Healthcare Data Finally Freed
This week I am talking to Jay Sultan, Vice President of Strategy, Healthcare, LexisNexis Risk Solutions, who arrived into healthcare as a technologists and software. His intersection with healthcare started out with personal frustration and disbelief of the lack of sharing of information and systems thinking that was pervasive. The great news is that for a $4.3 Trillion industry and small incremental improvements are going to have a big impact.
We discuss the Final Interoperability rule published by (CMS Interoperability and Patient Access Final Rule) that comes with some standards (including FHIR v4, and USCDI to name a couple) that addresses 40% of the the marketplace with patient consent allowing access to
“a highly standardized data set that is broad, that is deep and It’s very rich, and be able to do so in a remarkably consistent way across 300, roughly 350 different payer organizations that are governed by and regulated by this rule”
With the Federal Government’s as the largest payer in the world, by both dollars and many other measures you have the power of the purse, but also the power of regulation, and they are using both of those in this instance, to compel change.
We discuss the significance of the publication of the interoperability API in the CURES act and why and how the federal government has brought about change while building on existing standards and capabilities such as EDI and claims processing that has long since used interoperability that will allow data to flow freely where and how it is needed, while respecting the privacy and control that individuals should have
Listen in to hear how the remaining 60% of the industry will follow suit and why and Jay’s deep dive into this data and what you need to know about the future of data sharing, the standards involved and how to integrate this into your healthcare system. Don’t miss the details behind one of the most significant dates for any hospital coming up – January 1, 2023 and why.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Jay Sultan. He is the Vice President of strategy of healthcare in LexisNexis. Jay, thanks for joining me today. It’s a pleasure to be here Connect. So as I do with all my guests, I think it’s important to get a little bit of context of you the individual, how you arrived at this role, a little bit about your background, tell us how you got here and some of the highlights in your career, if
Jay Sultan
you would, I’d be glad to. So I’m from rural Georgia, and grew up in a fairly technologically backward part of the state. Got into computers and software, I’m not a clinician by background, I am a technologist, I often joke I’ve had every job you can have in a software company, including having own one at one point. And I got introduced into healthcare it as a result of my first wife going through and losing a five year battle with cancer. I was in my 30s at that point, and was astounded at, you know, my experience as a caregiver, seeing all the challenges and all the kind of experiential things that she and I went through that that just really, to me felt like a system in need of improvement. And so a good friend of mine had an idea for innovation in healthcare involves computers, he knew that just give him a call out his name is Dr. Clint Ashford, and he’s a practicing ob, but didn’t really know how to start up a software company. So again, I had a good friend named Dr. Clint Ashford, he was a practicing ob. And he had an idea for how to do an innovation in healthcare, but wasn’t a software person didn’t know how to get started. So that was my introduction to healthcare IT. And I’d say maybe 15 years ago, 10 years ago, I got lost. I found myself talking to attorneys more often than I was talking to programmers. And I realized that crossed over to the policy side of healthcare it. So I’ve had a number of jobs in startups. I’ve had a number of roles working either as a product owner, or as a advisory consultant. Over the last few decades, my career has been about 5050 payer provider, which is unusual for somebody that that has my background, and pretty much all the opportunities I’ve had, working at different companies have all been around the idea of innovation, not just technology, innovation, but how do we innovate healthcare, how can we make healthcare better, cheaper, easier, more effective, more evidence based, more, a better coverage, those kinds of questions and the real world technology meaningfully applied at the payer To provider in the hospital in the workflow, that’s really where my career has been about.
Nick van Terheyden
Fantastic. Thank you for that. So I, first of all, I’m deeply sorry to hear about your wife and your intersection with the healthcare system. You know, there’s no making up for that there’s no excusing it. People’s origin story are always a surprise to me. And you’re certainly well, so thank you for sharing that.
