The Role of Interoperability in Value-Based Care

Earlier this year, our team at Health Gorilla dug into the trends surrounding interoperability and hypothesized five predictions to keep an eye out for in 2024. While that blog is a great read and does predict trends we are seeing come to fruition, one area that was not highlighted was the significant investments value-based care organizations are making into interoperability solutions.

What is Value-Based Care

In the dynamic landscape of healthcare, value-based care stands at the intersection of innovation and efficiency, delivering improved patient outcomes and cost-effective healthcare delivery. 

Value-based care is a care delivery and financial model emphasizing high-quality, coordinated, cost-effective patient care. Unlike fee-for-service models, which allow providers to request reimbursements based on the volume of services they complete, regardless of the outcome, value-based care incentivizes providers to deliver quality outcomes and a positive patient experience at the lowest possible total cost. 

The overall goal of value-based care is to ensure patients receive the best, most coordinated care possible, leading providers and care organizations to invest additional effort into preventative care, care coordination, and remote patient monitoring.

A Brief History of Value-Based Care

Value-based care is not a new concept in healthcare. In fact, some reports state that the original value-based care models were introduced as early as the 1960s due to rising healthcare costs. However, it was the Affordable Cures Act (ACA), signed into Law on March 23, 2010, that launched a new era of value-based care incentives by introducing a new catalog of value-based care reimbursements, encouraging physician performance and patient health outcomes rather than service volumes. 

The ACA also included various initiatives to reform how the nation organizes, structures, and pays for its healthcare, including several mandatory national payment reforms through the Medicare program. 

The most recent catalyst in the healthcare community was the signing of the 21st Century Cures Act. The 21st Century Cures Act called for the establishment of a national Trusted Exchange Framework and Common Agreement (TEFCA), to create a floor for universal interoperability across the United States. TEFCA also established our country’s first Qualified Health Information Networks (QHINs), the designated entities responsible for facilitating the national exchange of health information by acting as brokers to ensure interoperability between their network participants. On December 12, 2023 Health Gorilla was formally designated as a QHIN, allowing our network participants to engage in a secure, federally endorsed framework for nationwide data exchange.

The 21st Century Cures Act also formally defined information blocking as “a practice that interferes with, prevents or materially discourages access, exchange or use of electronic health information.” Health Gorilla has an in-depth piece on the Information Blocking Disincentives Proposed Rule, but at a high level, the rule very much supports value-based care by ensuring that all parties involved in the healthcare ecosystem work towards enhancing the seamless flow of health information, which is critical for patient care, decision-making, and reducing costs.

The ACA, TEFCA, and the first designated QHINs have resulted in a paradigm shift in healthcare delivery and payment, supporting an increase in the adoption of value-based care models.

Types of Value-Based Care Models

Accountable Care Organizations - ACOs organize and work with networks of healthcare providers to coordinate patient care, improve quality, and reduce costs by incentivizing data exchange, collaboration and accountability among participating providers. Their ultimate goal is to improve population health by reaching out to and engaging high need and at risk patients, optimizing treatment, and coordinating care. 

Pay-for-performance - P4P programs provide financial incentives to providers based on pre-established clinical quality metrics, motivating providers to deliver optimal care and rewarding them for high performance and improved outcomes.

Capitation Payments - Capitation involves paying healthcare providers a fixed amount per patient to cover some or all necessary services, motivating providers to deliver coordinated and economical care while maintaining quality to maximize reimbursements. 

Bundled Payments - Bundled payments involve a single fee for all services related to a prespecified episode of care and encourage providers to collaborate efficiently to deliver high-quality care while controlling costs.

How Health Gorilla Supports Value-Based Care

While value-based care organizations offer numerous benefits to patients, they do have several challenges, one of which is gaining a comprehensive view of their patients’ complete clinical history.

As a QHIN and California-designated Qualified Health Information Organization (QHIO), Health Gorilla provides compliant and secure connectivity to national networks, including Carequality, CommonWell, eHealth Exchange, and the Trusted Exchange Framework and Common Agreement (TEFCA) ecosystem. 

Through these connections and memberships, Health Gorilla can provide to data from 220 million patients, 750 thousand clinicians, and over 147 thousand care sites nationwide.  

Participation in these national and regional networks involves important policy and compliance considerations. Health Gorilla has deep expertise in these areas and can help value-based care organizations navigate the policy nuances and requirements. In particular, while evolution on this front is underway, it is critical to ensure that these connections are used to gain access to patient data only for direct Treatment use cases.

In addition to clinical data, Health Gorilla supplies value-based care organizations with a national admission, discharge, and transfer (ADT) notification network. These ADTs allow providers and their care teams to proactively contact patients and schedule timely follow-up services as they are discharged from a hospital, allowing them to capitalize on CMS incentives for coordinating services and providing high-quality care.

Armed with complete and timely clinical information, value-based care organizations have the ability to:

  • Provide Better-Informed Patient Care: Access to comprehensive clinical data empowers healthcare providers to make more informed, evidence-based, and personalized decisions about diagnosis, treatment options, and care plans.
  • Close Care Gaps - Integrating complete patient data enables providers to gain insights into patients’ health status and needs, track progress over time, and proactively identify and address gaps in care, leading to more personalized and effective interventions and improved reimbursement.
  • Improve Clinical Care Coordination: With access to comprehensive clinical data and ADT alerts, providers can ensure that care is well-coordinated, transitions between care settings are smooth, and all members of the care team are informed and aligned, reducing the likelihood of medical errors, redundant tests, unnecessary procedures, or readmission. 

As mentioned above, it’s critical to be mindful of policy implications when accessing patient information. However, data requested to directly support the treatment of patients may also help your organization with additional use cases. These include, but are not limited to:

  • Risk Adjustment Accuracy: Value-based care models often involve risk adjustment methodologies to account for differences in patient populations’ health status and complexity. Ensuring accurate risk adjustment is crucial to identify and prioritize specific patient needs and to avoid penalizing providers who care for sicker patients or those with socioeconomic disparities.
  • Quality Measure Improvement - Access to complete clinical data allows value-based care organizations to develop more robust and accurate quality insights and metrics by quickly assessing the quality of healthcare performed against pre-defined benchmarks and driving continuous improvement initiatives.
  • Quality Reporting and Performance Improvement: Access to comprehensive clinical data supports continuous quality improvement efforts, facilitates benchmarking against peers, and enhances accountability for achieving value-based care goals.

Ready to Expand Your Access to Clinical Data?

If you are part of a healthcare organization and are interested in expanding the data available to your physicians or patients, the Health Gorilla team is here to help. We offer a comprehensive implementation plan with a dedicated implementation specialist and solutions architect who will work with you to configure the connection between our suite of APIs and your applications. We tailor our implementation to your organization’s unique clinical data needs and workflows and provide access to the Health Gorilla development sandbox. Our team of experts is available to answer any questions throughout testing, validation and implementation. Contact us here to learn more about how we can support your organization with comprehensive clinical data.