burden reduction

The podcast "The Dish on Health IT" is brought to you by Point-of-Care Partners, a distinguished health IT consultancy. In the opening minutes of the episode, the hosts, Pooja Babbrah and Jocelyn Keegan, set the stage for a dynamic conversation focused on the HL7 Da Vinci Project and its real-world implementation results.

Introducing their guests, they warmly welcome Anna Taylor, Associate Vice President of Population Health and Value-Based Care at MultiCare, and Heidi Kriz, Director of Medical Policy and Medical Management at Regence. Both guests are not only accomplished professionals but also members of the HL7 Da Vinci Project, where they play pivotal roles as early implementers of the Da Vinci Fast Healthcare Interoperability Resource (FHIR) Implementation Guides.

The hosts underscore the key themes of the episode, which revolve around sharing insights from early implementation projects, understanding the tangible benefits and returns on investment, and exploring how their experiences in the Pacific Northwest can serve as a model for nationwide FHIR adoption.

As the hosts and guests delve into the discussion, they shed light on the core issues they are working to address. Heidi Kriz highlights the existing silos in healthcare, where payers and providers often work independently, using different data standards and requiring access to multiple portals. They recognize the need to promote a common language and reduce the administrative burden of healthcare processes. A major area of concern is prior authorization, which often leads to delays in care. Their aim is to make the process more transparent and incorporate it into the provider's workflow, thereby automating several steps that currently require manual intervention.

Anna Taylor supplements this perspective, emphasizing that their goal is to find a many-to-many solution that involves multiple stakeholders. With thousands of members to care for and thousands of providers to collaborate with in the MultiCare Connected Care ACO. To navigate the complexities of these relationships, they aim to streamline data administration, allowing more resources to be devoted to direct patient care. Open standard APIs, like FHIR, play a pivotal role in this quest for a comprehensive, interoperable solution.

Jocelyn Keegan highlights the significance of implementation guides within the Da Vinci Project. She underscores the importance of repeatability and the need to get information to where it's needed, thus improving overall efficiency and user experience.

The hosts and guests underline the role of collaboration as the linchpin of their endeavors. They emphasize the necessity of involving diverse stakeholders, including providers, patients, community organizations, and other contributors to the healthcare ecosystem. The objective is to create a harmonious and collaborative environment that benefits all parties involved.

Heidi Kriz shares the story of how Regence, from a business perspective, became engaged in the Da Vinci Project. The organization's CEO and leadership recognized the need to enhance the member's experience, particularly regarding the prior authorization process. This realization prompted a series of discussions and plans to implement collaborative, interoperable solutions.

In the early moments of this podcast, the stage is set for a conversation that promises to explore healthcare's complexities, emphasize the role of collaboration, and advocate for interoperability. The guests, Anna Taylor and Heidi Kriz, offer valuable insights from both the provider and payer perspectives. They highlight the need for automation, standardized processes, and the creation of a seamless healthcare ecosystem, ultimately aiming to enhance the patient experience and streamline administrative tasks.

When asked about key insights or any “aha!” moments.  Heidi shares that it was realizing the power of collaboration between a payer and a provider. The ability to come together to solve complex healthcare transactions and streamline processes marked a profound shift in their approach. The synergy between MultiCare and Regence in tackling a common goal was a testament to the potential of collaboration in the healthcare ecosystem.

Heidi's second aha moment came when they went live in October 2022. After years of hard work and dedication, seeing their vision become a reality was truly amazing. The initial results were already impressive, but Heidi recognized that they were just scratching the surface of what could be achieved in terms of process automation and instant information delivery.

She also highlighted the importance of involving patients in the process. The ability to provide timely information to both providers and members, enabling them to make the best decisions for their care, was a transformative idea.

Another valuable lesson for Heidi was the necessity of embracing failure as part of the innovation journey. Adapting and making changes based on feedback and evolving needs was crucial, even if it meant not getting everything right the first time.

As for Anna, her aha moment was realizing that the combination of a business-centered approach and the right technology expertise was key to success. It wasn't a matter of choosing between one or the other; both were essential. This perspective underscored the importance of collaboration between these two aspects of healthcare organizations.

Anna also shared the concept of the "magic button," where providers found immense value in a simplified, streamlined process. The idea of having a single point of access to manage transactions and receive instant responses became a game-changer, simplifying the lives of providers and driving home the importance of automation.

