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ELECTRONIC MEDICAL RECORDS

to enable connectivity between many kinds of health ecosystems, consider- ations could include: • Full-audit ability and compliance with HIPAA and other federal regulations;

• The ability to deal with state laws that may change as data crosses state lines;

• Non-repudiation of clinical data; • The issuing of certifi cates and man- agement of trust through identity brokers;

• The ability to accommodate dif- ferent models for patient consent, opt-in and opt-out; and

• The discoverability of data and responsibility for accounting of disclosures.

In addition, some of the interoper- ability benefi ts for payers could be: • Standardized content to facilitate the exchange of eligibility and enrollment information among payers;

• Innovative solutions for trans- porting eligibility and enrollment data:

˚ Point to point: Small providers and organizations can reuse direct

backbone for simplifi ed eligibility and enrollment transactions;

˚ Reuse of existing systems: Mod- ular approach to support vendors

who want to add this as a feature through CONNECT;

• Increased access to care through expedited eligibility and enroll- ment by standardized and effi cient information exchange:

˚ Providers rightfully fear provid- ing care to someone who cannot

pay;

˚ Real-time access for providers to determine, “Can you pay?” ACOs may, in fact, be the model that could fi nally cause the fi nancial need for clinical data exchange that has eluded healthcare delivery for decades. The key to its success, however, will be patient-centered HIE technology that enables true communication at critical handoffs, collaboration across the continuum of care and analytics

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to determine best practices to reduce costs while improving quality.

Cost savings ACOs must deliver signifi cant cost savings by reducing ineffi ciencies in healthcare delivery and payment pro- cesses. HIE solutions offered through various companies may serve that goal by automating delivery of patient re- cords, referrals, orders, prescriptions and refi lls, test results and diagnostic imaging. The savings in physician and staff time and other cost factors are signifi cant and greater when billing systems are integrated.

Summary

It makes strategic and business sense for payers and providers to col- laborate on how to take substantial cost out of the healthcare delivery system. Acting independently, neither medical groups, hospitals nor health plans have the optimal mix of re- sources and incentives to signifi cantly reduce costs. Payers have core assets such as mar- keting, claims data, claims processing, reimbursement systems and capital. It would be cost prohibitive for all but the largest providers to develop these capabilities in order to compete directly with insurers. Likewise, medi- cal groups and hospitals are positioned to foster financial interdependence among providers and coordinate the continuum of patient illnesses and care settings. Payers and providers should com- mit to reasonable clinical and cost goals, and share resources to minimize expenses and fi nancial risks. It is in the interest of payers to work closely with providers on risk-management strate- gies because insurers need synergy with ACOs to remain cost competi- tive. It is in the interest of ACOs to work collaboratively with payers early on to develop reasonable and effective performance benchmarks. Hence, it is essential to have payer interoperabil- ity and data sharing integrated in an ACO model.

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