By Genevieve Diesing
Addressing long-standing interoperability challenges between administrative and clinical systems offers the opportunity to advance the exchange of data across health systems, particularly between payers and providers. This enhances the patient experience, lowers administrative costs, and improves health outcomes.
However, with few exceptions, administrative and clinical data streams are currently predicated on different technical standards and are coded differently. They are also subject to separate laws mandated by different entities about how they can be recorded and shared, which complicates the exchange of information.
Many patient scenarios require providers to share clinical data with payers. For example, prior authorizations (prior auths), the process by which providers obtain payers’ approval before ordering procedures or drugs, are particularly thorny. For one thing, payers’ approval requirements vary—both by payer and by plan—and those requirements often fluctuate.
As a result, each prior auth must often be customized via a time-consuming and often manual process. Just 12 percent of the 182 million medical sector prior auth transactions completed in 2019 were fully digital, making prior auths one of the most manual-intensive federally mandated transactions, according to the 2019 CAQH Index.
These bottlenecks cause administrative burden, care delays, and, in some cases, adverse events, according to the American Medical Association (AMA), with 86 percent of practicing physicians considering the burden associated with prior auths to be “high or extremely high.”
Prior auths have been further complicated by medical attachment requests. While the typical prior auth includes data fields for clinical information about the patient, payers often require more detailed information that must be fulfilled by sending attachments. And while attachments give health plans crucial information to resolve some claims, the workflow is time consuming, labor-intensive, and costly.
Of course, prior auths are not the only trigger events for sharing clinical data with payers. Concurrent reviews, which include utilization review and case management, and post-discharge processes, which include claims submissions and medical necessity reviews, come with their own administrative burdens and inefficiencies.
Trigger Events for Sharing Clinical Data with Payers
Source: Riplinger, Lauren, Alison Nicklas, and Chantal Worzala. “ONC Intersection of Clinical and Administrative Data Task Force.” AHIMA, 2020.
Without a strong utilization management program in place to ensure appropriate and efficient care coordination and transitioning, providers risk retrospective claim denials. Ineffective discharge planning processes can result in increased readmission rates, adverse events, and patient dissatisfaction.
These trigger events largely share the same solution—the need for increased clinical and administrative integration.
In the words of a recent Journal of AHIMA column on the integration of clinical and administrative data, “Imagine a world where health information management teams know in advance the documentation a payer needs to authorize an admission or conduct a medical necessity review, their IT systems populate the needed data for them to verify, and the documentation is then sent electronically to the right place within the payer organization for a timely decision.”
Some providers are turning to software that utilizes portals to automate the prior authorization process. Jennifer Mueller, vice president and privacy officer, Wisconsin Hospital Association, says that in a previous role, the health system that employed her used an artificial intelligence-based software embedded in their electronic health record (EHR), eliminating the need to fax paperwork to payers.
Mueller says the health system needed an alternative to their previous administrative processes because of staffing issues. While clinicians’ familiarity with the medical record made them natural choices for this work, they weren’t exactly working at the top of their licenses.
This is where the health information professional can step in, Mueller says. Their knowledge of EHR data and related workflows gives them unique perspective on how providers can best connect systems.
“Where health information professionals should beef up is in technology—in understanding how we can connect these systems and what’s out there,” she says. “I don’t think our role necessarily is in the prior authorization process, but I do think it’s in the leadership, implementation, and oversight of these kinds of processes.”
While the workflows for sharing clinical data with payers are challenging, new technology approaches show some promise. Experts say, however, that issues beyond technology need to be addressed to make real progress.
The Centers for Medicare and Medicaid Services (CMS) recently finalized a rule requiring health plans to make clinical data available to third-party apps, which creates a foundation to support data sharing. The Office of the National Coordinator for Health IT (ONC) finalized the technical standard in the recent information blocking final rule, adopting the Fast Healthcare Interoperability Resources (FHIR) 4.0.1 standards and will require that certified EHRs incorporate the standard over the next two years.
FHIR takes an internet-based approach to connecting discrete healthcare data and is designed to help developers to build standardized browser applications that enable access to data regardless of a provider’s EHR. A growing number of providers and payers are using APIs in their EHRs and tech infrastructure to use FHIR, which can enable real-time data interoperability.
