Closing gaps in interoperability could improve healthcare outcomes

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.

The disconnect

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.

Post-acute care

Consider the impact of interoperability gaps on patients recently been 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.

Coverage accuracy and insight

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 issues 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.

A different way of sharing data to reduce gaps in interoperability and gaps in care

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 participants connect to the network, they can connect with any other participant—payer, provider, or innovator—to share information 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 and blockchain, 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.

A network and platform that reinvents the business of healthcare

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 and how it can help your organization close interoperability gaps to reduce gaps in care. Let’s reinvent how healthcare operates together.

How Interoperability Can Boost Revenue Cycle Results

The annual cost of administrative and process inefficiencies in the U.S. healthcare system has reached into the billions, with billing, coding, physician administrative activities, and insurance administration being the primary drivers. Provider organizations spend approximately $39 billion each year and dedicate an average of 59 FTEs just to comply with hundreds of administrative regulations and requirements.

Think of the progress we could make in improving the lives of our patients, the investments we could make in state-of-the-art equipment and facilities, and how greatly we could expand access to care if we could redirect the billions spent each year on administrative waste towards innovation and direct patient care.

Current gaps in processes

 According to an article in HFMA Magazine, the top use cases for costly waste and inefficiency include:

These are all costs that could be significantly reduced through more effective interoperability. But how do we create an environment that addresses these inefficiencies while developing an interconnected infrastructure for the benefit of payers, providers, and innovators?

Certainly, FHIR gives us a good opportunity to work from a common protocol and set of standards when we talk about the payload of transactions on a network. However, FHIR itself does not translate into interoperability. FHIR is just the payload; it’s what’s inside the envelope when we exchange data. How an envelope moves through the enterprise and across the industry, and how it’s kept updated is based on  the ability to create a dynamic, interoperable network.

We’re currently spending way too much energy creating point-to-point interactions across a mesh of an ecosystem and not enough energy creating a shared environment where we’re all—payers, providers, and innovators—working from the same platform of knowledge.

Use Cases for a Decentralized Peer-to-Peer Network

One of the biggest issues with today’s EDI transactions, according to the director of revenue cycle management at a large health system, is a lack of consensus. “EDI transactions, the 270/271 especially, have been out there for 20 years or more, yet we know there are limitations with their use as a vehicle to support the exchange of information between parties.”

We have a unique problem that is very well positioned to be solved by a decentralized peer-to-peer network in that there are multiple stakeholders who are part of the insurance coverage determination process. In other words, all participants on the network would be able to work within the same system using the same set of requirements—as if they were all the same organization—through a consensus-based network.

Consider eligibility verification and prior authorizations. According to the 2022 CAQH Index , each manual eligibility verification transaction costs $12.86 and each manual prior authorization transaction costs $14.52. And this doesn’t even include the cost of gathering information for the transaction or for follow-up. Since 569 million manual eligibility transactions and 66 million manual prior authorizations are conducted each year, the impact on the bottom line is staggering.

Instead, providers and payers could leverage an application built on a decentralized, peer-to-peer network to conduct eligibility verifications and prior authorizations—without the need for time-consuming back and forth faxes, emails, and phone calls. With this type of network, the entity conducting the inquiry receives the most up-to-date information based on a number of data elements that are relevant to them.

For example, a primary care provider, a specialist, and a hospital would all receive information based on data elements that are specific to their specific scenario. This would be based on the type of provider, the kind of procedure, the type of facility, the patient’s remaining deductible, and the patient’s out-of-pocket responsibility, and more. It’s basically an “if/then” inquiry. If the inquirer is a surgeon, and if the procedure is covered in the patient’s benefit plan, and if the patient’s deductible has been met, and if the provider is in network, and if all prior authorization requirements are met, then this is what the provider will be paid and what the patient will owe.

The senior director of revenue cycle transformation at a large, multispecialty academic medical center believes that we have a misconception that patients don’t want to be bothered with the financial impact of a service at the time the service is rendered. “In the past we thought we were doing patients a favor by not approaching them about their financial responsibility. Then the patient receives a bill several months later and tries to remember even having the service and then figure out if the bill is legitimate.”

By giving patients an accurate amount that they will owe at or before the time of service, patients have the information they need to make more informed decisions about how to pay for their care. It also enables providers to collect on bills or set up payment plans, which can help reduce the cost to collect and write-offs, as well as surprise bills for the patient.

