A recent KLAS Research report featured a case study that involved insurance company Humana Inc., a South Carolina-based provider organization called SC House Calls, and EHR vendor athenahealth. They used FHIR APIs to create and automate a closed-loop exchange of clinical data between SC House Calls and Humana. In a recent conversation with Healthcare Innovation, executives from athenahealth and Humana described the value being derived from their collaboration.
Glenn Raley is director of provider interoperability at Louisville-based Humana. He said these problems with exchanging clinical data have existed for many years. “We've solved them for many years via paper, fax and spreadsheets,” he said. “We have been partnering with the EHR vendors to say, ‘Hey, let's build an integrated solution that's in the workflow that will make it easier for providers so that they don't have to log into another portal, or log in somewhere else. We approach the EHR companies with the strategy of saying let's do this for all of your clients, and that particular provider in question, SC House Calls, just happened to be the one that we highlighted, because they were one of our early adopters.”
“Athena is a partner that embraced the problem and when we entered into the arrangement, it was intended to be a strategic partnership that would go for multiple years for multiple use cases, and not just to solve this one problem one time,” Raley said. In cases where the EHR vendors are not as far along with these capabilities, there are often third-party solutions that act as a bridge between the payer and the HER to fill that gap, he added.
Raley said one of their key approaches with partners like athenahealth is FHIR first, using HL7 DaVinci FHIR specifications. “That makes it easier for me to partner with a different EHR company, and it makes it easier for athenahealth to partner with a different payer,” he said.
Driving these types of collaborations is the shift to value-based care. “There's a huge component of administrative burden that we reduce because we are asking these providers to send us the medical records to close the gaps in care,” Raley explained. “This makes it easy it make it happen in the software that they're already operating and not having to go somewhere else. That saves them time and money that they can redeploy for other member value or patient value.”
So how do FHIR-based APIs make a big difference in this work?
Michael Palantoni, vice president, platform and data services at athenahealth, said moving to a RESTful API allows for a couple of things. “It allows for more discreet interactions. It allows for bidirectional interactions, and allows for higher velocity interactions,” he explained. “You've seen this not just in the payer/provider world, but all sorts of areas of the industry where API transaction growth is outpacing traditional interface growth. We had an inflection point of that in general around 2018 and haven't looked back since. And so those advantages that API connections have in many of these cases create the body of a lot more powerful workflow interactions for users, and a lot less error handling and a lot less batches and retries and those kinds of things for operations teams, because you can do it much more through the software.”
Raley said it allows a company like Humana to be compliant with CMS regulations, “because we use the same FHIR standards for the consumer-mediated interoperability requirements that went into effect last year, and are intending to use the same ones for new CMS legislation that's get ready to come out. So the industry standards benefit the payers and benefits EHR companies and ultimately, it's going to benefit the providers.”
One friction they have had to overcome is that the provider community for a long time has not trusted payers. Not so long ago, most payers were trying to figure out how to deny the claim, rather than pay the claim, he said. “What we've seen is that with some of the high-value use cases like HEDIS measures and those quality functions, there's value to both sides, and so it opens up the willingness to participate. And then once you start building on that trust, then it gets a little bit easier to get to those advanced use cases, and that's what we're seeing now.”
I asked Palantoni if athenahealth has this type of relationship with other payers besides Humana.
“We do have similar relationships with other payers,” he said. “Some payers are really focused on reducing these frictions in the provider experience and opening up their platforms for these integrations to be built. Some are attempting to do this with intermediaries and some aren't even stepping foot in the arena, much less investing in the space. Standards allow you to pursue that arena with confidence, because you know, you can have a lot more repeatability in the work you do as more entities come to the table, both on the payer and the provider side.”
It often can take a year or two years to get an advanced capability working and out the door, Raley stressed. That's why taking on the simple use cases first and building that foundation of trust is key. “That enables the more advanced use cases like utilization management and prior authorization, where there is a lot of industry expectations that we should make it easier,” he said. “We're working now to simplify that and have seen it work at scale, where we're seeing reductions in calls, we're seeing reductions, and we're seeing faster approval times for prior authorization.”
For several decades in this industry, payers and providers have had whole floors of buildings filled with people employed to call each other to process administrative claims. Having a platform orientation to technology and service can help create much, more integrated workflows, lower cost, and higher convenience between the two parties, Palantoni said. “As much as this is about trust, it is also about the ‘platformization’ of the industry, and it's starting to replace floors of people calling each other.”
Raley mentioned that the partners are constantly evaluating how they can take what they have already done and learn from it and improve upon it. “We are starting to address things like how social determinants of health may be impacting care,” he said. “Care coordination is something that Michael and I spend a lot of time talking about because Humana has care managers, the provider has people that are caring for the same patient. How can they share a common caseload and how can we refer them into our disease management program? Also, a lot of this work has been focused on the provider and the payer. The third leg of that is the member. How do we make all of these things available and understood by the member in a simplified way, so that they can understand where they are in navigating the healthcare system?”
