RISE Radio

Episode 17: Cotiviti’s Katie Devlin on navigating the health care interoperability landscape

• Ilene MacDonald

Share episode

Katie Devlin, DHSc, MS, CPHIMS, vice president, interoperability, Cotiviti, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health.

In this 21-minute podcast, Devlin, author of the new white paper, Implementing a digital quality strategy,  discusses interoperability, federal requirements,  challenges, and how it supports improved risk adjustment and quality programs.

About Katie Devlin
Katie Devlin, DHSc, MS, CPHIMS, vice president, interoperability, Cotiviti, Inc.,  is responsible for creating  an enterprise-wide health data exchange strategy to address clients’ unique business needs while reducing provider abrasion, maintaining regulatory compliance, and optimizing value. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, including the expansion of Cotiviti’s electronic health data networks and strategic partnerships. Drawing on her extensive informatics and health information exchange experience, she is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience. 

About Cotiviti
Cotiviti enables health care organizations to deliver better care at lower cost through advanced technology and data analytics, helping to ensure the quality and sustainability of how health care is delivered in the United States. Cotiviti’s solutions are a critical foundation for health care payers in their mission to lower health care costs and improve quality through higher performing payment accuracy, quality improvement, risk adjustment, consumer engagement, and network performance management programs. The company also supports the retail industry with data management and recovery audit services that improve business outcomes. 



Ilene MacDonald:

Hello and welcome to the latest episode of RISE Radio. I'm Ilene MacDonald, the editorial director at RISE. Today we're going to discuss interoperability and how it supports improved risk adjustment and quality programs. To help us sort through it, my guest today is Katie Devlin, the vice president of interoperability for Cotiviti. For those who aren't familiar with Cotiviti, the organization enables health care organizations to deliver better care at lower costs through advanced technology and data analytics, helping to ensure the quality and sustainability of how health care is delivered in the United States. Welcome, Katie. Thank you for joining me today. Katie, let's start maybe at the very beginning on what is interoperability and why it's so important.

Katie Devlin:

Yeah, so when you look up articles or you read a book, interoperability is usually defined as exchanging data, exchanging clinical data, often for the purposes of continuity of care. But it really goes a little bit beyond that. It's exchanging clinical information, but it's really to the right person in the right format, the right information in the right format and in the right workflow and at the right time. So it's not just if you serve up data to a provider, for example, it doesn't mean anything unless it's put into context. So that's really interoperability being able to exchange clinical information for specific purposes and use cases. So I mentioned continuity of care. That is sort of the largest one. Treatment, payment, and operations is sort of the umbrella that everything falls under. But continuity of care is a big one.

Katie Devlin:

Individual access is something that came up recently, especially with the Cures Act, and we can go into detail about that later. But patients being able to get access to their own data. \We saw patient portals come around a few years back and there really wasn't a lot of adoption because it was hard for patients to actually use these portals, get in and figure out what their passwords are. So the Cures Act really tried to make that easier and simplify that process for patients. So individual access is another big one. And of course there's payer and provider needs being able to exchange data, close gaps in care, acquire data on behalf of payers to do quality reporting, risk adjustment, coding, all of that. And there's also alternative use cases that don't fall under this treatment payment operations umbrella. These include disability benefits determination, public health reporting. Even life insurance companies are requesting it. So there's really a lot that goes into interoperability and the exchange purposes are permitted uses for the data.

Ilene MacDonald:

So, given its value to health care, why do you think it's taken so long to establish and get it up and running?

Katie Devlin:

Yeah, so I think you know, if we go back, actually, when I started, my first job was working in a medical records department of a large integrated health system teaching hospital and we were all on paper. This was prior to EMRs. And, you know, different health systems were trying to come into this century and they were trying to introduce some type of electronic record, and it may have only been clinical notes, it may have only been sort of nursing documentation, maybe it was on microfiche actually, and each EMR as these EMRs came up, so Cerner, Eepic A llscripts allscripts, as these EMRs came up, they each had their own proprietary formats. So we, you know, and the providers really struggled with adopting it too, because many of the providers at the time were used to documenting on paper. They had their workflows ingrained. So you saw meaningful use one come around and that basically said okay, health care organizations, if you want to be incented from CMS and you want to be financially reimbursed, you need to be able to show me and demonstrate that you can meaningful use this EHR right. And that meant that a percentage of providers needed to be able to enter orders electronically. They called it computerized physician order entry. Nurses had to enter X amount of orders. Certain, you know elements within the EHR needed to be structured information.

