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.

Reinventing the Back Office to Deliver on the Patient-Centric Promise

Healthcare organizations have been talking for years about the importance of the patient experience. Yet, healthcare organizations have hit several challenges that have kept our patient-centric promise from becoming a reality. As a result, we all have at least one story about a personal experience when our ability to receive timely care for ourselves or a loved one was inhibited by an outdated, ineffective administrative process.

Consider the patient who has recently changed health plans. She wasn’t feeling well and made an appointment to see her primary care provider. When she arrived at the office, she realized she hadn’t yet received her insurance card from the new health plan. She also remembered that when she signed up for the new plan, she canceled her secondary insurance coverage. She thought the coverage might still be active through the end of the month but wasn’t sure. She didn’t have that card either as she didn’t think she’d need it any longer.

Because of the lack of information, the front desk staff had no way of knowing what the patient’s new insurance would cover, what her co-pays and deductibles were, or whether the secondary insurance might still pay a part of the visit. The patient was told she would need to pay the entire amount of the visit up front and then work it out with her insurance companies on her own after the visit.

It is unfortunate that our healthcare ecosystem is so dependent on a patient’s memory and a physical insurance card to be able to ascertain a patient’s primary and secondary coverage information, along with their financial responsibility. These issues can also impact claims processes and can increase manual work for the payer. This is just one of many examples of how administrative processes make it difficult to deliver on the patient-centric promise.

Where’s the disconnect?

These administrative processes need to be improved. We know the answer: healthcare systems need to become more interoperable. We have made progress. However, research from the ONC 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—like ultrasound results—with providers outside their organization. In fact, just 34% engaged in bidirectional electronic sharing of patient information. Why?

A significant challenge to achieving interoperability is that healthcare’s current data-sharing infrastructure is built upon one-to-one connections. These connections are expensive and resource-heavy to implement and maintain. The result is a lack of transparency that has caused distrust between payers and providers. At the same time, providers are faced with increasingly complex payer requirements that are hard to keep up with, which adds to their already overwhelming administrative load.

A new way forward

These issues could be mitigated or eliminated through a new type of interoperability that allows all healthcare stakeholders to easily connect to a single, decentralized network and then access, in real time, the needed information without the request/respond processes of today. In a world where this type of interoperability exists, the provider in the above scenario would have been able to easily discover the patient’s new coverage information and find out whether her previous secondary coverage was still in effect—all in real time either before the patient arrived or while she was checking in.

In a fully interoperable healthcare system, data wouldn’t need to be requested, aggregated, and validated each time it’s needed. Instead, it would be continuously refreshed, always current, standardized, and always accessible in real time via a secure and direct peer-to-peer network to those who are permissioned to access it.

Imagine a network where every authorized participant would have permissioned access to the same information while, at the same time, no single entity could control, modify, delete, or change the rules of how the network can be used. Each permissioned participant would retain its own data instead of sending it to a third party (centralized); the data would remain in the participant’s control (decentralized). Leveraging formats such as FHIR, all data would be standardized and ready to be accessed. This type of network would eliminate the payer-provider friction that has plagued our healthcare system for far too long—friction that ends up creating a poor patient experience, reduced outcomes, and increased costs for all.

Delivering on the promise

At its heart, all healthcare is human. At the center of every procedure, every diagnosis, and every transaction is a human being who expects to be treated with dignity in moments when they are most vulnerable. The only way we will be able to meet that expectation is by improving the back-end processes that support and facilitate high quality care. But that requires us to completely reinvent how healthcare is administered. It’s the way we will truly transform the care experience.

We’re building a new way of doing the business of healthcare and you can join. Learn more by contacting us.

Envisioning the Future of the Patient Experience

From complicated appointment scheduling and crowded waiting rooms to tardy doctors and rushed appointments, healthcare interactions can be frustrating and uncomfortable for patients. And that’s before adding in hard-to-understand medical jargon and confusing insurance hurdles. Is it any wonder that two-thirds of respondents to the 2021 Accenture Health and Life Sciences Experience Survey said they’d had a negative healthcare experience?

That simple truth matters because a negative experience with the healthcare system doesn’t just result in a bad day; it can lead to additional consequences for both the provider and the patient. In fact, more than one-third of participants in the Accenture survey said that after a negative experience, they changed providers or treatments or were less likely to seek medical care the next time they needed it. Other respondents decided not to continue their treatment and chose not to fill their prescription. Just 12 percent said the bad experience did not affect them or their future healthcare choices.

