Instead of continuing to add fixes on top of a broken system, healthcare needs to create a new, better system—a system built with a new kind of interoperability.
Healthcare organizations have been talking for years about the importance of the patient experience. Yet, healthcare organizations have hit several challenges that have kept our patient-centric promise from becoming a reality. As a result, we all have at least one story about a personal experience when our ability to receive timely care for ourselves or a loved one was inhibited by an outdated, ineffective administrative process.
Consider the patient who has recently changed health plans. She wasn’t feeling well and made an appointment to see her primary care provider. When she arrived at the office, she realized she hadn’t yet received her insurance card from the new health plan. She also remembered that when she signed up for the new plan, she canceled her secondary insurance coverage. She thought the coverage might still be active through the end of the month but wasn’t sure. She didn’t have that card either as she didn’t think she’d need it any longer.
Because of the lack of information, the front desk staff had no way of knowing what the patient’s new insurance would cover, what her co-pays and deductibles were, or whether the secondary insurance might still pay a part of the visit. The patient was told she would need to pay the entire amount of the visit up front and then work it out with her insurance companies on her own after the visit.
It is unfortunate that our healthcare ecosystem is so dependent on a patient’s memory and a physical insurance card to be able to ascertain a patient’s primary and secondary coverage information, along with their financial responsibility. These issues can also impact claims processes and can increase manual work for the payer. This is just one of many examples of how administrative processes make it difficult to deliver on the patient-centric promise.
These administrative processes need to be improved. We know the answer: healthcare systems need to become more interoperable. We have made progress. However, research from the ONC shows that in 2019, more than one in every three physicians still relied solely on fax (paper or electronic) or standard mail to share patient information—like ultrasound results—with providers outside their organization. In fact, just 34% engaged in bidirectional electronic sharing of patient information. Why?
A significant challenge to achieving interoperability is that healthcare’s current data-sharing infrastructure is built upon one-to-one connections. These connections are expensive and resource-heavy to implement and maintain. The result is a lack of transparency that has caused distrust between payers and providers. At the same time, providers are faced with increasingly complex payer requirements that are hard to keep up with, which adds to their already overwhelming administrative load.
These issues could be mitigated or eliminated through a new type of interoperability that allows all healthcare stakeholders to easily connect to a single, decentralized network and then access, in real time, the needed information without the request/respond processes of today. In a world where this type of interoperability exists, the provider in the above scenario would have been able to easily discover the patient’s new coverage information and find out whether her previous secondary coverage was still in effect—all in real time either before the patient arrived or while she was checking in.
In a fully interoperable healthcare system, data wouldn’t need to be requested, aggregated, and validated each time it’s needed. Instead, it would be continuously refreshed, always current, standardized, and always accessible in real time via a secure and direct peer-to-peer network to those who are permissioned to access it.
Imagine a network where every authorized participant would have permissioned access to the same information while, at the same time, no single entity could control, modify, delete, or change the rules of how the network can be used. Each permissioned participant would retain its own data instead of sending it to a third party (centralized); the data would remain in the participant’s control (decentralized). Leveraging formats such as FHIR, all data would be standardized and ready to be accessed. This type of network would eliminate the payer-provider friction that has plagued our healthcare system for far too long—friction that ends up creating a poor patient experience, reduced outcomes, and increased costs for all.
At its heart, all healthcare is human. At the center of every procedure, every diagnosis, and every transaction is a human being who expects to be treated with dignity in moments when they are most vulnerable. The only way we will be able to meet that expectation is by improving the back-end processes that support and facilitate high quality care. But that requires us to completely reinvent how healthcare is administered. It’s the way we will truly transform the care experience.
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