The Great Data Migration: How Health Information Networks Are Evolving Beyond Treatment

Once upon a time (let’s call it the EHR era), health information networks were all about treatment. Providers exchanged clinical data to coordinate care, avoided duplicate tests, and generally tried to piece together that elusive longitudinal patient record.

Today, we’re witnessing a maturation and expansion of these networks. The introduction of TEFCA (Trusted Exchange Framework and Common Agreement) looks to be a game-changer, opening up new exchange purposes beyond the traditional treatment use case. Take, for instance, operations-focused use cases: These workflows offer new value and opportunity, especially for payors.

This evolution isn’t just about adding new buttons to push. It’s a fundamental shift in how we think about health data exchange. We’re moving from a world of siloed, purpose-specific networks to a more interconnected ecosystem where data can flow more freely (with appropriate guardrails, of course) to serve a variety of healthcare needs.

Payors have always needed digital interchange, especially access to clinical data for risk adjustment, quality reporting, care management, etc. While providers were dragged out of the analog past via HITECH, this did not translate into digital exchange with payors for most workflows. Faxes, phone calls, and manual record retrieval has been the status quo outside of core eligibility and claims data exchange.

The emergence of operations-focused data exchange through networks like TEFCA provides payors with a more efficient paved path to accessing needed clinical data. This improved access not only streamlines existing processes but also opens up new possibilities for leveraging clinical data to enhance operations, improve decision-making, and drive better outcomes for members.

Several important use cases are now available to payors with this expanded network access:

1. HEDIS Reporting: With operations-focused data exchange, payors can potentially access the clinical data they need for HEDIS reporting directly through health information networks. No more chasing down individual providers or sifting through incomplete claims data.

2. Risk Adjustment: Accurate risk adjustment is crucial for payors, especially those dealing with Medicare Advantage or ACA exchange plans. Access to comprehensive clinical data through these networks can provide a more complete picture of member health status, leading to more accurate risk scores.

3. Care Management: For payors engaged in population health management or running their own care management programs, access to real-time clinical data is a game-changer. Imagine being able to identify high-risk members, track care gaps, or coordinate care across multiple providers, all through a unified network.

4. Prior Authorization: While not explicitly called out in the current TEFCA operations use case, there’s potential for these networks to streamline the prior auth process. Payors could potentially access the clinical data needed to make authorization decisions more quickly and accurately.

This shift in data access is likely to significantly impact payors workflows and decision-making processes.

First off, data acquisition processes are likely to be turned on their head. Instead of the traditional “pull” model where payors have to go out and hunt for the data they need, we’re moving towards more of a “push” model where data can flow more automatically through these networks. This shift has the potential to dramatically speed up processes like risk adjustment and quality reporting. Instead of waiting weeks or months to get the data needed for these activities, payors might be able to access it in near real-time.

But it’s not just about speed: The potential for more comprehensive and timely data access could fundamentally change how payors approach decision-making. Imagine being able to make risk adjustment calculations on a continuous basis rather than once a year. Or being able to identify and address care gaps as soon as they appear, rather than months down the line.

With this expanded data access comes increased responsibility. Payors must carefully consider how they use this information, ensuring adherence to patient privacy regulations, maintaining robust data security, and implementing appropriate use policies to protect member interests.

Although the expansion of health information networks offers promising opportunities, we’re still in the early phases of this transformation and face several challenges ahead:

• Building Trust: Ensuring buy-in from all stakeholders – providers, payors, and patients – is crucial for this expanded data sharing. Transparency about data usage and implementation of appropriate safeguards are essential to build and maintain trust.
• Technical Optimization: Scaling this data exchange to handle billions of transactions also poses significant technical challenges. Ensuring smooth operation of these networks at such volumes will require robust infrastructure and ongoing optimization.
• Regulatory Landscape: While initiatives like TEFCA are paving the way for expanded data exchange, there’s still a complex web of federal and state regulations to navigate.

Despite these challenges, the expansion of health information networks to include operations use cases represents a significant step forward in the journey towards a more connected, data-driven healthcare system. For payors, it offers an opportunity to transform operations, moving from reactive to proactive approaches and from fragmented to more holistic views of member health.

As we navigate this evolving landscape, the potential for improved decision-making and better health outcomes makes this journey a worthwhile endeavor for all involved in the healthcare ecosystem.

HTD is a healthcare technology consultancy specializing in interoperability and data liquidity. We offer strategy consulting and implementation services to help organizations like payors maximize the potential of health information networks. Ready to navigate this evolving landscape? Contact HTD today to learn how we can help you leverage these new opportunities and overcome the challenges ahead.