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 cogs 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 numerous APIs, data aggregation, 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.

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:

A provider submits claims directly to a network payer from their home base instead of through their traditional clearinghouse pathway.
The network’s real-time adjudication (RTA) solution automatically examines each claim’s details against the payer’s RTA criteria.
If the claim is “clean” and deemed processable by the payer for RTA, the claim will be automatically directed to the payer’s designated RTA endpoint.
If the claim is not processable by the payer for RTA, it will automatically be directed to the payer’s traditional clearinghouse endpoint.

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:

Leveraging FHIR for standardizing data
Allowing real-time, permissioned access to accurate data for all healthcare stakeholders
Enabling processes that used to take days or weeks to be completed within seconds or minutes
Eliminating time-consuming, manual, error-prone workflows
Giving providers the information they need when and where they need it to provide high-quality patient care

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.

What is Interoperability in Healthcare?

The official definition of interoperability, as put forth by the ONC (Office of the National Coordinator for Health Information Technology), is “the ability of two or more systems to exchange health information and use the information once it is received.” However, if you google the term you’ll find dozens of different definitions, each with a slightly different slant. At the core of all these definitions, however, is the sharing and accessing of data.

According to HIMSS (Healthcare Information and Management Systems Society), there are four levels of interoperability.

Foundational (Level 1): Establishes the inter-connectivity requirements needed for one system or application to securely communicate data to and receive data from another
Structural (Level 2): Defines the format, syntax and organization of data exchange including at the data field level for interpretation
Semantic (Level 3): Provides for common underlying models and codification of the data including the use of data elements with standardized definitions from publicly available value sets and coding vocabularies, providing shared understanding and meaning to the user
Organizational (Level 4): Includes governance, policy, social, legal and organizational considerations to facilitate the secure, seamless and timely communication and use of data both within and between organizations, entities and individuals. These components enable shared consent, trust and integrated end-user processes and workflows

Why do we need interoperability in healthcare?

In addition to the numerous clinical reasons to achieve interoperability, there is opportunity for the back-office administration of healthcare—which includes processes such as eligibility verification, prior authorization, claims submission, and charge capture. These processes are often fragmented, full of manual and error-prone workflows, and so inefficient that they cost the U.S. nearly half a trillion dollars each year, with billing, coding, physician administrative duties, and insurance administration being the primary drivers.

The current ways to connect for administrative transactions rely on a web of single-use, point-to-point connections and batch or call and response processes that lack data control and traceability. Payers and providers have invested millions in multiple platforms to modernize, but still lack full integration and interoperable functionality.

How does the lack of interoperability affect payers and providers?

One of the most significant issues caused by a lack of interoperability is friction between payers and providers. It’s understandable why a lack of transparency has created such high levels of distrust. Fraud, waste, and abuse cost payers billions each year, which is why they now use more sophisticated technology to identify potential claim issues. While this may help reduce fraud and overpayments, it has also caused more work for providers via increasingly complex payer requirements that are hard to keep up with.

The bottom line is that payers want to reduce their financial risk by ensuring that members receive the most cost-effective, appropriate level of care. At the same time, providers want autonomy around the decisions they make when caring for their patients, and they expect fair, timely compensation for that care. Both want to simplify the extreme administrative complexities caused by a lack of interoperability and data fluidity.

How does the lack of interoperability affect patients?

Administrative inefficiencies caused by a lack of interoperability can impact both a patient’s health and wallet. Prior authorization is a great example. In a 2022 survey by the American Medical Association, 94% of providers said the prior authorization process had caused delays in patient care, and 33% said those delays in care have caused a serious adverse event for patients.

The lack of financial transparency is another issue that impacts patients. When providers can’t tell patients with certainty what they will owe, it limits those patients’ ability to make informed decisions about when and where to get care and how to pay for it. This lack of transparency can negatively impact the entire patient experience, even offsetting a positive clinical experience. While the No Surprises Act has pushed the industry forward, there is much room for improvement.

Why is interoperability in healthcare so difficult to achieve?

The banking industry seems to have interoperability figured out. Consumers can easily send money to other people with no more than an email address or phone number, even outside their own banking system. And they can go to virtually any ATM anywhere in the world, see their account balance, and withdraw funds.

The primary reason interoperability in healthcare is so challenging is that payers and providers use multiple methods to exchange information, including:

Exclusive networks built by EHRs
Clearinghouse networks and solutions
Clinical networks
Data and solution platforms
API-centric companies
Health data exchanges and health information exchanges (HIEs)
Standards and frameworks like FHIR(R), EDI, EHNAC, CAQH, NCQA, WEDI

All these methods deliver some level of interoperability but require the implementation and maintenance of point-to-point connections with each trading partner. And most of these connections use request-response workflows that delay data and require the aggregation and storage of data by third parties.

Another challenge is a lack of standardization. While Fast Healthcare Interoperability Resource (FHIR) has given us a common set of protocols and standards for a payload of transactions on a network, FHIR alone does not translate into interoperability and data fluidity. It is still a highly complex system of multiple data gateways.

Are there any solutions that help solve interoperability challenges in healthcare?

The answer is “Yes!” In a truly interoperable healthcare ecosystem, data would not need to be requested, aggregated, and validated each time it is needed. Instead, it would be continuously refreshed, always current, and accessible in real time via a single network to those who are permissioned to access it. It’s a new way of conducting the business of healthcare and it’s here today via the Avaneer Health Network™.

The Avaneer Health Network™ is a secure, permissioned, decentralized network and platform built on a data fabric infrastructure. Once a participant—payer, provider, or innovator—connects to the network, there is not a need 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 genuine data fluidity.

How the Avaneer Health Network™ connects healthcare

Each participant receives an Avaneer SparkZone™, a dedicated, private, secure, cloud-hosted environment. The SparkZone is the connection between the participant’s internal system and the network, facilitating direct peer-to-peer data access with a suite of utilities and services for FHIR transformation. In addition, subscribed solution apps are loaded into the SparkZone.

Another important component of the Avaneer Network is Avaneer Collaboration Services™, which includes multiple tools and resources to facilitate interconnectivity. These services include a person-centric identity service that links person identities across network participants so that there is a shared context. Then, the Collaboration Service enable fluid and direct data exchange across the Avaneer Network. Governance of more than 20 autonomously administered security controls enforces authentication, authorization, access controls and audit controls to ensure data access is fully permissioned, auditable, and decentralized.

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 community of participants.

What’s next for interoperability in healthcare?

With each new technology that launches, the potential for innovation in healthcare increases exponentially. To successfully leverage and deploy innovative solutions requires a level of interoperability that supports collaboration and connectivity in a new way. With Avaneer Health, many of healthcare’s biggest challenges, both administrative and clinical, are resolved.

We invite you to join Avaneer Health on our journey to reinvent the business of healthcare.

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

Redefining healthcare interoperability

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 a decentralized network 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.