By Stephanie Jamison, Executive Committee Chair and Public Policy Leadership Workgroup Vice Chair, EHR Association.
In the months that have passed since the Office of the National Coordinator for Health Information Technology (ONC) issued the final Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing (HTI-1) rule, the health IT sector has been working diligently to meet the earliest compliance timelines even as it continues an in-depth analysis of the regulatory impact on both developers and the providers who use certified technology.
For the EHR Association, that analysis has given rise to several concerns and ambiguities that need to be addressed to ensure HTI-1, which was published in the Federal Register on Jan. 9, 2024, achieves ONC’s stated goal of advancing patient access, interoperability, and standards.
The new regulations are an important step toward implementing key provisions of the Cures Act and enhancing ONC’s Certification Program. However, there are several aspects of HTI-1 that we believe may have unintended consequences for certified EHR technology (CEHRT) developers and users.
The first deadline is Dec. 31, 2024. That is when CEHRT developers must deliver DSI capabilities to maintain certification. Achieving compliance will necessitate substantial development efforts, including in novel areas for the program like AI/ML for predictive DSIs. Other areas of concern include requirements for:
Developing an end-user feedback function for evidence-based DSIs, including an export capability for machine-readable formatted feedback data.
Developing support for a significantly expanded set of data concepts for which selection of evidence-based DSIs must be available.
Developing support for enabling the selection of predictive DSIs using any data expressed in the USCDI.
Producing nine new source attribute data points for all evidence-based DSIs supplied by developers and more than 30 source attribute data points for all developer-supplied predictive DSIs.
Developing support for customer users to access and modify source attribute information provided by developers for those DSIs they supply.
Developing support for enabling customer users to record and modify their own source attribute entries in the system for DSIs they create or implement on their own.
Developing detailed intervention risk management policies and procedures for ongoing management of predictive DSIs supplied by developers.
Meeting these requirements within the 12-month timeframe presents a formidable challenge for CEHRT developers – a challenge amplified by the lack of a certified companion or other resource guide to support developers with compliant updates. Also coming into play are current CMS requirements governing providers’ use of CEHRT that would force developers to deliver updated technology to their customers well in advance of the ONC deadline.
To alleviate these challenges, we are urging ONC to consider implementing an enforcement discretion period of six to 12 months. This would provide much-needed relief for CEHRT developers and healthcare providers alike, while still ensuring that meaningful progress is made toward real-world implementation of DSI provisions by the 2024 deadline.
Precision medicine encompasses a broad spectrum of technologies, sciences, and programs that emphasize tailoring medicine to the individual. These capabilities can empower clinicians to optimize treatment pathways and drastically improve patient outcomes, but the healthcare industry’s adoption of precision medicine technology has historically lagged.
Joe Spinelli, chief strategy officer of Aranscia, shares his predictions on how precision medicine tools will become more widely adopted in 2024 and beyond and explains what it takes for organizations to implement these programs successfully.
How is precision medicine evolving and in which areas of healthcare will it be most utilized in 2024?
This is an exciting time for precision medicine, as some of the more foundational work that’s been done over the past several decades in genomics, diagnostics, and artificial intelligence is finding meaningful applications in population health, rare disease treatments, and oncology. The evolutions the healthcare industry is experiencing now are less about the core/novel methodologies and have more to do with the effective practical utilization of those methodologies at scale across the spectrum of care.
What are some of the biggest, most recent healthcare hurdles precision medicine can help mitigate?
The evolution of precision medicine involves two distinct yet equally important initiatives: the development of innovative technologies and therapies to improve care on an individualized basis, as well as the effective utilization of those innovations within clinical care settings. Democratizing access to these types of precision medicine solutions through technology and workflow implementation will be a key factor in the clinical and economic success of these programs.
How will precision medicine solutions benefit providers from a business perspective this year?
As more care cohorts are attached to value-based initiatives and/or care models, multi-step processes of candidate identification, intervention, and outcomes tracking become increasingly important for care organizations and vendors alike to align on. In addition, companion diagnostic and biomarker programs will help providers and payers better align the cost and appropriate therapeutic use of innovative offerings.
By Derek Reis-Larson, senior vice president, claims pricing services, MultiPlan.
