The official definition of interoperability, as put forth by the ONC (Office of the National Coordinator for Health Information Technology), is “the ability of two or more systems to exchange health information and use the information once it is received.” However, if you google the term you’ll find dozens of different definitions, each with a slightly different slant. At the core of all these definitions, however, is the sharing and accessing of data.
According to HIMSS (Healthcare Information and Management Systems Society), there are four levels of interoperability.
In addition to the numerous clinical reasons to achieve interoperability, there is opportunity for the back-office administration of healthcare, which includes processes such as eligibility verification, prior authorization, claims submission, and charge capture. These processes are often fragmented, full of manual and error-prone workflows, and so inefficient that they cost the U.S. billions of dollars each year, with billing, coding, physician administrative duties, and insurance administration being the primary drivers.
The current ways payers and providers connect to conduct administrative transactions rely on a web of single-use, point-to-point connections, and batch or call and response processes that lack data control and traceability. Payers and providers have invested millions in platforms to modernize transactions, but they still lack full integration and interoperable functionality.
One of the most significant issues caused by a lack of interoperability is friction between payers and providers. It’s understandable why a lack of transparency has created such high levels of distrust. Fraud, waste, and abuse cost payers billions each year, which is why they now use more sophisticated technology to identify potential claim issues. While this may help reduce fraud and overpayments, it has also caused more work for providers via increasingly complex payer requirements that are difficult to manage.
While payers want to reduce their financial risk by ensuring that members receive the most cost-effective, appropriate level of care, providers want autonomy around the decisions they make when caring for their patients. In addition, providers expect fair, timely compensation for that care.
The bottom line is that both payers and providers want to simplify the extreme administrative complexities caused by a lack of interoperability and data fluidity.
Administrative inefficiencies caused by a lack of interoperability can impact both a patient’s health and wallet. Prior authorization is a great example. In a 2022 survey by the American Medical Association, 94% of providers said the prior authorization process had caused delays in patient care, and 33% said those delays in care have caused a serious adverse event for patients.
The lack of financial transparency is another issue that impacts patients. When providers can’t tell patients with certainty what they will owe, it limits those patients’ ability to make informed decisions about when and where to get care and how to pay for it. This lack of transparency can negatively impact the entire patient experience, even offsetting a positive clinical experience. While the No Surprises Act has pushed the industry forward, there is much room for improvement.
The banking industry seems to have interoperability figured out. Consumers can easily send money to other people with no more than an email address or phone number, even outside their own banking system. And they can go to virtually any ATM anywhere in the world, see their account balance, and withdraw funds.
The primary reason interoperability in healthcare is so challenging is that payers and providers use multiple methods to exchange information, including:
All these methods require the implementation and maintenance of point-to-point connections with each trading partner. And most of these connections use request-response workflows that delay data and require the aggregation and storage of data by third parties.
Another challenge is a lack of standardization. While Fast Healthcare Interoperability Resource (FHIR) has given us a common set of protocols and standards for a payload of transactions on a network, FHIRÒ alone does not translate into interoperability and data fluidity. It is still a highly complex system of multiple data gateways.
The answer is “Yes!” In a truly interoperable healthcare ecosystem, data would not need to be requested, aggregated, and validated each time it is needed. Instead, it would be continuously refreshed, always current, and accessible in real time via a single network. It’s a new way of conducting the business of healthcare and it’s here today via the Avaneer Health Network.
The Avaneer Health Network is a secure, permissioned, decentralized network and platform built on a data fabric infrastructure. Once a payer or provider connect to the network, there is no longer a need to build a direct connection to each other. Data remains decentralized and network participants can control how and with whom they collaborate. Through a permissioned process, their data can be shared with anyone on the network whom they have approved to receive it. Once the connection is established, data can flow freely in real time, eliminating interoperability barriers and allowing genuine data fluidity.
Each participant receives an Avaneer SparkZone™, a dedicated, private, secure, cloud-hosted environment. The SparkZone is the connection between the participant’s internal system and the network, facilitating direct peer-to-peer data access with a suite of utilities and services for FHIR transformation. In addition, subscribed solution apps are loaded into the SparkZone.
With each new technology that comes to market, the potential for innovation in healthcare increases exponentially. To successfully leverage and deploy these solutions requires a level of interoperability that supports collaboration and connectivity in a new way. With Avaneer Health, many of healthcare’s most significant challenges, both administrative and clinical, are resolved.
We invite you to join Avaneer Health on our journey to simplify the business of healthcare.
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