dire need of improvement. Today, revenue cycle management (RCM) data can be shared seamlessly. It has well defined standards and connections for information exchange and interpretation across ecosystems. Overall, RCM data exchange between providers, health plans, consumers and other organizations is robust and mature.

This is especially true when compared with problematic clinical data exchanges between all authorized practitioners, consumers, and health plans. With clinical data, providers face unique challenges exchanging information outside their health system.

Obtaining this data from settings outside a network requires complex data-sharing agreements and new interfaces between systems.

According to The Office of the National Coordinator for Health Information Technology (ONC)’s 2014 data brief, less than half of providers can access clinical information from outside of their systems. The brief also states that approximately 4 in 10 hospitals can access necessary clinical information from outside providers or healthcare sources.

Providers are well-aware of these challenges in sharing clinical data. According to a recent survey by a group purchasing organization (GPO), Accountable Care Organizations (ACOs) report that lack of interoperability between their HIT systems and outside providers is their biggest challenge.

Read on to explore universal challenges with clinical data exchanges and steps healthcare leaders can take today to address these challenges.

Interoperability Challenges:

·      Lack of Universal Adoption of Standards-Based EHR Systems:

With Meaningful Use Incentives, the exchange of data between lab, pharmacy and radiology center is digitized. However, Electronic Health Record HER-to-EHR communication has yet to digitize in the same way.

The only integration between EHRs today is the

exchange of summary of care documents. This exchange is not widely adopted by EHR systems.

In addition to limited adoption, summary of care documents are hard to read and include irrelevant information. This makes necessary data difficult to find for physicians.

For EHRs, data definitions and coding standards are inconsistent across providers as well. For example, for disease definition some providers use SNOWMED codes and some use the ICD Codes. As well, each EHR system has unique software types and APIs. Therefore, when data is exchanged between providers, interpreting such data and saving it in the other provider system’s patient medical record is near impossible.

These inconsistencies require custom integration and additional development for every single exchange type.  For example, custom integrations must be made for each EHR system’s supported Health Level Seven (HL7) version.

·      Prohibitively High Data Exchange Fees: 

Implementing interoperability is costly. Each integration requires upfront capital. Some EHR vendors may claim to have the capability to send and receive patient information from other systems, but this always comes at an additional cost of $5,000 to $50,000.

·      Outdated Legacy Standalone Systems:  

Legacy systems have poor interoperability. Establishing connectivity of legacy systems to middleware creates structural misalignment within existing data layers. Remediating these structural misalignments while also establishing connectively is extremely costly.

·      Impact on Providers’ Day-to-Day Workflow:  

New technologies impact existing workflows. This is especially true for industries like healthcare with highly complex workflows. Many providers are currently operating at maximum capacity. There is no reasonable bandwidth to add additional requirements of learning new workflows or record keeping.

·      Complex & Misunderstood Privacy & Security Policies:

Privacy and security policies present a major barrier to implementing interoperable systems. In order to exchange information, EHRs must integrate varying state specific privacy and security laws.

In addition to state laws differing vastly, federal laws are also poorly understood by providers. For example, HIPAA policies and certain privacy laws addressing paper-based documents are not universally agreed upon. The differing understanding of these laws impedes streamlined data exchanges between stakeholders.

·      Lack of Incentives to Develop Interoperability: 

A key inhibitor for streamlined health information exchange is economic incentives like traditional fee-for-service payment models. These fail to encourage hospitals or health information technology (HIT) vendors to prioritize interoperability. As a result, her developers have largely ignored interoperability. They have instead opted to focused on other capabilities like improving documentation for billing purposes.

·      Standards Not Adequate to Deliver Relevant Data: 

Lack of interoperability hinders comprehensive data on your patients’ health. Currently practitioner notes do not have to be written in a shareable format to share with other providers. Without a clear understanding from all specialists and health systems serving your patient, you cannot offer the most accurate diagnoses and ideal treatment options.  

Recommendations

·      Payment Incentives for Adapting Interoperability: 

High-value interoperability measures targeting both providers and vendors will help streamline data exchanges. New payer payment models and CMS’s introduction of Valued Based Reimbursements can realign incentives to prioritize interoperability for all stakeholders. In addition to rewarding high quality of care, information blocking activities should be penalized. Overall, to create an interoperable healthcare ecosystem there must be clear and specific incentives, defined measures and an actionable timeline with deadlines.

