3 ways IT leaders can improve the business transactions of healthcare

Most healthcare IT leaders have already laid out their priorities for 2024 and a recent report by Bain & Company finds that revenue cycle management, clinical workflow optimization, and patient engagement are top priorities. To address the challenges in these areas, healthcare leaders have significantly increased investments in technology and now consider IT a “strategic priority,” citing its ability to enhance revenue and reduce costs by “streamlining labor-intensive processes.” These include subset areas like “revenue integrity, charge capture, and complex claims.” 

Organizations can modernize their tech stacks to drive savings and reduce administrative burdens. We have identified three central areas of opportunity: data platforms and interoperability, automation, and AI. 

Data Platforms and Interoperability 

For all our efforts towards interoperability, data remains siloed across the healthcare ecosystem and continues to be difficult to access in the delivery of care. This is why our industry is still highly reliant on APIs and third-party aggregators to share data. While healthcare is making headway with industry-wide data exchange initiatives and the increasing adoption of industry standards like FHIR®, both initiatives require a great deal of work, money, and IT resources. 

Today, there are cloud-based data platforms that create a new kind of interoperability where payers and providers can share information without building and maintaining individual connections. These platforms enable data to be continuously refreshed and current, eliminating the need to question accuracy or integrity. These platforms include advanced technological components such as AI, machine learning (ML), and robotic process automation (RPA) meaning participants reap the rewards of greater interoperability without making substantial infrastructure investments. 

Avaneer Health’s network and its platform are designed for interoperability and applies a modern, secure infrastructure and leverages the FHIR standard for data exchange. Thus, payers and providers communicate and transact directly, eliminating the need for third-party solutions and reducing the number of transactions needed to support operational workflows. Because the platform enables permissioned and audited data sharing without data aggregation, data owners have more control over their data. 

 Automation 

We’re all familiar with the amount of financial waste in our industry, much of it related to inefficient manual administrative processes. While industry leaders have talked about the need for automation for years, today’s modern technologies hold much more promise than those of the past. Robotic process automation (RPA) is a prime example.  

RPA works by mimicking repetitive processes through rule-based tasks. “A set of scripted processes can access applications and data sources using structured data and logic to automate decisions according to predefined business rules and conditions.” In this way, RPA eliminates the potential for human error in manual processes while also increasing productivity with fewer staff.  

RPA is ideal for many patient access and midcycle processes like scheduling, coverage, and eligibility verification—all of which can impact the patient experience. RPA can also help with coding and can flag documentation requirements for prior authorizations and medical necessity as well, helping to reduce delays in care and denied claims, streamline revenue cycle processes, and optimize reimbursement.  

 Artificial Intelligence (AI) 

According to a new study by KLAS Research and the Center for Connected Medicine, 79% of health executives surveyed said that “AI was the most exciting technology in healthcare.” It seems each day we hear of new clinical and administrative use cases for AI. But when it comes down to choosing the appropriate application in our own organizations, the decision should be made by measuring both short-term and long-term gains and weighing them against available resources and capabilities. Organizations must ask themselves which applications are quick wins, and which will take more time and effort. Both need equal attention.  

 

Just 6% of IT leaders surveyed say they have a strategy in place for using generative AI, although 50% say they are or will be planning one soon. 

 

One ingenious application of generative AI that could be considered a quick win is its use in responding to patient messages in the patient chart. We’ve heard a lot recently about the unmanageable number of emails providers receive each day from patients. While some health systems have begun charging patients to send messages to their providers via MyChart, others are testing AI as a way to answer more common questions. One approach gives patients a tool and then punishes them for using it, while the other seeks to solve the problem with innovation. This is an excellent example of how AI can be used to facilitate better care while also improving the patient experience and reducing stress on providers.  

Longer-term applications of AI include better risk prediction for disease stratification, faster clinical trials, improved disease diagnoses, and better outcomes. But these more complex applications will only be beneficial if organizations can deploy them in a cost-efficient, timely, and easy to scale manner.  

Healthcare systems have invested heavily in legacy systems that don’t typically play well with modern technologies. Bolt-on solutions and multiple APIs are required just to share information with other providers and payers. And managing these systems consumes most of health systems’ IT budgets, leaving little room or resources to integrate AI applications and models cost-effectively. 

