Anthem Initiates Bi-Directional Capability for Health Plan-Provider Data Exchange

July 7, 2021
The leaders at health insurer Anthem, Inc. have launched an initiative that is connecting the insurer with providers around data, beginning with a connection with Cleveland’s MetroHealth integrated system

A few months ago, the Indianapolis-based Anthem, Inc., one of the largest U.S. health plans, which serves 107 million Americans, including 43 million in its health plans, announced a new initiative focused on health information exchange between Anthem and provider organizations. As a press release posted to the health plan’s website noted on May 19, “Anthem, Inc. (NYSE: ANTM) today announced an effort to facilitate secure, bi-directional exchange of health information between healthcare providers and Anthem’s affiliated health plans, as a result of its collaboration with Epic. Increasing and improving this communication aims to better leverage data-driven insights in care decisions, simplify healthcare, and ultimately improve health outcomes.”

“As an organization committed to a digital-first approach, we know that enhancing the interoperability of health data is critical in redefining the future of healthcare,” said Ashok Chennuru, Chief Data and Insights Officer at Anthem, in a statement carried in the press release. “This effort helps bring the industry into the next step of its evolution where the right information gets to the right people at the right time – resulting in a more seamless healthcare experience and consumers receiving the care they need – where and when they need it. Our work with Epic stands to benefit more than 14.7 million consumers served by Anthem’s affiliated health plans who see clinicians using Epic’s software.”

As the press release noted, “This initiative between Anthem, an innovation leader dedicated to improving health, and Epic, a leading health information company, leverages Epic’s Payer Platform. The secure and bi-directional exchange of data using Payer Platform involves clinical data as well as admissions, discharge, and transfer data from hospital stays. Epic’s Payer Platform will be integrated with Anthem’s Health OS, which is Anthem’s operating system to enable seamless health plan-provider collaboration.” And it quoted Alan Hutchison, vice president of population health at the Verona, Wis.-based Epic Systems, as stating that, “By better bridging communications between providers and health plans, this connection is making it possible for patients to receive timely access to appropriate care. This effort will also give clinicians more time to focus on delivering care and improve quality for consumers.”

“This capability,” the press release noted, “will help close clinical and medication gaps that may exist in an individual’s care. To do this, Anthem will be able to capture consumer health information provided by clinicians, analyze that data, and develop data-driven insights. These insights can then be delivered back to the care team – in near real-time – to flag potential care needs and inform treatment decisions, resulting in higher quality care.”

Among the key elements involved:

> Streamlining administrative processes, such as prior authorization: Providers will be able to send prior authorizations through Epic instead of using phone or fax. Health plans can then quickly make decisions and electronically communicate back to the provider – lowering administrative burden and freeing up staff to spend more time on care.

>   Enhancing care management: With near real-time access to consumer health data, clinicians will have additional insight into preventive care recommendations and addressing care gaps, such as medication adherence, to help them develop enhanced care plans that are proactive and personalized.

>   Notifying providers of significant health events: Providers will be notified when their patients are discharged from the hospital and encouraged to conduct more timely follow-up care.

Among the provider organizations already involved are the Cleveland-based MetroHealth System. The press release quoted David Kaelber, M.D., Ph.D., M.P.H., MetroHealth’s chief medical informatics officer, as stating that “Being able to better communicate and reduce the amount of time we need to spend on administrative processes will allow our clinicians to spend more time delivering care. Improving exchange and interoperability of data will help us give consumers the healthcare experience they have come to expect,” Dr. Kaelber stated.

Recently, Ashok Chennuru spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding this innovation. Below are excerpts from that interview.

Tell us about the origin of this initiative?

We serve nearly 110 million health plan members in the United States. Under the theme of simplifying members’ lives and improving the quality and affordability of care, one of our foundational capabilities involves how we reduce the administrative burden for providers and simplify healthcare for our stakeholders.

What made you decide to collaborate with Epic?

Epic has the largest footprint in the EMR space among big health systems; I’ve heard that something like 78 of the top 100 health systems leverage Epic. And as we were looking at the right partnership across the country, we wanted to build a bidirectional connection with provider partners at scale. And within Anthem, we’re building this platform, Health OS, which will streamline all interactions between the payer and provider. For example, we’re getting CCDAs from providers and are integrating those with claims data to create longitudinal records and sending back data on gaps in care. So we’re not faxing information back and forth. But at the highest level, it’s a software solution and interoperability network that allows easier interaction—that’s this collaboration. And how we get all this data together and develop predictive insights based on AI—and help to feed the provider workflow. And Epic is one of the EMRs; we’re talking to other EMR vendors to create additional releases in the future. Other EMRs are equally important as well. You need to go after both outpatient and inpatient providers.

What are the biggest challenges in creating those longitudinal records?

Assuring the providers—the data is about our plan members. It’s the consumer data that providers manage. How do we make sure to build trust with both providers and consumers, that we’re using it for the right purpose, while ensuring data security? We’re good at managing large volumes of data. And in terms of simplifying healthcare, protecting PHI and PII is foundational; we take it seriously. So that’s a challenge. And two, we want to be clear with the providers as to why we’re sharing the data. We’re focusing on identifying gaps in care in a more timely way. For example, if one of our members got admitted to and discharged from a hospital, the PCP might not know that. So we get the discharge data from the hospital and share it with the PCP. And sometimes, too, our care managers even help our members get appointments scheduled with their PCPs, to avert a readmission. So it’s about continuity of care across transitions of care, to put consumers in the center.  At the heart of everything is making sure the data is secure and is being used for the right purposes—providing the right service to the providers, who in turn will serve our members; or reaching out to the members directly.

When did this process go live?

We went live in May with MetroHealth in Cleveland earlier this month; we have a number of health systems in the pipeline, for later this year.

Have there been challenges of any kind?

Technology-wise, there were no challenges. We’ve been working with Epic for a while now. We worked with the right partners at MetroHealth. There have always been trust issues between payers and providers around data exchange. But looking at some of the rules for data-sharing under the federal regulations that will go live next year, this harmonizes with that.

This speaks to the free exchange of data that CMS and HHS [the Centers for Medicare and Medicaid Services and the Department of Health and Human Services] are demanding, beginning next year, then, correct?

Yes, absolutely. For now, though, I see this as a differentiator with other plans. So, we want to make this foundational, in the context of collaboration with providers. So the conversation shifts from, why are we denying claims, to pivot the conversation to be more focused on the consumer and the member.

How have the MetroHealth people reacted?

Very positively. They’re extremely pleased with the collaboration. And on the Anthem side, our care managers now have almost instantaneous access to information in the medical record, as the providers do. So our care managers—before, we had to make calls or wait for information or get faxes; now, the information is readily available to the care managers.

So the clinicians aren’t seeing your communications as an intrusion, but rather, as a support, correct?

Yes. In the past, care managers might have been gathering information on their own. Now, the information is right there, so the conversation is around how we can help and support providers, rather than on information-gathering. And more importantly, we’re not sending mixed messages, with Anthem care managers sending conflicting information to members and therefore confusing the providers. And in terms of digital adoption—if plumbers can now engage in digital adoption, why can’t we? And we plan to integrate everything into the mobile app that’s consumer-facing.

So the providers and plan can be sending the same messages to consumers, rather than conflicting ones, right?

Yes, and it’s timely information, too. The timing of data-sharing means everything. In the past, when we were relying purely on claims data to find out when a member was discharged from the hospital, for example, it could take six weeks. Now, you’re basing your actions on very timely information in the medical record. And if a member goes to a new, different hospital, they might not have that information, but we will. The data involved will provide the right, meaningful information to the physicians, to the consumers, and to our care team, so everyone’s operating off the same data set.

Is there anything that you’d like to add?

We want to focus on investing in areas that will simplify healthcare and enhance the experience for our consumers. This is one of our innovations; we’re actively working on several others around data insights and interoperability, but the overall theme is enhancing healthcare and improving the consumer experience.

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