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Interoperability and Why It Is Long Overdue to Bend the Cost Curve:

In March 2020, Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) released detailed rules and guidelines on healthcare data interoperability designed to provide patients with easy and complete access to their healthcare information. Seamless movement of healthcare information among health plans, providers and members is critical to better manage patient health. Interoperable movement of healthcare information has been a significant challenge. A solution long overdue in order to bend the healthcare cost curve.

Healthcare consumers interact with different types of care providers to manage their health based on their needs and this care can be delivered in different types of settings. Whenever a patient receives care an ambulatory or acute setting it generates important clinical data. Historically, this clinical data has been locked in various electronic health record (EHR) systems in proprietary formats and that market has been highly fragmented.

Once the care is delivered, these providers submit claims to insurers for reimbursement for these services. Health plans, in turn, process these claims and make appropriate payments to the providers a process that generates financial and administrative data. These data have been locked in various systems across health plans as consumers move from one health plan to another. In some cases, consumers had limited access to the clinical and financial data through their health plan and provider portals but they had to manually aggregate that data as these portals are siloed.

The interoperability standards will enable the health plans and providers to seamlessly share the clinical and financial data. Health plans will be able to provide the claims and provider directory data through common APIs that can be leveraged by third party apps. These third-party apps will be able to provide tools to better engage members in managing their health across the care journey.

Better member engagement is important to drive member enrollment in care management initiatives. It’s also critical for the effectiveness of case management, disease management and utilization management interventions that help reduce the cost of care across member populations. Updated provider directory and claims data can be leveraged to improve cost transparency for members and can help steer them to appropriate high quality and low-cost sites of care which thereby help improve affordability.

Interoperability and third-party developer access to healthcare data will provide opportunities for innovation. These developers will be able to aggregate patient data across multiple payers, providers and other healthcare entities. Consumers will get access to new technologies and tools that will support them to get more engaged in managing their health and wellness. As consumers get more engaged, providers will be more effective with their care management interventions across patient populations thereby helping improve costs and health outcomes.

Prolify is excited to be part of this change. We are leveraging our deep understanding of data interoperability standards like FHIR (Fast Healthcare Interoperability Resources) and digital technologies like artificial intelligence (AI) and machine learning (ML) to help accelerate the data revolution in healthcare.

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