The critical role of data interoperability in value-based care

A seasoned healthcare professional explores how overcoming data challenges can revolutionize patient care and healthcare management for the better.

This article is Part 1 of a 2-part series. Read Part 2 here

Value-based care models have ushered in an era of evolving consumer expectations and a demand for more holistic approaches to healthcare delivery and management.

The focus has shifted from the quantity of services provided to prioritizing the quality and outcomes of care. This pendulum swing highlights the importance of identifying and tackling root causes of health issues, concentrating on preventive measures, patient and member-centric care, and fostering collaboration among healthcare providers.

As we move towards value-based care models, we are essentially moving in the right direction for our care delivery approach. However, this direction relies on accessing existing data, ensuring its quality and promoting interoperability.

For more than two decades, I have had the privilege of practicing medicine as a board-certified internist and pediatrician in various care settings such as a hospital, a skilled-nursing facility, an employee health clinic and a correctional facility in the United States. I have experienced care delivery in an underserved village clinic in an underserved village abroad and concierge care in affluent communities. These experiences taught me firsthand the challenges of unequal access, fragmented care and misdiagnosis because of barriers of clinical data availability, data quality and failed interoperability.

I’ve watched family members suffer the consequences of poor care transitions, medical errors and misdiagnosis stemming from data silos within the healthcare industry. I had an uncle who was repeatedly misdiagnosed with pneumonia and treated unsuccessfully with antibiotics, when in fact he had an evolving rheumatic disease. My wife suffered a massive pulmonary embolism hours after delivering my youngest child, a frightening consequence of an atypical presentation.

I can recall countless examples of reactive and impersonal care experienced by my patients as they experienced care episodes outside of my office. The common denominator was the lack of readily available and interoperable data to drive the following:

  • Informed decision making.
  • Enhanced patient experiences.
  • Improved population health.
  • Reduced healthcare costs.
  • Improved provider work-life.
  • Improved health equity.
  • Accessing and utilizing clinical data

    Accessing complete clinical data is challenged by technological limitations, fragmented systems and data privacy concerns. These obstacles hinder the seamless and up-to-date flow of patient information between different healthcare entities for the nearly one billion annual clinical encounters in the United States.

    According to regular data quality analyses, including annual real-world data audits, conducted by Availity’s Clinical Informatics team, more than 50 percent of clinical data cannot be used in its raw form because of incompleteness, lack of interpretability or the absence of coded medical concepts.

    When data lacks interoperability because of diverse representations across various electronic health platforms, differing implementations and multiple providers, it hinders the creation of a consistent and coherent clinical story. As a result, patients become the essential link, bridging the gap and piecing together disparate data to form a comprehensive picture.

    As a result, patients face the burden of having to repeatedly share their medical history when seeking emergency care, visiting out-of-state or out-of-network providers or transitioning between health plans. Despite not always fully understanding the medical complexities, patients are forced to shoulder the responsibility of ensuring that their healthcare information forms a cohesive picture.

    Data quality improvement

    In response to these challenges, the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final rule was established with the aim of prioritizing patients. This regulation enables patients to access their electronic medical records through API connections, making it easier to exchange succinct yet thorough information with their family members, primary care and specialty providers, and even acute care facilities. Providers and payers are mandated to use the Fast Healthcare Interoperability Resource (FHIR) standard to help foster enhanced communication.

    With an increasing number of health plans and providers complying with the generation of shareable FHIR data, it is essential to acknowledge that incomplete or incomprehensive data fails to fulfill the intent of CMS in pushing for FHIR as the standard for data sharing and interoperability. Payers and providers must understand that for clinical data to be successfully leveraged as a strategic asset, it must be organized, consistent and complete before it is transformed into the FHIR standard. An industry commitment to improving data quality and interoperability through technology is requisite to ascertain the safety and efficacy of healthcare delivery.

    When healthcare professionals receive comprehensive and timely information about a person's health journey, it can be better tailored to fit their tools and workflows, enabling better decisions. Similarly, patient access promotes active participation, enhances health literacy and empowers them to better participate and direct their care. Patient and provider engagement ultimately facilitates cost reduction, decreased financial risks, enhanced clinical results and improved consumer experiences.

    When consistently accurate data fuels analytics and artificial intelligence tools over time, significant advancements occur in population health, risk assessment and quality evaluation, leading to substantial transformative effects. As clinical data becomes more ubiquitous and readily available, it represents a valuable resource capable of driving significant industry-wide disruption.

    The utilization of more accurate and conformant clinical data leads to enhanced outcomes through precise risk stratification, improved disease management and identification of gaps in care. The operationalization of insights derived from clinical data holds the potential to promote patient well-being while making healthcare operations more efficient, less wasteful and more cost-effective. It helps promote better provider and patient engagement and most importantly better overall and more equitable health for our country.

    Paulo Pinho MD, is vice president and medical director of innovation at Availity.

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