The lack of interoperability in healthcare is arguably one of the most significant challenges our industry faces. While other sectors have had advanced interoperability for years, healthcare lags far behind. This is one of the reasons why the U.S. spends significantly more on healthcare than other high-income nations but has poorer outcomes. The main drivers are administrative inefficiencies, such as billing, coding, and insurance.
Why interoperability matters
Processes around prior authorization are a great example of administrative inefficiency. According to the American Medical Association, the average provider completes 41 prior authorizations every week for each provider in the organization, which equates to nearly two full business days. Four out of ten providers say their organization has had to hire staff specifically dedicated to managing the highly manual, time-consuming process.
Besides excess costs and provider burden, the patient pays the ultimate price through delayed access to care. More than nine in ten providers say the prior authorization process causes delays in care, and a third say that those delays have caused a serious adverse event for the patient. And it’s all because there’s no easy way for payers and providers to share information and work together.
How we got here
The pursuit of streamlined data sharing in healthcare has been underway for decades, starting in the 1960s with the advent of electronic data interchange (EDI) for adjudicating claims. Then came the Health Insurance Portability and Accountability Act (HIPAA) in 1996, which regulated how healthcare entities could use personal health data and how it could flow and be shared throughout the healthcare ecosystem.
Jump ahead to 2009 when the American Recovery and Reinvestment Act (ARRA) was signed into law. Thus began the push for mass adoption of electronic health records (EHRs) through the Health Information Technology for Economic Clinical Health (HITECH) Act. And now we have hundreds of EHR systems deployed across organizations, some so customized that they can’t even exchange information with others on the same platform, let alone with organizations on other platforms.
Where we are now
In 2012, we were introduced to Fast Healthcare Interoperability Resource (FHIR), giving us a standard set of rules and specifications for exchanging healthcare information electronically. More recently introduced, the 21st Century Cures Act and the Trusted Exchange Framework and Common Agreement (TEFCA) built upon all previous initiatives to move interoperability across the finish line. The TEFCA model employs qualified health information exchanges (QHINs), a network of healthcare organizations that connect in a way that enables them to share data more efficiently.
Where we are going
Henry Ford is purported to have said, “If I’d have asked people what they wanted, they would have said faster horses.” In reality, people didn’t know what they wanted because they couldn’t imagine transportation that didn’t include what they already had: Horses. The same could be said for any industry where a limited number of options have been put on the table and where thinking “out of the box” isn’t encouraged. Could this be true with healthcare interoperability?
We’ve had enormous innovation in healthcare on the clinical side. New technologies, procedures, and medications are advancing our ability to transform treatments for conditions previously thought untreatable. Innovation on the administrative side hasn’t been as successful.
While we see entrepreneurs enter the market daily with incredible ideas that could transform healthcare administration, they exit the market before achieving meaningful deployment. Most don’t realize how difficult it is to connect and collaborate with the right stakeholders or integrate new solutions into our highly complex workflows.
We need to stop focusing on building “faster horses” and look for ways to empower innovation and disruption to the business of healthcare administration.
I’m not saying we need to ditch what we’ve already accomplished. But there are new ways to approach what we’re trying to achieve regarding interoperability and data sharing. One is through a decentralized network where payers, providers, and innovators can easily connect, collaborate, and transact through a single connection, regardless of which EHR platform or other information systems they use.
Without needing multiple APIs or third parties, payers and providers could connect and easily share information in a new way—where data doesn’t have to be exchanged or aggregated. Instead, data remains housed and under the control of its originator. Leveraging technologies like blockchain and AI, the data is continuously refreshed, always current, and available in real time to those on the network who are permissioned to access it. These technologies also enable data immutability and traceability for improved transparency and trust. Imagine how this type of network could transform coverage discovery, eligibility verification, prior authorization, real-time adjudication, and many more use cases by enabling these transactions to be completed in seconds instead of hours, days, or even weeks.
As for innovation, this type of network allows innovators to connect with other innovators and industry stakeholders in a private, secure, shared space. Leveraging a common set of tools and infrastructure, they can build and deploy solutions and services to anyone on the network. These solutions, over time, create a highly innovative marketplace of products and services, each building on the success of the others. This type of network environment advances healthcare innovation across the ecosystem exponentially.
Is there room in healthcare for new ways of doing business? For thinking out of the box? Or are we going to continue searching for faster horses?
Joe Rostock
Joe Rostock is Chief Operating Officer of Avaneer Health.