Jay Sultan
I raise it just to make the the observation that, well, you know, as somebody who thinks like an engineer and thinks about systems, I was very surprised at the things the system wasn’t set up to handle, for example, she got reconstructive surgery before she had a radiation treatments. Now, there’s no doctors in the world that I know of Who would think that’s the right solution of Eid sequencing, because, of course, the radiation damage the work done by reconstruction, but there was, you know, we as you know, 30 year olds didn’t know how to navigate the process, and the, the, our, you know, siloed, uncoordinated touches with different parts of the healthcare system, you know, the surgeon focuses on what the surgeon does, that’s what surgeons incentivized to do. That’s the rules of the game, he’s playing by the rules of the game. But the experience that leads to a patient is, you know, we’ve known for a while now that this is an area that we as an industry need to address. And so, you know, losing her was traumatic, if she’d survived, I probably would have the same thought. And that is that as a system, you know, I am the last to advocate for single payer or a government run delivery system. But at the same time, our for profit free market oriented system is in need of improvements. And these are improvements we can make, that I think will both not only benefit our men, our patients, our members, but they’ll benefit us in the healthcare industry, it’ll make us more profitable, it’ll, it’ll streamline things that will reveal take friction out of the system. So there’s, you know, the great thing about a $4.3 trillion industry is you don’t have to make much change to have real dramatic impact. And that’s really been the philosophy, you know, that I’ve had for my careers. How do we make systematic structural changes that benefit everyone, because there’s a lot of wind wind winds out there,
Nick van Terheyden
I gotta say, I love that, you know, you don’t have to make a lot of change in those numbers, to get my preferred term, incremental changes, but those are like enormous changes and hugely positive. And I think extraordinarily important to sort of focus in on those origin stories and the reasons why because passion drives this industry and drives people in it. And you know, it’s a drive for good in my view. So I really appreciate you sharing it, and also sharing the additional details. So thank you for that. You, you had talked a little bit about the future. And you know, one of the things that you referenced as part of your introduction was the sharing of information interoperability. And I think you sort of declared that the battle has been one where we’re where we have a new interoperability and patient access rule. Things are going to get better. What’s your feeling about that now.
Jay Sultan
So you’re referring to something I said in December of 2020. And here we sit in June of 2021, just days away from the next part of the 21st Century Cures Act rulemaking taking place which will be the publication of the patient access API for the payers. I stand by the view that by the end of 2021, I think as an industry, we will be surprised at how far we moved during 2021. And I think the seminal event will be number one, the publication of the patient access API, which just to remind people, it doesn’t affect every insurance company. It affects four named lines of business, Medicare Advantage, managed Medicaid, Chip, and qH PS, which most people know is Obamacare that operate on the federal exchange. Those make up about 40% of the US insured population. So for 40% of the US insured population, any application developer, anybody who wants to write an app, but much more importantly, any existing business, any existing entity inside of healthcare, and any existing entity outside of healthcare, will be able to get consent from a patient. And with that consent, access, a highly standardized data set that is broad, that is deep and It’s very rich, and be able to do so in a remarkably consistent way across 300, roughly 350 different payer organizations that are governed by and regulated by this rule. So that’s an awfully big statement. And it’s completely unlike anything that we could have said about Meaningful Use about the adoption of HIE, S or Rios. And I think some of the key tenants as to why I haven’t told you yet maybe what I think the impact will be. But defending the idea about why that impact will happen is first and foremost, there was action by the federal government. And I am not often a fan of action by the federal government personally. But in this case, it was necessary. The Federal Government’s the largest payer in the world, by both dollars and many other measures. And only they have not only the power of the purse, as you know, the principal payer for more than 50% of most providers revenue stream, but also the power of regulation. And they you’re using both of those in this instance, to compel change. And so if you don’t mind me extending the analogy, just a bit, Dr. Neck, I think a lot about what hasn’t hasn’t happened in healthcare that work. I often say that the new interoperability, which in my mind is different than what we’ve done in the last 10 years, what we’ve done with Meaningful Use, which was not used, it was meaningful, what we’ve done with the HIE is the Rios it’s not that they’ve had zero benefit or impact. But they certainly haven’t accomplished what we hoped they would accomplish, which again, for me, for some stakeholders is the idea that data should flow freely where and as it’s needed to provide effective, efficient quality health care, in a way that’s still representative still respects, the privacy and the the individual control that patients and members should have. So so that in my mind is really what we should be about. And that should that was I think the goal for meaningful use. I think that was the goal for HIV, but it’s largely not happened. And I think about what what has worked. And that causes me to make the following statement. We have some interoperability in healthcare today that works pretty well. We just don’t call it an operability. We call it the EDI AI or sometimes we call it the RCM, the revenue cycle management. It’s the flow of claims. It’s the data flow that handles the payment of healthcare. Because I’m old enough to remember the days before HIPAA, and pre HIPAA, it’s not that electronic claims didn’t exist, payers, and providers had computer systems. But there were no standards, there were no mandates, there was no uniformity. And so what would happen is one payer and one hospital would get together and make a point to point connection, data trade, I like to talk about trading data, they