Improving Interoperability Between Clinical and Financial Systems in Specialty Care

No matter what the setting or specialty, all healthcare delivery is founded upon the ability to access information. Accurate and complete data about demographics, insurance coverage, clinical history, test results, and treatment goals are all vital for clinicians looking to make the best possible decisions with their patients.

In recent years, the vast majority of this data has gone digital in an effort to make it easier to analyze information and apply new insights to patient care. But despite the ubiquity of electronic health records (EHRs) and countless other health IT systems, the digital care continuum is highly fragmented and siloed.

The interoperability problem can be particularly pronounced in the specialty care environment, where a myriad of clinical tools collides with the need for highly complex, detailed decision-making.

Improving the interoperability between their clinical and financial systems will help specialists develop the comprehensive, current, and accurate portrait of rendered services required to correctly document, treat, and bill each patient encounter.

Examining the Challenges of Activity Capture and Data Interoperability

While the healthcare industry tends to think about interoperability as basic connectivity between EHR systems necessary to share patient charts, the reality of health data exchange is far more nuanced, especially outside the worlds of primary and inpatient care.

Some specialty providers may work with the same patient for months or years to treat cancer, kidney disease, diabetes, or heart disease.

For long-term, highly complicated conditions such as cancer, a single patient can require input from more than half a dozen health IT systems, from drug dispensing cabinets and imaging machines to multiple EHRs, patient wearable devices, scheduling tools, and a revenue cycle management system.

Patients may require visits on a weekly or daily basis to receive chemotherapy or radiation treatment. They may need extremely expensive pharmaceuticals, multiple physician consults, and regular lab work to track and treat their disease. And they might work with additional specialists in pain management, nutrition, behavioral health, or surgery to holistically address their health.

Every one of these services must be scheduled properly, documented completely, coded to the highest degree of accuracy, and billed correctly and efficiently – all while maintaining compliance with the various privacy, security, and patient data access rules that govern the flow of health information.

Adding to the challenge is the fact that many of these systems do not currently share technical standards that would allow for the free flow of data across disparate systems. The result is often inefficient workflows, gaps in clinical information, and missed opportunities to code and bill for services.

With so many different moving pieces, it's no wonder that practices are finding it frustrating to accurately capture activity and compile a comprehensive portrait of services, diagnoses, and reimbursement for each individual.

In a 2019 survey conducted by the Center for Connected Medicine, "close to a third of providers said they still struggle with sharing medical data within their own organization." Nearly double that number cannot routinely communicate with other health systems or additional healthcare partners, which can have heightened impacts on specialists who tend to work with a greater volume of external referrals.

More than 30 percent of providers said that these interoperability challenges directly impacted patient care.

For more than half of respondents, the solution lies in a combination of strong executive commitment to improving interoperability and adopting new technology solutions to enhance connectivity and ensure complete activity capture.

Connecting the Dots Between Clinical and Financial Systems

Overcoming the divide between health IT systems in specialty care starts with recognizing the unique interplay of clinical, administrative, and financial systems.

In many specialties, for example, clinical factors impact whether or not a patient can schedule their next step in therapy. As a result, providers use their clinical system to book appointments – and they need access to the most current test results and reports in order to do so.

The timing of appointments and other clinical decisions can also depend on administrative issues, such as prior authorizations and insurance coverage. Clinicians must be aware of any potential restrictions at the point of care so they can discuss these dynamics with their patients and caregivers.

Creating rich connections between the clinical, financial, and administrative environments is essential for developing seamless care plans that account for all the variables involved in specialty practice.

Organizations should start this process by identifying all of the health IT systems in use and mapping the desired connections between them. If the tools cannot communicate appropriately, providers should consider a customizable interoperability solution to capture activity from every critical endpoint and synthesize the data into a unified, accessible view.

Further aligning these branches of health IT through use of a specialty-specific solution will enable higher quality patient care and more stable billing operations. By choosing a vendor clearly focused on specialty care, adoption of a new platform drives accelerated payback and avoids or minimizes clinical care disruption.

Embracing Automation to Enhance Efficiency and Outcomes

With an interoperable clinical and financial environment, organizations can start to trust that their data is complete, accurate, and timely enough to use for patient care and broader strategic decision-making.

They can also begin looking at automation as a way to improve efficiency, reduce waste, and bolster patient outcomes.

Using cancer care as a specialty healthcare example, a typical oncologist generates more than 80,000 billable line-items per year – yet practices still conduct many of their revenue cycle management tasks manually. In such environments, the sheer volume of unique codes and modifiers used for medical service billing, many of which are tied to detailed payer-specific rules, are easily missed when working on such a large scale.

As coding and billing become ever more complex with the expansion of value-based care reimbursement models, specialty practices will need to rely more heavily on technology to make sure they are capturing patient data correctly and receiving appropriate reimbursement.

Interoperability solutions that provide strong links between clinical data inputs and financial systems outputs encourage more accurate documentation, speed up claims processing, and avoid denials that cost the practice time and money.

Meaningful interoperability between clinical and financial ecosystems is the first step towards automating the reimbursement process. By improving visibility into the entire scope of patient activities, specialists can make better decisions about the health of their patients and the wellbeing of their practice.

Read the next article in the series: Optimized, Automated Activity Capture Supports Successful Revenue Cycle Management in Specialty Care.