Episode 17: Going Beyond "Checking the Box" for Policy Adherence
On this episode of The Dish on Health IT, Alix Goss vice president and senior consultant at Imprado joins our hosts Ken Kleinberg, Pooja Babbrah and Jocelyn Keegan to talk historical policy and standards milestones, how they brought us to where we are today and why it’s important for the industry to go above and beyond the mentality of just checking the box for policy adherence in order to gain a competitive advantage and achieve better patient outcomes.
Kens asks Alix to give us a breakdown of how we got to where we are today in health IT. Alix kicks off the podcast by explaining that for several decades, we’ve been trying to address improved affordability and outcomes in our healthcare system. It's about the right data at the right time for the right patient and in the right format. In 1996, under the Health Insurance Portability and Accountability Act, we set off on a journey that forced us to be on a trajectory, as a nation, in our information exchange for administrative simplification. Think of that as governing, or establishing, pharmacy and medical standards along the way, in the 1999 to 2003 timeframe.
Then, we rolled up our sleeves and tried to make all of that work only to realize we really needed to bring clinical aspects into it too. We started working on the American Health Information Community (AHIC) under the Bush administration, which helped us figure out what clinical data exchange needed to look like. A lot of the work was memorialized under the Health Information Technology and Economic and Clinical Health Act (HITECH) of 2009. Shortly after, we got the Affordable Care Act. Then came the Medicare Access and CHIP Reauthorization Act of 2015, which established a robust Quality Payment Program, changing the way Medicare rewards for clinical value over volume. Most recently, our journey continued with the 21st Century Cures Act in 2016, which promotes and funds the acceleration of research and drug and medical device development.
In the end, HIPAA gave us administration simplification and now 21st Century Cures is bookending decades of progress and forcing us into this intersection of clinical administrative data all around the patient.
Ken asks Alix if she believes Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs) and rated standards are innovative. She responds with a question. What is your definition of innovation? If you’re in other industries you’re probably thinking, yeah, not so much. But for healthcare, we’re so complex with the variability of all the data elements. Our current transaction evolution to adopt FHIR will provide us with greater flexibility throughout the entire process. Alix thinks FHIR is the way we're going to bridge a great deal of problems, but she does not necessarily see electronic data interchange (EDI) going away. It’s gotten into the DNA of our architectures and our business decisions. It’s the way we do things. We like to adopt new standards, but where we always fall short is doing the cultural transformation of workflows as opposed to sometimes just having a “check the box” mentality.
Jocelyn, who has extensive FHIR Accelerator experience, notes it is no longer just about the rules or the laws that have gone into effect, it really has to do with if we’re not figuring out how to make value-based care work, what is our alternative? What will push people to make the shift? The pandemic further exposed current weaknesses in our ability to exchange clinical data, to let us roll out vaccines at scale across our public health infrastructure. There could not be a more compelling business case for why it’s so imperative for everyone to start picking up existing tools and implementing. As data starts to free and more players implement, those that don’t react or those that have the “check the box” mentality are going to put themselves in a significant competitive disadvantage in the coming years.
Pooja has examined these issues from a patient, CARIN Alliance perspective. She is concerned with how we make it easier for patients to access and share their data. FHIR APIs finally get us to that point where it’s easier for patients to download their data. We’re getting to the point, thanks to some of the recent technology and standards, where it is easier for patients and consumers to download their information and to do searches on price transparency.
Ken moves the conversation to payers. He asks Alix if this stakeholder group is embracing change or just “checking the box”. Alix says it is a very mixed landscape out there as far as opinions and corresponding strategies. There are some who are only going to come along when the axe (aka penalties) comes down. Then there are others who are pushing the envelope and pulling folks along. Alix thinks there is a landscape in the payer community that feels overburdened and has its own compliance fatigue. She believes there is also skepticism around what might change. That skepticism coupled with longer term trust dynamics in the payer-provider community plus the sustainability themes for payers (rapidly changing business models) has caused them to start considering things with different lenses that they’ve never had to before. Past approaches have trained the industry to wait for regulations and incentives to create movement, meaning there is far more “check the box” mentality than anything. Alix is optimistic though, especially under the FHIR Accelerator community, that there is a group of thought leaders who are leaning in and trying to drive a stronger course forward for us all.
Ken asks Jocelyn what her comments are about payers being burdened. She notes it is a fair point and that there a couple of factors at play here. To Alix’s point, there’s a lot of entrenched operational support and infrastructure in place that’s been running to support EDI for a number of years, and there has been minimal effort in doing clinical data exchange with payers. Because of the historical combative relationship between payers and providers, we haven’t seen much progression yet. However, with the Da Vinci Project, we get to see daily how those relationships are changing. Payers who leverage modern APIs will transform their organizations, how they work and how they view their relationships with provider partners. They will be the ones who come through the curve faster.
Pooja notes we are essentially flipping the entire model payers are operating under today. They’re not used to opening up their data to others. It’s the same in the PBM space. On the pharmacy side, we’re not quite there yet but how do we make it easier for data to be shared? How do we make it easier for patients to access their data?
Pooja also brings up that payers are having to meet interoperability, patient access and price transparency rules, which is a lot. She has a feeling payers might default to just “checking the box” because they will all be in a rush to meet what’s in place today. The point is though, we need people to be thinking outside of “checking the box”. Where can they focus? What are the specific use cases that they could look to in order to achieve a market advantage? Pooja thinks that’s where payers need to be paying attention.
Alix comments that we’re not just transforming standards, we’re transforming culture. How does a patient become informed? We have an educational foundation here of using technology to interpret information in collaboration with someone’s payers, providers, benefit plans and their family’s budget. That’s how we stitch this all together. However, to Pooja’s point, the history of payers and the cultural transformation is one of our shortcomings in implementation efforts that we’ve undertaken in the last 30 years.
Ken asks Alix how she sees the new federal administration playing out over the next few years. Alix says public infrastructure has been duct taped together and underfunded for decades. The work people have done at a local and state level in partnership with the Centers for Disease Control and Prevention (CDC) has been amazing. It is also amazing how the commercial sector relies on registry and public health information. So many use the data, yet very few people help support the public health infrastructure. So, Alix thinks we are going to see a lot of transformation in the public health space (for the good). Having a new national coordinator like Micky Tripathi is going to really help leverage implementation efforts and take us to the next round of progress. Additionally, Alix does see FHIR as a key factor in bridging a number of issues out there, but she’s not expecting a hard left turn in this next administration.
Ken asks Alix for her final thoughts. Alix stresses for people to get educated and involved in standards development, both policy and technology standards. If you can’t play at the national level directly, you can always offer your public comment on proposed rulemaking. We all have experiences to share and we all should exercise our voice to strengthen our nation’s trajectory and agility to respond to all the amazing technology and medical advances that are yet to come. So if you can’t get involved directly, tap into the expertise of the folks at Point-of-Care Partners or Imprado because they can inject that knowledge and add your story to their library of perspectives from which we influence.