Health IT: The Promise of Interoperability

The promise of interoperability for health IT is that it can help knit together our fragmented, disconnected health care system, while at the same time help usher in a new era of consumerism. 

But it’s not as easy as it sounds. Consumers, physicians, hospitals, health care professionals – indeed, all of us – are currently paying the price for our fragmented, disconnected system. The rising tide of consumerism that will bring millions of Americans into this system will only challenge it more. 

As the CEO of a health care company and as someone who has had to navigate this system to receive urgent care, I’ll be the first to admit it: the system has not been designed for people but rather built from a supply perspective. The system has been cobbled together over the years and has been internally focused, not customer-experience focused. 

Statistics show the consequences of this fragmented system. Examples are glaring: $210 billion spent on unnecessary services such as repeated tests, $156 billion spent in 2007 on dealing with claims processing and prior authorization of physician claims. This is expected to reach $315 billion by 2018. 

The average physician spends approximately $68,274 each year interacting with health plans, with the total cost nationwide estimated at $31 billion. When more time is being spent on administration, physicians have less time to spend with their patients. And to make this even tougher, people have to wait two weeks or more to get an appointment with their family physician. 

More Stress on a Broken System 

The Affordable Care Act (ACA) will bring 25 million more people into this broken system by 2017 through the exchanges. The retirement of the Baby Boomer generation is reflected in the Medicare population potentially increasing to 81 million by 2030. These changes will have a significant impact on the consumer-centric evolution taking place in health care.

Our health care system has gone from episodic care in the last century to chronic care today. In the 21st century, chronic care is where the health care system needs the most help, as evidenced by the fact that “chronic illnesses account for 75% of the $2.2 trillion we spend on health care each year in the U.S.” 

This movement from episodic care to chronic care has further exacerbated the problem of system fragmentation. Slowing the progression of chronic disease depends on coordinated care, and coordinated care depends on connectedness. As we improve our understanding of people and their chronic conditions, we better our ability to monitor, understand and use influential points in a person’s life to improve health. 

Today’s health care business models are inhibiting progress in treating people with chronic conditions. The models are characterized by two overarching problems: 

• Fee-for-Service Reimbursement – Physicians are paid and incentivized based on volume (number of services they perform), not improved health outcomes for the patient.

• Siloed System – Fee-for-service reimbursement contributes to fragmentation and silos, where it’s about controlling information, making money from the flow of information, and the information not being shared where it could improve health outcomes. 

But the system is fragmented not because there is a lack of innovation or tools. The way we do business today is what has created this system and the system needs to change, from forfeiting IT restrictions that don’t enable information sharing to potentially reducing prior-authorizations.

An Ideal System 

So what does the ideal environment look like that solves these problems? For starters, it’s ubiquitous and transparent. Details on medical procedures – including easy-to-read pricing – are available at the tap of a button on any mobile device. There are three main elements that serve as the foundation for this ideal system:

• Value Rewarded – The transition to value-based payment models will go a long way toward delivering this ideal system, where physicians are reimbursed for the health outcomes of the patients they serve, not the number of services they provide. The Department of Health and Human Services should be applauded for its goal to move to 30 percent of Medicare into value-based payment models by 2016 because the evidence shows this delivers better outcomes and quality and lowers costs. 

• Consumer Choice – This ideal system’s holistic approach puts the individual at the center of care. As we’ve seen with the 16-plus million people who have signed up for Medicare Advantage, or the nearly eight million who signed up last year through health exchanges, it’s a person’s ability to choose their health partner that can help them get on the path to better health. 

• Fully Integrated – The ideal system is fully connected. Information flows freely and securely across the provider spectrum, connecting all aspects of care delivery and easing the process of decision-making. Information is fully transparent and easy to understand for individuals, thus creating a more knowledgeable and empowered consumer through a structure designed to promote innovation. 

Let me be clear: It won’t be easy building this ideal system. It will require us to change the conversation from volume to health and from the needs of industry to those of the individual. We’re making progress around the edges, but the real change will require bolder steps.

To begin with, health insurance companies need to take bold steps in simplifying processes and focusing on elements that improve the health outcomes of people. They need to deliver better information to providers in real-time – while connecting these providers – thus enabling them to close gaps in care.

