AI and Value-Based Care Growth Igniting Fresh Urgency for Interoperability

Brian Drozdowicz

Since passage of the HITECH Act, which included the “Meaningful Use” financial incentive program for providers to adopt electronic health records (EHRs), acceptance of the technology has rapidly grown from 12% in 2009 to 96% in 2021, according to a federal survey.

Results show that the vast majority of these EHR systems have been certified by the Office of the National Coordinator (ONC) for Health Information Technology as interoperable. This means that they meet the ONC standards established to ensure compliance with the 21st Century Cures Act, supporting the secure, seamless exchange of actionable data with other certified EHRs across care settings.

Yet, another government study shows this type of data sharing does not occur as often as one might assume, given the widespread adoption of certified EHRs. Just 70% of hospitals in 2023 were “sometimes” or “often” engaged in all four measured domains of sending, receiving, finding and integrating electronic information. Furthermore, only 43% “routinely” engaged in interoperable exchange, and just 42% of clinicians reported they routinely use the data when treating patients.

Bridging the gap

Hospitals have clearly made significant progress in interoperability since 2018 when just 46% engaged in all four domains of electronic information exchange. However, the care quality, patient outcomes and cost-control issues facing providers and health insurers demand that “routine” engagement across all domains increase and remain at a higher level.

That is because the introduction of generative AI and the growth of value-based care (VBC) require comprehensive, accurate, actionable and timely data to improve decision-making, reduce inefficiencies, and ultimately improve patient outcomes.

The proliferation of AI across every industry in recent years raises many questions. What is certain, however, is healthcare providers and payers are already integrating it into their workflows and operations. Results from a survey conducted in late 2024 that was sponsored by HIMSS and online clinician resource Medscape found that 86% of healthcare provider organizations already use some form of AI, primarily to transcribe patient notes and create routine patient communications. Another certainty is that supporting AI-powered tools requires high-quality, standardized data from multiple sources to deliver the most accurate and reliable insights to help automate administrative processes and, in emerging cases, support clinical decision-making.

Lack of collaboration

Yet supplying ample, accurate and timely data across care settings to power these AI solutions continues to encounter challenges. For example, in the previously mentioned government study on interoperability, only 16% of hospitals reported sending summary-of-care records to most or all long-term/post-acute care facilities, and only 8% received information from these providers.

This lack of data exchange reduces the reliability and objectivity of AI tools, not to mention the quality of monitoring that hospital clinicians need to perform in order to prevent rehospitalizations and poor outcomes. The disconnect between these two care settings almost certainly contributes to the 20% average hospital readmission rate from skilled nursing facilities (SNFs) within 30 days, compared with the 14% average rate for all readmissions.

A robust infrastructure that enables interoperability would ensure technologies across the continuum of care can share data in real-time to prevent adverse events. For example, the hospital could use AI tools to identify early signs of decompensation leveraging this data. They could then consult with the SNF’s clinicians to intervene before a readmission is required, improving the patient’s outcome, shortening their stay, and reducing costs for all healthcare entities involved.

Enabling value-vased care

By facilitating real-time data exchange and breaking down data silos, interoperability can prevent rehospitalizations, drive collaboration between care settings, and empower care teams to deliver high-quality, cost-effective care. These activities are essential if providers hope to succeed in the VBC environment regulated CMS, which has set a goal for 100% of Medicare beneficiaries to be enrolled in value-based programs by 2030.

Top organizations are not waiting for that deadline to adopt new technology that enables them to achieve VBC goals of improved patient outcomes and lower care costs. For example, CareOregon, a nonprofit health plan for 543,000 state residents, recently implemented a care monitoring solution that included access to a secure data network of 27,000 long-term and post-acute care providers, 3,600 ambulatory clinics, 2,800 hospitals and 350 risk-bearing providers to enhance care coordination using timely data insights. This real-time intelligence enabled CareOregon care managers to launch preventive interventions, resulting in a 50% reduction in hospital readmissions in the first year. This integration also eliminated manual processes like faxing census reports, allowing care teams to focus on direct patient engagement through at-home visits.

These results underscore how interoperability supports data-driven care, which enhances patient outcomes and operational efficiency and creates tangible financial benefits for providers operating in VBC models.

Emerging consensus

Numerous organizations are working to support healthcare delivery organizations in reaching this collaborative, interoperable state. For example, the federal government’s Trusted Exchange Framework and Common Agreement (TEFCA) provides a secure foundation for interoperability, ensuring providers can meet regulatory requirements while safeguarding patient data.

The private-sector-driven interoperability framework Carequality began a similar initiative in 2014 as part of the Sequoia Project, and has grown to connect more than 600,000 providers, 50,000 clinics, and 4,200 hospitals, supporting the exchange of 940-million documents monthly. Carequality has pledged to align with TEFCA where appropriate “with an eye towards future convergence of the two frameworks.”

These frameworks and other industry leaders recognize the growing need for accurate, high-quality, and standardized data to power AI applications and support VBC goals. However, unifying previously siloed care data, knowledge, and insights is not just the responsibility of a small number of government or industry groups, but all stakeholders across the care continuum. By enabling secure data exchange and fostering collaboration, interoperability creates a more connected and efficient healthcare system that benefits everyone, most importantly, patients.

The transition to a more interoperable and value-driven future hinges on a collective commitment to secure data sharing and innovative collaboration. Harnessing the power of data will be crucial in cost-effectively delivering high-quality care that results in optimal patient outcomes.

Brian Drozdowicz is senior vice president and general manager of acute and payer markets for PointClickCare.