Drive Interoperable Systems and Data Integration with a Unified Platform

CG Adams: Hello, everyone, and welcome to The Payer Principle, a Salesforce healthcare podcast created exclusively for payers. I'm your host, CG Adams. On the show you'll hear insights from healthcare industry experts and trailblazer organizations on all things payer, such as trends, business challenges, and the latest technological solutions. Today's episode focuses on interoperability and the importance of integrating data, systems and technologies. I'm joined today by Sean Kennedy. Sean is currently a Public Sector Health Go- To- Market Lead and Senior Interoperability Architect at Salesforce and has over 25 years of health IT experience. Sean, welcome to the show, it's great to have you on today.

Sean Kennedy: Thanks, CG, happy to be here.

CG Adams: So let's start with the basics. How would you define interoperability?

Sean Kennedy: Interoperability is essentially the extent to which systems can share data and interpret that shared data. Whether within or between organizations, it's all integration. You need to establish the pathway for data to flow, that pathway, however, has interoperable qualities, best categorized by HIMMS as foundational, structural, semantic and organizational. So examples would be being able to share data from a PCP to a specialist, or a hospital to a skilled nursing facility, to coordinate a referral or a discharge, as examples.

CG Adams: And what exactly is the current state of interoperability today?

Sean Kennedy: Well, honestly CG, it could be better. It's been a slow build for years. Data is nearly all digital for payers, providers, but sharing within and between organizations is really proven challenging, resulting in a number of challenges, right? Fragmented patient, member experiences, we've got delayed digital transformation, in large part due to the incompatibility of legacy and modern systems, and we've got a growing inventory of costly point to point, hard to maintain integrations. Now, the good news is that 21st Century Cures Act, in its use of APIs without special effort requirement, are now in effect through the new interoperability rules, which means organizations will increasingly feel the pressure to meet rural requirement deadlines to share their digital data. The other item that's driving, if you will, the status quo, is COVID. If there is any silver lining to COVID- 19, it is that it is speeding healthcare's digital transformation. Telehealth technologies have seen unprecedented growth. The need for data has never been more critical. Heck even the public health system is getting their well- earned attention and seeing a much needed upgrade. Central to all of this is the sharing of data. And HIEs, they can play a really important role here given they frequently sit at the intersection of all these organizations. So with COVID, with the new rules, we have a need to more easily and quickly share data and our requirement to do so. So the conditions to springboard the current state of interoperability are here.

CG Adams: So now that you've defined interoperability for us, why do you feel like it's so critical to the healthcare industry in particular?

Sean Kennedy: Well, most importantly, it's a safety thing. Without visibility to your medical history, to your allergies, your meds, your current conditions, doctors are flying blind. Second, it improves care coordination and experiences of patients. Think about how often you need to restate your history verbally to your care team. One other item that is certainly relevant during our pandemic is the need for more accurate public health data. Public health professionals need that data quickly to better understand the scope of the problem and tracers need contact information that is frequently missing from reimported lab results. Bottom line, interoperability promotes a safer, more real- time and less burdensome healthcare system.

CG Adams: So how has Salesforce, a company better known for CRM software, involved with healthcare interoperability? What is our contribution? Our approach?

Sean Kennedy: Sure. So frequently Salesforce is used to extend the value of an EHR or a claim system or other source or destination system. As such, we see all sorts of integrations from batch files to real- time calls, from API based queries to event driven push messages, from restful exchanges to presentation layer integrations. In any case, it is vitally important to first define the business need, to define the use case. That use case, whether to load patient data, to schedule an appointment or outreach around gaps in care, must be defined to understand the data needed, the source systems at play and the directionality and timing of the data. Once you define the use case, you can identify the integration layers. What is the security handshake? Is this a data or process or application layer integration? After the type of integration needed is established, you then select the integration approach. Use a middleware or not, query response or event- based as examples. Finally, after you have defined the integration pathway, you select the implementation approach. Do it in- house or contract externally. And we offer a range of capabilities to enable integration, from our multi- layer integration support to a range of data models. Provider, clinical, financial care plan, in which you can persist or virtualize your data through a myriad of APIs, which we've been maturing since we first launched them 20 years ago, to our integration orchestration capabilities that enable end-to- end connectivity.

CG Adams: Sean, I want to double- click into a concept, an acronym that you had in your last response there around APIs or application programming interfaces, which have been instrumental in revolutionizing healthcare. How is the payer market evolving to adopt these APIs to drive more interoperable systems?

Sean Kennedy: Right. Well, healthcare has been on this API trajectory for a while now. FHIR has been gaining momentum, now culminating in being incorporated in the new rules. 21st Century Cures Act launched the government's interest in the use of APIs and the rules implementing the Cures Act cemented them in March of this year. And along the way, standards groups have emerged like the Da Vinci project to better describe uses of FHIR in the payer space, for use cases such as eligibility and benefit response or coverage requirements discovery, for prior authorization, for provider directory query and update, for check claim status, et cetera. With the rules now in effect, payers are working hard in the midst of a pandemic, I may add, to meet rule requirements. And we, as a provider of tech services to our payer customers, are working hard to provide the capability necessary to hasten digital transformation efforts.

