Healthcare Interoperability Benefit 1: Streamlined Data Exchange Between Health Plans, Healthcare Providers, and Patients

Jun 17, 2021

According to a study conducted by Johns Hopkins, 44% of medical error deaths were preventable. As the CMS Mandate for healthcare interoperability approaches, the requirements come not a moment too soon for an industry lacking effective data exchange capabilities. Medicine and treatments have advanced tremendously through the years, as we’ve witnessed with the rapid development of the COVID-19 vaccines. But in all the medical advances, data exchange capabilities for important medical information between payers, providers, and patients have too often seemed to remain in the Stone Ages.

The CMS Mandate for healthcare interoperability requires a payer-to-payer data exchange by January 1, 2022. Plans must be able to share pertinent healthcare information (including some clinical data) with other plans when a patient changes insurance carriers and chooses to request this information be shared with the new plan.

Health plans must be able to:

  1. Receive healthcare information on a member from other plans – and integrate that data into their own databases.
  2. Transmit health data to other payers who currently cover a former member, as requested by that member.

FHIR® Standard Data

HL7 FHIR® is the standard for plans to share this data across platforms. With incoming information from various non-plan data sources, especially in the early stages of the mandate compliance, being able to convert that data into FHIR® will be a critical step of maintaining a data lake of normalized, correctly mapped data. In addition, translating data into the FHIR® standard provides an infrastructure and support system that assures the information shared from payer-to-payer is consistent, organized, viewable by various end-users, and meets mandate requirements.

Real-time access to medical records and information – made available by standardized FHIR® data – delivers tangible benefits to all participants in the healthcare ecosystem. A patient’s longitudinal health records will aggregate medical history, empowering the patient with important medical education to ultimately increase positive health outcomes.

CAVO Connect® Delivers Benefits for Hospitals-to-Payers & Payer-to-Payer

Though not part of this CMS mandate, a logical byproduct of interoperable data and systems is the ability to also exchange data between payers and providers. From TREND’s viewpoint of the claims review process, we’ve been aggregating various data sources (medical records, itemized bills, and additional clinical data) to minimize administrative burdens for health plans and providers and streamline appropriate reimbursement. CAVO Connect, one of our latest innovations, enables health plans to access real-time EMR information directly, delivered instantly as FHIR® standard data to the CAVO user interface, ready for claim review.

What does this mean regarding benefits specific to hospitals and payers?

    • Healthcare providers: CAVO Connect eliminates the provider’s administrative burden for release of information (ROI), and it also reduces hospital time-to-revenue for associated claims.
    • Health plans: CAVO Connect’s interoperable data gives the payer instant access to EMRs and important clinical information – minimizing the time, staffing, and money historically required to “chase down” medical records and itemized bills. Paired with CAVO’s consistent user interface – regardless of EMR system – that’s specifically built to add efficiencies throughout claims reviews, payment integrity teams leverage a cohesive suite of technologies designed to increase productivity.
    • Payer to Payer: Our open API also allows for seamless and instant exchange of clinical information between health plans to support continuity of important medical care when members transition to other insurance plans.

CAVO Connect provides the technological infrastructure to support data flow from provider EMRs to payers, literally transforming the medical record retrieval and claims review processes while simultaneously supporting the payer’s interoperability initiatives.