Both Anna and Heidi spoke about the remarkable return on investment they experienced. Anna cited the Data Exchange for Quality Measures (DEQM) implementation, where they saw immediate returns by closing quality gaps and receiving financial incentives. The investment in developing these open standard APIs proved to be worthwhile, not only in terms of financial gains but also in making providers' lives easier.

The discussion revealed that the journey to healthcare transformation through initiatives like the Da Vinci Project is challenging but entirely feasible. Success hinges on a combination of collaboration, transparency, and a willingness to embrace change. The ability to iterate and adapt is essential, and organizations that strategically invest in these initiatives will position themselves for long-term success in the evolving healthcare landscape.

In this podcast segment, Anna Taylor and Heidi Kriz discuss their experiences and insights regarding healthcare interoperability and the impact of open standards and APIs in the healthcare industry.

Anna emphasizes the importance of embracing open standards and APIs, highlighting their potential to transform the healthcare landscape. She encourages organizations to take a close look at their current processes, especially if they are spending a significant amount of time and money on old-fashioned ETL (Extract, Transform, Load) packages. By adopting open standards and APIs, they can free up their employees' capacity, transform their culture, and ultimately improve healthcare.

Heidi adds that the risk of not adopting these technologies is greater than taking the leap. She cites the staggering amount of money wasted due to the lack of open standards in healthcare and emphasizes the potential for financial savings and enhanced patient care through interoperability. She also stresses that putting patients and people at the core of healthcare is vital.

Both Anna and Heidi underscore the importance of community collaboration, particularly through organizations like Da Vinci, which provide resources and support for implementing open standards and APIs. They encourage organizations to start small, focus on foundational changes, and build a culture of transparency and collaboration.

As they conclude, they invite more providers and partners to share their success stories and experiences, urging the community to come forward and tell their stories to inspire and educate others.

In summary, Anna and Heidi emphasize the transformative power of open standards and APIs in healthcare, the necessity of community collaboration, and the need to embrace change to improve healthcare for all. The discussion also highlights the significant impact these technologies can have on productivity, transparency, and patient care in the healthcare industry.

Learn more about this and other Da Vinci Project Implementations: 

• Da Vinci Roundtable Presentations: https://confluence.hl7.org/display/DVP/Da+Vinci+Video+Presentations
• CMS Presentation: Catching FHIR: Lessons Learned from Achieving the First Prior Authorization Automation via HL7® FHIR® - https://www.cms.gov/files/document/hiig-august-2023-isc-speaker-slides.pdf
  • Fierce Healthcare Article: https://www.fiercehealthcare.com/payers/regence-multicare-team-fhir-enabled-prior-authorization
  • Revcycle Intelligence: https://revcycleintelligence.com/features/how-a-better-prior-authorization-process-is-rising-from-fhir News Coverage:
• KLAS Points of Light Award: https://www.mcg.com/client-resources/news-item/mcg-regence-multicare-klas-points-of-light-award/

This episode features special guests, Ceci Connolly, President and CEO of Alliance of Community Health Plans or ACHP and Virginia (Ginny) Whitman, Sr. Manager of Public Policy for ACHP. They join host, Pooja Babbrah, filling in for Ken Kleinberg and co-host, Jocelyn Keegan to discuss ACHP’s perspective and work on building trust between payers and providers and why that’s important, how price transparency policy is translating into real-world changes, and the cultural shift happening as more data becomes shareable. 

Pooja kicked off the episode by having Jocelyn briefly introduce herself and share what she's looking forward to learning from the discussion. Jocelyn shared that she recently had the good fortune of presenting at an ACHP conference in May where she met a lot of the community members.

Jocelyn went on to share that she’s been with POCP for six years as the Payer Practice Lead and has been focused on interoperability and the convergence of sharing clinical data between payers and providers to help automate interactions like prior authorization and support value-based care. 

Pooja then asked each guest to introduce themselves and share how they came to work with ACHP. 

Ceci Connolly shared that she is the president and CEO of ACHP now but had a 25 year-long career in journalism before catching the healthcare bug. She recounted that she was covering healthcare and specifically that passage of the Affordable Care Act which led her to pursue a second act of her career which entailed working the McKinsey and helping them set up the Center for Health Reform before moving on to lead the Health Research Institute at PwC before landing at ACHP. She expressed how fortunate she feels to havean amazing group of members and a passionate team that’s aligned to take healthcare where she believes it needs to go. 

