Electronic Health Reporter

By Bobby Sherwood, vice president of product development, GuidingCare.

A lack of interoperability permeates U.S healthcare. Despite the rapid adoption of new technologies, we have failed to fully realize some of the most impactful opportunities they present. Data silos that hinder collaboration, efficiency, and innovation stubbornly persist across the industry. For health plans, embracing digital transformation to digitize process and improve member experience pays dividends, but can come with difficult integration and interoperability challenges if not done properly.

There has been a recent spotlight on government initiatives and regulations to address these growing concerns. Take the new CMS proposed rule on interoperability and prior authorization, which will require payers to implement an electronic prior authorization process, shorten the time frames for payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent.

In a world where nearly anything can be instantaneously ordered from your mobile phone or laptop and delivered overnight, it seems inconceivable that prior authorizations – something so critical to member and population health – is managed by an antiquated system. This seamless exchange of data will reduce provider abrasion, improve the member experience and potentially their health outcomes, and ultimately decrease the cost of care, as the manual effort and time linked to prior authorizations markedly decreases.

As we execute on the year ahead, interoperability remains top-of-mind for stakeholders: a new report suggests that barriers such as poor data quality and information sharing remain challenging to over 60% of healthcare executives. For health plans prioritizing interoperability, consider these three areas of focus:

Double down on population management through improved care coordination

The National Association of Community Health Centers outlines care coordination as involving three crucial parts: identifying the patients who are or who may get the sickest; sharing information among involved healthcare stakeholders; and managing the patient’s use of care to prevent unnecessary services. Improving care coordination is a common goal for health plans focused on population management.

Coordinated care not only results in better patient outcomes, but helps lower overall healthcare costs by preventing avoidable duplicative tests and procedures. However, quality care coordination requires significant interoperability among primary care practices, specialists, hospitals, labs and payers alike. Addressing common problems, including interoperability barriers, data integration and competing health IT priorities, is integral.

Payers should prioritize products that are built on solid processes that produce accurate, real-time data. With this, providers and plans can easily access data and improve population health, increase customer satisfaction, and decrease provider challenges.

Optimize care management to support patients in between care settings, at scale

When it comes to care management, payers may face a laundry list of challenges: complex workflows, a lack of coordination among medical, behavioral and community health organizations, inadequate partner and patient engagement, lack of access to real-time data, and more. A successful care management program will allow for improvements in care, coordination of care, and the ability to share data – meaning interoperability is key. Harnessing this data can create unique insights into patient needs and behaviors that extend far beyond the traditional walls of in-person care.

Scaling these solutions requires next-generation data integration and workflow management tools that streamline workflows, facilitate coordination and collaboration, accelerate quality improvement, and promote provider and patient engagement.

Think big picture

It may seem overwhelming, but the concept of serving tailored, customized information to an individual is not far-fetched. If a consumer turns on their TV or opens a streaming service, they see a menu of options with suggested programming or channels of interest based on previous activity. With interoperability, individuals can apply that same concept to healthcare.

Interoperability provides information and analytics that can empower individuals to be a more active participant in their overall health. Interoperability allows individuals to address their concerns, ask questions, identify additional steps, and make lifestyle changes to improve their well-being and have the full picture of their health.

The goal at large is to provide a secure, connected healthcare system that empowers patients and their providers to access and use their health data to make better informed and more efficient decisions. Payers who embrace next-gen platforms with connected ecosystems and real-time data insights that impact cost and quality outcomes will be the ones that move the needle in the future.