Ayad Shammout is Director of Data Platform & Business Intelligence for Beth Israel Deaconess Medical System (BIDMC) in Boston. At Convergence, Shammout will be part of the Data Governance panel and discuss how BIDMC is working with payers to use data more effectively.
How is your organization beginning to focus on convergence of payers and providers?
One of the key drivers for BIDMC in working with payers is population health management (PHM). We started working on PHM three years ago, and it has evolved into payer convergence. We are trying to improve quality of care, focus on wellness and prevention, provide more patient self-service, and be more proactive in monitoring and working with patients. We want to improve the way we exchange data with payers and make it a smoother process. We’re always looking for ways to reduce the cost of care for our patients.
What is driving this convergence more: providers, or public /and or private payers?
From our perspective, we’re driving this more than our payers, but they are doing their part as well, both public and private. As we transition from fee for service to outcome-based pay for performance, we see an improved payer relationship. Key measures for this relationship are accuracy, transparency, and reliability of data. We have different relationships at different levels with the various payers when it comes to data exchange, how to file for claims, and how to code correctly. We are always looking to reduce the cost of care and improve the efficiency of quality measurement, to focus on better patient care – regardless of which payer we’re working with.
To ensure information and notifications flow between [hospitals, payers, and pharmacies] in a timely manner [is] a big job…The technology is available to make it happen, but I think it’s more a political decision.
What data can and should be shared and among whom when it comes to payer provider convergence?
We look for ways from a strategic perspective to understand how other organizations of similar size and volume are sharing their data with payers. The complexity of data exchange, especially claims, has increased now with the payer-driven transition to ICD-10. We’re working on a clinical documentation improvement (CDI) initiative to ensure we’re documenting fully to support the proper level of reimbursement. ICD-10 has definitely added a lot of work on our part, and required increased staff.
Who has access to patient clinical data?
This is a challenging area. Every payer asks for something different. We have to develop a custom extract for each of them, and it would be much better if there is one (complete) standard we could use with all of them. More than that, it’s a political issue. Each organization uses the data as its own asset, and for primarily financial reasons they don’t want to share it with others.
At the most basic level, it’s the patient who owns the data, and he or she should decide who gets to see it or not. Lack of transparency and concerns about sharing data between providers and payers can lead to denied claims and patient impact. There should be a mandate that the patient should be the owner and have full control of the data. When a patient travels to another provider or city, his or her data should be shared in that new locale without friction. If a provider is concerned that their medical judgement may be questioned if they share data with another stakeholder, this should be up to the patient to decide. Sharing data in a more transparent approach will become very important, so that even patients will be able to understand the information more clearly.
How does consent extend beyond the four walls of a provider?
Consent is closely related to patients owning their data. Unfortunately, most patients are not reading every word in the consent documents they are asked to sign; today, if you refuse to sign a consent form, you are denied the service. And consent documents (many of which are still paper-based, not electronic) are usually not specific enough to meet the needs of a patient – for example, explicitly stating what is to be shared and with whom.
We should revise the way we do this – the use of bullet points and clearer forms, for example, would make this information easier for patients as well as other stakeholders (such as payers, pharmacies) to read and understand and improve transparency. It’s a key area to review, and it’s important in the payer provider relationship. Once this barrier is removed, I don’t think there will be as much back and forth for what can and cannot be shared for specific claims.
How can payers provide more real-time data to enable providers to minimize out-of-network care?
Each hospital works with different EHR systems – Epic, Athena, MEDITECH, etc. We have our own homegrown system. Payers have their own systems. You’re talking about a lot of work to ensure information and notifications flow between all of them in a timely manner. I did work a few years ago on a hub system between payers, providers, and pharmacies. It’s a big job, but it is working. The technology is available to make it happen, but I think it’s more a political decision.
As a provider, you’re asked to provide all kinds of information to your payer. Do you ever wish there was more information coming proactively from payers – notifications of patients receiving care out-of-network, for example?
Yes. Think about readmissions, which are one of the key areas that can cost a hospital a lot of money. As a provider, I want to know in a timely manner if a patient was readmitted to a different hospital or seen by a different provider. That relationship should be mutual. That way we know, are we doing a poor job, or if it was our lack of services. Accountable care organizations especially need this kind of information.
Anything else you would like to add or stress?
Data sharing is important, but we should drive standardized data models for agreed-on data sets of clinical quality and outcomes that are transparent to all to improve accuracy and better collaboration.
As technology evolves, we should be able to use it to improve patient care services and reduce cost of care. Security is also a major concern these days, the data must be protected, accessible, accurate, and usable across disparate contexts if a healthcare provider is to realize greater ROI while keeping costs under control.