Medical costs continue to vary widely by location, provider, and coverage type, making it difficult for patients to understand the true cost of care and inhibiting their ability to compare pricing. Sweeping bi-partisan healthcare reform was put into action at the beginning of 2022 to help improve the healthcare experience for out-of-network patients with the ultimate goal of alleviating any surprise bills following care delivery.
More specifically, the No Surprises Act (NSA), which was put into effect on Jan. 1, 2022, was implemented to make it easier for consumers to understand how much they will pay, compare costs, make more informed provider selections, and be protected from surprise bills after receiving care. Since then, there have been significant industry hurdles in adopting the new measures, such as the Independent Dispute Resolution (IDR) process and its efficiency.
Current proceedings
On Nov. 3, 2023, the Biden Administration released the Federal Independent Dispute Resolution (IDR) Operations Process Proposed Rules to address backlash and improve the IDR process to ensure timely payment determinations. Pain points these rules attempt to address include the unexpectedly high volume of IDR cases, the high proportion of ineligible claims submitted for IDR, and the inadequate sharing of information between the parties in the initial stages of the process.
None of the proposals included in these Proposed Rules will be effective without a Final Rule being published. The administration requested feedback on these rules should they be adopted, and comments were initially due by January 2, 2024, and were reopened for an additional fourteen-day period in January. On Dec. 15, 2023, the Departments reopened the Federal IDR portal for all dispute types, including previously initiated batched disputes, new batched disputes, and new single disputes involving air ambulance services. With this reopening, parties could access extensions of certain IDR deadlines.
MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to minimize billing risk and maximize revenues, announced today it has elevated the artificial intelligence (AI) and automation capabilities of its industry leading billing compliance and revenue integrity platform with the addition of Insights.ai and SmartScan.ai.
A Generative AI tool, Insights.ai democratizes faster insights in response to natural language questions while SmartScan.ai leverages AI to automate key aspects of the external audit workflow process to efficiently manage payer audits. The MDaudit platform is used for compliance and revenue integrity outcomes by more than 70 of the nation’s top 100 health systems with $1 billion in net patient revenue.
The MDaudit enhancements come at a time when federal and commercial payers are ratcheting up audits to identify and claw back billions in improper payments. Consider that the U.S. Department of Justice (DOJ) collected more than $1.7 billion in improper payments in fiscal year 2022. Further, the Office of the Inspector General (OIG) identified more than $200 million in expected audit recoveries and over $277 million in questioned costs in its 2023 Semi-Annual Report to Congress.
The Centers for Medicare & Medicaid Services (CMS) is also expected to claw back $4.7 billion from Medicare Advantage plans over the next decade thanks to recent adjustments to its risk adjustment data validation (RADV) program.
Ritesh Ramesh
“AI has the potential to transform healthcare and drive sustainable outcomes, but only if we maintain a relentless focus on the human experiences and operational processes it impacts rather than amplifying the technology itself. With this principle in mind, MDaudit continues to innovate and deliver AI solutions in the compliance and revenue integrity space,” said Ritesh Ramesh, CEO of MDaudit. “With Insights.ai and SmartScan.ai, our core mission is to enable healthcare organizations to retain their hard-earned revenue and reduce compliance risks by data-driven decision making and automation.”
Insights.ai makes it fast and easy to access the deep insights needed to drive strategic decision making. Whether it’s information about at-risk facilities, providers, coders or which DRG had the highest number of denials for medical necessity in a specific timeframe, Insights.ai democratizes insights across all levels of a healthcare organization – from billing compliance auditors, revenue cycle analysts, operational leadership and to the C-suite – by responding to questions posed in natural language with precisely the insights being sought. Insights delivered are then tightly integrated with actionable workflows to drive outcomes.
By Amy Groden-Morrison, vice president of marketing and sales operations, Alpha Software.
In an era where technology intersects with health to create impactful solutions, healthcare mobile applications are proving to be a lifeline in remote and underserved regions. These digital tools are not just applications but are transforming into portals of hope, providing critical healthcare services that were once deemed inaccessible.
Let’s dive into the transformative power of healthcare mobile apps, particularly in regions where traditional healthcare infrastructure struggles to reach — primarily focusing on the realm of healthcare and technology, shining a light on innovations that spark inspiration and demand active participation and advancement within this critical sector.