·      Interoperability Standards Definition:

The US federal government is the largest healthcare insurance payer (CMS’s Medicare & Medicaid) and provider (DoD, VA, IHS, etc.). These organizations will have a large impact on shaping the future of nationwide health information exchanges. Federal agencies have strongly supported HL7, Consolidated Clinical Document Architecture (C-CDA) and Fast Healthcare Interoperability Resources (FHIR) through Meaningful Use (MU) incentives. However, these agencies have not achieved interoperability due to lack of a defined structure and process. Without this clear structure, there is no way to drive development, adoption, and self-regulation of industry-wide standards.

In private sector dominated industries like banking, firms come together to provide necessary standards for interoperability. The US federal government should study these standards from the private sector and implement them within the healthcare ecosystem. Health systems and HIT vendors should ally with the government to support these adoption efforts to achieve interoperability.

·      Enterprise Master Patient Index: 

To enable data exchange across the continuum of care, patient identity must be reconciled accurately across organizations. Currently these patient-confirming capabilities are inferior to those delivered by an embedded Enterprise Master Patient Index (EMPI).

The core function of this technology-agnostic index is to aggregate data, including identity data, between applications regardless of data type or format. They usually employ a probabilistic matching engine. This engine leverages statistics and data analytics to pinpoint variation and establish more accurate forecasting. system can be problematic depending on the environment’s size and complexity. It is well suited for complex organizations with numerous disparate systems and databases.

·      Connecting Private Electronic Health Information Exchanges (HIEs): 

Black Book Research in April 2016 reported growing HIE user frustration over lack of standardization and preparation of providers and payers.

Today HIE’s pose additional challenges for data exchange. These challenges include added costs and resources to achieve interoperability goals, as well as needed governance and trust among entities to facilitate sharing health information.

To address this, healthcare vendors are turning to middleware solutions employed by other industries like retail, banking, and transportation. Middleware platforms facilitate transparent, yet secure access of patient health data. They do so by translating information directly from disparate systems including EHRs and HIEs. They create a business intelligence layer providing data to all stakeholders in real-time.

·      HIT Alliances Collaboration:  

The Sequoia Project and the CommonWell Health Alliance are advocating for a nationwide health data exchange and interoperability.

Sequoia supports Carequality, a public-private collaboration developing common interoperability frameworks for data exchange.

CommonWell launched in 2013 and has grown to 40 HIT organizations. CommonWell supports secure access to and exchange of health data nationwide. Its members are committed to implementation of initiatives person enrollment, record location, patient identification, linking, data query and retrieval.

Alliances like CommonWell and Sequoia should further collaborate amongst themselves to implement a common interoperability standard across various healthcare sectors.

·      Regulations to Drive Necessary Clinical Data Exchange:

Regulatory mandates don’t enforce exchange of non-standard data like notes between health systems.

As well, the adaption of FHIR, that supports non-standard clinical data, is largely limited to influence CMS’s interoperability rule.

CMS’s interoperability rule should be expanded to mandate the exchange of needed non-standard clinical data between the health systems.  The regulation should also focus on building trust across health systems to improve data exchanges.

Benefits of Interoperability:

·      A unified standard implementation enables all disparate systems to interpret data accurately.

·      Middleware enables secure exchange of data across various source systems

·      An interoperable EMPI helps identify and locate the right patient record

To achieve healthcare interoperability, synchronous collective action is needed among multiple stakeholders. It also requires consensus among all healthcare participants on an actionable roadmap, timeline, and standards for interoperability.

Interoperability Implementation at Your Health Plan

Although it takes an entire healthcare ecosystem to establish nation-wide interoperability, there are some action items your health plan can implement today to create a more interoperable environment within your company and patient and provider networks.

The most effective way to streamline interoperability is to partner with a healthcare SaaS professional, like Source, to incorporate information exchanges within a single API. To get started book a demo for your team today.

The Importance of Leading & Living with Empathy

When people feel cared for, valued, and supported, they tend to:

• Perform better
• Have stronger bonds with leadership and the organization
• Be more committed to the company’s mission

Empathy is an increasingly important skill, with particular emphasis on establishing bonds between employees, leadership, and company values. Empathy is humble curiosity. It is a skill set fundamental to emotional intelligence, resilience and building strong, trusting professional relationships. It is the ability to identify other people’s challenges and see them from their perspective.

