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The challenges of today’s outdated interoperability architecture are significant.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.

Benefits a decentralized network can deliver include:

Participants have increased data integrity, immutability, and traceability to a single source of truth.
Data originators maintain control over their data and who has access.
Data is always available when and where it’s needed without having to be requested, aggregated, and validated.
Data can be consumed in any format: API, XML, database, etc.
Participants experience a reduced need to manage multiple interfaces and stand-alone connections.
As the network grows, data becomes more valuable.
Due to its structure, participants can leverage the network for unlimited use cases.

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.

It’s time to redefine what we mean by interoperability and reimagine what it could be

Interoperability. It’s a term that’s been widely discussed in healthcare. While at its core, the term refers to connectedness between systems or products, the implications are much broader. And therein lies the opportunity. Healthcare needs a more encompassing definition of what interoperability could mean on a grander scale.

For example, we talk about interoperability within a single health system or a single geographic region or between entities. But the backbone of today’s definition of interoperability is still the traditional API. And this is an issue—a roadblock, really. Besides the lack of clarification and standardization within federal legislation and mandates, provider and payer organizations are struggling to achieve compliance via APIs, especially regarding privacy and security. Further, implementation and maintenance are proving to be a significant burden on IT leaders since each connection requires building a separate API to meet each entity’s requirements. It’s a drain on resources and finances—both in short supply right now.

Furthermore, APIs are great at establishing connectivity, but aren’t the answer for delivering comprehensive interoperability. Healthcare data, which doubles every 70 to 80 days, still exists in disparate silos among thousands of databases spread across the country, even within individual enterprises. Building individual connections isn’t the answer.

While APIs provide individual connectivity between entities, they aren’t the hoped-for conduit that finally allows us to maximize the potential of the fast-growing landmasses of data we have available.

Going beyond APIs

What healthcare needs—and APIs can’t provide—is a data exchange infrastructure that acts as a network where participants can connect once and then have access to many. Instead of one-to-one connections, a true data interchange network provides a collaborative platform through which organizations can develop joint processes that help the healthcare community communicate more efficiently.

A decentralized, peer-to-peer network makes data interchange possible. Instead of pushing and pulling data through a single gateway between two entities, a network allows access to information among all participants. The potential number of use cases in this type of network is unlimited.

How it works

A decentralized, peer-to-peer network enables all participants permissioned access to the same information through a single connection. The network provides secure, tamper-evident storage of transaction data, as well as permission-based access to stored information so that the information can be protected and more reliable and its provenance can be verifiable.

Source: istock

Payers, providers, and third-party vendors who want to participate must agree to allow the data to be discoverable. Members of the network connect via the cloud, where the ID keychain and master index will match the requested data to the available data, then locate the information and deliver it to the requestor. Certifications, cybersecurity, and compliance are all managed by an outside intermediary. Leaders from one of our founding members, Sentara Healthcare, gave their view of how decentralized networks can support transformation within healthcare organizations, read more in the article here.

Limitless benefits

A decentralized, peer-to-peer network offers unlimited opportunities to advance the quality and efficiency of healthcare delivery in our country. The term “transformative” is not hyperbole here; the potential to transform our industry goes as far as our imaginations can take us.

Accelerates innovation in healthcare delivery
Streamlines the cost and management of IT operations
Improves data access security
Promotes more effective, efficient collaboration between payers, providers, patients, and vendors
Simplifies and optimizes workflows and joint processes
Enables providers and payers to achieve shared outcomes
Reduces gaps in care and improves clinical outcomes
Enables a more patient-centric healthcare experience

An accelerated path to interoperability

The broad adoption of APIs and FHIR has been essential in enabling interoperability to move forward into the 21^st Century. Up to this point, it’s enabled incremental progress to move us closer to our goals. As technology evolves, we need to leverage a decentralized, peer-to-peer network to eliminate the need for multiple APIs while providing all healthcare stakeholders the ability to work together as a community to build the healthcare ecosystem of the future.

Webcast: Digital Transformation – How Automating the Back Office Delivers Consumer Trust

There’s been a lot of conversation about digital transformation, interoperability, and the rising administrative costs in healthcare. What if all three challenges could be addressed by digitizing the back office? Digitizing the back office is similar to how retailers have automated their processes and infrastructure to create experiences that are consumer-friendly and more efficient. It’s now possible in healthcare.

Join an exploration of how healthcare could work differently as the panel members challenge the way healthcare approaches data exchange today, what is meant by digitizing the back office, how the revenue cycle can be improved with automation, and how it could impact the healthcare experience. Payers, providers, and innovators are coming together to collaborate.

During the webinar, the speakers will be discussing:

How to move from point-to-point ecosystem to a connect-once-to-many
Ways providers can collaborate and co-create with payers to improve the patient healthcare experience
Ways payer-provider relationships can evolve and lower healthcare costs
How a decentralized, peer-to-peer network eliminates layers, complexity, and fragmentation in administrative processes and technology
Insight into how an interconnected, digital back office can support common processes for payers and providers while automating revenue cycle processes in a new, re-imagined way

How Interoperability Can Boost Revenue Cycle Results

The annual cost of administrative and process inefficiencies in the U.S. healthcare system has reached an ominous $496 billion, 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:

Securing accurate information
Inefficient and lengthy phone calls with payers
Automation barriers, payer inefficiencies
Lack of transparency
Denials

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, vendors, and patients alike?

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, patients, and vendors—working from the same platform of knowledge.

