Connecting the data dots between payer and provider

Another HIMSS conference has come and gone and, as usual, there was a ton of great information shared at the event to reflect upon. One educational session in particular stood out for me because of how well it illustrated cooperation and collaboration between two healthcare partners that are often at odds with one another — the provider and the payer.

The session, entitled Payer Insights to the Provider at the Point of Care, was led by Nancy Beavin, interoperability leader at Humana, Inc. and Dr. John Michael Robertson, MD, an independent family practitioner from Harrogate, TN. These presenters provided an in-depth look at how Humana has established real-time bidirectional communications with Dr. Robertson’s office.

Through this partnership, Humana shares discrete claims-based clinical data (e.g. hospitalizations, lab results, prescription history, allergies, etc.) on members that are also patients of Dr. Robertson. This data is delivered through Dr. Robertson’s existing EMR so it can be referenced at the point of care to support clinical decision making. This insight also alerts Dr. Robertson to any information that might be missing in his record or in the data provided by Humana.

You can’t always count on patients to remember to volunteer all pertinent medical information.

When Dr. Robertson completes a patient note, the EMR sends updated patient data back to Humana, assuming they are the payer for the patient. Dr. Robertson also has the ability to send direct messages to Humana. This collaboration and interaction provides Humana with instant access to the patient’s condition and Dr. Robertson’s prescribed treatment.

Bidirectional data sharing benefits providers, payers and patients

The bidirectional sharing of electronic patient data has several benefits for both the payer and provider. First, there is a significant reduction in the manual labor required by Dr. Robertson’s staff to perform tasks such as collecting medical records and completing paper forms for Humana, a payer that represents about one-third of the practice’s patients.

These employees now have more time available to focus on other tasks that directly impact the practice and its patients.

According to Ms. Beavin, reducing the burden on the physician and his staff was Humana’s primary objective with this initiative. However, the payer also benefits by receiving provider information in a more timely and secure manner. This helps facilitate and accelerate accurate reimbursement and eliminates the need for Humana to send staff to Dr. Robertson’s office.

Connected healthcare delivers increased patient focus

According to Dr. Robertson, another benefit is that he no longer receives meaningless alerts from Humana. He used the example of getting annual mammogram notices for women who had undergone total mastectomies. These types of alerts were an annoyance to him and his staff prior to this initiative.

Patients also benefit from this collaboration between payer and provider. Not only are claims settled quicker, but the physician also gains access to medications and care patients receive from other providers. This could alert Dr. Robertson to potential adverse drug interactions or other complications and give him the insight to prevent them.

“You can’t always count on patients to remember to volunteer all of their pertinent medical information,” says Dr. Robertson. “Sometimes they don’t even know it is relevant to their primary care physicians. It’s easy and common for people to forget to share all the details of their care. “

I left this session more encouraged about two things. One, it’s a great example of interoperability in action. Two, this program reduced much of the paperwork and documentation that physicians are shackled with today.

The more we reduce this burden, the more doctors and nurses are free to practice medicine and focus on their patients.

Julie Clements

Julie Clements is a healthcare solution marketing manager at Hyland.

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