Katie Devlin:

So that was all well and good, but there was a need for more adoption. We saw providers sort of going down the hall and calling the nurses to put in a phone order for them. We saw things like dictated reports being done more and more because the EHRs weren't necessarily configured for provider usability. The workflow was really still very clunky. So now we have meaningful use too. And that came around and it said okay, we're going to up the ante here. You need to have more providers using this, more nurses using this. And now you have to demonstrate that you can share this information outside of your EHR with an external organization. And if you think about it, that makes perfect sense because most of us patients, if we're going to a large, you know, health system or integrated network, we see providers right outside of that network. Maybe you're referred to a specialist, maybe you go to an urgent care center.

Katie Devlin:

There are many reasons that that data needs to be exchanged, referrals, for example. So, for meaningful use to these health systems, and providers who wanted to get the CMS money needed to be able to demonstrate that they could share the information. But it was really hard because the EMRs that were in place, or the EMRs in place at the time, they didn't have any sort of standard format to share the data. So everything was sort of proprietary. And when EMRs were first established they would still have to speak internally across the health system to, you know, the revenue cycle systems and the patient scheduling and registration systems, and what they used was called HL7 messages and that was really meant for internal health system communication.

Katie Devlin:

But with the Meaningful Use 2 Requirements, we said, ok, well, maybe we can use HL7 to do this. So that was sort of very clunky trying to exchange data from an Epic to a Cerner system at that time. So now it's really evolved Meaningful Use 3 evolved into promoting interoperability standards and we saw the Cures Act come shortly thereafter and now mandating what's called Fast Healthcare Interoperability Resources, which is really a sort of open sourced way of exchanging data. It's using APIs, of course, secure APIs meant for patient information. So that's sort of how it's evolved and you know we've gone from in the past 20 years. I think we are today where we thought we would be 10 years ago, to be honest, and we still have a lot of work to do with it.

Ilene MacDonald:

I know you've mentioned the CARE Act. We've talked about Meaningful Use. Are there any other federal requirements that help, sort of pushing us forward, so that we can maybe fast track and sort of get to the point we thought we would be at it right now?

Katie Devlin:

Yeah, so out of the Cures Act.

Katie Devlin:

The Cures Act basically established this floor for universal data exchange and with using the FHIR standard. But how do we do this? How do we actually get this done? And we have national networks today that are in place, that have been exchanging data. They kind of figured out how to leverage HL7, how to use what's called IHE-based profiles to share information in the Continuity of Care Document format. So that is all well and good. We have these networks. They have a lot of health system participation. They have a lot of health information exchanges participate mostly for treatment purposes, but others are sharing data for payment and operations as well. So out of the Cures Act.

Katie Devlin:

The way that we are going to do this is called the Trust Exchange Framework and Common Agreement and also known as TEFCA. And TEFCA basically builds on what we already have accomplished as a nation in terms of data exchange, but it takes it a little bit further and it supports the patient access, individual access. It supports payer-to-payer data exchange, payer-to-provider prior authorization. It supports these other use cases like government benefits determination, public health reporting, etc. So the TEFCA is very, very detailed. It operates in sort of this broker approach, because these health systems and HIEs that participate in national networks today can apply to become a qualified health information network, or QHIN, under TEFCA, and what that means is they go through a really rigorous vetting process where they have to apply to be a QHIN, their QHIN application is approved and now they have to test and they have to meet the technical requirements of TEFCA, called the QHIN framework right, so the QTF Technical Framework.

Katie Devlin:

So as they do that and once that comes up, treatment will be the first use case and these QHINs can basically exchange data from each other. So if I'm Katie Devlin and I live in Massachusetts, I can use my regional QHIN to exchange data if I need my data shared with, maybe, the West Coast QHIN. So it's a really good way of approaching nationwide information exchange. But it is going to be a very specific process that needs to be followed to get there. So the initial focus with TEFCA right now is, of course, on treatment. Patient care is the most critical treatment in patient access and we're in this place right now where the TEFCAs are doing this onboarding process. But the framework does say that these other use cases, including payer-to-payer and payer-to-provider exchanges, will be supported. It's just a matter of when that mandate will happen. So just something for other health care stakeholders to think about.

Ilene MacDonald:

What would you describe as sort of the primary challenges for organizations? You know, whether it be Medicare Advantage plans, whether it be provider organizations, hospital systems. What are you hearing from your clients?

Katie Devlin:

Yeah, I mean, I think it's not just our clients, I think we're seeing it ourselves at Cotiviti, right, it's the policy influences data availability right now it's sort of the slow drip, so and consistency in the data, the data content Are we getting the data in CCDA format? Are we getting it in FHIR, which is a JSON format? Not so much, really, that the reality is not. A lot of hospitals are using that yet, though that is where the industry wants to go.

