Patrick Getzen, senior vice president and chief data and analytics officer for Blue Cross Blue Shield of North Carolina, said we are still fairly early in the journey to interoperability between payers and providers. “Today it is largely canned reports or claims extracts we send them on a monthly or quarterly basis,” he said. ‘It is not real-time enough to be actionable. And on the member side, it is even more limited,” he admitted. The information members receive is more about policy than about member health. “Often the data is not understood well enough to be trusted,” Getzen said, and there is no consistent process for certifying data as high quality. “If the data is not trusted it won’t be used effectively.”
Morgan Honea, CEO of the Colorado Regional Health Information Organization (CORHIO), said that alternative payment models are going to be critical to advancing interoperability. He said one of the big challenges is working through legal privacy protections relating to different types of data and whether actionable data is actually available to monitor for quality purposes.
“I would say one of the biggest challenges is consent and authorization, and that is not a technology issue. CFR 42 Part 2 flies in the face of what we are trying to do on the opioid epidemic,” Honea said.
“Regarding social determinants of health, we are doing it in very different manor in Colorado,” he said. Stakeholders there are trying to get state agencies to leverage the infrastructure at CORHIO. “How do you engage with state agencies that have never been asked to share data?” he asked. “As we talk about social determinants, all our FQHCs have adopted the PRAPARE assessment tool,” he explained. Care managers are using it to assess individuals to better understand their nonclinical challenges, but once clinicians determine someone has a housing challenge, are they responsible for finding someone a house? The plan is to connect them to the state agency administering housing services.
Honea noted that in Colorado, perhaps surprisingly, state agencies don’t know who is in other state agency programs. People eligible for Women, Infants and Children (WIC) support are also automatically eligible for Medicaid, and vice versa. One goal is to use CORHIO’s master patient index to better understand who is eligible and not enrolled. “The outcome is going to be staggering,” he added, because the number of people eligible and not enrolled is estimated to be huge. “As we wander into social determinants, there is a vast array of privacy and governance issues across state agencies and federal programs. We are just starting to scratch the surface. I recommend dusting off your legal manuals and getting ready.” For instance, he said, the Colorado Department of Human Services operates under 137 privacy policies, including ones for adopted children. Different state agencies such as public health and Medicaid may even interpret HIPAA differently. “It is shocking how little communication happens around these issues until it boils up to the attorney general’s office.”
Speaking from a different perspective was Philip Parker, CEO of Coral Health, a startup company working with EHR vendor APIs and health systems to consolidate consumers’ health data in one place for them. “We are interacting with EHR vendors to connect with the APIs they have available and going to provider organizations to get authorized to access their end points,” he said. “We are very dependent on the EHR vendors. Epic makes it easy to connect to end points once you are approved. With Cerner you have to get authorization from each provider organization.” From the patient side, they don’t always remember where they have received care, or they have five or six portal accounts and passwords to try to remember. He said Coral would like API access to the patient’s individual claims data to help them figure out exactly where they have received care.
Parker noted that there has been fairly good standardization on the use of FHIR-based APIs across major vendors. “Unfortunately, some EHRs do still have proprietary APIs and are not using the FHIR standard,” he said. The primary challenge is more around getting access to APIs. From the patient side, there is very low awareness that they have this ability to get access to data. Patients aren’t asking for it yet. That makes it difficult for app developers. It is an awareness problem.”
Blue Shield of North Carolina’s Getzen said the arrival of Patrick Conway, M.D., former head of the Center for Medicare and Medicaid Intervention, to lead his organization has had a big impact. “We were already doing work on how to pay providers differently, but he really accelerated the change to paying for value,” he said. Physicians are held responsible for total cost of care and quality. “We signed five of the largest health systems in the state to multiyear contracts with upside and downside risk.” In order for providers to be successful, there are three things Getzen said they must have: high-quality trusted data, actionable insights, and a pipeline to get them that information so they can deliver a different outcome at the point of care. “We can’t hold them accountable without these three things,” he said. “Where CMS is going with standards, we are working hard to become fast adopters.”