The Missing Link in Generative AI for Healthcare

Innovative technologies come to the market every day that promise to solve some of healthcare’s biggest problems. Unfortunately, many are abandoned before they have a chance to fulfill their potential. Often, the reason is that it’s too difficult to navigate our complex healthcare system in a way that makes collaboration, development, and deployment cost effective. The effort required just to connect to the right stakeholders is immense.


The potential of Gen AI

An example of such an innovation that holds enormous, industry changing potential is Generative AI (GenAI). GenAI is a specific type of artificial intelligence that generates text, images, and other modalities in response to prompts. The technology grows in value with each use by discerning patterns and applying deep-learning algorithms based on existing data to create new content.

In healthcare, the potential of GenAI is tremendous. From generating rich clinical notes after an encounter, to better and faster disease diagnoses and outcomes, to assisting with drug discovery, GenAI holds great promise for advancing healthcare and patient experiences in ways never imagined just a few years ago.


The challenge

Regardless of the potential benefit of GenAI, there still exists the same roadblock to realizing its full value as innovators and entrepreneurs have faced for years—the inability to deploy new technologies in a way that is cost efficient, timely, and easy to scale. Healthcare systems have invested heavily in legacy systems that don’t typically play well with new technologies. Bolt-on solutions and multiple data interfaces are required just to share information with other providers and payers. And managing these systems takes a significant portion of most health systems’ IT budgets, leaving little room or resources to cost-effectively integrate GenAI solutions.


The missing link – permissioned AI

Today, the primary model for collecting, processing, and training data for GenAI models is centralized data aggregation, which comes with significant privacy and security risks. This approach is especially problematic when proprietary or sensitive data is used, and it requires considerable safeguard measures during model training and solution deployment. Unfortunately, this can limit the collective value of GenAI solutions. This approach also provides little to no transparency of how the data is used to train the models or how the generated data is eventually shared with users.

All these challenges can be addressed, however, through a decentralized network. A decentralized network can be a powerful GenAI enablement platform to accelerate adoption. It works by enabling:

Initial industry use cases for such a Gen AI-enabling network can help physicians with clinical documentation, such as transforming conversations into prescriptions, follow-up appointment letters, and consultation summaries. However, the potential use cases are practically limitless.


Unlocking the full potential of GenAI

GenAI has the potential to genuinely transform our industry by enhancing patient experiences, improving outcomes, and significantly reducing clinical and administrative inefficiencies. But fully realizing these benefits requires a new kind of network through which these innovative technologies can be leveraged. That network is here today.

Avaneer Health 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.

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

Learn how the Avaneer Health network and platform enables generative AI, large machine learning, and the development of models.

Reimagining the business of healthcare

Since joining Avaneer as founding CEO in the summer of 2021, I’ve had countless conversations with a wide range of people, our founding investors, many leaders at payer, provider, and innovative companies, curious tech futurists, and prospective investors. In the past few weeks, I have had the opportunity to speak with many at ViVE23 and Becker’s 13th Annual Meeting. It’s been encouraging to hear the positive response when I share Avaneer’s vision, which is founded on the idea of “Imagine if…”

Imagine if we had a healthcare ecosystem where health information could be shared freely, without hesitation, and in real time – where we could eliminate redundancies caused by a lack of confidence in shared information.

Imagine if we had a system where “right-time” claims adjudication was the norm, where claims are automatically examined against a payer’s criteria and processed in real time – without the need for a third party.

Imagine if a consumer could know confidently what their visit or procedure will cost, including their portion and exactly what their health plan will pay. Better yet, imagine if that consumer could leave their doctor’s office knowing their bill is paid in full because the claim from their doctor was adjudicated in real time at checkout.

Imagine if we had a system where coverage information is continually refreshed and, if issues arise, the data’s owners are automatically notified and the information is updated throughout the system.

We no longer have to “imagine if” because the Avaneer Health Network is now beginning to bring these scenarios to life today. On March 13th, we announced the launch of our new network and platform, with the first connections to CVS Health, Cleveland Clinic, Elevance Health, and Sentara Healthcare. The vision of Avaneer Health isn’t to simply streamline existing processes; it’s about completely reinventing the business of healthcare.

Stuart Hanson
Chief Executive Officer
Avaneer Health

In This Issue

Featured Avaneer Content

A New Way Forward for Healthcare

Imagine a healthcare ecosystem where payers, providers, and innovators can share data in real time through a single network—with a single connection. It’s a completely new way of doing business.

Industry News

Administrative expenses account for approximately 15% to 25% of our nation’s total healthcare expenditures, representing an estimated $600 billion to $1 trillion annually.

– Health Affairs

Reengineering the Business of Healthcare

CIO Review
Have you ever wondered what it would be like to be able to connect to all your trading partners without having to build or maintain separate connections for each one? Where real-time adjudication is the norm and where prior authorizations could be completed in minutes instead of days (or weeks)? Where payers, providers, and innovators could collaborate on a single network and build and deploy solutions on a single platform? That’s the topic of this insightful and forward-thinking article.
Read the article

Inconsistencies Found in 81% of Provider Directories Across Large Health Insurers

Health Leaders
Research into more than 600,000 physician entries in online directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana found vast inconsistencies in provider information. Why does this matter? Researchers suggested that “Beyond surprise billing, inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans.” Learn how this issue can cost the industry billions each year.
Read the article

Avaneer Health’s Interoperable Network Creates an ‘Information Highway’

Healthcare Finance News
How can an information highway transform healthcare? By eliminating fragmented data silos, numerous point-to-point connections, layers of technology debt, incomplete information, and manual processes. Get the perspectives of Jamisson Fowler, chief digital officer, Sentara Healthcare; Sherif Kamel, senior vice president of enterprise delivery at CVS Health; and Sonja O’Malley, senior director of Innovation at Cleveland Clinic.
Read the article