Katie Devlin:

So it's the content, it's the availability, and because of TEFCA, right that not all of these health systems in HIEs are mandated yet to share the data for use cases beyond treatment, even though they may support and encourage sharing of the data for payment operations, they're not required to do so yet but they will in the future. So that's one barrier, right, the availability of data. Another thing is the exclusivity right that we're seeing with some of these vendors, health systems. It really goes against the spirit of interoperability, right, when you see, when you unfortunately want to get data from a health system and say, oh, I only work with this vendor, you know that really doesn't sort of, you know, just, really, in my opinion, goes against the spirit of what we're trying to do as an industry.

Ilene MacDonald:

Can you describe how interoperability supports improved risk adjustment and quality programs. I know that's become sort of a talking point from the people I speak with.

Katie Devlin:

So you know getting structured data because as we're acquiring this information, it's becoming more and more structured. We have the new US core dataset, so it's called USCDI and that's the content, right. So we have protocols to get the data via IHE and ihe and other mechanisms. Whether it's a not so fun as FTP, that is the reality. But the content of the data is coming in in structured format. It needs to meet the USCDI core requirements, which basically says you need to have these elements within the data that you're sharing. It doesn't matter if you get it via FHIR or CCDA, but you need to have these elements. So the data is getting better, and structured data means better insights, right, the ability to use this information to more effectively close gaps in care, et cetera. So, event you know, the hope too is that this information can be used for the digital measures as well, right, and we see that NCQA has stood up a really rigorous process for vetting the content of the information, called a DAV certification program or a DAV validation program, and we're seeing a lot of these HIEs go through that.

Katie Devlin:

In fact, I was just at, Cotiviti is actually part of the used to be called the Strategic Health Information Collaborative. It's now called Civitas and I was just at that conference this week and I was really, really impressed with how many HIEs and partners have gone through that process to validate their data. Now, when you talk about somebody being DAV validated, it doesn't mean if they have a thousand participants in their network that all of those participants have gone through that program. It's data stream by data stream, so it is a really onerous process but it's I've heard it's been very good for improving the data quality. So you know, certainly is going to help with a lot of these payer use cases like risk adjustment and quality.

Katie Devlin:

Yeah, so I think you know, just building on what I just said, if you plan to use digital data, you know you really need to make sure that your organization has an understanding of NCQA's requirements. Right? The DAV validation program. Who has gone through that? And are they a data stream that's validated? Or is it maybe a vendor partner that had gone through this validation process with a data source? Because that is different. Just because you know an organization has gone through, there is a, I guess, a difference, right? If you're a vendor and you are supporting, maybe, analytics or doing something with the data to help clean it, et cetera, that does not mean you have data to give. These organizations have gone through this certification with a data partner. So it's important to understand that difference there. And then, if the data is going to be used as supplemental, you know, then understanding whether or not it's subject to audit and primary source verification.

Ilene MacDonald:

I'm thinking some of the listeners today might be in the early stages of all of this. Can you offer any suggestions if you're just in the beginning? What do we think about?

Katie Devlin:

Yeah. So I think you know it's really important to take a step back and assess your infrastructure right. You need to make sure that before you start getting over your skis here and making all these connections to data partners or trying to work with them, you need to look at what you have internally and assess your infrastructure, figure out how scalable it is. Can you accommodate various ways interoperability, protocols, ways of connecting to these data partners, whether these data partners are health systems, health information exchanges, data aggregators, national networks you know you do really need to have an infrastructure that can accommodate different formats. So, for example, we have a FHIR-based application that health systems can use to share their data. We also use IHE-based profiles. So it's a what's called an XCA-XCPD data exchange and it's this sort of multi-step dance that says, okay, do you have Katie Devlin? And they say, yes, we do have Katie Devlin. You do have Katie Devlin's records now for this time period? Yes, we do. And then they'll send the CCD over. So that's sort of the second way. And then, as I alluded to earlier, some of these health systems want to put the structure data on an SFTP folder and just use it as like a patient panel kind of approach and we have that option as well. So we have a provider portal that health systems can use to share that data. So having an infrastructure that's really scalable and can meet your data partners where they are is great.

Katie Devlin:

And the idea is, as FHIR becomes more adopted and TEFCA, you know, becomes reality for payers, that the other sort of protocols will diminish right, and we'll see more adoption on fire, but I don't think they'll ever go away, so it's definitely worth building.

Katie Devlin:

I think you need to also have a really good understanding of your market and where you want to build your network. Relative to potential data partners. So I've talked to many clients and I've experienced this myself before, where I get really excited about working with a data partner and they say, yes, we have all this access to data, it's wonderful, we have four million lives. That's great, and when you actually dig in and you actually look at the network, they have four million lives for treatment purposes. It doesn't mean that payers or business associates of payers, like like Cotiviti, can actually use that data or have access to it at least not yet. So really doing your due diligence, making sure that you understand what data is available to you when you contract with somebody and for what use case is right, especially if the source provider health system is not part of a national network.

