By Chantal Worzala, PhD
Through a combination of public and private sector efforts, the health information underlying our healthcare system has undergone digital transformation, leading to great promise for better informed and safer care, increased individual engagement in health, and improved efficiency. However, the two main streams of health data the system relies on—administrative and clinical—have developed on separate trajectories, use different technical standards, and are not yet easily integrated. This reality leads to less than ideal consumer experiences, significant provider burden, and excessive administrative costs. Delays in care and missing information also can lead to adverse outcomes for patients.1
These challenges have recently caught the attention of federal policymakers. This spring, two federal agencies joined forces in releasing a report on how to reduce the burden of using health information technology (IT). One aspect that the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) focused on was reducing the burden of prior authorization and other administrative transactions that require sharing administrative and clinical information across providers and payers. These agencies are actively considering how to better integrate administrative and clinical data.
Separate Data Streams, Separate Rules
Until now, the rules for how to record and share administrative and clinical data have traveled separate tracks. CMS generally sets the policies and adopts the standards for administrative transactions, as required by the Health Insurance Protection and Portability Act (HIPAA). These transactions, such as eligibility, claims submission, and remittance advice, are at the heart of the revenue cycle. By contrast, ONC adopts standards and certification criteria for electronic health records (EHRs) that generate and store clinical data, as set forward in the Health IT for Economic and Clinical Health (HITECH) Act. That data supports care provision but is also used to document and justify provider billing.
We Live in a Digital World
Both administrative and clinical data are now largely digital. For example, more than 3 billion medical claims were processed electronically in 2018, representing 96 percent of all claims, according to the 2019 CAQH Index.2 And, according to federal statistics, 96 percent of hospitals and nearly 80 percent of physicians have adopted certified EHRs.3,4 However, when it comes to sharing clinical data to support administrative processes, or integrating clinical and claims data to support value-based care, automation is not a given. In fact, many times, provider organizations are forced to default to web portals, fax, and phone to justify an admission, treatment, or prescription.
Benefits and Barriers
Creating ways to bring together the two tracks of clinical and administrative data would ease these provider pain points. For patients, there is the potential to decrease wait times and interactions needed to complete authorizations and provide a better understanding of financial obligations at the point of care. For clinicians, these improvements could reduce burden in responding to data requests and decrease time spent on administrative activities. For payers, more efficient exchange of clinical data could provide more usable information for tasks such as proving medical necessity and identifying fraud and abuse, among other things. In short, all parties stand to benefit.
However, greater sharing of data across provider and payer settings will require trust. For example, how will providers know whether payers use clinical data exchanged to adjudicate payment for other purposes, such as setting premiums or benefits design? Could greater payer access to clinical data lead to greater second-guessing of clinical judgement? There are also many aspects to be worked out beyond automation. For example, prior authorization and authorization for inpatient care currently is characterized by variability in the data requested to make a determination—both across payers and across plans offered by a given payer. More standardization of business rules will be needed to really reduce burden. Creating greater integration may also require looking at operational issues, workflow, changes to IT systems, and how to ensure the workforce has the right skills to manage a more automated approach. Additional key issues include data integrity, protecting patient privacy, and implementing adequate security tools.
Increasingly, policymakers see that finding ways to better integrate these data streams could allow for better automation of some of the biggest sticking points in healthcare—inpatient authorizations, prior authorizations, utilization review, case management, and medical necessity review, to name a few. For example, CMS has implemented a pilot program to facilitate real-time sharing of clinical data in support of existing fee-for-service Medicare documentation requirements. The pilot covers oxygen and continuous positive airway pressure (CPAP) devices.5 Three other efforts are notable:
- CMS recently finalized a rule requiring the payers and plans it regulates to make claims and other data available to third parties by apps via an application programming interface (API) that uses a standard adopted by ONC (HL7 FHIR 4.0.1).
- ONC finalized a rule requiring EHR vendors to make clinical data available to third-party apps using the same API standards. This creates a technical framework to support sharing.
- A joint task force of two federal advisory committees, the National Committee on Vital and Health Statistics and the ONC Health IT Advisory Committee, is working to develop recommendations for the federal government on how to “support the convergence of clinical and administrative data to improve data interoperability to support clinical care, reduce burden and improve efficiency.” The joint task force plans to make recommendations in September and NCVHS will separately address the issue this year.
CMS and ONC have also shown interest in the Da Vinci Project, which is an undertaking of the HL7 standards body to leverage new technical approaches, such as the FHIR API, to share data across providers and payers. Among other use cases, the DaVinci Project is tackling real-time interactions to automate payer/provider communication mechanisms on coverage requirements discovery, documentation templates and coverage rules, prior authorization support, and data exchange for quality measures.
Increasingly, technical solutions to facilitate the flow of data across administrative and clinical purposes are being developed. Policy actions will be needed to ensure that the many factors beyond automation—such as trust, standardization of business rules, privacy, and security—are adequately addressed. And health information professionals should be at the table to ensure that their perspectives and operational know-how inform policy. To that end, AHIMA is actively monitoring policy efforts and has created a work group to inform the association’s advocacy in this area. That work is just beginning. We will be sure to keep you updated as it continues.
- National Committee on Vital and Health Statistics. “Additional recommendations for HHS actions to improve the adoption of standards under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.” December 10, 2019. https://ncvhs.hhs.gov/wp-content/uploads/2019/12/NCVHS-Recommendation-Letter-HHS-Actions-to-Improve-the-Adoption-of-Standards-Under-HIPAA-December-2019.pdf.
- “2018 CAQH Index: A Report of Healthcare Industry Adoption of Electronic Business Transactions and Cost Savings.” 2019. https://www.caqh.org/sites/default/files/explorations/index/report/2018-index-report.pdf.
- “Office-based Physician Electronic Health Record Adoption.” Health IT Dashboard. 2017. https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php.
- “Percent of Hospitals, By Type, that Possess Certified Health IT.” Health IT Dashboard. 2017. https://dashboard.healthit.gov/quickstats/pages/certified-electronic-health-record-technology-in-hospitals.php.
- “Documentation Requirement Lookup Service Initiative.” Last modified January 13, 2020. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/LookupServiceInitiative.
Chantal Worzala is principal at Alazro Consulting and is currently working as a consultant to the policy and government affairs team at AHIMA.
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