would do it but it wasn’t scalable. Beyond that one relationship. And the government said, This is crazy. I’m gonna there’s a standards body I like they’re called x 12. They got a family of standards I like called 4010. Now we have 5010. And I don’t like all the standards, but I like this a 37. I like this a 35. I’m gonna mandate those. Now, this was before this rule took place. People thought that because remember, at the time, while there were a few hospitals doing electronically, the vast majority were either starting with paper and sending paper to the payer, or they were starting with the computer, they’re using the computer to create paper or fax. And then we’re sending that to the payer, right? That was that was what that was when we lived in. And people thought wasn’t going to be a big deal. But maybe it’s not going to completely change the way we treat, it’s not going to cause us to organize our hospital differently. And I would argue that’s in fact, exactly what happened. That, you know, it’s been attributed to many people, I choose Bill Gates. He says that in the technology world, we always underestimate what we can accomplish in 10 years, but we always overestimate what we can accomplish in one. I feel like the EEI the x two other the the process electronic processing the claims is a great example of that, because in the first year, there were incredibly low auto adjudication rates. People were having to change systems, they’re having to train armies of new people to do coding in new and different ways that we had never done before. It was incredibly expensive, was incredibly disruptive. But what comes out of it now is we’ve gone from auto adjudication rates, you know, around 10 to 15%, to where most payers are able to audit Judah Kate around 85 to 90%. And that matters to everybody. It matters because of the volume of claims we processed. We couldn’t go back to paper today if we wanted to. There’s just not enough people, scanners, whatever to be able to print process the the volume of claims, nevertheless, the complexity of claims that we have today. And so when we think about new funding models of how, you know, outpatient surgical standards work and how they get compensated in ways that add value to the system, we think about this, you know, kind of longitudinally, we see all these places where have we never had electronic claims, we would have never been able to see the system change the way that it has. And remember, I’m not talking yet really about the treatment of health care, I’m talking about the payment of health care. So the E, I worked it so much. So today that we would struggle to do without it if like, you were to get withdrawn for some reason. And that is in operability, you have 1000s and 1000s of providers sending information to hundreds of pay payers, and it all works largely without humans having to touch it. And I would argue that it actually benefits all of us for providers, every time you know, a payer cannot have adjudicate, the provider has to spend money on you know, touching it and calling and delayed payment. And, and the free flow, people were skeptical. In the zero sum world of paper claims where they said, Well, my ability to process claims at a higher volume gives me a competitive advantage over now I have the hospital the competitive advantage over my my payer, because I can, you know, because of the way the paper claims work. And the they felt like they were potentially losing that advantage. I feel like that’s where we are today, there’s a number of stakeholders in the industry, who I believe have not been enthusiastic about the meaningful free flow of data for the treatment of healthcare. This is what the 21st Century Cures Act targets is the data needed for the treatment and the operation of healthcare. And I would argue they do that because they’re concerned about the future, and about losing their current competitive advantage. And, and I think that that’s going to prove to not be the case.
Nick van Terheyden
So for those of you just joining on, don’t connect the incrementalist. Today, I’m talking to Jay Sultan, he is the Vice President of strategy for health care in LexisNexis. We were just talking about the rollout of interoperability, and specifically the new API that’s coming through the Cures Act. And, you know, the value proposition. You know, just to dive in a little bit, you made a couple of statements around, you know, those fearful of sharing this information, you know, many would say that some of that failure of interoperability was not about technology, although, you know, some of it was but a fair proportion of it was economics, fear of, you know, loss of business. You’ve taken a subset, as you define clearly the four lines of business and the 40%, that, you know, is being addressed, which, you know, to your point earlier on is a huge impact. You know, when you consider the size of the healthcare system, what about the remaining 60%, you think those are cards that are going to fall and why.
Jay Sultan
But we know those cards will fall, it requires getting a little bit technical about how the law is put together. So let me give you maybe three or four bullet points on the 60%. The first point I’d make is this, I think, even in the first year to have the payer part of the patient access API rule operating, we will see payers voluntarily starting to support all their lines of business. And a few of them are mission oriented, they’ll do it because they think it’s the right thing for their members for health care. I think for most of them, they’ll do it because of the effect of the employers Remember, the principle customer that most payers care about our employers, if you’re an employer, and you’re used to paying, you know, far more for health care than that, then the Medicaid plan does. And you’re being told patients on the Medicaid plan can access their data, but patients in my expensive employer plan Can’t I think employers will start to bring pressure to bear on their payers to expand that the you know, voluntarily without the mandate. I also think we’re likely to see a tough call roll out of the new administration somewhere in the next six to 12 months. And I think that has the potential to, again, significantly disrupt what all of us think, but I don’t want to guess at what test is going to say. So I’m just going to comment that test could give me something else that opens up altering the picture of what data can be accessed and by whom and when and how. The next point I want to get to though is a very important date if you work for a hospital system or physician, and that’s January 1 2023. By the current rule, assuming there’s no more changes to the role, and I see no indication