Achieving a fully interoperable healthcare system requires solving complex data challenges. As a founding member of the Da Vinci Project, Cognosante works with industry partners to build the foundation for smooth and safe movement of patient data throughout the healthcare system.
Currently, the Da Vinci Project team is working to enable prior authorization review and approval in real-time while including all necessary, related records. By working with industry partners like Health Level Seven (HL7) International to identify disparity across the various data standards, we can streamline the prior authorization process.
This initiative addresses a real pain point in the patient experience, and one that Mary Kay McDaniel, Cognosante’s Principal and Senior Advisor for Health Data Standards, experienced personally.
“In December 2004, my daughter was diagnosed with Type 1 Diabetes. I have spent most of my career advancing the goal of interoperability, and the timing of her diagnosis provided real insight into what our efforts at the national level mean for a patient managing a chronic condition.”
A Personal Perspective on Why Interoperability Matters
2004: The Beginning
In 2004, my daughter was hospitalized while on vacation. She was diagnosed with Type 1 Diabetes and was discharged after a week. Although HIPAA-compliance was the standard, there was still confusion about what information could be released and to whom. In my case, I initially had no access to my daughter’s hospital records, even though we were going straight to a hospital in our home state and needed to ensure continuity of care. Thankfully, extensive HIPAA knowledge aided in my ability to obtain the records to share with her doctors at home.
At that time, gathering the necessary data to manage a chronic condition was labor intensive and did not occur in real time. A Continuous Glucose Monitor (CGM) would be loaned out by the physician’s office for a two-week period to help monitor blood glucose levels. Prior authorization for a device like this took weeks or months, and required the repeated, manual transmission of medical information, forms and other records.
We kept daily records of my daughter’s food intake, finger sticks , general health and emotional observations to provide at medical appointments. Paper forms were used between appointments and updated medical records were generated after each update or change. Over the course of the next two years, I acquired 3 binders full of paper records!
2010: EHR Adoption Begins at the National Level
This time period saw measurable progress in national electronic health record (EHR) adoption. According to the National Coordinator of Health IT. By 2009, 16% of hospitals and 21% of providers had adopted basic EHRs. By 2011, the federal government would publish its Health IT Strategic Plan, and 27% of hospitals and 34% of providers would have adopted basic EHRs.¹
For patients, challenges remained. Emergency rooms and hospitals still required manual re-telling of the patient history. Records might be incomplete, or difficult for the clinician to understand. Prior authorization was done via fax, and often required a lot of back-and forth between patients and insurers.
2020: The Patient Benefits from Interoperability
In 2020, patients noticeably benefit from advances in interoperability. Congress passed the 21st Century Cures Act in 2016, which makes patient information more accessible, and emphasizes the importance of making patients aware of their rights to access that information. Nationally, 95% of hospitals and 86% of providers now use EHRs. Patients who were offered access to their online medical record by a health care provider or insurer was 42% in 2014 and had risen to 51% in 2018, the most recent year available.
Payer portals also make things easier for the patient. For instance, providers can log in digitally to get information about prior authorization requirements and upload medical records. However, we recognize it can still be difficult to share information between hospitals or providers due to an individuals’ health care use, Internet access and socioeconomic factors and solution development takes those challenges into consideration.
Patients will spend less time at the doctor’s office as we improve data gathering and sharing. In the case of diabetes management, reports are now generated electronically and can point out missing information or unusual readings. This means clinical staff can spend time reviewing information with the patients, rather than collecting it.
2030: What’s Next?
We expect to see more improvement as security improves. As physicians complete medical notes, following all privacy and security protocols, the appropriate information will then immediately be sent out to others involved in that patient’s care.
An emergency facility admission will trigger two-way quality data flows to ensure relevant care information is available to current providers involved with the patient’s care. The definition of ‘relevant information’ will continue to evolve past 2030 but will include such things as patient history, current medications, contacts, next of kin, and end-of-life requests.
With HL7 and the Da Vinci Project, we are working to ensure that all the “handshakes” exist for prior authorization information to be transmitted correctly. We are specifically focused on making sure that all data elements are mapped between critical interfaces so that information between provider and payer remains easily accessible and reference-able.
Simplifying the previous pains of a manual process relieves the stress of managing a chronic condition and improves the overall patient experience for a wide range of healthcare needs.