Connecting the dots and the data: Interoperability lays an integrated foundation to improve health and healthcare

Much has to occur to build and sustain a truly cohesive healthcare system that works well for everyone and bears positive health outcomes and experiences. The coronavirus pandemic demonstrated this throughout 2020 in spades (as referenced in Humana CEO, Bruce Broussard’s recent article).

For the past several years, Humana has been advancing an integrated, value-based care delivery model. If you think of it in terms of a wheel, it’s an approach that puts the patient in the center (hub), surrounded by a highly-connected care team (spokes), powered by meaningful data and analytics via the latest technology (engine). The result is a “whole person” view of health that is simple, insightful, and accessible by all relevant parties who can make the best use of the information, with the common goal of improved health. 

Clearly, this is not an endeavor we can pursue alone. It involves numerous clinical and business partners, in addition to patients and caregivers, who must work together to share information and responsibility. From a foundational point-of-view, it requires interoperability. 

“Interoperability” is kind of a clunky word but, in short, it means the ability of systems to exchange information. In healthcare, we use it specifically to refer to transferring and accessing electronic health information without special effort on the part of the user (e.g., patient, healthcare provider, insurer).  However, there’s a much bigger picture here – one that extends far beyond mere system-talk. Ultimately, effective interoperability means people can easily tap into robust health information that can inform and empower better decisions. Here’s how we’re leading the way in this area.

An Epic collaboration for easier, more informed point-of-care decisions

More than 250 million people currently have an electronic health record with the software company, Epic, and an estimated one-half of Humana’s Medicare Advantage members see a doctor who uses its platform, which supports numerous patient care functions (e.g., registration and scheduling; clinical systems for healthcare providers; systems for lab technologists, pharmacists, and radiologists; and billing systems for insurers).

Last year, Humana integrated our IntelligentRx “real-time benefit check” tool with Epic’s technology, making Humana the first national insurer to collaborate in such a way that patients and their practitioners have integrated, real-time access to interdependent decision-making information, such as:

• the patient’s individual medication costs and coverage
• health insights from evidenced-based outcome
• the patient’s unsatisfied HEDIS/Star measures and safety alerts

This translates to a decreased administrative burden on physicians and other healthcare providers, who can now work more collaboratively with their patients to make point-of-care decisions about which treatment (including prescriptions) may be the most effective and cost-efficient. In the future, the prior authorization process will also be integrated into the clinical workflow, eliminating the need to go to other platforms to initiate and complete the process separately. Bottom line impact: Care quality is improved; costs are reduced; and providers and patients can work together from the same “playbook,” creating price transparency and improving overall satisfaction of the experience.  

Empowering clinical quality in real time with One Medication List

Having an up-to-date, accurate, and centralized medication list is essential for the best patient care. In the past, this has been a difficult feat, since such information comes from a variety of sources and may become quickly outdated. Humana’s One Medication List (OML) tackles the challenge head-on with a comprehensive database that stores near real-time data on our members’ medications, allergies, and vaccinations. Connected to 13 once-disparate clinical systems, it’s known as the “single source of truth” for medication lists, incorporating input from pharmacy claims, pharmacists, nurses, care managers, case managers, and members.

The value of OML is to provide clinical teams with a better picture of a member’s medications by collecting manually-added information and making it accessible as soon as it is input and when it matters most, such as when a medication reconciliation is completed after a member transition of care. Bottom line impact: OML decreases the time required to keep medication lists updated, which allows clinicians more time to care for the member … and backed with more accurate information for improved decision-making.                        

Leveraging pharmacists and technology for comprehensive medication management

While pharmacists are frequently key players on a patient’s care team, their role is sometimes behind-the-scenes. However, as the healthcare system continues to be stretched and costs escalate, we’re finding new ways to leverage their significant expertise on the front lines of care. Case-in-point: Humana is now collaborating with Aspen RxHealth, using its app-based platform to connect its network of pharmacists with Humana’s Medicare Advantage members in select markets to deliver actual clinical services, including medication therapy management or MTM. (In short, MTM is an educational and treatment program, wherein a patient’s prescription medications are evaluated for optimal use, dosage, interactions, and therapeutic outcomes, particularly important for those with multiple chronic conditions.)

With this tech-enabled connection, each piece of the “medication puzzle”– from the patient, the healthcare provider, the pharmacist, and the insurer – is brought together and thoroughly evaluated from the “whole person” view that I mentioned earlier. Bottom line impact: With the full-picture medication perspective, and counsel from highly-proficient pharmacists, gaps in knowledge and care are minimized, resulting in better outcomes. And, we’re leveraging technology to create capacity in the system by matching the supply side (pharmacists who want to work in this way) with the demand side (the payers who need to have these important clinical interventions completed in a timely manner).

Using data analytics to simplify and accelerate prior authorizations

One of the biggest “headaches” from the perspective of healthcare providers may be obtaining an insurer’s prior authorization for treatments that they recommend for their patients. On the flip side, insurers are challenged with confirming that prescribed treatments meet important quality and cost standards (or utilization requirements). Finding a solution to meet each group’s needs, in addition to ensuring patient satisfaction, ultimately led to Cohere Health, a company funded and influenced  by Humana to streamline the prior authorization process with the help of data, analytics, and technology.

Using evidence- and value-based clinical care pathways as a framework to collect critical patient information, the Cohere decision support tool allows providers to request upfront approval of “already-vetted” specific care pathways, resulting in a single authorization for that course of treatment (vs. repeated requests for the same). Bottom line impact: This “super-auth” approach will result in fewer friction points among the physician, patient, and insurer due to a streamlined process and use of contemporary analytics to guide the pathway approvals; it reduces the overall administrative burden; and all parties benefit from enriched patient information supporting higher quality, value-based care and optimal outcomes.

Whether we look at healthcare from a 40,000-foot systemic perspective or a more focused individual patient view, one thing is clear: We must all work together to achieve the best results. This means digital platforms sharing data. It means people collaborating to solve challenges together. It also means organizations and healthcare professionals partnering across various boundaries, with consumers at the center, to work toward the greater good, improving health and healthcare. Enhanced interoperability is foundational in enabling such interaction. We invite regulators (to help with enabling the sharing of data), entrepreneurs (to bring your creativity), and other potential partners (to bring your passion, desire, and new ideas) to join us on our journey.