The shift from fee-for-service (FFS) to at-risk reimbursement also represents a shift from siloed data sources and facilities to physician-driven networks that need to be connected with patient-centric decision support and work flow applications. In the FFS world, health systems and health plans often thought of patient data as a strategic asset to help recruit and retain both physicians and patients to their networks and services. Yet, in the at-risk world, the more data available about the patient, the better the ability to manage risk and coordinate care. The change in mindset from controlling patient data to allowing it to flow freely (albeit, securely) across networks is a radical transformation in the U.S. healthcare system. The three key barriers to overcome are business model, proprietary data formats and governance.
At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.
In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.
Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).
Director for Strategy and Business Development