- True interoperability for improved health data exchange persists as a top healthcare industry priority among stakeholders in both the public and private sector as 2017 comes to a close. Health IT developers, health information exchanges (HIEs), and provider organizations have collaborated extensively this year to enable improvements, but regulatory burden and industry complexity continue to inhibit progress.
Massachusetts eHealth Collaborative Senior Project Director Dave Delano currently serves as the Executive Director for the New England Health Exchange Network (NEHEN) and has seen interoperability advance significantly throughout his 35 years of health data exchange experience. Still, Delano estimates the healthcare industry is only half of the way toward achieving true interoperability.
“As far as we’ve come with interoperability and exchange capabilities, there’s still so much more to do,” Delano told EHRIntelligence.com. “CommonWell, Epic Share Everywhere, and all these capabilities that are evolving are great, but they’re baby steps in terms of what the industry really needs overall for true interoperability in exchange.”
According to Delano, strict federal regulations and oversight have held the industry back from making large strides in interoperability advancement.
“We’re the most regulated industry in the US,” he said. “When you look at the number of regulations, the types of regulations, and the regulatory oversight and accountability we have as an industry, healthcare is more regulated than the airline industry, banking and finance, and insurance.”
Transitioning from the fee-for-service model to the value-based care system has further complicated matters.
Enabling Value-Based Care in a Fee-For-Service World
The Quality Payment Program (QPP) under MACRA is currently heading into its second year. Already, some providers — particularly those working in small or rural physician practices —have expressed concern about meeting federal requirements. Anxiety over meeting requirements partially stems from past federal incentive programs. In 2016, over 171,000 clinicians were hit with payment penalties as part of the EHR Incentive Programs.
CMS tried to ease providers into the new system by relaxing requirements through the newly-released QPP final rule, but frequent regulatory changes may have only added complexity to an already complicated situation.
“Shifting to the value-based care system either adds a layer of complexity to everything we’re doing, or it completely changes everything we’re doing,” said Delano. “At this point, it really adds a layer because we’re still operating in the fee-for-service world. It’s like trying to rebuild the airplane while you’re flying it.”
Because much of the healthcare industry still operates in the fee-for-service world, Delano said there is a misalignment of new health IT product offerings and provider demands. Health IT developers have innovated the technology capable of improving exchange and enhancing interoperability — providers sometimes just aren’t willing to adopt it.
“It’s the change in the business model that’s holding us back,” Delano said. “The technology isn’t the challenge. Sometimes technology limitations hold us back, but it’s usually around process and business flow.”
For example, NEHEN recently began offering a solution to its HIE participants that will streamline prior authorizations. Currently, these requests are a necessary part of getting services approved for health plans.
"It’s like trying to rebuild the airplane while you’re flying it.”
“NEHEN is trying very hard to crack the nut of prior authorization, because it’s the next big frontier in terms of administrative simplification,” said Delano. “All the other transactions have been addressed. We’ve got an automated solution to try to make it smoother and easier for providers and payers.”
Challenges associated with prior authorizations account for a significant portion of administrative burden. A survey this year from the Medical Group Management Association (MGMA) found 74 percent of responding physicians say significant burden stems from complications with claims and prior authorizations.
However, some NEHEN participants have been hesitant to invest any portion of already-tight budgets into new technologies with the healthcare industry in constant flux. One payer group part of NEHEN was unwilling to commit to adopting the prior authorization solution because of uncertainty about the current political environment.
“The payer group essentially said they’re interested in the prior authorization solution and believe it has tremendous operational benefit. But they’re hesitant to commit until they understand where the political environment is going with healthcare in general,” said Delano.
“Here we are on the ground attempting to advance things and doing technological development to help solve some of these challenges,” he added, “and you’ve got these overlying political clouds that are shadowing our ability to move these things forward.”
Hesitance to adopt new technologies partially contributes to the slow rate of progress in interoperability and exchange. Aligning use cases with new technologies will be key to spurring improvements.
“Until there’s an alignment of the technology and the business process use-case driving it, people aren’t going to want to commit,” emphasized Delano. “That’s the biggest interoperability challenge that we face. Adoption of new services like this prior authorizations service is a significant business process change for people, and it’s positive across the board, but it’s hard for people to shift from the old to the new.”
Closing the door on the old way of doing things to open the way to a newer, faster approach to exchange and interoperability requires simplicity. With complicated, shifting federal requirements and uncertainty muddling the future of healthcare, HIE participants seek to simplify exchange in any way possible.
According to Delano, the healthcare industry’s solution to all of this complexity will likely come in the form of consolidation.
Simplifying Exchange with Consolidation, Collaboration
The increasing popularity of large enterprise health IT companies offering single-solution EHR systems already points to the healthcare industry’s preference for larger companies over smaller, more specialized vendors. The same is true for HIEs and interoperability services providers.
Furthermore, large health IT companies and interoperability services providers have recently joined forces to add additional clout to their dominance over the industry. In October, Cerner extended free CommonWell interoperability services to all clients for three more years at no additional cost, and eClinicalWorks began offering a way for users to connect to CommonWell through a new self-service option.
NEHEN — a small niche HIE services provider — is well aware of this trend.
“We’re seeing more and more consolidation in the industry,” said Delano. “NEHEN and other niche HIEs are being normalized out of the equation by exchange communities like CommonWell. We have questions about the long-term viability of a model like NEHEN, if people continue to move toward these larger consolidated networks.”
While NEHEN is aware of the challenges ahead, the organization is prepared to adapt to the changing market and continue to provide services as part of a larger exchange network.
“It’s very possible that NEHEN could be subsumed into some larger exchange network,” said Delano. “There could be other service organizations that we might consider becoming a part of over time.”
Likewise, NEHEN has seen smaller organizations reach out and request access to their exchange partners. Working alongside other HIE organizations in this way improves connectivity and provides benefits for all involved.
“It’s not necessarily consolidation — it’s cooperation and collaboration within the market that allows us connectivity we wouldn’t otherwise have,” he said.
Down the line, Delano hopes to see interoperability support a more holistic view of a patient’s information across multiple data sources so that patients are more aware of their current health status and care needs.
“It’s not necessarily consolidation — it’s cooperation and collaboration within the market that allows us connectivity we wouldn’t otherwise have."
“Whether that’s achieved through an Apple app or some other collective, consolidated view that still has yet to be developed, that’s ultimately where we should be headed,” he said. “That will impact society and communities and individuals in how they receive and access healthcare information.”
Delano emphasized that these changes need to happen regardless of the state of healthcare regulations or requirements in the future.
“Whether we still use the current model of healthcare in the United States or a different one shouldn’t matter,” he said.
Enabling users to access multiple entities through a single point of connectivity is part of what NEHEN does, and Delano stated he expects the market will continue to foster increasingly simple, open exchange.
“With Commonwell and some of these other consolidating organizations, you’re starting to see they’re attempting to connect dots that have yet to be connected through a common open exchange agreement,” he said.
NEHEN is prepared to continue to build relationships with other HIE organizations and interoperability services providers to enhance health data exchange capabilities for all of its partners. Whether this collaboration will involve consolidation in the future remains to be seen.
“That’s where the market’s heading,” said Delano. “This is just the beginning.”