Value-Based Care at Stake in the Push for Interoperability

Interoperability is critical to achieving quality goals and reducing the $4.9 trillion the U.S. spent on healthcare in 2023. 

While adoption of EHR technology has rapidly grown from 12% in 2009 to 96% in 2021, data sharing does not occur as often as one might assume. In one government survey, 70% of hospitals reported they “sometimes” or “often” engaged in “sending, receiving, finding and integrating electronic information.” That is a significant improvement over 2018, when just 46% engaged in all four domains of electronic information exchange.

However, less than half (43%) of hospitals “routinely” engaged in interoperable exchange, and just 42% of clinicians reported routinely using the data when treating patients. It’s a given that we need to reduce care costs and improve quality and outcomes. Yet, to achieve these goals, routine engagement across all data exchange domains must increase and remain higher.

Shifting Priorities

While interoperability is still a focus, healthcare’s technology priorities have expanded in recent years. Specifically, the industry has been exploring generative AI and its ability to rapidly learn patterns in existing data and produce original content.

Although a new technology, its adoption rate in healthcare for some activities has already surpassed electronic health information exchange. For example, a survey in late 2024 sponsored by HIMSS and online clinician resource Medscape found that 86% of healthcare provider organizations already use some form of AI, primarily to transcribe patient notes and create routine patient communications.

Another significant change in healthcare is the growth of value-based care (VBC) models. VBC programs have also grown, but not nearly as quickly as AI adoption. The most recent value-based care payment report from the Health Care Payment Learning and Action Network found that 28.5% of healthcare payments in 2023 came from models where providers faced risks of losing revenue if they did not meet quality and/or cost requirements, up from 12.5% in 2017.

Data Fuels Transformation

Besides their increased prevalence, AI technology and VBC models require comprehensive, accurate, actionable and timely data to improve decision-making, reduce inefficiencies, and ultimately improve patient outcomes.

Yet supplying ample, accurate and timely data across care settings to power these AI solutions or succeed in VBC programs continues to encounter challenges. For example, in the previously mentioned government study on interoperability, only 16% of hospitals reported sending summary-of-care records to most or all long-term/post-acute care facilities, and only 8% received information from these providers. 

This lack of data exchange reduces the reliability and objectivity of AI tools, not to mention the quality of monitoring that hospital clinicians need to perform to prevent rehospitalizations and poor outcomes. The disconnect between these two care settings almost certainly contributes to the 20% average hospital readmission rate from skilled nursing facilities (SNFs) within 30 days, compared to the 14% average rate for all readmissions. These preventable readmissions and other types of avoidable care utilization directly impact financial performance under VBC models.  

Interoperability is the Foundation

A robust infrastructure that enables interoperability would ensure technologies across the continuum of care can share data as it’s needed to prevent adverse events. For example, an accountable care organization (ACO) could use AI tools to identify early signs of decompensation, leveraging this data. 

Furthermore, by training machine-learning models on a massive volume of historical records from SNF residents, an ACO could develop a highly reliable method of risk-scoring their patients discharged to these facilities. Care managers could start their shifts by reviewing risk scores across the network of post-acute facilities. The actionable metrics would supplement and likely alleviate the time-consuming process of manual evaluations and root cause determinations, which can often overlook important indicators. 

They can then prioritize the highest-risk patients and consult with the SNF’s clinicians to intervene before readmission is required, improving the patient’s outcome, shortening one’s stay, and reducing costs for all healthcare entities involved, protecting their VBC revenue. Likewise, if a patient from an SNF returns to the hospital through the emergency department (ED), then the timeliest data that led up to the event would be available to the care team, supporting faster, fully informed clinical decisions. Seamless data access and guidance within the ED could also enable the patient to avoid a readmission and return to the SNF sooner.

As shown in these real-life examples playing out in ACOs, health systems, and hospitals every day, interoperability is already significantly impacting healthcare organizations that have embraced it. Interoperability facilitates actionable data exchange and breaks down data silos, preventing rehospitalizations, driving collaboration between care settings, and empowering care teams to deliver high-quality, cost-effective care. These activities are essential if providers hope to succeed in the VBC environment regulated by the Centers for Medicare and Medicaid Services (CMS). 

A Unifying Cause

In an era when disagreements abound, healthcare interoperability can and should be the exception. That’s because there is no question that accurate, high-quality, and standardized data will be required to power the AI applications and VBC programs that will transform healthcare for the better over the next decade and beyond.