While FHIR has “changed the game,” according to Walter Suarez, MD, executive director, health IT strategy and policy, Kaiser Permanente, a HIPAA regulation that originated in the early aughts still complicates matters. The regulation stipulates that prior authorizations must be performed using the X12 278 standard, which most EHRs do not have the capability to use.
“Even if both parties use FHIR, the data will have to be converted to a 278 in order to meet the HIPAA requirements today,” Suarez says. “It’s going from electronic to fax, to back to electronic.”
Both CMS and ONC and the private sector are addressing workarounds to this problem.
Experts say that CMS now allows payers and providers to request exceptions to using the X12 standard so that they can perform prior authorizations without it and not run afoul of HIPAA.
This was a reminder to the field that it can use FHIR, and, with that exception approved, providers “can do it without having to stop and do a 278 in the middle,” Suarez says.
Additionally, a joint task force of two federal advisory committees, the National Committee on Vital and Health Statistics and the ONC Health IT Advisory Committee, has created the Intersection of Clinical and Administrative Data Task Force to help the federal government work to improve data interoperability to “support clinical care, reduce burden and improve efficiency.”
The Da Vinci Project, a private-sector initiative of industry leaders and health information technology experts working together to boost the adoption of HL7 FHIR to support value-based care, is also making strides.
The group creates and applies FHIR-based implementation guides across the areas of coverage burden reduction, quality improvement, member access, process improvement, and clinical data exchange. For example, FHIR can be used to leverage EHR data for prior authorizations and make immediate patient benefit information transparent, says Jocelyn Keegan, program manager at the Da Vinci Project. Its members are also helping to test prior authorizations using FHIR without the X12 278 standard.
Patrick Murta, Da Vinci Project member and chief interoperability architect and fellow at Humana, uses the Da Vinci model FHIR API to collect data directly within the EHR in real-time, making the authorization a part of the standard workflow, as opposed to using web portals, fax machines, and phone calls.
This allows Murta “to have the right data at the right time in the right workflow to improve our member’s health and remove friction from the care experience for both providers and patients,” he says.
“A good analogy is a contemporary retail app,” he adds. “You have a single unified experience to make a purchase and do not log in to other web portals to check inventory or to make sure it can be delivered on time or to verify enough funds are in the account. APIs handle all of that. We want the prior authorization experience to be a single unified experience as well.”
Patient Privacy Considerations
FHIR-based apps have a privacy advantage over manual communication exchange in that they leverage the same modern security standards that we use in our daily lives with our banks, travel, and retail websites, Keegan says.
“One of the benefits providers and payers gain through automation, beyond reducing waste and burden, is [they] share only the necessary data needed to meet medical necessity between two trusted parties and their intermediaries,” says Keegan. “Secure API interchange drives to more real-time answers, with less data in flight, leveraging modern security protocols resulting in more secure data infrastructure and increased ability to track and audit.”
Payers and providers agree that automating such data exchange is key, but there are caveats. Will payers pull only the data that’s necessary, and not use it for secondary purposes? Allowing EHR access for an external party may raise additional concerns, as payers’ IT systems may face data quality and terminology gaps.
“Privacy is a big concern when using FHIR to support this workflow,” says Steven Lane, MD, clinical informatics director, Sutter Health. Because providers share the address of their FHIR servers with payers to facilitate data exchange, limiting the payer’s access to just the data that the provider “feels they have a right to access” can be tricky, he says.
Mueller agrees. “I don’t know if there’s a lot of trust between payers and providers and allowing payers that carte blanche access to the provider data,” she says. “We’d have to make sure there are processes in place where only the minimum amount of data is obtained.”
Lane says that some providers are implementing a data layer between their clinical and business systems and their FHIR servers so that they can choose to expose only a subset of their data to payers.
While payers typically want all of a patient’s data, Lane says, most providers don’t want to give a payer access to all of their clinical, operations or business data, as there is an inherently adversarial business relationship between payers and providers.
“As such, there need to be controls on data access (and potentially use/re-use), either based on agreements [and] contracts or technical controls,” he says.