Empathy’s Positive Impacts

A Catalyst study surveying 889 employees found empathy significantly impacts production in the following ways:

• Innovation: People who reported having empathetic leaders were 48% more likely to be innovative.
• Engagement: 76% of team members who experienced empathy from leaders reported they were more engaged at work compared to only 32% of those who experienced less empathy.
• Retention: 57% of white women and 62% of women of color said they were unlikely to leave their companies when life circumstances were respected and valued in the workplace.
• Inclusivity: 50% of workers with empathetic leaders reported their workplace as inclusive, compared with only 17% of those with less empathetic leadership.
• Work-Life Balance: When people perceived leaders as more empathetic, 86% of employees reported they were able to better navigate demands of work and life. In contrast, only 60% of people with less empathetic leadership felt this same level of competency.

Empathy is not only important for teams and leadership but also for customer interactions. Empathy better aligns us with consumer perspectives, allowing companies to better understand pain points and provide optimal solutions.

What can we do to manage teams with greater compassion and understanding to improve communication, increase productivity, and enhance team morale? Here are five tips for leaders and teammates to develop empathy within your organization.

1. Value People Not Just Deliverables

It’s common to focus on deliverables and attribute missed deadlines to individual productivity – instead of personal challenges. This establishes a void between leaders and who they lead, and staff feel less valued.

Take the time to understand what is really driving your team member’s performance or under performance.

“Empathy is about being concerned about the human being, not just about the output.” — Simon Sinek

2. Increase Active Listening

Active listening is essential to building an empathetic workplace. What are your intentions when listening? While they are talking – are you brainstorming ways to fix their problems or counteract their arguments?

Listen to understand and learn, versus listening to ‘fix’.

3. Prioritize Clear Communication

In a recent study, researchers asked a group of workers, “What do you need more of to feel like you can be your best at work?” The only consistent response was clearer communication from leaders. To achieve this:

• Provide transparency and ongoing status updates
• Clarify roles and goals for team members
• Ask how people are doing
• Have open conversations about stress and other challenging topics
• Talk about a time when you overcame a workplace challenge

4. Avoid Judgement and Assumptions

Judgements and stereotypes, impede empathy in the workplace. Avoid making assumptions about your colleagues. Give your teammates the benefit of the doubt before forming opinions.

5. Recognize Feelings

Work can be stressful. Some handle stress better than others. Be mindful of how you speak and react to colleagues. Consider their workloads, and lives outside of work. Try to always communicate with respect and kindness. You will notice that speaking with empathy is more effective.

Using Empathy to Set KPIs

When deciding your quarter or yearly initiatives it is important to leverage empathy and consider what frustrations your teams are facing. If you don’t know what barriers are for your employee’s success, ask them.

One of the most challenging parts of working in healthcare is information sharing and ever-changing policies. This may be a great starting place for empathetic KPIs.

Developing empathy in the workplace is a potent way to empower your team to perform better, have stronger bonds with the organization, and be more committed to the company mission.

There’s likely to be movement among Medicaid and Affordable Care Act (ACA) membership as the nation seems to be inching toward the end of the pandemic, at least from a regulatory standpoint.

Medicaid rolls swelled during the pandemic as relief packages guaranteed coverage for members even if they became ineligible over the course of the Public Health Emergency (PHE). But nothing lasts forever and states are bracing for an end date to the PHE, now expected to occur in mid-October. Political pressure is building to end the PHE, even as various entities plead for more time. If the PHE is not extended for another 90 days this fall, state Medicaid programs will need to begin re-verifying eligibility for members. There won’t likely be immediate disenrollment, but the process will begin and the clock will start ticking. To make things more challenging, the accuracy and success of this is likely to vary greatly according to state budgets and administrative effectiveness. There will be no coordinated, uniform approach. The U.S. Department of Health & Human Services (HHS) has promised a 60-day notice period to states before the PHE expires, so look for the administration to signal mid-August whether the PHE will renew again in October.

At the same time, the end may be in sight for the ACA subsidies legislated under the 2021 American Rescue Plan Act that served as a healthcare cushion for millions of Americans who became newly insured under the March 2021 pandemic stimulus package. The relief package specified that this support would end at the close of 2022, unless Congress acts to extend it. Some 3.4 million people could lose coverage out of a record 14.5 million ACA enrollees. The impact in terms of uninsured is a bit of a moving target, as some enrollees who are currently covered by one program may become eligible for the other. Some may have gained employer-sponsored coverage in the meantime. Either way, the task of contacting, educating, disenrolling and re-enrolling this many people will be daunting.