One of the most significant contributions of healthcare mobile apps is the facilitation of telemedicine services. In remote areas, where the nearest healthcare facility could be hours away, telemedicine has become a game-changer. It enables patients to seek advice from healthcare professionals via video calls, messages, or emails. This immediate access to doctors and specialists can mean the difference between life and death in critical situations. Moreover, it helps manage chronic conditions, mental health, prenatal care, and post-surgery follow-ups, making healthcare a continuous, rather than sporadic, service.
Empowering Community Health Workers: Training and Data Collection
Healthcare mobile apps are instrumental in empowering community health workers (CHWs) in remote regions. These apps serve as both a training tool and a data collection platform. With tailored apps, CHWs can access up-to-date medical information, training materials, and guidelines, enhancing their ability to provide care. Furthermore, these apps facilitate real-time data collection and patient monitoring, enabling healthcare providers to make informed decisions and track health trends in the community. This digital empowerment of CHWs extends the reach of healthcare services, making them more effective and responsive.
Responses from Dr. David J. Sand, chief medical officer, ZeOmega.
The healthcare industry is fraught with workflow challenges that impact care quality and costs, but tools like AI and ML have sparked a turning point. These technologies are opening new doors for healthcare organizations to streamline processes and automate tasks with accuracy, allowing staff to focus on matters that require their hands-on attention. David J. Sand, MD, MBA, addresses the need for workflow automation and explains how AI/ML can be a game-changer.
What staffing hurdles are payers and providers facing this year, and why is workflow automation the solution?
Two of the biggest challenges facing the healthcare industry are staffing adequacy and the cost of staffing. COVID took its toll on the healthcare workforce, igniting a spike in labor needs that had a lasting impact on organizations. Consequently, healthcare labor costs surged by 57% post-pandemic and now constitute over 50% of hospital expenses. These financial burdens have severely impacted the industry and contributed to 73 healthcare organizations’ (including 12 hospitals and health systems) bankruptcies in 2023.
Finding and retaining employees is a longer-standing issue that can be partly attributed to factors like staff burnout, spurred by heavy workloads laden with administrative tasks. The industry is also experiencing demands for escalating salaries and workforce strikes from staff who feel overburdened by the escalating pressure to balance workloads laden with administrative duties and meet patients’/members’ needs.
It is more important than ever for healthcare organizations to look at ways to optimize workflows and automate time-consuming manual processes so staff can focus their time on pressing member/patient issues that require hands-on involvement. Technology provides excellent opportunities to improve utilization management by reducing time spent on administrative duties, ultimately reducing staff burden, saving costs, and improving patient/member experience.
How will technology help organizations alleviate staff burden and automate processes in 2024? Can you share any examples of areas in which it may be most impactful?
When we think about how and where technology can assist in healthcare, it’s useful to think in terms of peripheral, or care-adjacent, tasks that don’t involve actual hands-on treatment. Envision repetitive tasks with little variation and processes or workflows that inform our practice. While many of these applications are discrete, they are really part of a continuum.
Ambient listening is one area that is gaining widespread acceptance. The ability to listen and transcribe has become commonplace in many industries. Complaints about the provider looking at the screen rather than the patient, as well as the alternative cost of hiring a human notetaker, can be relieved. Data generated by digital scribes can be mined with natural language processing in real time using keywords and phrases to call relevant insights from the medical record or trigger care recommendations based on large language model queries of, hopefully, rigorously curated big data.
Our challenge is not to just have enough granularity in the data for precision propensity matching but to have adequate outcome data associated with the recommendations. By generating accurate, specific, and consistent recommendations, automated workflows can eliminate unwanted variation caused by human bias, lack of information, or even intentional discretion. The elimination of unwanted variation is the definition of Quality. Analysis of the spoken words can similarly save time dedicated to repetitive and tedious assessments. Contextual information such as speech cadence, tonal variation, and other characteristics can be used to objectively complete and reliably compare behavioral health assessments, potentially more accurately than self-reported measures.
It might be a new year, but healthcare is dealing with old problems:
Too much time spent on administrative tasks. Staff struggling to keep up with high call volumes. Patients waiting too long for care or falling through the cracks altogether. Services delayed or cancelled because patients were not appropriately prepared.
