The need for greater interoperability is escalating due to an increasingly sicker population. According to the CDC, 60% of Americans have a chronic disease, while 40% have two or more. As our nation ages, these numbers will likely increase as older individuals typically have more chronic conditions that require more—and more complex—care. Chronic disease is the leading driver of our $4.1 trillion annual healthcare spend. Effectively managing patient care, especially for those with chronic conditions, requires continuity across the care continuum and that continuity isn’t possible without closing gaps in interoperability first.
According to HealthIT.gov, 32% of individuals surveyed who had seen a provider in the previous 12 months experienced a gap in care due to ineffective information exchange. Nearly 20% had to bring a test result with them to a provider appointment; 14% had to wait an unreasonable period to get their results; 5% had to have a test or service redone because the data from the first test or service wasn’t available; and 5% had to provide their medical history more than once because the provider couldn’t find their existing chart. This lack of access to timely, accurate information is one of the primary reasons for gaps in care, a negative care experience, higher costs, and poorer outcomes.
Consider the impact of interoperability gaps on patients recently discharged from a hospital to a post-acute care facility. The Agency for Healthcare Research and Quality (AHRQ) reports that 20% of patients discharged from a hospital experience an adverse event after just three weeks. The report finds that 40% of patients are discharged with test results still pending. The same percentage is discharged with orders for a “diagnostic workup,” but often without a way to close the loop on whether that workup occurred. This may be why 99% of providers choose a post-acute provider that offers interoperability over one that does not. This is likely driven by value-based care models that penalize readmissions and poor outcomes.
Another example of how gaps in interoperability cause gaps in care involves the accuracy of coverage information. Now that patients are responsible for a larger portion of their healthcare costs, they need price transparency. While many providers offer patient responsibility estimations, those estimations are often incorrect. One study found that 79% of providers are unable to correctly estimate a patient’s out-of-pocket costs due to inaccurate price and coverage information. When patients don’t know the ultimate cost of a service, they may be more likely to put it off or skip it altogether. For providers participating in value-based care and population health initiatives, this lack of benefits and coverage information can impact outcomes and, thus, reimbursement. It can also increase denied claims and create issues in the revenue cycle, leading to cash-flow challenges and delayed or inaccurate reimbursement.
Poor financial transparency can also impact the patient experience and patient satisfaction scores. One study found that 60% of patients would consider changing providers due to incorrect estimates or unexpected bills. When a patient overpays, it can take months to get a refund. And when patients pay less than they owe, they can be hit with a surprise bill they weren’t prepared to pay.
While we’re making headway with initiatives like the Trusted Exchange Framework and Common Agreement (TEFCA) and the increasing adoption of industry standards like FHIR®, they require a great deal of work, money, and IT resources for healthcare organizations. However, a recent innovation is advancing interoperability in ways previously thought impossible. It begins with a digital ecosystem and decentralized network built on a platform and data fabric architecture.
Once payers and providers connect to the network, they can connect with any other payer or provider on the network to share information, and they can do it without building and maintaining multiple connections. Instead of having to aggregate data, it is always available and accessible in real time. Information is continuously refreshed and current, eliminating the need to question accuracy. And because the network is cloud-based and includes advanced technological components such as AI, participants benefit from greater interoperability without making huge infrastructure investments.
The network applies modern, secure infrastructure designed specifically to meet the needs of today’s healthcare businesses. Leveraging FHIR standards for data sharing, the network facilitates peer-to-peer communication directly between payers and providers without the need for third parties, thereby reducing the number of transactions needed to support operational workflows. And because the network enables permissioned and auditable data sharing without data aggregation, it gives data owners more control over their data.
As we start to close the gaps in interoperability, it’s the perfect time to reevaluate some of our long-standing beliefs about what’s possible within the revenue cycle. We don’t have to depend on data aggregation, numerous APIs for point-to-point connections, and third parties to conduct the business of healthcare. There’s a new way and it’s already used by some of the nation’s largest payers and providers.
Discover more about Avaneer Health, Avaneer Coverage Direct, and how it can help your organization close interoperability gaps to reduce gaps in care. Let’s simplify how healthcare operates together.