Coordination of benefits (COB) is another process fraught with administrative waste and inefficiencies that could benefit from a decentralized, peer-to-peer network. COB processes often cause cogs in the revenue cycle on the back end that can lead to delays in reimbursement and excessive rework. Because of the latency of data, there can be a long lag in getting updated information on multiple coverages or changes in coverage status. COB works better if all parties have full insight into multiple enrollments. With a peer-to-peer network, updated enrollment information on each participating member/patient is already in the system and can be accessed by all participants on the network.

Imagine a decentralized, peer-to-peer network that allows payers to co-develop processes to streamline coordination of benefits. Working together, payers can develop the rules, processes, and the analytics that provide greater standardization and insight into primary, secondary, and tertiary coverage for network participants. Today, what is a heavy administrative burden that can result in costly, labor-intensive denials, instead becomes a simple network inquiry that facilitates faster, more accurate claims.

How it works

The foundational benefit of a decentralized, peer-to-peer network is the concept of connecting once to many instead of one to one. Instead of having to build and maintain separate connections to a myriad of different services, trading partners, and counterparties within the industry, all network participants have access to a shared base of knowledge.

In the network, payers and providers submit data to the cloud where it becomes discoverable based on permissions that are set by each participating organization. Users connect to the network via the cloud, where the ID keychain and master index locate the information requested, match it to the data available, and then deliver it to the requestor. The network design provides certification, cybersecurity, and compliance.

Where we go from here

No one could have imagined Amazon before the Internet was invented. With a decentralized, peer-to-peer network, the sky’s the limit in terms of innovation in healthcare. The use cases discussed in this blog are just the tip of the iceberg. We’re now at the point where we need to look beyond just transactions. Working in partnership with payers, providers, vendors, banks, innovators and other stakeholders will allow us to see the full potential of a network from a different lens—one that enables us to truly optimize the patient/member experience.

The more organizations we add to the network, the value grows exponentially because the connections grow exponentially. It’s not 0 to 10 growth; it’s 10 squared. The more connections you have, the more chances for innovation. And the more innovation you have, the more chances there are to achieve true transformation and “eureka” moments.

Time to act is now

Advancing administrative interoperability is the only way we will ever reduce the cost of healthcare and achieve long-term revenue improvements. We have to ask ourselves what value we could generate if we weren’t spending billions of dollars on administrative waste and how that would enable us to make things better for the patient. A secure, decentralized, peer-to-peer blockchain-enabled network provides the infrastructure that can make that happen.

The real challenge that we’re trying to solve is how to accomplish this in a decentralized, shared manner. Anyone can build a walled garden. We could say, here’s all the perfect use cases we want to tackle and then set about building proprietary, closed technology that everyone has to connect into. In this scenario we’d never hit the point where we reach mass adoption because not everyone wants to work within another organization’s walled garden.

Instead, we must build an ecosystem where everyone can participate and get equal access to the information they need when they need it with permission—all on a single, secure network. As the revenue cycle director at one healthcare system said, “When you start looking at what this type of network allows you to do, it is really a transformational approach to sharing data. And it’s going to fundamentally change the way payers and providers interact going forward.”

Decentralized Network: How Does It Work?

In a previous blog, we discussed a new approach to interoperability that doesn’t require data to be requested, aggregated, and validated each time it’s used or shared. Unlike a traditional network design, a decentralized network enables healthcare stakeholders to access continuously refreshed, always current data in real time with permission, allowing them to communicate, transact, and collaborate with any other network participant. Innovators can deploy solutions on the network for participants to subscribe to and use. And they can do it without building separate connections to each entity.

In this blog, we discuss how a decentralized network works to enable more effective collaboration, drive innovation, and improve the healthcare experience.

How does a decentralized network work?

On a decentralized network, participants have their own private, secure cloud-hosted environment as their home base. This home base is populated with a prepackaged suite of utilities and services that can be used to create, deploy, and subscribe to solutions on the network, eliminating interoperability challenges and making collaboration easier. This means organizations can spend less time and financial resources deploying and implementing solutions.

An excellent example of how a decentralized network works is the real-time claim adjudication process. This workflow includes:

The ability for stakeholders to transact directly with each other transforms the business of healthcare, modernizing how it operates and ultimately, can lower the cost of administering healthcare.

How do data security and immutability work on a decentralized network?

On a decentralized network, participants always have control over who can access their data and how that data can be accessed. This is made possible through services that manage and unlock access to permissioned data based on the use case.

When participants join the network, they must register their clinical or administrative data associated with members, patients, and practitioners and given a person ID, a unique network identifier. When the network detects other organizations who share data for the same person ID, data-sharing authorization policies are automatically evaluated to determine if access to data is permissible. Where authorization is approved, data is shared directly and securely between network participants. The network itself does not see or store the data that is shared between participants.