It’s past time for healthcare to adopt workflow automation and patient self-service tools to address these challenges. Other industries embraced these options years ago, documenting better performance and higher satisfaction among staff and consumers.
Where do bottlenecks occur and what solutions are available to improve workflows related to the patient care journey?
Obstacles impede these pathways in two significant ways:
How patients access information and care. Most consumers want to go online at their own convenience to check symptoms, learn about providers and make appointments. They prefer not to make a phone call – and, candidly, providers seek strategies to reduce call volume too. It’s critical for providers to deliver smart, conversational chatbots and virtual assistants that can be accessed across the web, text, email or voice channels to satisfy patients and alleviate staff workloads.
How patients navigate an episode of care or procedure. Both patients and staff struggle to complete forms, education and prep steps – in the right order and at the right point of the process – to ensure scheduled services happen in a timely manner. Interactive digital tools guide patients through their journey and give them online options to complete all prerequisites. Dashboards allow staff to monitor patient progress and flag individuals who need one-on-one intervention.
How can these tools support the complex nature of healthcare, as well as ensure the information provided is accurate?
Early generations of chatbots failed healthcare. Rarely did they provide patients the information they needed, resulting in dead ends, inaccurate answers and an unacceptable level of drop-offs.
But today’s virtual assistants and online tools are smarter and more responsive. Developers leverage conversational AI so patients can pose questions in the words and phrases they are comfortable with. Interactive dialogs probe for more details to add context. This means the virtual assistant can zero in on the precise answer the patient is looking for.
By Val Poltorak, head of US Regulated Industries, Sterling
Merger and acquisition (M&A) activity within the healthcare industry has experienced a slow decline over the past couple of years due to the economy’s downturn. However, as we approach 2024, the forecast predicts that M&A activity could rebound. Hospital and health systems are looking for ways to alleviate operational and budget control challenges due to staffing shortages and high wage inflation. In a report by KaufmanHall, hospitals and health systems who underwent M&A in 2023 indicated that financial distress was a key transaction driver.
In this ever-changing environment, healthcare organizations must navigate the challenges, complexities, and risks involved in the M&A process. Some of these risks include omissions of material information, conflicts of interest, verification of credentials, or past criminal activities. To safeguard heath systems’ interests, investments, and reputation, while protecting their patients, an in-depth review and investigation of an organization and its employees should be an integral part of all investment deals.
Mitigate Risk by Introducing Background Screening Providers into the M&A Process
Partnering with a reliable background screening provider early in the M&A process is critical for success. These organizations play a vital role in navigating the complex and often public nature of the process, and can assist healthcare organizations in hitting the reset button on deals and acting as liaisons with the integration teams.
A background screening provider can help hospitals and health systems involved in a M&A by:
Protecting Against Liability: Negligent hiring during M&A can lead to legal liabilities and can also damage the reputation of the merged organizations. Conducting thorough background checks can identify any past criminal records or unethical behavior, reducing the risk of employing individuals who may pose a threat to your organization’s reputation.
Adhering to Compliance and Regulations: As a heavily-regulated industry, health systems need to meet specific regulation and compliance requirements at the federal, state, and county levels. A background screening provider with deep healthcare expertise can help organizations to verify incoming staff, especially those in sensitive positions, helping to ensure that they have the regulatory requirements and certifications.
Maintaining Quality of Patient Care: When healthcare organizations are consolidating, they are introducing new staff and bringing together different organizational cultures and practices. With the responsibility to ensure patient safety, conducting a thorough background check enables companies to confirm that their employees have the necessary qualifications, experience, and ethnical standards needed for maintaining high-quality care standards.
The sooner a background screening provider is looped into the developing deal, the better they can position the merging organizations for success.
Digging Deeper: How Due Diligence Can Uncover More Information
Due diligence is an integral part of all healthcare mergers and acquisitions that go beyond standard background checks. A standard background check is meant to help organizations make an informed selection on job candidates by determining their criminal history and verifying their credentials. Due diligence investigations, on the other hand, seek to take this one step further and uncover information not disclosed by a subject or a business entity. They paint a full picture for your hospital or health system, and can be your first line of defense in protecting your organization from serious financial issues, reputational damage, and even legal repercussions.
By Derek Reis-Larson, senior vice president, claims pricing services, 