to think that we will see this change or delayed On January 1 2023, every certified EMR must support the patient access API for providers. Now, the patient access API for providers is very similar to the API for payers. In particular, they both use the same smart on fire workflow. What is that? The smart on fire workflow is a standardized process whereby anybody who wants to access this data, whether it’s to app developers in a garage in San Jose, or it’s, you know, a major payer, or major hospital system, whoever it is that wants to access the data, can go through a standardized set of steps against any payer, and then starting in 23, against any provider, again, that hasn’t certified EMR, and be able to validate that they have x should have access to the data, get the consent needed from the patient slash member and be able to create that technical connection. It’s also similar in that they both contain the US CDI, or sometimes known as the US core, there’s a slight difference between those two, but for this conversation, let’s call them synonymous. And the US CDI is a very broad and deep and very, very well developed, in my opinion, a set of standards and specifications, far better than the CCD axes that we worked with for eight or 10 years. Because they’re far more prescriptive. They’re far broader. And they do a far better job of bringing context and metadata that allow automated systems to simply take the value and start using it, rather than to have to do lots of, again, specific to one trade one, one data trade work, figuring out how to make the data meaningfully go from one place to the other. So it’s that they have these this great us CDI, that does not only got all this great specification, but it’s very, very broad and includes notes, it includes a large set of structured data around everything from lab results to meds to problems. I mean, there’s there’s a, I’m gonna forget the narrative, I had the 20 something resources that are richly defined in this standard. And it’ll be the most comprehensive standardized data set we’ve ever worked with as an industry. And so I say that to make the point that the data that it will allow us to transport from a provider from a hospital from a doctor is identical to the clinical portion of the data of the payer access API. Now, the payer access API also has claims as encounters it has some benefit information about pharmacy. But I think the game changer is the fact that any entity that wants to collect data about a person, whether that’s me as a patient, whether it’s an app that I’ve chosen to use, or whether it’s a company that I’m doing business with the payer hospital, or Walmart, or Amazon, they can all use the same technology to access the same format of data from all the different silos where it lives. And so I see this July 2021 date where the payers go live as the beginning of a training period, when people will start to prepare for January 2023, when it’s available on any patient, regardless of the line of business, any patient who has data inside of an EMR that’s certified.
Nick van Terheyden
Alright, cool. I I’m excited. And, you know, I think the pathway is laid out and it feels like, you know, there was some solid guardrails that are going to get as bad in the closing minute, also, that we have. You mentioned that we have enough in the way of data standards, you know, the elements up my my sense is that it’s, it’s never perfect. Do you think there’s still pathway and opportunity to expand that? What are we going to do to build on that?
Jay Sultan
Or without question, and one of the smart ways that the government and HL seven and the organizations out there like Da Vinci and Karen and all the others that have been working so hard on this has done is they’ve given us a standard and governments giving us a mandate on that standard to get us all started on the same place. The standards are designed to be future compatible, future forward working, so we can make changes to them without breaking everything. And there are established stakeholder groups that are constantly needing to figure out how to improve it. So I just mentioned the US CDI will be implementing v1 initially, they’ve already figured out their balloting, I think somewhere later this year on the v2 and eventually I hope we’ll see a mandate that we all have to move to the v2 and these are designed To make it so that these can be living breathing standards and standards themselves are set up with capabilities and it’s it gets technical that the fire standards we’re talking about have the ability to do extensions and and to support metadata about provenance and stuff and all of that extra effort built into the standards makes them both standardized and flexible in the ways that we need. Really fire for Dotto is going to replace all the previous versions of fire but also in my mind, HL seven two Dotto CCD CCD x’s and HL seven three Dotto adts o R Us stuff like that, because it’s such a better standard. And it is a standard that, you know, we’ve had the 837 standard for 35 years now. Now, I want to point out, it has changed over time. I mean, we’ve modified the every year that standard changes. But we as a system are great at adopting and handling those changes, I think it’ll be the same thing with the US CDI and the other related fire standards. And I also think we will see more mandates this administration is going to want to focus on public health, we’re going to probably have mandates around sto H, maybe the gravity standard that’s in final stages of being developed. So I think we will see it extended as the business needs of all the constituents drive it. And again, there has to be a healthy place for the government to make sure that we are moving together as a group. Without that I don’t think we’ll be successful.
Nick van Terheyden
Fantastic. I unfortunately, as usual, we’ve run out of time. You know, what’s extraordinary to me is I have lots of conversations, most people are pretty passionate about, you know, the future. If anybody ever pushes back in terms of interoperability, I’m gonna refer them directly back to you because it is clear to me you see that vision, you can see the pathway. And I think it’s extraordinarily important. We missed that completely with Meaningful Use and a number of other things. But I see that and I love it because you’ve come from the technical side with a passion around health care. And I think it’s just so important for us to get to that position. So, Jay, thank you for sharing all of this. It’s been a real pleasure talking with you and I know our listeners are going to really enjoy the insights and the passion.
Jay Sultan
Thank you that connect was great to join you and your guests.