Ilene MacDonald:

Is there any other something I didn't ask you that you think is important for anyone who's listening today, what they should take away from all of this?

Katie Devlin:

Yeah, I think just understanding that interoperability is really just more complex than I think a lot of folks think you know, even you know understanding TEFCA and how that's going to work. It is not saying, again, just coming from this conference it was refreshing to hear the industry experts say you know we are not seeing broad adoption of FHIR yet. These other protocols were invented for a specific reason to solve a problem. So Continuity of Care Documents, CCDs or XML documents, structured information that comes across, that was meant to share data during Meaningful Use 1, transitions of care documents, that kind of thing. Hl7, as I mentioned, was used for messaging internally but can be used for other things and it's really valuable on the provider side for admission discharge transfer notifications. So those protocols aren't going to go away but we will see FHIR adoption grow over time but it's not.

Katie Devlin:

There's no sort of single bullet to solve this problem. Even these, you know organizations, HIEs and health systems are struggling with understanding TEFCA for treatment purposes. If I'm a national network, I can have some of my participants opt in to share for TEFCA and others opt out of it. It's not required but it's obviously it's beneficial for organizations to do so, so they have to build different data streams. It gets very, very complex very quickly. So, you know, I think it's easy to get frustrated if you're not getting this sort of widespread access to data yet, but the reality is is that it is this sort of very slow, slow drip, you know, to say again, and you just have to be very specific about where you're, where you're looking for data, and very, you know, cautious of making sure that you're not getting into agreements with data partners that require minimums, because you might not be able to meet those based on the data that's available on the other side.

Ilene MacDonald:

And given this complex topic, Katie, if people have any questions, how can they reach out to you?

Katie Devlin:

I think the best way to do that is you can go to answers@ cotiviti. com and send me a message that way. That way we can sort of track that information that's coming in and make sure that we're responding in a timely format. <span data-v-07c63b49="" style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-translate-x: 0; --tw-translate-y: 0; --tw-rotate: 0; --tw-skew-x: 0; --tw-skew-y: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-pan-x: ; --tw-pan-y: ; --tw-pinch-zoom: ; --tw-scroll-snap-strictness: proximity; --tw-ordinal: ; --tw-slashed-zero: ; --tw-numeric-figure: ; --tw-numeric-spacing: ; --tw-numeric-fraction: ; --tw-ring-inset: ; --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,. 5); --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-shadow: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-shadow-colored: 0 0 #0000; --tw-blur: ; --tw-brightness: ; --tw-contrast: ; --tw-grayscale: ; --tw-hue-rotate: ; --tw-invert: ; --tw-saturate: ; --tw-sepia: ; --tw-drop-shadow: ; --tw-backdrop-blur: ; --tw-backdrop-brightness: ; --tw-backdrop-contrast: ; --tw-backdrop-grayscale: ; --tw-backdrop-hue-rotate: ; --tw-backdrop-invert: ; --tw-backdrop-opacity: ; --tw-backdrop-saturate: ; --tw-backdrop-sepia: ; font-weight: 700; white-space-collapse: collapse;">Ilene MacDonald</span><span data-v-07c63b49="" class="font-normal ml-2 text-gray-400 relative" style="--tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-translate-x: 0; --tw-translate-y: 0; --tw-rotate: 0; --tw-skew-x: 0; --tw-skew-y: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-pan-x: ; --tw-pan-y: ; --tw-pinch-zoom: ; --tw-scroll-snap-strictness: proximity; --tw-ordinal: ; --tw-slashed-zero: ; --tw-numeric-figure: ; --tw-numeric-spacing: ; --tw-numeric-fraction: ; --tw-ring-inset: ; --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,. 5); --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-shadow: 0 0 #0000; --tw-shadow: 0 0 #0000; --tw-shadow-colored: 0 0 #0000; --tw-blur: ; --tw-brightness: ; --tw-contrast: ; --tw-grayscale: ; --tw-hue-rotate: ; --tw-invert: ; --tw-saturate: ; --tw-sepia: ; --tw-drop-shadow: ; --tw-backdrop-blur: ; --tw-backdrop-brightness: ; --tw-backdrop-contrast: ; --tw-backdrop-grayscale: ; --tw-backdrop-hue-rotate: ; --tw-backdrop-invert: ; --tw-backdrop-opacity: ; --tw-backdrop-saturate: ; --tw-backdrop-sepia: ; --tw-text-opacity: 1; white-space-collapse: collapse;">Host</span> hanks so much. Yeah, thank you.