So what exactly does an ideal patient experience look like? In a word: communication. Whether in personal interactions or data administration, it’s crucial to keep the lines of communication open. Avaneer Health’s unique vision for exceptional outcomes — starting with secure data sharing and streamlined administrative processes — can help accomplish this goal.

Continue reading to learn more about the key components of the ideal patient experience and explore our vision further.

The Ideal Patient Experience

The patient experience spans every interaction an individual has with the administrative staff, nurses, and doctors in any healthcare facility as well as the communication they have with their health plan. While the patient experience involves a lot of moving parts, researchers have found that people look for several key elements as they navigate their health journey. These elements include:

Clear communication
More than half (55 percent) of respondents in the Accenture survey said having a provider who explained their condition and treatment clearly was the most important factor in creating a positive healthcare experience. According to the 2020 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) study, this type of communication requires that providers take the time to discuss treatment plans in laypeople’s terms so patients thoroughly understand the information being conveyed.
Responsiveness
Research suggests diligent attention to a patient’s emotional and physical needs — which can be demonstrated by responsiveness to the call light, the communication of up-to-date wait times and clear and accurate status reports, and more — can positively impact the patient experience.
Whole-person care
When patients are treated as individuals, they tend to view their interactions in a better light than when care is driven by a system that gives little thought to each person’s emotional and physical needs. Consolidating vitals checks and medication administration (rather than waking a patient multiple times during the night), as well as discussing private information when roommates or visitors are not present, for instance, puts the patient first. Whole-person or patient-centered care also means honoring patients’ wishes regarding autonomy and how involved they want to be in their own healthcare journey. Compassion and emotional encouragement are key as well, with 52 percent of respondents in the Accenture survey ranking a provider who listens, understands their needs, and provides support for what they’re feeling as the most important element of a positive experience.
Communication between care teams
Establishing great connections between different care teams is another crucial factor patients seek, with more than one-third (35 percent) of Accenture’s survey respondents saying well-coordinated care and excellent communication between providers was their number one criterion for a good experience. On the other hand, patients not only find contradictory feedback from different healthcare providers and changes in care plans frustrating, but also an indicator of disorganization and conflict among their care team.

Ways to Ensure an Exceptional Patient Experience

While some of the criteria for an ideal patient experience depend on individual healthcare providers, healthcare interactions start well before patients see their doctors. At Avaneer Health, we recognize that the patient experience starts with the care and detail devoted to administrative efficiency. Top strategies to improve the administrative experience include:

Providing accurate data
Ensuring the provider has the most accurate and current data available at the first point of contact with the patient sets the tone for a positive interaction. A thorough digital patient intake plus an in-person review of personal contact details and insurance information can save time and reduce patient, provider, and administrative frustration.
Improving access to benefit and coverage information
Having access to patient benefits and coverage information in real time at or before the first visit is a key component of whole-person care. With more benefits and coverage transparency, patients can feel empowered to make more informed decisions and confidently pay their share upfront instead of waiting for a statement to understand their responsibility.
Ensuring timely billing
In cases when it’s not possible to know or collect the full payment for a patient’s share upfront, it’s critical that the billing process with the insurance company moves smoothly and quickly. Reviewing billing and insurance information and automating basic billing functions (including denial prevention) can cut down on the time it takes for patients to see how much they owe and make a payment. The faster the provider’s administrative staff can receive payment from the insurance company, the more promptly they can bill the patient for their portion.
Standardizing health data
Health data should be stored in a standardized format that makes it easy to share among providers. Data standardization encourages collaboration in a patient’s care and consistent messaging about their treatment.
Creating a seamless administrative experience
A seamless healthcare administrative experience with clear expectations and thoughtful, efficient processes can make a positive impression and play a crucial role in patient satisfaction before and after a visit with a doctor. When benefits verification, prior authorization, and billing feel as simple and easy as swiping a credit or debit card at any other merchant, patient trust and the likelihood of continuing treatment go up while the fear of inaccurate charges or surprise bills goes down.

While there is work yet to be done to solve the complexity and lack of standardization in administrative processes, the benefits are well worth investing in improving the patient experience.

Healthcare, Heal Thyself

We have the innovation and technology to do it, but are we ready to act?

