Every day, tens of thousands of patients seek care to treat fresh or existing conditions. Behind the scenes, a elaborate web of information about health records, benefits, coverage, eligibility, authorizations and other aspects plays a key role in the type of treatment patients will receive and how much they will have to spend on prescription drugs. This means that immense amounts of data are created, stored and exchanged every second, also characterized by inefficiencies and access gaps between patients, healthcare providers and payers due to inconsistencies in how healthcare data interoperability standards are being realised. In the US, these inefficiencies contribute to growth waste of the healthcare system and the challenges of providing cost-effective and high-quality care.
On over Twenty yearsdiscussion on how to address this challenge has permeated the industry with no clear solution. Just in 2020 The Centers for Medicare and Medicaid Services (CMS) published the rule for healthcare systems where patients, healthcare providers and payers must be able to easily exchange information. This principle defined an interoperability path that supports seamless data exchange between both payers and providers, enabling future functionalities and technically incremental apply cases. Beginning in 2021, health insurance companies, also known as payers, which set rates for services, collect payments, process claims and disburse benefits to healthcare providers, are required to meet the interoperability requirements set in 2020. These requirements enable the exchange of crucial data between payers and healthcare providers.
The basis for enabling is the establishment of a clear interoperability framework administrative simplification, one of five provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This provision aims to reduce paperwork and streamline business processes across the healthcare system, using technology to save time and money. WITH 63% of physicians report signs of burnoutAND 47% of doctors plan to leave their jobs in the next two to three yearsthis provision could not be more timely and relevant than it is today.
When combined with artificial intelligence (AI), an interoperable healthcare data platform has the potential to drive one of the most transformative changes in the history of American healthcare, moving away from a system where events are currently understood and measured in days, weeks, or months to an interconnected ecosystem operating in real time.
Why is data interoperability a necessity?
Simply put, a healthcare ecosystem in which all stakeholders can easily share information enables payers and providers to better collaborate to deliver high-quality, cost-effective care. The return on investment (ROI) from increased efficiency, reduced unnecessary medical expenses, and improved member experience outcomes can be in the hundreds of millions for a mid-sized payer with 3 million members.
However, realizing the benefits of the business case can be a daunting task for stakeholders in the healthcare ecosystem, especially given the number of requirements and standards that must be assessed and met, including the implementation of the Rapid Healthcare Interoperability Resource (FHIR) standard for exchanging care information health. CMS recognizes the importance of FHIR in advancing interoperability and national standards reduce administrative burden.
As healthcare providers and payers independently evaluate the capabilities, maturity, and architectural patterns necessary to adopt FHIR, as well as implementation costs and the impact of implementation on ongoing business processes and analytics, IBM is observing varying adoption rates and significantly different enterprise architecture adoption patterns across the industry.
Four levels of maturity in implementing interoperability
We believe that achieving the goals set by CMS and others requires a adaptable, modular capability structure that supports the ability to first integrate data from various health care sources and then adapt, standardize, and combine that information in a common canonical format. Once consolidated into a common canonical format, the data is made available to downstream consumers in a standardized format via APIs. This can be demonstrated in the graphic below, where each layer or “ring” supports a fresh range of apply cases, data expansion, and fresh technologies.
Ring 1 forms the foundation of the interoperability platform and provides the capabilities necessary to ingest, standardize, and integrate data from various sources to create the initial Longitudinal Patient Record (LPR). This “ring” of the solution includes key components for data collection, terminology standardization, patient matching (master data management), and data persistence in the FHIR format.
Ring 2 expands the capabilities of the FHIR data platform to perform data exchange for quality measurement (DEQM) calculations. These capabilities are needed to determine patient assignments, identify individual patients with care gaps, and update the patient’s care plan with necessary actions to address patient risks and care gaps. This also supports the ability to insert actionable insights and updates to care plans directly into a provider’s care flow within the Electronic Medical Record (EMR).
Ring 3 leverages the capabilities of Ring 1 and Ring 2, including the platform’s data integration capabilities to standardize terminology and match people. This would break down existing silos in the U.S. health care system: the silos of physical health and behavioral health. FHIR provides a single standard that promotes bridging two silos and understanding health status, goals, care needs and socioeconomic conditions. The emerging outcome is the ability to create a care plan that addresses the needs of the “whole person.”
Ring 4 supports five key provisions to improve the exchange of health information to ensure appropriate and necessary access to the complete health record for patients, health care providers and payers, including the automation of currently manual processes that would greatly benefit from fresh technologies, such as artificial intelligence. These provisions are included in the proposed CMS rule: Increasing interoperability and streamlining prior authorization processes (CMS-0057-P).
Realizing the benefits of prior authorization interoperability
The next, but one of the most crucial steps towards interoperability is the apply of data to provide more cost-effective and high-quality patient care, without creating unnecessary administrative complexity.
That’s why interoperability is critical to transforming prior authorization, a process health care payers implement in utilization management programs that deal with high-cost medical procedures and drugs, in which providers must demonstrate that the care they provide to patients is both medically necessary and and consistent with the latest evidence-based clinical quality guidelines. To achieve this without impacting patient care, payers and providers must exchange information in real time.
However, inconsistent adoption of interoperability standards across the healthcare industry, coupled with physician burnout and adverse outcomes due to delays in obtaining approvals to provide needed care, is creating friction between patients, payers, providers, and regulators.
This has also led to the proliferation of point solutions in the market, pushing the boundaries of innovation. Many of these solutions leverage artificial intelligence, specifically machine learning (ML) and natural language processing (NLP), to enable wise workflows that can automate the process of confirming medical necessity and compliance with clinical quality guidelines based on patient clinical data extracted from documents submitted by healthcare providers or through interoperability with electronic health record (EHR) systems. The introduction of generative AI takes this solution pattern a step further, particularly with its ability to better handle unstructured data.
Ultimately, while technology and interoperability standards exist to enable real-time information exchange to automate prior authorization, value remains trapped in the face of fundamental challenges in how clinical data is collected and stored, as well as how medical necessity criteria and clinical quality guidelines are applied and created stored.
How IBM can lend a hand
Transforming interoperability and prior authorization from end to end is easier said than done. Payers and providers must have the right combination of people, processes and technology to make this happen. In an environment where resources are restricted and the stakes are high, working with a systems integrator and process integrator with IBM-like capabilities is necessary.
That’s why IBM has developed a comprehensive strategy and approach to lend a hand our healthcare clients drive value through true end-to-end digital transformation, leveraging the best of the market together with our differentiated technology and consulting capabilities.
One of the aspects that makes IBM unique is our ability to leverage our customers’ existing investments in IBM technologies and our world-class software development capabilities to fill gaps that would otherwise not be available as off-the-shelf solutions. This enables our clients to access incentives that combine the power of one IBM, technology and consulting to meet our clients’ needs, from consulting to execution to operationalization.