Use Cases for a 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 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 2021 CAQH report, each manual eligibility verification transaction costs $16.07 and each manual prior authorization transaction costs $14.49. And this doesn’t even include the cost of gathering information for the transaction or for follow-up. Since 502 million manual eligibility transactions and 43 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 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, 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 have to 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.”

Who Needs Data Aggregation? There’s a Better Way

Imagine our country without interstate highways, where each city must build its own roads to every other city. Traveling between two cities would be easy enough but traveling between 100 cities would be a nightmare. And the money and time needed to create such a micro-network infrastructure would be monumental. Yet, this is the scenario playing out every day in healthcare as hundreds of payers, providers, and vendors build one-to-one pipelines with each other to exchange data. Even then, the data has to be aggregated, normalized, validated, and combined to form a single data set, which results in numerous silos of aggregated data. It’s a far cry from true interoperability.

We need a brand new way of administering healthcare. Today, we’re trying to address our interoperability issues with workarounds, bolt-on technologies, and more APIs. To truly fix healthcare, we have to take a step back and reimagine a new way. We need to come together and look at the problem through a new lens — from the perspective of the patient and with the patient in the center. After all, healthcare is human…not merely a business process.

Reinventing the system

Instead of hundreds of one-to-one pipelines, wouldn’t it be better to have a one-to-many, decentralized, peer-to-peer network that connects all stakeholders across the country, allowing them to access information in real time? Like an interstate highway that enables true mobility without limitations, a one-to-many network enables true data fluidity. Such a network provides a conduit—a superhighway—through which payers, providers, and vendors can access the data they need when and where they need it.

An exchange is not the same as a decentralized network. The former requires data to be aggregated and validated. The latter enables full access to immutable data wherever that data lives—without the need for aggregation.

In such a network, each permissioned participant acts as a node on the network. All nodes have access to the same information at the same time and can use or reuse the data with other participants for varying purposes. And because the network is decentralized, no node can tell any other node what actions it can or cannot take, or with which entities it can or cannot share data. No single entity has the ability to control, delete, or change what other entities do.

Another benefit of this type of network is that it provides ultimate security in that there’s no longer a need to reconcile data. Each permissioned participant is the author of its own data instead of sending it to a third party (centralized); the data remains in the participant’s control (decentralized). And each participant is able to reuse the data for different purposes.

Use cases

There are dozens of use cases already identified for a decentralized network, although the potential is limitless. Coverage verification is a great example. Through a decentralized, peer-to-peer network, payerswould be able to develop the rules, processes, and analytics that provide greater standardization and insight into primary, secondary, and tertiary coverage for network participants. Through a series of preconfigured coverage pathways—or data channels—with automated workflows, coverage data would be continuously refreshed, validated, and discoverable. When a discrepancy exists, such as missing or inactive coverage data, the network could automatically inform the payer so that the information can be updated. Without a single transaction being created, the most up-to-date coverage information would always be available for any permissioned participant to access.

Prior authorization is another example. What is often an excruciating process for providers could be completed within minutes instead of days or weeks, eliminating delays in care. Prior authorization requirements would be instantly available, giving providers the ability to submit their authorization data in real time right over the network. No more back and forth between the provider and payer while patients wait.

These are just two examples that highlight the value of data fluidity. This goes way beyond automation, exchanges, and aggregation. It’s an entirely new way of doing business.

Enabling innovation

Even beyond clinical and administrative use cases, a decentralized network enables the creation of a platform of innovative and collaborative services, and a common set of tools that enhance interoperability. Hundreds of entrepreneurs enter the healthcare industry each year with an innovative idea about how to disrupt and fix healthcare’s many problems. Most don’t succeed because they weren’t prepared for the complexities our industry presents. They quickly discover that there are myriads of issues that must be addressed before they can deploy their own solutions. It’s unfortunate that hundreds of brilliant ideas go unfulfilled each year, ideas that have unlimited potential.

The fact is that true disruption can’t happen when data is isolated or aggregated in individual pipelines. A platform of services allows innovators to easily access and collaborate with other innovators, and to more quickly and effectively deploy new solutions to the marketplace. In this way, the platform becomes the foundational element of our industry’s first intentional architecture for healthcare.

Henry Ford once said, “If everyone is moving forward together, then success takes care of itself.”

The transformation has already begun

At Avaneer Health, whose founding members include Anthem (now Elevance Health), Cleveland Clinic, CVS Aetna, HCSC, IBM Watson Health (now Merative), PNC Bank, and Sentara Healthcare, we are building that network, platform, and solutions to accelerate change and lead the change to reimagine how healthcare is administered. We’ve created common utilities to ensure vital collaboration and encourage creative thinking and problem solving. We have engineered a digital ecosystem leveraging truly innovative technology that will give participants the confidence to share critical data in a way that removes traditional barriers, optimizing efficiency and laying the foundation for a completely new experience for all.

Core to our mission is to invite developers and innovators to the network to utilize our platform to accelerate the scaling of solutions for digital health, revenue cycle, analytics, value-based care, SDOH, and more. The Avaneer Network facilitates the ease and speed of connecting to multiple stakeholders across the ecosystem to enable co-creation and encourage trial and testing, supporting speed to market of much-needed innovations.

The journey forward

Data fluidity, not data aggregation, is the key to unlocking the true potential of healthcare. Instead of building more one-to-one pipelines, we need to think bigger.

While Avaneer’s focus is on reengineering the now fragmented and inefficient processes of healthcare administration, we will never lose sight of the ultimate recipient of all that we do—the human being who deserves to receive the care they need, when they need it. Unencumbered by layers of inefficient processes, together we can strive to reinvent the patient experience for good.