Ginny Whitman introduced herself sharing that she’s been with ACHP for almost four years and that it was only a few months into her tenure that a dear friend and colleague pulled her into the world of health policy. She continued by saying that she’s been focused on exploring what health plans need, what their pain points are and where can they excel and do wonderful and creative things to support their communities. 

Pooja then asked for Ceci to share more about ACHP, it’s mission and the work it’s been focused on most recently. 

Ceci responded by saying that the ACHP member criteria is essentially also the mission. ACHP represents not-for-profit provider aligned regional health plans adding that many of those are plans that are in big integrated systems across the

She explained that many ACHP members are smaller and local in their communities with tight relationships with their provider community which often include risk arrangements which ACHP believes is a model with a bright future for healthcare. 

Ceci went on to say that ACHP members are very much about access for all in their communities and focused on health as opposed to acute care. She relayed that the ACHP roadmap set by the board of directors includes setting a course to really serve the consumer, meet members where they are and improving transparency and data fluidity so consumers and providers both have the data they need to make the best decisions. Affordability is also a big focus for ACHP, they release a report each year and have taken a pledge on two chronic diseases, diabetes, and cardiovascular to start to move the needle in our members' communities on those.

Ceci expressed that she is very positive about the recent law President Biden just signed on inflation reduction that included provisions about drug pricing which is a huge pain point for ACHP members and their communities. She explained that she is also pleased about the enhanced affordable care act provisions as well. 

Pooja then transitioned the conversation to focus on the theme of a recent ACHP event that highlighted the need to build and improve trust between payers and providers. Pooja asked Ceci to provide her assessment of the historic level of trust between payers and providers and why it’s important to redefine and strengthen these relationships?

Ceci responded by explaining that the recent event was Ginny’s brainchild and would like her perspective on this topic. She went on to explain that ACHP has been hearing from all directions that trust is an issue. 

Ceci expressed that they were thrilled to have a keynote by Dr. Jan Berger who has written the book on the theme of trust in healthcare. There is a strong foundation to work from because ACHP members are grounded in their local communities. She explained that developments in the technology and the data arena can be positives when it comes to trust, but also pose potential risks. 

Ginny added that ACHP member plans have close relationships with their provider systems and provider groups but that sometimes the technical infrastructure doesn’t support good communication. Part of the focus of the ACHP event was how to make technical level changes to improve that communication with providers ACHP members value so much. 

Pooja then asked if there were any specific initiatives or programs ACHP members have employed to improve trust with providers? 

Ginny explained that there are so many programs but one example she described was a vaccination campaign in Minnesota where the community health partners, using data, recognized they were missing communities of color in the vaccine effort. Stakeholders from across the community collaborated to create education and vaccination events to close those gaps. She went on to explain some other examples of partnerships and collaborations between ACHP members and their communities that help build on the foundation of trust. 

Pooja asked Jocelyn to comment on payer provider trust and data exchange based on her work as the program manager of Da Vinci.

Jocelyn started her response by making the observation that there is a duality with how big nationals come into these regional markets and work hard to make themselves seem small and local. They will do things like sponsoring local teams, getting involved in local charities to make themselves seem like part of the community. The small plans, on the other hand, who are already connected to local provider system plans and the community, are spending all this effort to make themselves seem bigger and seem wider and deeper right out into the market. Jocelyn expressed that she finds this juxtaposition interesting. 

Jocelyn went on to say that the reusability of the work that's emerging in the industry around things like DaVinci and other FHIR initiatives and other standards helps create a more level playing field for smaller plans to make investments in interoperability and more easily tackle regulatory challenges. 

Pooja then asked what ACHP, and its members are doing around price and patient cost transparency. 

Ginny responded by saying that many ACHP members had price estimator or cost estimator tools prior to any regulations coming out which put everyone in a very good place when regulations did drop. Most plans had either already met the requirements or only needed to make small adjustments to do so. She explained that the challenge now is how to incentivize the providers and patients to use these tools. 

Ginny expressed some concern around some future regulations particularly with some of the overlap of the No Surprises Act and the transparency and coverage rule. 

I'm not that worried about it, but I will say that I, I do have some hesitations and reserves when it comes to future regulations that we are expecting, um, particularly some of the overlap that was in the no surprises act part of the consolidated appropriations act and what's in the transparency and coverage rule.

