Confessions of a Care Manager: The Power of Member Engagement, Data, and Interoperability

I have devoted my career to supporting patients and families through some of their most vulnerable healthcare experiences. From the age of 16, I worked as a Certified Nursing Assistant with seniors in a memory care unit until becoming a Registered Nurse (RN) in 2010. After spending four years in acute care, I transitioned to care management for Medicare Advantage and Medicaid payers. Through that experience, I learned the value of human interaction and member engagement. Data exchange and transparency alone will not transform population outcomes. They’re prerequisites. Interoperability may not change the future, but equipping teams, patients, and families with tools and actionable data has the potential to improve individual patient outcomes and shift benchmarks at the population level. 

The Road to Interoperability in Healthcare

Looking back, alot was happening in the industry when I became a RN. The roadmap to Interoperability in Healthcare was originally paved around this time. We went from charting on paper and sifting through massive files for History & Physicals, recent orders, and laboratory results to digitalization. Over time, the first Electronic Health Record (EHR) systems emerged. By 2014, Managed Care Payer strategies and Value Based Care models were evolving as the industry began incentivizing quality care and risk management. Regional Health Information Exchanges (HIEs) were established over time. Payers and providers began exchanging Continuity of Care Documents (CCD) and Admission, Discharge, Transfer (ADT) notifications – offering more data sharing across silos. 

Fast forward to 2021, when the next major milestone in interoperability – Patient Access APIs – enabled patients to access all their health data maintained by their payer via any third-party application of their choosing, in close to real time. This advancement required a common data structure, Fast Healthcare Interoperability Resources (FHIR), and strong data governance.

As we continue to advance, providers are becoming compliant with FHIR and bulk data exchange. Today, payers and providers are producing and exchanging a common data structure accessible to patients and caregivers in addition to operational teams within organizations. Where do we go from here?

4 Recommendations for Creating Business Value with Data Exchange via FHIR APIs

As an experienced nurse that is passionate about improving patient outcomes and data interoperability in healthcare, I have a few recommendations to help you create value for your organization and the patients you serve:

  1. Care Management strategy is essential to improving population-level quality outcomes and reducing risk and the total cost of care. Interoperable data sharing via FHIR offers care management teams the actionable insights they need to prioritize and engage members within an attributed population at the right time. 
  2. Administrative and supplemental clinical data integration with patient matching is critical to producing patient bundles for future digital reporting, such as quality measurement and risk management. 
  3. Educating patients about data access and applications available empowers them – along with their family members and caregivers – to stay informed throughout the health journey.
  4. Leveraging a FHIR data platform that utilizes clinicians and subject matter experts (not just really smart engineers) is probably a good idea.

Interoperable data exchange via FHIR APIs creates value for payers, providers, patients, and caregivers.

Human Interaction and Engagement, Powered by FHIR 

As the industry continues to make strides toward full interoperability, we finally have a way to convert both claims and clinical data to a common standard. As more data is made available and exchanged by payers and providers, we must continue to advance tools to uncover actionable insights that support teams in care strategies, such as prioritizing patients within an assigned population. The ultimate goal should be enabling Care Managers to engage the right patients at the right time. My hope is the tools we develop next don’t replace human interaction, but instead equip care teams to have stronger interactions with their patients. The most powerful results come when we combine human interaction and engagement with actionable insights via FHIR data.  

The 1up FHIR Platform is a leading health data solution that brings clinical and claims data together in the FHIR standard to help payers and providers develop care strategies. Let 1upHealth help you make the most of your health data, and every patient interaction.

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