Payers Play a Pivotal Role in the Rapid Adoption of EHR by Providers
Health
Care Technology: What do you see as the current state of payer-provider collaboration
in the United States today?
John Capobianco: I believe that payerprovider collaboration is in its early stages and will expand tremendously. Starting this year, I predict significant improvements as payers begin reaching out to share more of their member information with the provider community. MEDecision is helping payers supply providers with more critical, patient-oriented information to improve member outcomes, which is a primary concern for the payer and the provider.
HCT: What role does MEDecision, as a vendor, play in fostering collaboration between payers and providers?
JC: Ultimately, MEDecision plays the role of infomediary. We link payers and providers and supply them with intelligible, actionable information that helps them improve patient outcomes while reducing administrative and medical costs. Weve been playing that role successfully for the past 15 years. Going forward, I think our success will continue to have a positive impact on payer-provider relations, especially as they are encouraged by developments such as the electronic health record (EHR).
The much-talked-about EHR looks quite similar to MEDecisions payer-based health records that we provide to our managed care organization (MCO) customers today. With our extensive payer experience, its clear to us that payers need to be a part of the information transfer because of the vast amount of patient data that is housed in their systems. In fact, we believe the payers can play a pivotal role in launching EHR and ensuring its rapid adoption by providers.
Remember, before providers can take advantage of EHR, those records themselves must be populated with patient information. Key to EHR success, then, becomes rapidly filling records with patient information that offers immediate clinical value. Enter the MCO. With MEDecision systems in place, MCOs have a sweeping view of patient histories that includes detailed data from the many referrals, authorizations, and claims submitted by labs, physicians, hospitals, and pharmacies to the MCO.
Given the vast amount of available patient data, MEDecisions expertise lays in providing data cleansing, analysis, and summarization. Within the context of the MCO and the payerbased health record, we distill the records voluminous raw data into a few pages of actionable information providers can use to make more accurate, informed decisions and diagnoses at the point of care.
HCT: MEDecisions iEXCHANGE product and the underlying technologies and how it works and whats that going to mean to the industry can you talk about that more specifically?
JC: MEDecision provides a set of analytical tools that can effectively digest a ton of data and put it into a meaningful package the payer-based health record that MCOs can feed into their utilization management, disease management, and case management workflows. Soon, MCOs will begin porting that record out to providers and, ultimately, patients over the Internet via iEXCHANGE. With payers delivering significant, summarized patient data to providers and patients, well see a better set of choices available to patients, who will get the care that they desire and think is the most reasonable for them. At that point, we will see the best quality health care at the best price for everyone.
HCT: Please talk about the implementation timeframe on the payer and provider side and how this will work with existing legacy systems.
JC: The timeframe depends largely on having MEDecisions Integrated Medical Management (IMM) systems in place to consolidate information and thereby provide the high-level data for the betterment of patients. IMM places all the data, both historical and current, in the hands of the care managers and provides comprehensive, automated tools to ensure the most efficient handling of information and consistent application of rules throughout the medical management decision-making process. Currently, we have approximately 14 percent of the market moving forward with IMM systems. These systems enable the next big step sharing data with payers, providers, and patients.
We believe we can help the transition to true electronic interchange among payers, providers, and patients by establishing relatively simple, Internet delivery of our payer-based health record. We can deliver that information to the point of care, regardless of location, regardless of the providers electronic medical record system, or lack of system. All the provider needs is Web access. We think this will increase the rate of adoption.
To implement IMM, the system must integrate with existing claims systems in order to actively pull out and analyze their data. Additionally, the IMM system has to be integrated into the workflow of the care management side of the business. Implementing IMM, however, does not need to be a huge, one-time system overhaul or installation. It can be done in stages. Payers can start with Advanced Medical Managements workflow automation to increase productivity and profitability of staff. Later, they can implement Analytics and Disease Management to focus staff on the membership that needs the most help and most care. Later still, they might choose to rollout Transactioning and Automated Authorizations. By letting the system automatically execute routine referrals and authorizations, staff time isnt unnecessarily used on routine matters.
HCT: Everyones shooting for better patient care. How does this kind of system help with that?
JC: IMM focuses the organization on those patients you need and want to help the most. The automation and workflow for utilization management, disease management, and case management improves efficiencies. MCO clinicians and providers have the information they need at their fingertips to best assist patients in getting the care they need, when they need it.
Automating authorizations and referrals makes the process more efficient and gets care to people sooner than manual systems. It also alerts care managers when specific actions are taken for a member. By receiving an alert early in the process, care managers can send any additional, needed information to the point of care.
While IMM helps drive down administrative and medical costs, the end benefit is better outcomes for the patients. More of the payers and providers efforts are focused on making sure patients get what they need, when they need it. All of the information needed is available at every point of care, so providers have all the information they need to provide the best care possible for the individual.
HCT: Talk a bit about HIPAA and how thats impacted this technology and whether you think thats a plus or a minus.
JC: We believe HIPAA is a big plus. Without HIPAA, we wouldnt have the rules of engagement defined for communication between payers and providers. We wouldnt have permission built in from the consumer to share pertinent information between different payers, between different providers. We couldnt make sure theyre getting the best value for their money as well as the best care available.
A year ago, we had the same set of information that we have today, but we couldnt easily share it because most of the people involved in the sharing both the providers and the payers were concerned about the capability and liability to share. They were entirely at risk. With HIPAA in place and with patients informed about how their information is being shared (for treatment, payment, and health care operations), we can send, for instance, the payerbased health record out to the provider, enabling them to assess and treat patients current symptoms in the broader context of their clinical histories. The patient is going to receive a better level of care.
HCT: What barriers in payer-provider collaboration still need to be addressed?
JC: The next step in payer-provider collaboration is to educate the provider community about this wealth of information that payers have, and their ability and desire to share it. Each group has data the other wants both for their own benefit and for that of the patient. The integration of information between payers and providers aligns their goals at the patient level, defining a far more cooperative relationship.
HCT: What do you think the future holds for MEDecision and what changes do you anticipate within the next few years?
JC: We are committed to the path we set for ourselves 15 years ago ¨C improving the relationship among payers, providers, and patients to achieve the best level of health care possible. To that end, we¡¯ve delivered IMM, and we¡¯re about to deliver a new product ¨C Clinical Rules and Processes. That product set will add to the workflow, content, and processes necessary to improve care. In the short term, we are going to be one of the early partners shipping information between payers and providers to improve care and communication between them. Our future, then, lays in continuing our original mission to connect patients, providers, and payers through the consolidated information system that is the next generation IMM application set.