Lane says that he and his Sutter colleagues have “been stuck on this point for well over a year” and are working with a payer partner to limit the payer’s data queries to “only the appropriate data for the appropriate patients for the appropriate periods of time,” he says.
In addition, Lane says, Sutter is working with its EHR vendor to be able to audit FHIR data releases as a way of staying accountable to both payers and patients.
A Need for Transparency
Without transparency of payer needs, even automated systems that pull only the required data discretely from the EHR in real-time will fall short, says Lane. Crucial data might not be discreetly documented in codified EHR fields, making it impossible to find. If the patient has had relevant procedures elsewhere, there’s a good chance that data in the ordering provider’s EHR won’t reflect that information.
“We need to have accurate, real-time data to make available to payers if these digital conversations are to occur successfully and securely,” Lane says. “We need to know just what patients are covered by what payers for what services.”
While FHIR query use cases/implementation guides can be utilized by providers to get this information from the payers, the technology is new, he says. Ultimately, existing processes that rely on “sending spreadsheets back and forth, or maintaining point-to-point interfaces,” must evolve to “new, more nimble processes” if progress is to be made, he says.
Even so, automation is often hampered by inconsistencies over when authorization is required and what data the payer needs to make a determination, making it difficult for providers to know what information they need to provide.
To overcome this problem, some health information departments are turning to multi-payer platforms to serve as a single source of truth for provider data. Multi-payer platforms are centralized portals that enable providers and plans to exchange and reconcile provider data. By using a single platform for providers to update and manage data for all of their contracted health plans, payers and providers can save time and money with streamlined processes and achieve better data quality and accuracy.
As a short-term bridge to standards-based automation, multi-payer platforms can provide value through their ability to leverage the strength and market participation of many health plans as well as access data across all health plans. Provider staff members who submit information do not have to worry about using different interfaces, menus, workflows, and commands because they’re the same across all participating health plans and, done well, the data analytics can help them reduce time by focusing on just the questionable data items.
In the bigger picture, better collaboration between payers and providers will enable them to more effectively share quality and risk data—cooperation that will be increasingly necessary under current and future value-based arrangements. Through better information sharing, this increased payer-provider cooperation has the potential to increase efficiency and lead to better patient care and outcomes.
Realizing the promise of value-based healthcare will require a level of payer and provider collaboration virtually unheard-of in the recent past—and health information professionals play an essential role in achieving this reality.
Both payers and providers must work together to develop the most efficient means of sharing data, managing risk, validating provider credentials, processing claims, controlling costs, and optimizing the consumer experience.
- “2019 CAQH INDEX A Report of Healthcare Industry Adoption of Electronic Business Transactions and Cost Savings.” https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf.
- American Medical Association. “2019 AMA prior authorization (PA) physician survey.” https://www.ama-assn.org/system/files/2020-06/prior-authorization-survey-2019.pdf.
Genevieve Diesing (email@example.com) is a freelance health writer.
AHIMA Issues Policy Statement on Clinical and Administrative Data Integrations
AHIMA recently published a policy statement on Integrating Clinical and Administrative Data affirming that the organization “supports the use of policy and other tools to realize the benefits of greater integration of clinical and administrative data, including improved patient experience, decreased administrative costs, reduced provider burden, and improved quality of care and outcomes.”
The statement identifies seven policy considerations to ensure the best outcome for individuals. To develop these policy principles and ensure they were grounded in operational realities, AHIMA brought together a member work group on integrating clinical and administrative data to first paint the picture of how these transactions happen today, and then address policy considerations. The group affirmed that the challenges in sharing clinical data with payers are significant and pose financial and time burdens on patients as well as providers, and that everyone would benefit if they could be simplified and automated.
Based on the group’s operational experience, many of the challenges in sharing clinical data for administrative processes come from variability and lack of clarity in the documentation needed by the payer, which can also vary by plan and change over time without notice. In addition, multiple formats may be needed to share information, from using a payer-specific portal to sending a CD or defaulting to phone and fax. Sometimes, multiple formats are needed for a single patient event.
By sharing operational realities, AHIMA was able to help the task force understand that automation will bring significant benefits by integrating clinical and administrative data, but success in that endeavor will require addressing the many issues beyond automation that are addressed in the policy statement.