Interoperability in the U.S. healthcare system has been an ongoing challenge. While there are several industry initiatives that are going to advance the industry and make incremental progress toward interoperability, there remain several gaps that are unaddressed.
Interoperability is a much broader concept that encompasses more than protocols, APIs, and limited networks. It’s about more than exchanging data through one-to-one connections between a provider, payer, or vendor. True interoperability requires three key elements: trust, transparency, and data fluidity.
What we need is the ability for all permissioned stakeholders to access data where it originates, fluidly, securely, and in real time without going through multiple data lakes, aggregation-based intermediaries and multiple data transformations. With our current focus on data exchange—what most people think about when they think of interoperability—the data still needs to be aggregated and validated each time it’s requested. Just think about coverage verification. Providers check coverage when an appointment is scheduled, days before service, at the time of service, and often a fourth time just before the claim is submitted. If there’s an issue with the claim, they may check a fifth time. Even through multiple, timed data exchanges, we can never be genuinely confident the data is accurate and current.
Creating a broader vision
We need to think beyond data exchange and focus on data access, a data fabric. Take a look at the banking industry. It’s been more than a decade since the creation of Venmo and Zelle banking apps that let consumers request or send money electronically to another person regardless of where each person banks.
We don’t see banks hoarding their customers’ banking information, or refusing to participate in electronic money transfers unless they’re within the same banking system. We don’t see banks forcing customers to only use the bank’s app to send or receive funds. And we don’t see banks requesting funds transfers with other banks via fax or email. These digital transactions are seamless, secure, and centered around the customer experience. They enable trust, transparency, and data fluidity. They eliminate friction – both for consumers but also inefficient processes between banks that would simply add cost to the transactions. Imagine that in healthcare – a better healthcare experience and at a cost savings to the industry. This is possible.
Trying to create interoperability with tools and processes we already have is limited thinking that leads to limited results. We need to think beyond our current systems to develop a broader definition of interoperability—one rooted in “possibility thinking” that focuses first and foremost on the patient experience. It’s something we talk about a lot in our industry. But the fact is that the limitations of our current systems are the reason delivering a better experience is so challenging. The COVID-19 pandemic shined a spotlight on this challenge. In the 2020 Black Book Interoperability Survey, 93% of consumers surveyed said they were disappointed in “the lack of data sharing” across vendor systems. Of those surveyed, 67% said they would “consider changing their physician and hospital providers” because of it.
What if we could create a digital ecosystem built upon a highly secure network where continuously refreshed, always-current data could be viewed securely and in real-time by anyone with permission on the network to access it? This is the type of interoperability that could revolutionize healthcare.
Just think of what this would mean to patients. Instead of waiting weeks for prior authorization to be processed, it could be completed in minutes—even while the patient is in the office. Patients get the care they need without delay. Instead of having to fill out the same paperwork for every provider they see, the patient’s information would be seamlessly accessible in real-time to those providers. Instead of waiting to receive an EOB from their insurance company, patients would know with certainty what they will owe prior to the time of service. No more surprise bills months down the road. Real-time adjudication, real-time payments, maybe even NO patient billing?
Providers could see the patient’s current coverage in seconds, reducing the potential for rejected or denied claims. Less time spent searching websites or calling payers for coverage information means more time for patients. And knowing what the patient will owe upfront enables more effective proactive collections.
Payers would benefit by knowing immediately whether a patient has secondary or tertiary coverage. Because of the highly immutable data this type of healthcare data fabric or digital network provides, the instances of fraud and abuse could be significantly reduced.
The way forward
Health systems have spent years and millions of dollars building legacy technology infrastructures and long-standing vendor relationships. The idea of moving beyond these tools can feel counterintuitive after such investments of time and money. But if banking can do it, so can we.
Let’s reinvent healthcare in 2023, not based on our current reality, but on a new way of thinking about interoperability, courageously embracing “possibility thinking.”
About Stuart Hanson
As CEO of Avaneer Health, he leads the team in building an inclusive network that solves the problem of interoperability by ensuring all stakeholders have equal and easy access to patient data when it’s needed most. Prior to joining Avaneer, Stuart served as head of healthcare payments and served as a senior healthcare executive at JP Morgan Chase. He identified, led and negotiated the firm’s 2019 acquisition of InstaMed.
Previously, Stuart served as general manager of consumer payment solutions at Change Healthcare. Stuart has also served in leadership roles for healthcare solutions at Citi and Fifth Third Bank. He chaired the HIMSS Revenue Cycle Improvement Task Force (FY15-16), focused on creating a vision for the next generation of revenue cycle management tools and processes to drive administrative cost containment, interoperability, and a better consumer experience.