Avaneer Health Can Unlock the Full Potential of IT Investments 

Interoperable data platforms, automation, and AI have 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. 

 The Avaneer Health Network is a secure, permissioned, and decentralized network. Once a participant—payer, provider, or innovator—connects to the network, they never have to establish a direct connection to any other participant. Data remains decentralized, and participants can control how and with whom they collaborate. Through an authorization 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 and in real time, eliminating interoperability barriers and allowing genuine data fluidity. 

Healthcare leaders have realized not just the need, but the immense potential of investing in technology. To get the most from those investments, they’ll need to be able to integrate and deploy those technologies in a way that makes them usable across the entire ecosystem. Once all the pieces are in place, we will truly be able to reinvent the business of healthcare. 

Learn how Avaneer Health can help your organization achieve optimal results from your IT investments. 

FHIR® is the registered trademark of Health Level Seven International and is used with the permission of HL7. The use of this trademark does not constitute a product endorsement by HL7. 

Healthcare happens in real time. Shouldn’t your data?

Insider News for Nov/Dec 2023

Our team has fun calling out the obvious challenges of creating and launching healthcare infrastructure. Among our many sarcastic hashtags, we use #killthefax. It reminds us that it wasn’t that long ago that medical records were paper, data comes in multiple formats and is often in disparate databases, and our industry is still in the midst of digital transformation. It’s a paradox that most healthcare technology professionals will understand.

Further, AI is on everyone’s mind as a transformative technology across many industries. At the same time, data sharing in healthcare is still done via fax. This century-old technology still has us firmly in its grip, even as AI-enabled healthcare solutions are hitting the market!

No more excuses

The fact is that we can communicate without the fax machine. We can share data and transact with others in real time. And we can apply AI to large data sources to glean critical insight. Through the increasing adoption of industry standards like FHIR, we’re able to normalize data and continue to make progress and evolve. The challenge is that developing and deploying FHIR-based solutions is expensive and requires extensive IT resources to manage.

There’s a better way

The Avaneer Health network and platform are designed for interoperability and simplicity. With a modern, secure infrastructure and a built-in suite of FHIR-enabled tools, payers and providers can communicate and transact directly without requiring huge infrastructure investments. And because the network enables permissioned and audited data sharing without data aggregation by Avaneer Health, it eliminates the need for third-party solutions, giving data owners more control over their data.

There’s no excuse to stay tethered to the fax, file exchanges, or data aggregation. Payers and providers can begin reaping the rewards of greater interoperability today.

Gerald Bortis, PhD

Chief Technology Officer, Avaneer Health

In This Issue

Industry Highlights

Identifying the right use cases for federated learning and analytics

Integrate.ai

Most data science initiatives fail because they don’t have access to the appropriate data. But that’s changing thanks to federated learning for data silos. “In traditional machine learning, all data must be centralized in one database before training a model. In federated learning, models are trained on decentralized datasets – that is, the data resides in two or more separate databases and never needs to be moved.”

This insightful article shares the five steps to identifying use cases for federated learning.

Read More

Featured Avaneer Content

What if you could access all active and inactive coverage data in real time without aggregating data? And what if that information were always updated and available within your own system? It’d lead to:

Request a personalized demo

Collaboration Services for Developers: tools and services for launching solutions

Watch a short demonstration of how Avaneer Collaboration Servicesᵀᴹ enables developers to launch solutions seamlessly and automate workflows.

Watch now

From the Avaneer Podcast

New podcast focusing on innovation

The Avaneer Health team is launching a new podcast that will feature discussion with innovators who are disrupting how healthcare works, truly transforming processes and infrastructure, and challenging the status quo. Our first episode describes our vision for the podcast.

Listen here

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Closing gaps in interoperability could improve healthcare outcomes

The need for greater interoperability is escalating due to an increasingly sicker population. According to the CDC, 60% of Americans have a chronic disease, while 40% have two or more. As our nation ages, these numbers will likely increase as older individuals typically have more chronic conditions that require more—and more complex—care. Chronic disease is the leading driver of our $4.1 trillion annual healthcare spend. Effectively managing patient care, especially for those with chronic conditions, requires continuity across the care continuum and that continuity isn’t possible without closing gaps in interoperability first.