By Stuart Hanson

Anyone who says innovation in healthcare doesn’t exist hasn’t been paying attention for the past 18 months. From the way providers large and small pivoted to telehealth to keep patients safe, to the way scientists from around the world came together to develop vaccines and treatment protocols, to the way public health agencies worked to provide mass distribution of the vaccinations—innovation and cooperation abounded. Was it all perfect? No. But it does show that we are capable of innovating urgently.

One area where innovation is clearly lacking, and has been for a very long time, is interoperability. It’s an issue that numerous companies, consortiums, agencies, and others have been trying to solve for decades. Regardless, the issue remains.

A personal story

In the midst of the pandemic, I needed an emergency eye procedure. I was lucky that my provider was able to quickly verify my coverage with my insurance company and I was able to get the treatment I needed. During my follow-up exam, I met another patient who also needed an emergency eye procedure. If he didn’t get it, he risked retinal detachment, a condition that could lead to blindness if not treated in time. While we were in the waiting room, the man told me that he had already been to the office twice before to have the procedure, but was sent home because the provider hadn’t been able to connect with the man’s insurance company to verify coverage. I don’t know what happened to the man, whether he got the surgery in time to avoid retinal detachment or whether his condition deteriorated.

This same scenario is played out all too often across our country. In a time when can share news in near real time with family and friends on Instagram, it can still take weeks or months to share critical administrative and clinical healthcare data between two entities whose actions—or inactions—can be the difference between life or death. Why?

The issue isn’t that we lack innovation to fix the problem. The issue is that we’re focused on fixing the wrong problem. We have entrepreneurs and tech giants entering the healthcare market every day, bringing with them new apps or solutions that promise to “transform” healthcare. But most of those solutions sit ON the technical infrastructure, whereas the real problem is the infrastructure. A great telehealth app may streamline workflows or improve patient-provider connectivity, but new apps can be virtually impossible to bolt together with the provider’s billing system, clinical record system, or privacy and security controls. Although it may be great, innovative, timely technology that we desperately need, it’s yet another layer added on top of previous layers that sit atop an outdated, ineffective infrastructure—an infrastructure built primarily to support batch-based, one-way communications like EDI. It’s like building a yacht on top of a rowboat.

Network as a Service

If we want to create real transformation in healthcare, we need a new infrastructure blueprint—one that doesn’t add additional features on top of a fractured system. We need an infrastructure that starts from the bottom up. It exists, thanks to truly innovative companies that recognized the problem and realized that a viable solution is already available. In 2019, IBM, PNC Bank, Anthem, CVS Aetna, Cleveland Clinic, Sentara Healthcare, and Health Care Services Corporation came together to discuss how blockchain and other new technologies could solve the systemic problems that have plagued our industry for too long: data sharing, data integrity, and trust. Together, they formed Avaneer Health.

The focus of Avaneer Health is leveraging blockchain and other technologies to create a neutral network through which healthcare organizations, patients, and other key stakeholders can access accurate, timely information in real time—an Internet for healthcare.

How it Works

First, payers and providers commit data to the cloud and allow it to be discoverable based on permissions that are set by each party. Users can connect to the network via the cloud, where the ID keychain and master index locates the information requested and matches it to the data available, then delivers it to the requestor. The intermediary—Avaneer Health—provides certification, end-point validation, an immutable audit trail, cybersecurity, and compliance. Use cases include eligibility verification, prior authorization, and real-time access to accurate, complete medical records.

The network also connects with rich solution providers like revenue cycle management companies, telehealth platforms and others that are involved in care coordination or the business of healthcare. This eliminates the need for payers and providers to build and maintain connections with multiple systems. Fewer touchpoints means fewer opportunities for security issues, not to mention reduced IT costs and resources needed to manage those gateways.

The Time to Act is Now

If the U.S. healthcare system were its own country, it would rank forth in GDP, right behind China but ahead of countries like Germany, India, and the UK. We spend between 25% and 30% more per person on healthcare than any other country. This might be okay if our outcomes were better, but they aren’t. I keep thinking of the man I met in the waiting room and wondering how much longer he had to wait or if he ever got the surgery at all.

We know the problem and we have the technology, innovation, and ability to solve it. The question is whether we’re going to act or if we’re going to continue to build layers on top of layers on top of layers. Our patients are waiting on us to make the call.