The Power of Payer Interoperability in Healthcare for Value-Based Care

Interoperability is the backbone of quality care in the modern healthcare world and has been a staple of the health information management conversation for decades.

At first, this conversation focused on the clinical data exchange within a health system. Then interoperability rapidly expanded between enterprises with the meaningful use era. Over the past few years, the dawn of the value-based care era has ushered new stakeholders into the interoperability space. Population health, connected devices and consumer-mediated exchange became new buzzwords around interoperability in healthcare. And on the sidelines, payers began to quietly exchange clinical data with their contracted providers.

When a healthcare payer contracts with a provider for reimbursement based on the quality of care, measurements of the outcomes of this care are required for payment. This includes items like lab results, admission and discharge information, body mass index, vital signs and results of screening procedures and preventative health assessments.

Just knowing that the provider had performed the procedure/test/assessment was enough for payment under a fee for service contract. However, under a value-based contract, the healthcare payer also needs to know the results to measure the quality outcomes of the care. This brings exchanging clinical data between a provider and payer under the Treatment, Payment, and Operations section of HIPAA, and makes it possible for payers to utilize the power of clinical data to improve the health of the populations they serve.