Ceci added that some ACHP plans are further along in this journey and are incorporating quality information for instance which starts to get at value. She expressed that healthcare is a funny world where transparency is currently defined with price. She explained that if you look at travel and are looking for a hotel, one might look at the cheapest hotel or the cheapest flight but maybe location or a comfortable bed is more important to you. 

It's the same in healthcare. Some consumers are going to be looking for that value package. Ceci added that some ACHP members have gotten very sophisticated and developed tools that are so easy to use but consumer uptake is still very small and slow.

To make her point, Ceci highlighted a health plan in Michigan that developed a super slick tool that’s extremely easy to use. The tool shows where plan members are in their deductible, what the co-pay is and where services are located. This plan put in financial incentives, and they have seen some uptick in the utilization, but it's going to take a long time and a big, big effort. In the meantime, there are all these machine-readable files out there creating an insurmountable mound of data that is challenging for payers to sift through. 

Jocelyn responded by expressing the important role of standardization in helping solve many of these issues. She explained that so many stakeholders are so focused on using standards to meet regulatory requirements they lose sight of the real-world problems that need solving like how to get patient important cost and value information so they can make better decisions about where they get their healthcare. 

Jocelyn continued to explain that here is a huge investment related to many of these transparency projects and when there is so little uptake, it can be discouraging but that the more we normalize the data using standards we can reduce the overhead cost.

Jocelyn explained that it’s important to get the right information to the patient at the right point in time. She went on to use an analogy of when someone is in Target shopping, they may look at their Amazon app to see if they can find the item cheaper but sometimes, if a person is on their way to a birthday party and hasn’t shopped for a present yet, convenience may be more important in that moment than price. 

Jocelyn added that the question is how we can create information parody so the provider team and the patient have equal information about the patient's benefits so they can discuss a treatment, procedure or test and where or even when a patient may want to go to get maximum coverage. 

Ceci jumped in to provide an example of how a mid-Atlantic plan not only provides patients with where they can get a colonoscopy but will mail plan members a home test kit with all the pertinent information about risk factors. This helps make patients more health literate while also allowing them to take more control of their health in the convenience of their own home on their schedule. She added that it's about data, communication, and trust. If your health plan and provider sends information about a colonoscopy and home kit saying this would be good for you to do, you’re probably going to do it. So, it’s a win, win. 

Ceci explained that using data in this way to support the patient in a transparent way, it goes a long way in repairing trust in the healthcare system. Adding that if a patient is surprised by an astronomical bill, that's not going to repair their trust, but when data can be used to support conversations leading to a strategic care and financial plan, progress can be made. 

Pooja then zoomed out the conversation to focus on how interoperability projects are making more data flow and changing how businesses operate. Pooja asked Ceci and Ginny to describe how ACHP is counseling their members on how to approach making this cultural shift. 

Ceci shared that they emphasize that this is going to be hard work. She pointed back to the early days of electronic health record adoption which took about a decade. Change is hard, especially when it's something personal, like healthcare. Ceci and Ginny both expressed that they just continually beat on the drum to remind their member plans to not give up and make sure the interoperability and serving patients the best way possible through the best use of data must be a top priority, but it will take a long time. 

Jocelyn agreed that the cultural shift for both big and small plans is still in the early days but that there are some early adopters starting to make more substantial changes. She added that of course there are still organizations that are still checking the regulatory box versus making real, systemic changes but as CMS and ONC continue this unprecedented alignment and increased communication with the industry about their priorities, it may make it easier for stakeholders to make the changes needed. Ultimately leaders need to keep evangelizing and painting the picture of the future and what it looks like from a roadmap perspective. 

So really laying out where things are headed from a regulatory perspective, [00:34:00] it does still surprise me that folks are taking the checkup, check the box approach. But I wholeheartedly agree with CC and Jenny, I think that this is about evangelizing and painting that picture forward, helping people understand what the roadmap work is and that it includes APIs and a patient-centered approach. Some will lead and some will follow. 

In closing, Pooja asked the guests if there were any final messages or calls to action, they wanted to put out to the industry. 

Ceci responded by saying that she thinks this is an incredibly exciting and a bit unnerving time and that she wanted to share the mantra all ACHP members get on a laminated card which is “think big, start small, act fast” 

Pooja closed out the episode by thanking guests, Ceci and Ginny before reminding listeners that they can find and subscribe to The Dish on Health IT podcast on Apple podcast, Spotify, or whatever platform you use to pick up podcasts and that videos of episodes can be found on the POCP YouTube Channel. 