CG Adams: That's such a critical point to make, in that basically the interoperability rules that you referenced that are coming from the centers for Medicare and Medicaid services, are really accelerating more adoption around API uptake and interoperability within the healthcare ecosystem.

Sean Kennedy: Yeah, absolutely. For people in the integration space and people that really have a love for APIs, it's a welcome change for sure, but it comes with much work ahead.

CG Adams: So, Sean, I know that you work really, really closely with a ton of payer organizations. I'd love to dive a little bit deeper into some of the examples of where you're seeing payers leverage APIs and other systems to drive more interoperable systems within their companies.

Sean Kennedy: Yeah, absolutely. And, frankly, it's a bit of a mixed bag. API's in general are new to providers and payers. Providers have been moving FHIR for a while now, albeit with slow adoption, but unlocking EHRs has been a very big pain point for some time now. Payers are also moving toward API based exchange. As I mentioned, groups like the Da Vinci project are helping to make sense of the application of APIs among health plans. Their identifying priority use cases, defining the technical details that would bring them to life in a meaningful and more consistent manner. That said APIs are not wide use among plans right now. Many of the incumbent claims and eligibility systems are not enabled with APIs. So the big effort now is to develop a strategy to meet the rules that will require use of APIs among plans. Now that's not to say that APIs are not in use, they are. We see use largely for member service type exchanges, so surfacing member demographics to a call center agent, allowing them to quickly check the status of a claim, as examples. Some payers have provider directories, they can hit via API APIs. And APIs are also a bit more prevalent among payers with clinical systems, where FHIR APIs are in place enabling such use cases as medication reconciliation with members and generally surfacing member clinical data, like gaps in care for at- risk contracts.

CG Adams: Sean, tell us about the new interoperability rule and how payers can take action to comply with CMS interoperability requirements.

Sean Kennedy: I think it starts with getting to know the rules and I would do that quickly. Rules are in effect now. And the first major date is January 1st of next year, 2021, with an enforcement push to July for two APIs, patient access and provider directory APIs. So within a year from now, regulators will begin inspecting to see that payers have gone from limited use of APIs to then putting into place two APIs that will almost certainly see heavy traffic. That is not a lot of time. So, first, it's important to know that there are two rules, one from ONC and one from CMS, both of which implement provisions of the 21st Century Cures Act. And both intend to advance interoperability, give patients, members access to their data and attempt to make the healthcare system more accountable and price transparent. The big thing to know of the ONC rule is that FHIR R4, now a normative standard, is now the standard for patient population services for providers. And USCDI defines the minimum data set to be exchanged. For CMS, and specifically for payers, you have two APIs coming. Patient access API, where your members will be able to access their claims and counter and cost data via third party app, and the provider directory API that will allow discovery of your providers. USCDI also applies to you as part of the payer- to- payer data exchange, where you need to be able to send clinical data to another plan in the event a member chooses to switch plans, as an example. While this one is not required until April of 2022, many organizations are viewing these two APIs and the payer- payer exchange as really one project to tackle at an enterprise level.

CG Adams: So you're seeing payers really look at addressing all three of these different requirements simultaneously?

Sean Kennedy: Yes, absolutely. Because the time span is really July 21 is when the enforcement starts for the two APIs, in April of'22 is when payer- to- payer exchange happens. Given API APIs are likely to be used for all three, it really takes that longer view and couples of them as a project, at least what we've heard from some of our customers.

CG Adams: Sean, let's wrap up the episode by talking about what do you think is on the horizon? What is the future state of interoperability?

Sean Kennedy: Well, I think the big state that we're going to see is really this interoperability has always been a bit of a barrier to achieving that value- based healthcare system that we're looking to get to, other factors certainly there. As we start to cross over, and we now start to see interoperability within organizations and between organizations and, frankly, between providers and payers, and those barriers start to drop. Now, you're going to start to see that seamless, authorized access to information. You're going to start to see patients now have greater access to their data via these new consumer apps that likely will become available as the APIs get put into place. So you're going to see patients with their data, able to do things with their data and share it in ways that they find valuable to them. You're going to see a lot of the friction taken out of healthcare because data is more easily moved around, but ultimately I think these rules are a good thing. It's really helped the market, or will help the market, get to where it's struggled to get to, and allow us to do it now in a more consistent and timely manner.

CG Adams: Sean, thank you so much for joining us today on the Payer Principle podcast and for all of your insights.

Sean Kennedy: CG, thanks for having me. It was really a great effort.

CG Adams: Listeners, if you want to learn more about our interoperability solutions, visit salesforce. com/ healthcare. I'm your host CG Adams. Thank you for listening.