The disconnect

According to HealthIT.gov, 32% of individuals surveyed who had seen a provider in the previous 12 months experienced a gap in care due to ineffective information exchange. Nearly 20% had to bring a test result with them to a provider appointment; 14% had to wait an unreasonable period to get their results; 5% had to have a test or service redone because the data from the first test or service wasn’t available; and 5% had to provide their medical history more than once because the provider couldn’t find their existing chart. This lack of access to timely, accurate information is one of the primary reasons for gaps in care, a negative care experience, higher costs, and poorer outcomes.

Post-acute care

Consider the impact of interoperability gaps on patients recently been discharged from a hospital to a post-acute care facility. The Agency for Healthcare Research and Quality (AHRQ) reports that 20% of patients discharged from a hospital experience an adverse event after just three weeks. The report finds that 40% of patients are discharged with test results still pending. The same percentage is discharged with orders for a “diagnostic workup,” but often without a way to close the loop on whether that workup occurred. This may be why 99% of providers choose a post-acute provider that offers interoperability over one that does not. This is likely driven by value-based care models that penalize readmissions and poor outcomes.

Coverage accuracy and insight

Another example of how gaps in interoperability cause gaps in care involves the accuracy of coverage information. Now that patients are responsible for a larger portion of their healthcare costs, they need price transparency. While many providers offer patient responsibility estimations, those estimations are often incorrect. One study found that 79% of providers are unable to correctly estimate a patient’s out-of-pocket costs due to inaccurate price and coverage information. When patients don’t know the ultimate cost of a service, they may be more likely to put it off or skip it altogether. For providers participating in value-based care and population health initiatives, this lack of benefits and coverage information can impact outcomes and, thus, reimbursement. It can also increase denied claims and create issues in the revenue cycle, leading to cash-flow issues and delayed or inaccurate reimbursement.

Poor financial transparency can also impact the patient experience and patient satisfaction scores. One study found that 60% of patients would consider changing providers due to incorrect estimates or unexpected bills. When a patient overpays, it can take months to get a refund. And when patients pay less than they owe, they can be hit with a surprise bill they weren’t prepared to pay.

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

While we’re making headway with initiatives like the Trusted Exchange Framework and Common Agreement (TEFCA) and the increasing adoption of industry standards like FHIR®, they require a great deal of work, money, and IT resources for healthcare organizations. However, a recent innovation is advancing interoperability in ways previously thought impossible. It begins with a digital ecosystem and decentralized network built on a platform and data fabric architecture.

Once participants connect to the network, they can connect with any other participant—payer, provider, or innovator—to share information without building and maintaining multiple connections. Instead of having to aggregate data, it is always available and accessible in real time. Information is continuously refreshed and current, eliminating the need to question accuracy. And because the network is cloud-based and includes advanced technological components such as AI and blockchain, participants benefit from greater interoperability without making huge infrastructure investments.

The network applies modern, secure infrastructure designed specifically to meet the needs of today’s healthcare businesses. Leveraging FHIR standards for data sharing, the network facilitates peer-to-peer communication directly between payers and providers without the need for third parties, thereby reducing the number of transactions needed to support operational workflows. And because the network enables permissioned and auditable data sharing without data aggregation, it gives data owners more control over their data.

A network and platform that reinvents the business of healthcare

As we start to close the gaps in interoperability, it’s the perfect time to reevaluate some of our long-standing beliefs about what’s possible within the revenue cycle. We don’t have to depend on data aggregation, numerous APIs for point-to-point connections, and third parties to conduct the business of healthcare. There’s a new way and it’s already used by some of the nation’s largest payers and providers.

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

How Interoperability Can Boost Revenue Cycle Results

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

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

Current gaps in processes

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

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

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

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

Use Cases for a Decentralized Peer-to-Peer Network

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

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

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

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

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

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

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

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

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

How it works

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

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

Where we go from here

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

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

Time to act is now

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

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

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

Decentralized Network: How Does It Work?

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

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

How does a decentralized network work?

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

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

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

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

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

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

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

How does a decentralized network further innovation?

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

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

How does a decentralized network improve the patient experience?

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

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