Host Pooja Babbrah, Senior Consultant and Payer and PBM lead kicked off the episode focused on prior authorization, reducing burden and why working ahead of final federal rules isn't as risky as you might think. Pooja filled in for Ken Kleinberg, who is out of the office on an extended grand adventure. Pooja was joined by co-host Jocelyn Keegan. They welcomed guest, Danny Brennan, Executive Director and CEO of the Massachusetts Health Data Consortium (MHDC). 

Jocelyn introduced herself and shared that she’s literally done hundreds of hours of educating and evangelizing out in the industry about the work that is happening within HL7 from the FHIR community. She went on to explain that while doing this industry education, John Kelly, now retired from Edifecs, recommended she meet Denny Brennan explaining that Denny literally knows everyone in Massachusetts. Jocelyn continued to say that she has gotten to know Denny and the MHDC team over the last four years and has learned they are super smart, focused industry veterans filled with a lot of pragmatism about how the industry can get things done. 

Denny Brennan then introduced himself, sharing that he’s been the executive director of MHDC for the last 10 years. Denny explained that he spent the prior 20 years evenly divided between consulting and technology services. Denny added that MHDC has been around since 1978, so going on 45 years. Denny responded to Jocelyn’s point about knowing everyone, by saying0 that getting to know everybody in Massachusetts would have been an extraordinarily difficult thing if he didn't work for MHDC. 

Pooja then asked Denny to tell us more about MHDC before the transition over to the discussion topics. 

Denny shared that MHDC is comprised of everyone in the health data community in Massachusetts, some regional and some national players but that the center of gravity is the Commonwealth of Massachusetts. MHDC came about because the state, health plans and providers wanted an unbiased organization focused on health data with less focus on technology. Denny explained that nowadays technology and data are so intertwined that industry stakeholders end up moving between them more effortlessly than historically. The mission of MHDC is to create a patient centered health data system that enables the kinds of cost reductions, burden reductions, improvements in quality of care, enhancements in the patient experience, improvements in equity and access that are not possible when enterprises try to do this on their own. The MHDC motto is to start small, to start at the individual, and work from there. MHDC approaches this in a few different ways. One is to assist payer and provider members in understanding data governance in this new world. What does it mean to comply with regulations? What does it mean? What is FHIR? What does it mean to move to a world where patients are banishing their health data from the device and are connected to any and all of the services that help them achieve health? 

Denny continued to say that governance is just a start, to help people understand what's coming. Why? What happens if their organization doesn’t do it? What happens if they do? MHDC offers exchange services that operate to provide payers and providers the ability to share data with each other. MHDC also uses the exchange service as a launchpad, or a test kitchen, to explore how to automate real time processes, like making real time prior authorization a reality. MHDC also offers a web-hosted analytics service called Spotlight to organizations. Finally, Denny explained that MHDC is also called in to support consulting efforts to help organizations figure out how to implement some of these more modern approaches to data exchange. 

Pooja responded that she loves the idea of the test kitchen role. She then asked him to expand more on the test kitchen idea, describe why the Massachusetts location is so important, and why prior authorization seems to be such a central focus on MHDC. 

Denny responded by saying that the test kitchen concept is a reflection of a personal bias of his, but also that healthcare is an industry that is governed in many respects by followership. He added that nobody wants to be the first to fall off the pier and land on their heads. They want to see other organizations do that, do it successfully, and then others will follow creating a tidal shift in adoption. Denny emphasized that it’s important that organizations recognize that they won't know everything when starting out and won't know where a project may end up. He went on to explain that rather than ready, aim, and fire, the MHDC approach is more aim, fire, get ready again, aim, fire, get ready again. Interoperability is an iterative process. Denny changed analogies and said that the industry doesn’t have to try to eat the entire elephant and to just take one bite at a time.Denny further explained that the test kitchen is a way for organizations to start with what is known but to reduce the risk so an organization can experiment without basing major business operations on it.

Denny transitioned to talk about why prior authorization is a major focus of the work that happens in the test kitchen. He explained that it’s because everybody hates prior auth. PA involves patients, physicians, and health insurance plans. Denny observed that it seems everyone would like to do it better but has a different idea about how to do it better based on their perspective. The MHDC approach is that this is a business process that, if automated, will enable organizations to automate other things that are far less complex. The work undertaken to automate PA could take a big chunk out of what goes into avoiding another industry focus, surprise billing. 

