What it takes to enable data interoperability between health insurers and hospitals: Trust and tech

Providers and payers know interoperability is needed to share data to achieve value-based care and reduce costs, but getting there demands more than collaboration.

It requires insurers to foster a deeper trust on the part of providers to share their clinical data and the technology to use that information, according to Anthem and Surescripts experts.

For technology to drive the free-flow of health information that's being promoted by Centers for Medicare and Medicaid Services Administrator Seema Verma, IT systems must be interoperable.

Two of the largest EHR systems, Cerner and Epic, are unable to communicate with each other, according to Senator Johnny Isakson of Georgia who chairs the Senate Committee on Veterans' Affairs.

In choosing Cerner for the Department of Veterans Affairs, his committee made sure the software was interoperable with that of the Department of Defense, Isakson said July 31 during a Senate Committee on Health, Education, Labor & Pensions hearing on reducing healthcare costs.

"I've come to believe one of the most important things we can do to reduce the cost of administration and record keeping and I would think probably pre-authorization too, would be to have as much standardization and interoperability of software as possible, so wherever the patient comes from and whatever hospital or physician is serving them, the system is common, " Isakson said.

Medical record and billing systems need to communicate with each other

In another instance of IT that's not working to make healthcare administration easier or less expensive, medical record and billing systems do not connect, said David Cutler, a professor of Economics at Harvard University, in testifying before the Senate HELP committee.

"So you have an electronic medical record system that keeps some information, have a billing information system that keeps separate information. The two don't talk to one another," Cutler said. "So as a result you have people involved on the one and people involved in the other and it's extremely costly to do that."

Cutler recommends the integration of medical record and billing systems to help reduce the 30 percent of a healthcare bill that goes to administrative expenses. Simplifying the complexity in which patients are coded and standardizing preauthorization requirements would also go a long way toward his recommendation to the Department of Health and Human Services to work with healthcare organizations to develop and implement a plan to reduce the administrative burden by 50 percent over the next five years.

"In most industries, what happens is that computers take over for people," Cutler said. "What happens in healthcare administration is that people take over for computers."

FHIR standard enables health information exchange

Health Level Seven International's Fast Healthcare Interoperability Resources (FHIR) is seen as the industry standard for enabling value-based care through the transfer of clinical and administrative data between disparate systems.

Mark Gingrich, chief information officer for Surescripts, focuses on standards' efforts such as the Argonaut Project, a private sector initiative to advance interoperability, and the Da Vinci Project, which enables insurers to access clinical data.

Gingrich works with providers, insurers, pharmacies, technology vendors and others in Surescripts' health information exchange.

This includes connections to 1.5 million clinicians and most of the industry for pharmacy, health insurers and pharmacy benefit managers.

Surescripts automated prescriptions by having the script sent directly from the physician to the pharmacy, driving down the $300 billion annual cost incurred by the 26 percent of patients who don't pick up their medications and end up needing emergency care or hospitalization, according to Margaux Thomas, director of Product Innovation for the company.

"It's all about the efficiencies," Gingrich said. "To get it electronically and expediently, using capabilities such as FHIR is where we're exchanging data today."

Traditionally plans request the data on 10 million people and it sits there. 

FHIR allows the technology to be used individually to create risk scores and to build predictive models for earlier interventions.

'Ultimately, it's about winning trust'

But before data can be exchanged between providers and insurers, a relationship of trust must be developed, according to 

Joe Bayouk, director of Product Solutions for Anthem's Enterprise Analytics and Insights team.

In California, Anthem partnered with seven competing health systems to create the integrated Anthem Blue Cross Vivity. Clinical data from the EHR is shared, which has resulted in a patient-centered approach that closes care gaps, Bayouk said.

"The results we've seen just by taking a patient-centered approach, from cost savings to getting the healthcare they need to creating fewer inpatient admissions, because they haven't had to wait so long to get the care they need," Bayouk said. "It's growing organically." 

The provider wants to know that the insurer will use the information to help them clinically, not just to extract what they can and squeeze on cost, according to Gingrich.

"It has taken a while to get provider organizations to the table," Gingrich said. "It's gaining that trust."

"The challenge has always been the trust factor between the provider and the plan," Bayouk said. "How do we really change the game as it amounts to increasing the ability for plans and providers to collaborate more broadly? Ultimately, it's about winning trust."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com