Health Information Exchanges (HIEs) enable data sharing among neighboring healthcare organizations such as hospitals, labs, pharmacies and ambulatory practices and clinics. While the payer community largely sat on the sidelines in the early years of the HIE movement, they have recently become much more important players in this space.
Why is payer participation increasing?
First, interoperability platforms can now extract, aggregate and normalize data from a variety of systems. Natural language processing engines have matured. These engines can read and organize unstructured data like clinical notes and summaries and more easily correlate it with highly structured claims information.
Second, HIEs provide a more comprehensive source of clinical information to satisfy a number of payer use cases including risk stratification, quality measurement, and payer-led care management programs. Access to clinical data helps payers better predict which conditions a member may develop over time and better coordinate with their medical providers. For example, if a payer knows a person is at risk of heart failure, they can work with the provider to develop an individualized care management plan to improve member health and prevent the need for future high cost services.
Third, providers now want the payers involved. Spurred by the rise of value-based contracts, providers need claims data to understand how their care management programs and interventions impact the cost of care. And as they are increasingly paid for value over volume, providers want to collaborate with payers to design equitable payment models that reward delivery of higher quality and cost effective care. With both clinical and claims data available in the HIE, providers and payers can work together to address gaps in care, co-morbidities and preventative treatment needs.
Obstacles to payer HIE involvement
This collaboration is not without challenges. There are a number of roadblocks preventing payers from fully participating with HIEs.
On the technical side, clinical and revenue cycle management systems were not developed to integrate with each other. This leaves some work to be done to efficiently and effectively integrate these two very different datasets, because they employ both separate transaction standards and clinical terminologies.
Financially, the value proposition for use of HIEs has not traditionally aligned with payer needs. Payers require timely structured clinical data to identify NCQA HEDIS measure gaps. Today, an inefficient and costly process (“the chart chase”) is used to gather clinical information for Medicare Stars reporting. While an HIE could theoretically automate this process, most lack a mechanism to identify when a claim has been submitted and cannot filter clinical data by payer source. The payer needs a highly automated solution that delivers the right clinical data, on the right patient, at the right time. While HIEs were intended to do exactly this, it was for a completely different use case – supporting providers in the delivery of care. Furthermore, even if the HIE is able to filter data by payer, the data c
an rarely be used to support HEDIS reporting because it has usually been transformed to facilitate transport or storage into the HIE’s data repository.
Finally, the value of the HIE’s data is limited by the number of payers’ members whose data is available. Many of a payer’s members may not have consented to have their information shared into the HIE. Payers have no control over how HIEs manage consent, and patient participation and consent models differ widely due to state laws, provider membership and contractual agreements. In addition, allowing payers to contribute and access patient data requires a change in HIE policies triggering board approvals, notice to participants, new consent forms, and perhaps even legislative action. This can further impact the number of patients who consent to share their data through an HIE.
Addressing the obstacles
Resolving interoperability issues starts with a thoughtful plan. Before any technical work begins, HIE participants should outline the highest impact use cases to prioritize what systems and data to integrate first. That plan will include building a master patient index, identifying adapters needed to integrate disparate systems, and employing mechanisms to aggregate and normalize data into a single application and view.
Payers, providers and HIEs often choose to collaborate with an integration partner experienced in custom HIE architecture. That partner should be vendor-agnostic and have experience with a variety of systems and technologies used by providers and payers. That integration partner will help HIE participants understand their needs and options and build the connections between the many different applications involved.
To encourage payer participation, HIEs must rethink their operations to accommodate some of the most important use cases for payers. In the 2016 study “Assessing payer perspectives on health information exchange,” some of those use cases included payer-led care management, population health analytics and quality reporting. Any new use cases will require legal counsel to rework or establish business associate agreements as required by HIPAA, as well as participation agreements and relevant policies and procedures. This is all part of an important trust framework, made up of a set of technical, business, and legal standards that all HIE participants agree to follow.
So while many obstacles remain, the rise of value-based care and introduction of better technology will continue to spur payers to work with HIEs. As this happens, it’s clear that all involved must view the others as partners to ensure HIE participation provides equitable and impactful benefits for all stakeholders, including patients.
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