Denny stressed that MHDC is a consortium and brings members, who are both competitors and partners, into the same room to tackle what is essentially infrastructure challenges they all face. This type of collaboration allows MHDC to learn what their issues are, what their fears are, what their concerns are and we can start addressing those right up front. 

Pooja then shifted the conversation and asked Denny to explain the Automation Advisory Group including its maturity, how many members are participating and whether listeners can expect any reports or other outputs.

Denny explained that the Automation Advisory Group is being done in partnership with the Network for Excellence in Health Innovation (NEHI) and the effort is one side of a two-sided coin that MHDC is using for prior auth. The other side is prototyping, a real prior authorization implementation in an automated compliant, industry standardized way so it can be replicated and scaled across multiple payers and providers. MHDC is starting with one payer and one provider, one technology company to take a bite out of the first piece of prior authorization sticking to the rules, sticking to the standards and learning from the experience. The Automation Advisory Group is made up of about 40 approaching 50 individuals, representing payers, providers, hospitals, medical groups, individual physician practices, vendors and policy makers, that will be assembled over the course of the next year or two. Denny went on to say that MHDC’s strong suit is bringing together a coalition, a consortium of representatives from across the industry in Massachusetts and nationally to tackle problems together. Government participation includes Center for Medicare and Medicaid Services CMS, the Office of the National Coordinator (ONC), Massachusetts Executive Office of Health and Human Services as well as the Health Policy Commission. The effort is being funded by a mix of vendors, technology services companies and the Health Policy Commission. The goal is to take the Commonwealth of Massachusetts and automate prior authorization statewide in two years which will require legislation. Regulators were brought to the table so they can get everything they need to create a meaningful law. The idea is that this law should not just be a stick, but also offer carrots in the form of implementation and technical assistance. 

Jocelyn responded to Denny by saying that this Automation Advisory Group is providing a great test bed that allows organizations to see how certain products and technologies can be leveraged but to also think about the business processes that will need to change. Joce explained that there are hard decisions about what happens when new technology is applied in the real-world. Jocelyn continued by saying that the industry is at a sea change where standards have a critical role. Jocelyn then expressed how thankful she is for organizations like MHDC who are willing to be forward first and that she wishes there were more organizations out there doing this kind of work and recognizing that there is a competitive advantage to starting down the path early. Jocelyn went on to say that this work is a set of building blocks putting together the right technology with the right processes to solve problems rather than checking a regulatory box. 

Pooja asked Denny whether he felt like it was risky for organizations to move toward automating prior authorization before the PA and burden reduction rule is re-issued. 

Denny responded that there is always a risk at being out in front, but the risks are bounded by the fact that you stub your toe in a relatively circumscribed implementation and you move on. The downside risk of not moving forward is you don't know what you don't know and can be caught flat-footed when a project has a longer lead time than expected or requires expertise or resources an organization doesn’t have. Denny further explained that the emergence of acute need for telemedicine during the pandemic has made the use case for innovation more clear in some cases which helps make the decision to act a little easier. Denny added that the risk of a failure to implement is much higher than being out in front. 

Denny continued by saying there is a convergence of consumer demand for information and transactions to be more real-time and at their fingertips in the same way they get it from their bank or shopping on Amazon, policy to drive interoperability and standards and technology to enable the shift. Denny concluded by saying that consumers will find the payers, providers and tools that meet their needs so if an organization doesn’t act, there is a huge risk of losing customers, members, patients to competitors that have done the work to be interoperable. 

Jocelyn responded by commenting on the unique Massachusetts landscape due to the competitive payer market. There isn’t one predominant payer that owns most of the market. Jocelyn went on to say that another thing that is different now is that CMS and ONC are looking to the industry to lead, they are watching and listening to what is happening and making policy to spur the rest of the industry into the direction of what seems to be working which is APIs. Jocelyn expressed her complete agreement that there is more risk in doing nothing rather than taking on incremental projects and incurring some risk but moving the needle. Jocelyn continued to say that we know these projects will take longer than people think and that means that those choosing to do nothing and wait policy to force change will be at a huge disadvantage. 

Pooja followed up by asking about the seemingly increased coordination between CMS and ONC in their policy making and wanted to know whether Denny felt this coordination made their overall rulemaking stronger and more robust. 