CMS Administrator Chiquita Brooks-LaSure said June 22 that “time is of the essence” for Congress to extend ACA subsidies in order to be ready for November Open Enrollment.

Step 2: Evaluating Payment Integrity Vendor RFPs

“Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare…”.¹ Here’s what health plans can do to effectively partner with vendors in addressing it.

Recommendations

To achieve prospective payment integrity, health plan CIOs should:

• Issue an RFP to both current and potential partners.
• Evaluate vendor capabilities and results pertaining to:
  • Percent of claims processed correctly the first time.
  • Number of provider types and settings included.
  • Automated updates and data loads.
  • Frequency of updates.
  • Transparency of audit trail.
  • Infrastructure cost-savings.

What is the Goal of an RFP For Payment Integrity?

RFP reviews will help health plans to identify:

• Yet-to-be-leveraged advanced solution capabilities.
• Opportunities to consolidate vendors.
• Innovative approaches not previously considered.

Who should conduct the evaluation?

All business leaders responsible for payment integrity should help evaluate the RFP findings, while procurement specialists should focus on identifying opportunities to recontract existing vendor solutions.

An executive committee should be formed (see How to Achieve Claims Automation for Health Plans) which will have the final say in this analysis.

RFP Criteria

Issue your RFP to both current and prospective vendors. There is a plethora of payment integrity partners to choose from, each with varying claims processing capabilities. It is important to consider vendors that:

– Are Cloud-Based: updates and IT infrastructure can be delivered automatically to improve accuracy and decrease workflow inefficiencies.

–Address Root Causes: work as partners with payers to address root cause issues and deliver on transparency that enables payers to fix upstream issues in the payment process.

–Customize Solutions: understand your long-term vision and work iteratively with you to achieve long-term goals organization-wide.

–Offer Open API: data is centralized and accessible for more informed business decisions.

Criteria include:

• Percent of claims are processed correctly the first time. Make sure your vendor is making updates more frequently than four times a year. This allows your health plan to adapt to changing markets more effectively, remain in compliance, and pricing right the first time.
• Number of provider types and settings included. Ask about data covering all providers in every care setting to eliminate the need for multiple and disparate data sources.
• Automated updates and data loads. Ask about automatic updates to data sets and subsequent client improvement in delays and errors.
• Transparency of audit trail. Ask if there is an automated audit trail and complete archives. This eliminates the burden on the user to prove and support claims pricing results.
• Infrastructure cost-savings. Ask if the solution is cloud-based and the subsequent reduction in IT demands, costly legacy software, and maintenance clients have achieved.

How to Start Investing in Prospective Payment Integrity Solutions Today

By leveraging your dedicated committee for RFP evaluation, you’ll forge payment integrity partnerships with a thorough understanding of vendor capabilities.

Have questions about how to form your dedicated committee? (read more)

Want more information about automating claims and the impact of prospective payment integrity for health plans? (read more)

To learn more, get complimentary access to Gartner® research here.

¹Gartner®, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment, 24 September 2020, Mandi Bishop

GARTNER® is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

Step 1: Objectively Measure Impact of “Stacking” vs Prospective Payment Integrity

With complementary access to Gartner® research, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment

Read Step 2: Evaluating RFPs

“Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare…”.¹ Here’s what health plans can do to address it.

Recommendations

To achieve prospective payment integrity, health plan CIOs should:

1. Quantify the value of current “stacking” or other payment integrity efforts. Do this by establishing a comprehensive and in-depth ROI analysis, including metrics from:

• Finance
• PNM
• SIU
• Claims Leadership

2. Capture key performance indicators (KPIs). Identify methods used to achieve KPIs and how to measure success.

Who should establish objective impact? What team members should be consulted?

Implementing prospective payment solutions can be challenging because it requires buy-in from stakeholders across the health plan enterprise.

