Scaling Up Provider-Payer Workflows

Published 2020.9.30

I am involved in several health information technology (health IT) interoperability efforts including the Da Vinci project (a private sector initiative that addresses the needs of the Value Based Care community by leveraging the HL7 [a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services] FHIR platform), Office of the National Coordinator for Health IT Fast Healthcare Interoperability Resources (FHIR) at Scale Taskforce (ONC FAST, a group of “motivated healthcare industry stakeholders and health information technology experts” set to identify HL7 FHIR scalability gaps and possible solutions, perform analysis to address current barriers and accelerate FHIR adoption at scale), and DirectTrust.

The Da Vinci project is either developing or planning to develop the following use cases:

  • Quality improvement
    • Data Exchange for Quality Measures – some HL7 standards are published and other are in balloting
    • Gaps in Care & Information – HL7 standards in balloting
  • Coverage/Burden Reduction – all three have some HL7 standards published with others in balloting
    • Coverage Requirements Discovery
    • Documentation Templates and Rules
    • Prior Authorization Support
  • Member Access
    • Clinical Data Exchange – some HL7 standards are published and other are in balloting
    • Payer Data Exchange: Formulary – HL7 standards published
    • Payer Data Exchange: Directory – some HL7 standards are published and other are in balloting
    • Payer Coverage Decision Exchange – HL7 standards in balloting
    • Patient Cost Transparency – HL7 standards being built
  • Process Improvement
    • Risk Based Contract Member Identification – HL7 standards in balloting
    • Chronic Illness Documentation for Risk Adjustment – planned
  • Clinical Data Exchange
    • Notifications – some HL7 standards are published and other are in balloting
    • Patient Data Exchange – planned
    • Performing Laboratory Reporting -planned

The ONC FAST identified seven shared technical challenges to FHIR scalability along with a set of proposed solutions:

  • Patient & Provider Identity Management
    • Mediated patient matching
    • Collaborative patient matching
    • Distributed identify management
  • Directory Services – national solution for FHIR endpoint discovery
  • Version Identification – supporting multiple production versions of FHIR
  • Scale – requirements for FHIR RESTful exchange intermediaries
  • Exchange Process/Metadata
    • Reliable routing with metadata across intermediaries
    • Reliable routing across intermediaries using destination-specific endpoints
  • Testing, Conformance & Certification – ONC FHIR Testing and Certification Program
  • Security
    • Trusted Dynamic Client Registration
    • Tiered OAuth
    • UDAP Authentication & Authorization

Meeting providers where they are

Although all of work is necessary for health IT systems to facilitate more data liquidity across organizational boundaries, I believe efforts to address these challenges are not sufficient. To engage providers to do the necessary work to update their workflows for more advanced health IT to automate some processes, the problems to be solved need to be large enough to justify the transitions costs to move to a new operating state. I believe the three most important challenges that payers can help interested providers address are:

  • Prior authorization,
  • Identifying the highest-value medication regimen to manage the patient’s condition(s),and
  • Transitions of care across care settings including
    • Hospitals, emergency rooms and primary care offices
    • One-time consults and ongoing subspecialty co-management, and
    • Episodes of care (e.g., hip replacement, heart surgery)

Ideally, all providers with an ambulatory EMR would benefit from this proposed arrangement. Unfortunately, not all ambulatory EMRs are created equal. Shi et al. reviewed a sample of 17,861 ambulatory clinics across 1711 health systems. They found clinics were more likely to have an ONC-certified EMR in 2016 compared to 2014 (91% versus 73%). The researchers identified 16 health IT functionalities that the ONC, the National Academy of Medicine, and the Health Information and Management Systems Society (HIMSS) deem important:

Core Health IT Areas
Clinical data repository* Physician documentation
Current encounter data functions Exam results support*
Computerized provider order entry e-Prescribing for new medications
Clinical decision support Clinician charting
Medication management* Electronic messaging
Clinical information exchange with hospitals* Clinical information exchange with other clinics*
Patient health record Patient follow-up care reminders
Patient portal access to personal health information* Summary reporting for transitions in care*

*Functions that could be supporting by a willing partner with access to records inside and outside a provider’s office.

In 2016, 38% of clinics had adopted all 16 functionalities (up from 28% in 2014). Among practices with 10 or fewer providers, less than 10% of clinics had adopted all 16 functionalities (for solo practitioners, the rate was 2.7%).

In lieu of being acquired by a large health system or forced to go out of business, a payer or another business entity could offer to supplement some health IT functions that may not be present in a practice’s electronic medical record. The payer would be able to have members go to practices outside the clinics owned by a regional health system with similar levels of support with presumably lower payment rates. The payer would be motivated to help members feel like they are receiving the same level of care quality as what they might receive from a provider within a health system.

Prior authorization

Most providers and their office staff rank prior authorization to be either the worst or second-worst part (after electronic medical records [EMRs]) of their professional life to for a higher-value healthcare system. Reducing the burden of prior authorization might require additional staff to learn provider and payer workflows, some working knowledge of payer authorization policies as well as new health IT. The Da Vinci prior authorization work under coverage/burden reduction is focused on use cases that have clearly defined criteria to approve or reject a prior authorization request. Unfortunately, most providers will argue that the initial prior authorization use cases will not reduce the work for them or their back-office staff.

To address the prior authorizations that are more time-consuming for provider offices, payers (or other parties) will need to make agreements with providers about accessing EMRs to better understand the details of each case that might merit a prior authorization review or exception. Rather than going back-and-forth with a payer without clear guidance about what might be required, providers could allow payers review any documentation within the patient’s chart and highlight any missing data to help finalize a prior authorization decision.

Identifying the highest-value medication regimen to manage the patient’s condition(s)

Providers may not always have the right information to help determine a medication regimen that meets the patients’ needs. Providers should consider drug efficacy, side effects, drug interactions and patient out-of-pocket costs. Pharmacists, pharmacy benefit managers or payers who employ pharmacists may be in a better position to help patients determine the optimal medication regimen based on the patients’ own preferences and experiences with specific drugs in the past. Although this level of medication intervention may be novel in some areas of the country, it is moving forward in select states. If nothing else, pharmacists might highlight medication optimization opportunities for providers to consider in the future.

Transitions of care

Among the healthcare market participants, payers may be in the best position to help manage transitions in care. They receive claims from all providers who interact with a patient, regardless of provider affiliation. Payers know the providers who are in-network and out-of-network. And payers have a financial incentive to coordinate care across settings. The transition of care paradigm can apply to urgent care, emergency room care, hospitalizations, consults and even surgical episodes of care. If payers could share information with providers and patients without a fully interoperable electronic interface, many more patients might benefit from these efforts. Waiting for all providers to adopt the technology to support fully electronic interactions may take many years and only include the “easiest workflows” to automate.


The national interoperability efforts may not lead to immediate value gains for providers or patients. Many of the existing efforts assume a high level of information technology adoption across the provider community. Given the recent findings of health IT adoption among smaller practices, there is a need to develop some processes that are less tightly coupled with the most advanced health IT functions and more aligned to delivering value to provider-patient interactions across a provider community with a range of IT sophistication. Prior authorization, medication management and transitions of care could all be improved without complete electronic interactions. Payers or other clinical support entities could deliver some value to these processes with some basic electronic functionality and then adapt their interactions based on the capabilities of a provider or provider group.