The authorized transactions between network participants are trackable, auditable, and immutable through a blockchain node within each participant’s home base. This effectively lowers issues of distrust, friction, and data hoarding between payers and providers.

How does a decentralized network further innovation?

Taking a new product from an idea to launch to implementation can be faster and more straightforward over a decentralized network, leading to a faster ability to demonstrate value and scale. Using a set of common services in their home base, innovators can collaborate, develop, and deploy new solutions over the network without having to build a separate connection to each customer. Solutions can be optimized to support direct participant connectivity, which enables them to be deployed in a distributed method to each participant’s home base. Network participants can discover, offer, and source solutions right on the network without the need for a third party to act as a central data authority.

In this way, a decentralized network becomes the perfect conduit for a marketplace for innovators that features an exchange of solutions, helping bring new products and services to market faster. The network also promotes financial transparency, which can transform claims adjudication workflows and reinvent the way payers and providers work together.

How does a decentralized network improve the patient experience?

The administration of healthcare—those back-end processes like coverage discovery, prior authorization, and collections—are highly complex and often involve inefficient, manual, error-prone workflows that can impede a patient’s ability to receive timely access to care and know how it will cost. A decentralized network provides an entirely new way to administer those processes by:

In Part III of our blog series, we will share top use cases for a decentralized network along with case studies of a decentralized network in action.

How a Decentralized Network Empowers Innovation

In this three part blog series, we’ll discuss how decentralized networks can enable healthcare interoperability. In Part 1, we’ll discuss how decentralized networks can eliminate data silos and resolve payer-provider friction.

Every day in the U.S., innovators and entrepreneurs embark on a journey to create new healthcare solutions that can improve lives, reduce costs, and help fix our broken healthcare system. Unfortunately, many abandon their efforts when they learn just how complex our healthcare system is and how much work—and money—it takes to reach meaningful scale and deployment. The effort it takes to establish a series of one-to-one connections to collaborate and transact with payers, providers, and other innovators is simply too immense and too costly.

How many clinical and administrative advancements could we have achieved by now were it not so difficult to bring innovative new solutions to market? 

A decentralized network could change innovation in healthcare.

What is a decentralized network?

Typical networks are designed around a master server that manages all information and activities within a network. Decentralized networks, on the other hand, consist of multiple servers, each acting as a master server while still managing its own information and connecting with each other. This balances the load and distributes it across the entire system, which improves network resiliency and data redundancy. The organizations using the individual nodes can control how, to whom, and for what purpose data is exchanged. In this way, a decentralized network speeds the rate of data exchange while keeping data secure between all network participants.

What are the benefits of a decentralized network for innovators?

One of the most significant benefits of a decentralized network is that it enables innovators to use a platform with a common set of tools and services with which they can jointly collaborate, develop, and deploy new solutions without having to build individual connections with every stakeholder. Some of the benefits of a decentralized network includes:

Where do we go from here?

A decentralized network has the potential to become our industry’s first intentional architecture for healthcare and one capable of spurring innovation in ways never before seen. It’s a new direction, a new way forward. It’s not about streamlining existing processes. Instead, it’s about rethinking what healthcare could be.    

The good news is that the network is live today. The Avaneer Health Network™ is a secure, permissioned, decentralized network and platform built on a data fabric infrastructure. Once a participant—payer, provider, or innovator—connects to the network, they never have to build a direct connection to any other participant. Data remains decentralized, and 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 true data fluidity.

How it works

Each participant receives an Avaneer SparkZone™, their dedicated, private, secure, cloud-hosted environment, and their “home base” on the Avaneer Network. Included in their SparkZone is a pre-packaged suite of utilities and services, providing everything they need to develop and deploy their network solutions and to subscribe and connect to other solutions.  

Also, a part of the Avaneer Network is Avaneer Collaboration Services™, a person-centric identity service that connects to data discovery workflows that unlock access to permissioned data. The authorization review and exchange of data are trackable, auditable, and immutable. This all happens in real time, giving participants access to the data they need when they need it.

The Avaneer Network also provides a digital marketplace, the Avaneer Solution Exchange™, where participants can discover, offer, and source other solutions on the Avaneer Network. It’s a shared resource for the entire Avaneer Health Network community.

The potential for collaborative innovation over a decentralized network is limitless. If you’re interested in learning more about Avaneer Health, we invite you to join us on our journey to foster greater innovation while we reinvent the business of healthcare. 

 

In Part II of our blog series, we will discuss how a decentralized network enables healthcare stakeholders to access continuously refreshed, always current data in real time with permission.

