The Evolution of Data in Healthcare; A Primer for Citizen Health
|by Tapan Shah; Healthcare Technologist, Citizen Health Ambassador
As someone who has spent his entire career in healthcare, I have considerable experience in the way healthcare data is moved around behind the scenes to facilitate healthcare transactions and get “things done”. It started with scanning paper Medicare Part B claims, running OCR on them, doing high speed data entry to get all the data right including handwriting, mapping the data and then ultimately uploading an electronic file to a mainframe system so that the claims could then auto-adjudicated with macros or manually reviewed by claim processors. This was my 1–2 payer world where Medicare was primary and if there was a secondary payer then the claim would automatically get crossed over to the Medigap (Medicare Supplemental payer).
Moving on from my batch world that existed of 1–2 payers, I then got exposed to the real time action of healthcare clearinghouses where providers needed information immediately, so the health care ID card had to operate like an ATM card. CAQH is doing some excellent work in this area, trying to apply what they learned in the financial industry to the world of healthcare. In addition to the batch claims and payments, real time transactions like eligibility, claim status, referrals and prior auths were mandated by HIPAA and the industry started to implement them. With the clearinghouse exposure I learned that providers could connect to payers with the help of CHs, the providers needed just one electronic connection to a CH instead of building an electronic connection to each payer they were transacting with.
My fee for service background was mainly centered around the administrative transactions of healthcare and that mainly became a commodity with time. Value based care is becoming a lot more prevalent now and that has vendors racing to see how they can meet providers’ needs and “handle” (normalize, route, present at time of decision making, etc.) clinical data. With the shift to value-based care I think organizations like Citizen Heath can apply their blockchain expertise to help providers transact data in a more seamless way. Faxes are still used in healthcare, especially in scenarios where two systems don’t talk to each other. With faxes the information is encrypted hence the widespread use. Eligibility and Benefits, Referrals, prior authorizations, requests for medical records, claim adjudication could potentially be done using blockchain.
Healthcare being such a large part of the US economy has attracted a lot of talented people and companies from other industries such as financial, supply chain, tech, etc. This is a good thing as this industry needs people to constantly challenge the status quo and make sure all the players are adding value. Consumers need more options and the system has been broken for a long time now. I think Citizen Health has a valuable role to play here and I am sure it will show us how healthcare needs to be designed and implemented by creating a new ecosystem. It’s like starting an IT project and you get the wish list of the business sponsors before you start writing requirements. If you gave doctors, nurses, and patients a clean slate, what would their ideal world look like? Welcome to Citizen Health and join the revolution! May the force be with us!
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