What does it mean to adapt? To make something suitable for a new use or purpose? To modify? That is just what US payers have been preparing to do since the CMS Interoperability rule proposal was announced at HIMSS19. Like it or not, the healthcare industry is inching towards consumer-driven healthcare. And with the help of legislation and regulations, inching will turn into sprinting. Tech-savvy consumers will be looking to use their spending power for healthcare that works for them and their families. Consumer applications that can provide the tools and services to those consumers and their community will harness that power – think Facebook! Removing data sharing barriers will force the health IT industry, payers included, to adapt to a new financial strategy that will spark the innovation that is needed for consumers to benefit from community-based healthcare.
Health information exchanges (HIEs) are already in the heart of the community and they are no stranger to innovating and adapting to remain relevant. Once federal and state government investment in HIEs started to dwindle, HIEs had to pivot, some successfully and some not, to provide high-value services and data in order to maintain revenue. This experience positions HIEs perfectly to meet the IT needs of payers to facilitate data aggregation, normalization, privacy, security and data sharing.
HIEs initially approached electronic health information with the patient at the center of the data, which included consumer inclusion and engagement to promote data exchange to raise the quality of healthcare, lower costs and improve the patient experience as part of the mission. Using HIPAA regulations, the HIEs provide secure open access to patient data for providers that are caring for the patients in the community regardless of insurance coverage.
Over the last decade, the HIEs have invested in understanding the nuances of clinical data, normalizing data and adapting to clinical code updates while working with “standard” documentation that isn’t populated in a standard way. HIEs have been at the table with the major electronic medical record companies that were driving the conversation around interoperability in the industry, but reluctant to facilitate any data flowing out of their systems. These are the hidden costs of interoperability that aren’t sexy and are glossed over in sales presentations. But you can’t create consumer value applications and services without that baseline of data.
Data acquisition isn’t the only barrier to providing consumer-driven healthcare. There is still the issue of solving garbage in/garbage out. HIEs handle the data that is available, they don’t or can’t improve the quality of the data for clinical use. As interoperability evolves to include the consumer, clinical data quality standards for the clinician needs to be the next focus.
Giving consumers the financial power as well as the legal power to drive change in data exchange is a major step towards the behavior modification that is needed for more patients to engage more actively in their healthcare
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
In our increasingly global society, the consumer needs the support of the community in order to avoid going from a high risk of chronic illness to managing chronic illness. Payers are already catching on to this by providing low-income housing, Uber-like services and food vouchers in order to keep their members healthy. The data required to facilitate community-driven healthcare needs a secure, flexible space to rally around. HIEs have been preparing for community-based health information exchange since inception. Payers will be mandated to make member health records easily accessible and transferable to other providers and payers. This will require the payers to adapt to become a member of the consumer’s community and not the owner of that community.
A secure, flexible and normalized data foundation is an essential investment for facilitating data exchange. Experience, provider engagement and technology innovation from the HIEs and the financial power of the payers create a powerful synergy to drive collaboration with the consumer community and meet the interoperability mandates of 2020.
Photo: shylendrahoode, Getty Images