Providers need to embrace and chart a course to the value-based payment model. The change won’t be easy for many. In the short run, it will require hard choices, especially when hospitals’ long-time focus has been filling beds. But the health, quality and costs benefits can help these providers usher in a new approach to care. 

Lastly, the health IT community needs to embrace the free flow of information and not look at it as an opportunity to charge tolls or restrict progress when it comes to data sharing. Some progress is being made. Recently, I had dinner with the CEO of a major medical device company, who talked about how his company had been so focused on the expansion of devices but not about how the devices could do more to improve health outcomes. He challenged his sales and products teams to focus on changing the devices specifically to improve health outcomes.

The Promise of Interoperability 

Interoperability is fundamental to building the ideal system that can stem the rising tide of these chronic conditions while ushering in widespread adoption of preventive care measures. But interoperability is still on the horizon, not due to a lack of technology, but due to the way we view the problem. 

We’re all familiar with the promise of interoperability. It eliminates waste in the system by removing medical errors and duplication; helps coordinate care and improve prevention; fosters value-based payments; and delivers more options and choices for consumers and providers.

The good news is that we’re moving towards interoperability: 62.8 percent of U.S. physician practices have adopted EHRs. But, as we know, EHRs are not fully integrated; they’re siloed. So how can we create the connectivity to unite these siloed EHR systems? 

It’s not standards or new technology. It’s a question of access to information sharing and personalization. Many people think interoperability is a technical problem that requires a new tool or solution. In actuality, it’s a cultural problem that requires a new way of thinking.

Interoperability is multidimensional, not linear. It doesn’t just connect the doctor and the patient. It also connects caregivers, the gym, the pharmacy, social support network, the family, etc. Interoperability is the symptom of the disease we have as an industry, which is our siloed structure. We need to change because the consumer can’t do it.

It’s also important to understand the impact of interoperability on data generated by participants in the health care system. Interoperability unlocks aggregated and integrated data. Integrated data is unlocked by data analytics. When you use analytics, you unlock coordinated care, and coordinated care unlocks improved health outcomes.

Changing the Focus

Interoperability’s main benefit is not for the health industry; it’s for people and their doctors. And it requires placing people and physicians first, versus protecting current business models. Connecting all parts of the health care system by addressing the cultural aspects required for interoperability will do more for the consumers and their health. 

It will be tough, but other companies and industries have faced and met similar challenges. Take Apple. Instead of just focusing on the hardware (iPods, iPhones), the company knew that the empowered consumer wanted content. The partnerships that fostered an explosion in content through iTunes enabled Apple to build a brand loyalty unlike anything seen in our time.

Also consider Charles Schwab. After the dot.com crash, the company doubled-down on its customer experience focus and worked to tailor customer interactions to match personalized investment needs. Despite the highly regulated industry – similar to ours – Charles Schwab was able to deliver a customer experience (“Talk to Chuck”) that has served as a model for many to follow. Apple and Charles Schwab had something in common: they knew that the customer experience needed to be transformed by changing their business models.

From my experience as Humana’s CEO, I can tell you that going from an underwriting-based model to one where we take all comers was a big move. So is Humana’s bold goal which we recently announced: To improve the health of the communities we serve 20 percent by 2020 by making it easy for people to achieve their best health. We went into the most under-served areas of Mississippi where we provided health coverage in the first year of exchanges when no other carrier would do so. These actions are not reflective of the traditional insurance company but it’s going to enable us to make a real difference in health. 

Let’s Do This Together

Building this ideal health system requires all of us – health insurers, providers, technology companies – to challenge the way we do business. We may all be contributing to the progress of interoperability, but we’re doing so independently. As an industry, we need to take atypical steps and make ourselves uncomfortable. This will challenge our business model in ways we never imagined. 

We can make this happen in health care by starting to look at interoperability in a different light. Consumers can’t create interoperability. Government can’t create it; they can only set standards. The industry must create it. By recognizing that our business models need to change, we can take the key first step in delivering on true interoperability.

It’s time to put the consumer first and industry second, making information less proprietary and more of a shareable asset. If we want to change the industry, we all have to get uncomfortable and take bold moves. It’s about the free flow of information. It’s not about paying claims; it’s about improving health outcomes. 

And the time to be bold is now.