Denny responded by explaining that MHDC knows Micky Tripathi, the National Coordinator well because he is a Massachusetts native and used to manage the Massachusetts eHealth Collaborative. Denny continued by saying that Micky knows the provider side of the business extremely well, he understands APIs and knows technologies. Micky also knows moving providers to interoperability is an entirely different exercise than moving payers to interoperability. He also knows there are deep cultural shifts that must happen. Denny went on to say that because the industry initially built enterprise level electronic medical records, health data was sort of feudalized and in many ways, providers were incentivized to hold on tight to their data. This enterprise level approach did not develop the kind of agility required for interoperable data exchange that will better support patient care but the industry didn’t know then what it knows now. 

Denny continued to say that with respect to ONC and CMS that when the first rule was published from CMS about prior auth. The rule was groundbreaking because it brought the agencies together and put the patient squarely in the middle. This was a different approach from focusing on the bickering that had been happening where providers arguing they weren’t paid enough and payers arguing providers spent too much. CMS and ONC, rather than saying payers and providers start getting along, they said, you've forgotten about somebody, the patient, the consumer, the member, the person, the individual. There are 330 plus million of them and they are a critical part of solving healthcare problems. Denny concluded by saying that neither payers or providers want to seem like they don’t care about the patient and ultimately consumers need access to information to help make the best healthcare decisions. 

Pooja expressed her agreement that the patient should be the focus and asked Denny to describe his future vision of healthcare. 

Denny responded by saying that he believes that having patient advocates at the table will help get us where healthcare needs to be. He clarified by saying that by patient advocates he means people who can give voice to the type of data that is most needed by patients and their caregivers to make the best decisions. He explained that health plans and health systems in the healthcare delivery business may lose sight of those granular patient needs because they are dealing with administration, regulations, and compliance. Denny continued to say that another movement that is huge is health equity. With equity the industry doesn’t yet know what to measure to make an impact. Denny recommended that everyone start small instead of trying to set up a great big equity initiative. Denny added that instead of trying to envision the perfect equity solution, which is impossible to envision because everyone is different, start with something that supports the disadvantaged members of your own community. Try out something on a smaller scale, see what works and build on it, just take a bite out of the problem.

In closing, Pooja asked if there is a final message or call to action that Denny wanted to pass along to listeners. 

He responded by saying to get outside of your organization, meet with business partners and competitors and recognize that many of the challenges they all face is about infrastructure not sources of competitive differentiation. He went on to say the industry needs to lay the railroad tracks or the highway system or the power grid. He expressed that the industry is building something that will make it possible for us all to live better and do business better and care for patients better than before, but it can’t be done in silos. He encourages the industry to come together. He continued by saying that as organizations start working on things and start winning, however small, people will start coming to those organization because they’ve done something that hasn’t been done elsewhere. Denny concluded by saying that organizations just need to take a step, however small, and to not forget about the patient. 

Pooja concluded the episode by thanking Denny for joining the podcast as a guest and thanking Jocelyn for being a fun and informative co-host along with a reminder to any new listeners that they can find The Dish on Health IT on Apple Podcasts, Spotify, Healthcare Now Radio and the Podcast Channel and that videos are posted on the POCP YouTube Channel. 

On this episode of the Dish on Health IT podcast, guests April Todd VP at the Council for Affordable Quality Healthcare (CAQH)and Erin Weber Committee on Operating Rules for Information Exchange (CORE) Director at CAQH to discuss driving adoption of transactions and standards in pharmacy and medical benefit, FHIR use cases such as prior authorization, burden reduction and return on investment as well as value-based care.

April opens the discussion by giving a brief overview of her professional career and time at CAQH. She notes her fortune in being able to work in almost every sector of the healthcare and healthcare policy space. April has had experience in government, the health plan side working in the consultant and IT space, and now with CAQH within the nonprofit sector. She mentions her learned appreciation of the diversity of perspectives and the need for agreement and alignment to make progress within the industry.

Erin says her experience is in strategic revenue cycle consulting. She has done work with the Veterans Health Administration as well as with an advisory board company where she worked with hospitals and health systems around the country to identify and implement best practices. The mission of CORE speaks to April. She is passionate about bringing together disparate stakeholders to have difficult conversations around driving interoperability.

Ken asks April and Erin to give an introduction into CAQH and its activities. They explain CAQH is a nonprofit organization focused on helping to streamline and simplify the business of healthcare, mainly the administrative space. The company can be divided into three parts. The research arm, called Explorations, works with the industry to gauge the progress towards automation and to identify areas of improvement. There is also a policy arm called CORE trying to work towards consensus on how to operate between plans and providers on transactions and standards. CAQH also brings solutions (utilities) to the industry, a central place to do things where a competitive approach doesn’t make sense. Overall, the organization is really trying to bring people together to drive consensus. 

