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.

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.

Advancing Healthcare Innovation – Empowering Healthcare Innovation In Today’s Network Ecosystem

Stuart Hanson, CEO of Avaneer Health, discusses with Michael Stamatinos about how a decentralized, peer-to-peer network connects payers, providers, and innovators in the healthcare ecosystem to deliver value. Stuart describes the vision of the founding members and why they started Avaneer Health. Stuart and Michael discuss how Avaneer Health is solving the challenge of data exchange with a unique approach.

Unlocking the Full Potential of Healthcare

Imagine this: A healthcare ecosystem where payers, providers, patients, and partners can seamlessly connect to securely share information directly with each other, tearing down the barriers in healthcare. Also in this ecosystem, innovators can deploy and scale solutions that improve healthcare experiences by leveraging a network, standards, and processes that are developed collaboratively and can work for all. This is the vision behind Avaneer Health.

A conversation in 2017 sparked the vision between a small group of healthcare industry leaders who saw the potential for a new way of working together. They discussed how to create an ecosystem that facilitates collaboration, real-time data sharing, distributed governance, and common processes running in a trusted, permissioned, and secure environment wherein participants can transact with one another. The conversation grew to include an impressive group of innovative leaders from both payers and providers who shared the enthusiasm and vision of creating a healthcare network to enable direct connectivity between participants. This connectivity would include common data models, the latest in technology standards and infrastructure capabilities, modern security, and immutability that could be the answer to solving healthcare’s connectivity and interoperability issues.

Those early conversations led to the formation of a consortium called the Health Utility Network. Its name reflected the commitment to create a healthcare-focused network with common utilities that would scale to the healthcare industry’s needs. Its initial founding members — Anthem (now Elevance), Cleveland Clinic, CVS Aetna, HCSC, IBM Watson Health (now Merative), PNC Bank, and Sentara Healthcare — put aside their individual views, competitive overlap, and individual interests, and committed to work together towards a common goal of advancing healthcare transformation. The consortium created a framework for how an independent company would operate, tackling the challenging issues of trust, data ownership, access, privacy, and governance, while driving to a business model with a central focus on industry participation. In addition to seed capital, each of the founding members contributed its unique perspective, expertise, and passion.

In June 2021, the consortium officially funded and launched Avaneer Health as an independent company, formed to create a network with common infrastructure, interoperability tools, solutions, and a solution exchange capable of enabling the transformation of healthcare. The Avaneer Health team and the founding organizations continue to work together to co-develop joint processes and solutions. This type of collaboration creates opportunities for business models yet unimagined to help solve age-old challenges and unlock massive cost, process, and technology inefficiencies.

In an industry where new, innovative solutions often bring new complexities and have trouble getting to scale, Avaneer Health is working to create an ecosystem, a platform for collaboration, and a secure industry infrastructure that can help improve efficiency, and enhance outcomes, save billions in administration costs and, most importantly, improve patient outcomes and the overall patient experience. With the platform coming to life this summer, we are now turning our attention toward growing the ecosystem of organizations that are committed to tearing down the barriers that have plagued healthcare for decades. Please reach out if you and your organization want to be part of the next generation of healthcare.