How healthcare can become more interoperable with a decentralized network

The back-office administration  of healthcare is fragmented and full of manual, inefficient processes that impact patient care, provider reimbursement, and costs. These processes are a result of our inability to connect effectively. While payers and providers have invested millions in multiple platforms and legacy systems, some still lack full integration and interoperable functionality.

The annual cost of administrative inefficiencies in the U.S. healthcare system has reached an estimated $496 billion, with billing, coding, physician administrative activities, and insurance administration being primary drivers.

An ecosystem full of obstacles

The challenges of today’s outdated interoperability architecture are significant. From a connectivity standpoint, partner connectivity and workflows require multiple vendors and system integrations. From a data management standpoint, today’s interoperability systems require multiple entities to support, which has led to a lack of traceability, control, and auditability. These third parties must aggregate, store, and repurpose data, which means they control the redistribution to payers, providers, and partners. Because of this, the stakeholders who actually use the data—payers and providers—have little control over when, where, and how they can access it.

Most healthcare organizations have invested in digital and interoperability strategies that, ultimately, have narrow potential and limited scalability. The high costs to maintain connections to multiple third parties require payers and providers to implement and maintain numerous single-use, point-to-point connections.

Regarding infrastructure, we now have a web of interconnected systems that don’t easily adapt to evolving trading partner business needs. This has resulted in a wide array of custom, proprietary integration requirements for APIs and third-party platforms—all of which further deteriorate our industry’s quest for interoperability and administrative efficiencies.

Manual transactions, administrative burdens, incomplete interoperability, and costly and ineffective legacy systems have led to increased total processing spend, provider burnout, poorer outcomes, and limited innovation.

A new kind of interoperability in healthcare

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.

The term interoperability has different meanings. While we can all agree that sharing data is at the heart of the definition, there are disparities in what that looks like. For example, Fast Healthcare Interoperability Resource (FHIR) has given us a common set of protocols and standards for a payload of transactions on a network. Still, alone, FHIR does not give us full interoperability.

In a truly interoperable healthcare system, 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 secure, decentralized network to those who are permissioned to access it.

What is a decentralized network?

The typical network design consists of a master server that manages all the information and activities on the network. On a decentralized network, there can be multiple servers acting as master servers. They each manage information on their own while still connecting with each other. In this way, they “balance the load and distribute the work across the system.” This helps improve network resiliency and data redundancy; if one node goes down, the others are unaffected. Likewise, because data exists in multiple locations throughout a decentralized network, it cannot be changed in one place without changing it across the network.

decentralized network

Benefits a decentralized network can deliver include:

Eliminating data silos and resolving payer-provider friction

Health systems and payers have made progress in improving data accessibility throughout their own enterprises, but remain challenged to seamlessly make data accessible between organizations. That lack of data fluidity has led to an industry with a complete lack of transparency that has led to friction, distrust, and data hoarding.

With a decentralized network, payers and providers achieve complete transparency and data fluidity, and they do it without involving third parties. This allows for enriched transactions, providing more actionable patient and procedure-level specificity and clarity. Without a third party, payers and providers require fewer transactions to support operational workflows, while improved data insight supports more effective data management strategies.

This new way of transacting healthcare is not just redesigning current processes. It’s not about just streamlining the way we currently do things. It’s about disrupting how we conduct healthcare and doing things differently. It is about reinventing the business of healthcare.

Improving innovation

Another benefit of a decentralized network is its ability to facilitate innovation and host new solutions that can go to market and implement new clients faster. Hundreds of entrepreneurs enter the healthcare industry each year with innovative ideas and solutions that could improve healthcare’s many challenges—from clinical to administrative and beyond. One of the reasons that many don’t succeed is because they aren’t prepared for our industry’s complexities. They quickly discover that there are myriads of issues that must be addressed before they can deploy their solutions, issues primarily around data connectivity. The time and effort required to establish one-to-one connections with payers, providers, and other innovators is so great that many startups fail before they ever reach the scale needed for full deployment. Thus, many brilliant ideas go unfulfilled each year, ideas that have unlimited potential.

With a decentralized network, innovators can more easily access and collaborate with industry stakeholders and other innovators. Leveraging a platform with a common set of tools and services over the network, they can streamline collaboration and develop and deploy new solutions without building individual connections to every entity. In this way, a decentralized network becomes a foundational element and our industry’s first intentional architecture for healthcare.

A new era of interoperability

While we’ve made progress on the road toward interoperability, we have to ask ourselves if our current trajectory can get us where we need to be. Avaneer Health sees a new way forward. We are building a digital ecosystem that accelerates change and enables us to reinvent how healthcare operates. Our decentralized network is now live, and we invite you to join us as we reimagine healthcare together.