Ken asks how the industry is managing recent transformation. April states that as technology advances, the industry is going to need to learn to adapt more quickly. She believes we are always going to have a push and pull between existing standards and technology and new standards and technology. CORE is trying to facilitate organized industry advancement where there are common expectations. April notes there are always going to be organizations way ahead and others that trail behind. We’re seeing the biggest challenge to be getting stakeholders aligned and moving in the same direction using similar processes.

Erin adds that “attachments” mean clinical documentation (for CAQH and their participating organizations), and how you connect the clinical and administrative data to support where the industry is at now. She goes on to explain there is a lot of partially electronic and manual work being done to exchange this documentation for both prior authorization and claims, which is a significant source of administrative burden. A CAQH subgroup just completed the development of draft operating rules for prior authorization use case related to the exchange of attachments. The hope is those rules will be finalized later this year. A key aspect of the draft rules was how to consider how both X12 and FHIR transactions can work well together. We know this is what will have to happen for a successful transformation, so the group looked at the various exchange formats, and both are included in the draft rules.

Jocelyn notes that as we see transformation happening, we must be cognizant of our massive investment in X12 and the fact it runs a large part of the world we operate in. However, we need to bring administrative and clinical data together to make the shift to value-based care. Looking at stakeholder roadmaps and pipelines, what is being prioritized is what’s pushed from a regulatory standpoint. We need to make sure we’re meeting everyone where they are today. We’ve seen if we don’t acknowledge current state, then we don’t get the adoption we expect. Jocelyn says the work CAQH and others are doing are going to be incredibly important for regulators to look at to make sure they have an inclusive answer, taking advantage of the existing technology, but also understanding people may want to leverage existing rails already in production.

Ken asks April about CAQH’s methods for determining cost reductions, time savings, burden reduction, etc. for standardized transactions. What are the findings? April says one of their methods is through their explorations program, particularly the CAQH Index that surveys payers plans, providers and vendors in the industry. The goal is to understand the volume of different types of transactions. How are they conducted? Are they done manually? If your phone and fax and mail? Are they done electronically using the standards that have been established? What is the cost of staff time to do all the transactions? More recently, the survey included questions about value-based care, the use of FHIR and the impact of COVID on transactions.

Jocelyn reinforces the importance of the survey as we must measure things in order to understand where we’re making progress and where there are barriers. The goal is to get people to move to automation.

Ken asks the group why the use case of prior authorization has the lowest level of adoption and what could improve the current situation. Erin says there is a lack of understanding around the breadth of information available in the transaction. She was surprised by the number of providers they spoke to who were unaware of the HIPAA transaction, despite the work done to educate the industry. Erin did see a bit of an uptick in the automation of prior authorization in the CAQH Index from 2019 to 2020. CAQH CORE has developed a set of prior authorization operating rules addressing things like additional data content needs to convey documentation needs. The industry needs to continually adopt and align expectations across various transactions and standards available. 

Ken asks what role CAQH plays in the adoption of value-based care. Erin notes that, just as when CAQH CORE was founded and HIPAA transactions were first being implemented, the board is feeling some of the same pain points. Even though you may have standard processes and ways of doing things, everyone will still do things just a little bit differently, which makes it hard to automate and can create real burdens. The board proposed conducting research to really understand where there might be opportunity to create some more uniformity in the industry and reduce that administrative burden, improving information change and enhancing transparency across the clinical and administrative verticals. Erin says you can’t look at value-based care and fee for service as two separate worlds, it’s a continuum. They approached research by looking at the revenue cycle, across fee for service and value-based payments, and tried to understand where there needed to be differences where there were different data needs.

April discusses next steps. She says they have a priority list from the advisory group and attribution was identified as most important. They are also monitoring FHIR, and progress being made there. April says they are currently working on things we can do in the exchange of information to support quality measures and gaps in care. They are conducting an environmental scan to gauge what is happening and what could be done to simplify. Overall, she thinks CAQH’s role is aligning and bringing stakeholders together to create common expectations. 

Erin’s gives her final thoughts. She asks that if you see a request for their Index, please respond. She also brings up the fact that they have been working to help put a utility out to support the CMS and ONC interoperability rules and to help people connect to have a trusted place of information around FHIR.