From the Avaneer Blog

How a Network Empowers Innovation

The healthcare industry is brimming with innovation. New companies enter the market every day with ideas and solutions that could bring vast improvements in both care quality and administrative efficiencies. Unfortunately, many of these companies exit the market before they have a chance to make meaningful contributions. This blog explores the challenges and opportunities and offers a new way forward that would make it easier for innovators to deploy their solutions at scale.
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Data Sharing in the Age of Digital Healthcare

As the number of connected health devices skyrockets, so do opportunities for creating improved outcomes and a better patient experience. Deloitte predicts there will be 440 million wearable health monitoring devices by 2024. In addition to wearables, healthcare apps, which have been on the market for years, continue to grow in popularity. For example, the market for digital mental health apps has grown exponentially since the start of the pandemic. According to Deloitte Global, spending on these digital apps worldwide will reach $500 million this year.

Approximately 30% of data being generated in the world is generated through the healthcare industry. Each patient generates nearly 80 megabytes of imaging and EMR data each year.

Other digital health solutions with room for improved outcomes include telehealth, which experienced high growth since 2020. While most providers are back to in-person visits, the vast majority of consumers want to keep telehealth as an option going forward. Telehealth is promising in its ability to broaden access to care, especially in underserved populations like rural communities. There are  46 million Americans living in rural areas and there are fewer than 40 physicians for every 100,000 residents. Telehealth can help bring timely access to providers, specialists, and other clinicians without patients having to make long commutes to urban facilities.

The missing piece

These digital opportunities are well-positioned to improve outcomes, lower costs, and enhance the patient experience. But they’re missing one key element that is necessary to be successful: the seamless sharing of data between healthcare stakeholders.

For example, the increased popularity of telehealth has led to an increase in telehealth providers and platforms. Today there are 1,370 telehealth services companies in the U.S. Unfortunately, those companies typically do not seamlessly share data within the provider’s systems or workflows. Research shows that 60% of clinicians cannot access their telehealth platform directly from their EHR. And when patients see a telehealth provider instead of their primary care physician, the physicians may never know about the appointment unless the patient remembers to tell them. Missing information leaves providers with an incomplete picture of the patient’s health.

The situation is similar for chronic disease management. Wearable devices such as smart insoles for diabetics can alert a physician when an increase in foot temperature is detected. This can mean the patient has a foot ulcer, which is a leading cause of lower-extremity amputation in diabetics. To be most effective, providers need to be able to track, measure, and analyze that data alongside the patient’s full medical history, including A1C, blood glucose levels, and other vitals. Chronic disease management in general includes a long list of care coordinators, specialists, primary care providers, labs, payers, and others—all of whom need timely access to current data.

The benefits of digital health innovations such as telehealth and wearable health devices will never be fully realized without clinical and administrative data fluidity.

Getting innovations to market more effectively

It’s challenging for new health tech companies to launch innovative solutions for healthcare because of the way data is disjointed. Before a new digital solution can be deployed, numerous individual connections are required between EHR companies, other health vendors, and the payers or providers themselves. While FHIR standardization helps, there is still a lot of customization that must be done to create each connection.

FHIR has leveled the playing field somewhat and increased competition by enabling smaller health tech companies and startups the same access to data sets and key stakeholders as larger, legacy system companies. Regardless, data is still notoriously difficult to share and manage at scale. If the solution requires the end user—whether provider, payer, or patient—to log into multiple systems or deal with cumbersome workflows, what might be a truly innovative solution will likely struggle to scale easily and quickly.

Research 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 with providers outside their organization. Just 34% engaged in bidirectional electronic sharing of patient information.

While FHIR enables the standardization of data in a way that helps improve workflows and usability, it still requires the building and management of APIs between entities. And that means data still has to be exchanged, aggregated, and validated each time it’s used. It also does little to address issues of data ownership, control, and transparency—all of which lead to a lack of trust in the quality of the data, as well as payer-provider friction. And without the ability to seamlessly share data between entities, it is difficult to integrate new technologies in a way that lets them work together. If each solution must be accessed via separate systems, data has to be pulled out of the solution and manually entered into the provider’s systems. This does little to address today’s costly administrative inefficiencies.

What we need is a data-sharing superhighway

Disparate data from disparate solutions, no matter how innovative those solutions may be, will lead to disparate care. What we need is a digital ecosystem—a peer-to-peer network—through which healthcare stakeholders can collaborate with payers, providers, and innovators in a secure, private, dedicated environment, while still maintaining full control over their organization’s data. This could include a digital marketplace where participants could discover, offer, or source proven solutions that harness the network. Any solution could be deployed directly to other participants without the need for a third party to act as a central data authority.

This type of ecosystem would enable data from any digital solution to be accessed and used by any participant who is permissioned to access it. Common infrastructure and tools built on FHIR, blockchain, AI, and other innovative technologies, would provide the security and immutability of the data.

Once a participant connects to the network, the need to build direct connections is significantly reduced—saving millions in IT resources.

Reimagining healthcare

Imagine telehealth providers being able to facilitate a virtual visit without having to change their workflow, duplicate processes, or access separate systems. Imagine if chronic care providers could see real-time vital data from their patients’ wearable devices as part of the patient’s health record, right alongside the patient’s complete medical history. No need to download and log into individual apps and manually enter data into the EHR.

Healthcare is human and at the heart of every procedure, diagnosis, transaction, and encounter is a human being who needs care. Imagine how the seamless sharing of data could transform lives and our entire industry.

Avaneer Health is building a network to enable the type of data sharing that’s needed to fuel innovation in healthcare. The time to act is now.

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 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:

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.”

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