AH108 - Fixing Healthcare Interoperability and Modernizing Digital Workflows, with Brendan Keeler

Interoperability has been a healthcare buzzword for well over a decade. The industry constantly talks about longitudinal data and seamless clinical exchange, yet workflows like prior authorizations (PA) still rely on phone calls and faxes. This stubborn gap between modern healthcare technology and daily workflows frustrates providers, payers, and patients alike.

To dive deeper into this issue, host Justin Venneri invited Brendan Keeler (Interoperability Practice Lead at HTD Health) into the Astonishing Healthcare studio. Brendan’s popular newsletter, Health API Guy, dives into an assortment of health technology topics. But in this episode, he dove into some of the biggest issues currently facing healthcare: why systems struggle to connect and how new regulatory pushes might finally result in change.

The current state of healthcare interoperability

As Brendan noted, “Interoperability is a superset of 60 different problems and jobs to be done. Workflows in a trench coat, right?”

It’s an apt comparison – some workflows, like e-prescribing, are almost fully digitized, while others, like PA, remain painfully reliant on outdated technology, like fax machines.

That’s why Brendan suggests the true measure of success for these initiatives is not the technical standard used; it’s ubiquity.

In essence, if a digital standard only works for a handful of organizations, providers will inevitably fall back to faxing to reach the rest of the network.

How are CMS rules pushing digital prior authorization?

The Centers for Medicare and Medicaid Services (CMS) is actively pushing to digitize prior authorization. Rules like CMS 0057 and 006 target both medical and pharmacy benefits, aiming to make electronic PAs a universal standard for all CMS-regulated plans.

This push mirrors the successful mandate that brought e-prescribing to ubiquity in the late 2000s. Digitizing this process would drastically reduce the incremental cost of grading and processing PAs.

"If we digitize these things, the incremental cost of grading and processing prior authorizations will go down. Will it mean that there's more or less prior authorizations? Well, there's a bit of a paradox here in that the ease of the transaction means that overall, the volume will go up - the number of times that we submit prior authorizations. It took me 10 days to do a prior authorization, and then if there was a failure. I might just do it once and then say, too bad. But if I can do it instantly, well, I might do it once, and then twice, and then three times for different drugs or different procedures. And so the total volume will go up, but the burden will likely be lower.” - