Insurer Guidewell Makes Progress on Da Vinci Use Cases

Oct. 6, 2020
Florida-based company working with eClinicalWorks, other EHR vendors on FHIR-based payer data exchange

Many provider and payer organizations are just beginning to figure out how they are going to comply with the CMS Interoperability and Patient Access final rule, including creating a patient access application programming interface (API). But Guidewell, the parent company of Florida Blue, got a head start on its API strategy two years ago by getting involved in HL7’s Da Vinci Project.

The Da Vinci Project is a collaborative effort based at HL7 to standardized FHIR-based interfaces between payers and healthcare organizations, replacing legacy interfaces for sharing documents. The work product is being balloted by HL7 and becomes part of the HL7 FHIR standard.

In a recent interview, Amit Shah, IT director for shared applications/services and GuideWell Health Clinics, described their journey so far. He noted that he oversees the teams focused on EDI (electronic data interchange) gateways between payers and providers — and that work continues. But as he looked for ways to modernize those transactions, he learned more about FHIR and the Da Vinci Project.

“Da Vinci is doing a fantastic job of building standards so that we all can consistently talk to each other,” Shah said. “I was intrigued from the get-go. Anything they have built as an implementation guide, we have piloted.” Guidewell has created a pipeline so that every new implementation guide is tested and then put into a roadmap for production.

Shah decided that the best way to approach this was to build a separate team with a new set of skill sets, but he noted that the FHIR skill set specifically “does not yet exist across the country. We had to build it from scratch. We trained people.” He also needed people with database, security, analytics, and API management skills in order to scale this up to work with multiple providers, EHR vendors and third-party applications. In addition to the technology experts, he said, the team has to include legal and compliance experts.

This week Healthcare Innovation quoted Aneesh Chopra, president of analytics firm CareJourney and co-chairman of the CARIN Alliance, who argued that payers should be thinking about building a data governance strategy so that they are not just complying with the CMS Patient Access Mandate, but actually seeing it as an opportunity to create a strategic advantage and improve member outcomes. “If you are only complying with the rule, you are missing an opportunity to put in place the data governance principles that will drive the successful strategies for your plan for the coming years,” said Chopra, who also served as the first U.S. Chief Technology Officer.

Shah says he agrees with Chopra 100 percent. “CMS has teed this up and made it a mandate, and I am glad they have done that. It forces organizations to pay attention and start thinking about it, and that is exactly what happened to us,” he explained. “As we started looking into it, data governance became such a critical thing. For example, there are vendors that Guidewell delegates to manage certain services for its members. But if Guidewell is sharing member data with a third-party application, it needs those vendors to share data, too.  But some of those vendors are not ready to share data via API so quickly. “So we are now taking them along on this journey with us,” Shah said. “We are saying to them, ‘For us to be successful meeting this mandate, you guys have to also come with us.’ It is a learning exercise.”

Guidewell is working closely on pilots with multiple EHR vendors to make the data exchange seamless. He said that creating the FHIR-based approach with EHR partners takes time, because the insurer needs to enable proper IT security and gain consent from providers to use FHIR to access their patient records. Guidewell is currently in discussion with several EHR vendors, and next year hopes to reach an agreement with a few more.

The insurer has gone live on a deployment with eClinicalWorks and some of its provider customers in Florida on a use case called payer data exchange. An example would be providing timely and relevant information when a doctor’s office schedules an appointment for one of Guidewell’s members. “We have an analytics tool that says this particular member did not get a vaccination. We push that information to the provider’s EMR so that when they have a scheduled appointment, the doctor can ask the patient if they are open to doing the vaccination right then and there,” he said. Also, for certain Medicare patients, the payer and provider have financial incentives to close those care gaps, Shah added. “We are still fine-tuning how that happens,” he noted. “It is not happening so smoothly that we can scale it widely yet. It is a learning exercise. Before we get really good at it, we don’t want to go to a larger roll-out. “

But other business areas of Guidewell were intrigued by this effort and suggested another area to address, called medication therapy management. Certain patients have conditions that require a medication plan involving communication coordination between the clinician, the pharmacist and the payer. “Everything today in that use case is happening via faxes and hard copy,” Shah said.  We are taking payer data exchange, which involves the payer pushing information, and expanding it a little to solve a specific problem on medication therapy management. We now have 20 groups using it and we want to scale it up to 300 groups.”

One of the key use cases Da Vinci has worked on is prior authorization: “Hands down, that is the most important use case for us as a payer but also for the members,” Shah said. Anytime somebody goes to the doctor’s office and needs an MRI, it could take two weeks to get a response back. It is not the best experience, he said. “We have piloted it and  are looking to go live with two EHRs. Here is the challenge with that use case: It is so complex. There are so many different variations of prior authorization. It is one of the use cases we are targeting for next year.”

Guidewell is already working on ways to more readily exchange data directly with members. The payer is conducting a remote patient monitoring pilot study to monitor certain members with chronic conditions using digital health devices, such as blood pressure monitors and scales that are connected to cellular networks. Members use the devices once a day to measure vitals that are important for their condition. The data is then transmitted remotely to Guidewell, where nurses receive real-time alerts and intervene if needed by contacting the member and suggesting that they contact their physician for follow-up care or to take immediate action. Patients who are participating say it is life-changing to have this active monitoring of health signs that could indicate worsening conditions. “We have gotten good feedback from the members participating, and we would like to expand it to more devices,” Shah said. “We can push data back to the members. This is all opening up a new world of communication back and forth.”

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