All business leaders across the enterprise who are responsible or accountable for payment integrity initiatives should be consulted when conducting an ROI analysis and KPIs. This includes professionals in:

• “IT (including reporting and analytics functions)
• Finance and actuary
• Compliance
• Claims
• Network management (including provider relationship management)
• Medical management
• Customer service (provider and member, as payment integrity affects both constituencies)
• Vendor management
• Specialty business management
• Legal
• Delegated entities”

To spearhead ROI and KPI analyses, CIOs should establish a formal committee made up of leaders in each of these departments. Gartner research states that together they should determine:

• “What are the specific objectives of the department’s payment integrity effort? For example, is the goal to open 20 new investigation cases per month or recover $5 million over 12 months?
• What types of payment integrity processes are in use to meet the objectives (that is, retrospective, prospective or preemptive) and are they delivering on their promise?
• What solution partners are assisting the department in addressing payment integrity and are they performing up to expectations?
• How does the business unit measure and report payment integrity performance and how are those metrics trending?
• Do the existing solution partners have performance requirements and incentives as part of their contracts, what are they, and are the goals being achieved?”¹

Establish Company-Wide KPIs

Once the above questions are answered, your committee should record each business unit’s specific KPIs related to payment integrity. They should also note how these KPIs are measured and achieved.

Highlight the KPIs which are:

• Uniform across business units
• Related to payment integrity goals
• Impact customer experience (cx)

Notes: Claims payment accuracy and timeliness significantly affect provider and member relationships.

Customer experience is especially important because poor provider/partner and purchaser alignment can influence revenue-generating activities, such as network contract negotiations and large group renewals. Customer experience also impacts:

• Net Promoter Score (NPS) for members and providers
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores
• Medicare Advantage Star ratings on health plan experience measures
• Rate of grievance and appeals
• Membership churn
• Network adequacy gaps

If the payment integrity and customer experience objectives are fragmented between departments, consult with c-suite executives to define enterprise-wide corporate goals. Create a final list of goals related to KPIs that considers stakeholder responses.

Your final list of goals and related KPIs could include:

• Decrease the current claims spend
• Reduce the percentage of claims requiring rework (goal)
• Reduce the cost per claim processed (goal)
• Reduce claims-related provider call volume
• Reduce member touchpoints
• See more in the table below.

How to Start Investing in Prospective Payment Integrity Solutions Today

By developing a dedicated committee to determine cost-benefit of “stacking” strategies vs prospective payment solutions as well as establishing company-wide KPIs, you’ll overcome barriers to adoption.

The next step to payment integrity is to issue an RFP. Your committee should then evaluate current or possible vendor capabilities for improving cost avoidance as well as enhancing business and provider partnerships. (learn more)

To learn more, get complimentary access to Gartner research here.

¹Gartner, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment, February 16, 2022

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

Providers Grapple with Regulatory Realities

Providers appear to be grappling with the regulatory realities of value-based care, especially when it comes to data transparency. Although they claim that the wording of various data transparency regulations is too vague, as one example, it seems obvious that hospitals and health systems find paying fines preferable to disclosing their prices.

A recent KLAS poll of 66 revenue cycle leaders at hospitals and health systems indicated many will do only the bare minimum to comply with pricing transparency rules. Most are not doing even that much 18 months after these rules became law.

Hospitals have been required since January 1, 2021, to post cash prices and negotiated rates with payers for 300 common services. Full compliance demands that information is posted in both machine-readable files (i.e., searchable files) and is formatted in a “shoppable display,” (i.e., a consumer-friendly manner) Yet, a recent JAMA analysis found that half of hospitals don’t adhere to either standard. Fourteen percent have machine-readable files and 30 percent have a shoppable display. All told, just 6 percent of hospitals are compliant with both standards. The least compliant facilities are in highly concentrated markets and those in rural areas.

The Centers for Medicare and Medicaid Services (CMS) said June 9 they would fine a Georgia hospital system more than $1 million for violating federal transparency laws, citing the lack of a “consumer-friendly list of standard charges,” an incomplete list of services and failure to produce these within a single file. The system had been given an opportunity to correct these issues but did not do so. CMS has issued more than 350 warnings to hospitals and systems, but the Georgia fine was the first issued nationwide. Fines can reach $300 daily, but this does not appear to be a sufficient incentive, although a number of providers have changed their tune, but only after receiving corrective action plans from CMS.

Perhaps only in America does this create an entrepreneurial opportunity for companies to gather the posted information, convert it into meaningful formats and sell it back to insurers, employers and others. In a digestible format, this data can provide negotiating leverage for future contracting, so it has distinct value.

Some hospital groups have filed suit against transparency regulations, but so far the rules stand. A coalition of large employers argues the simplest way to gain compliance is to substantially raise the fines. Transparency is inevitable, even if the wheels turn slowly.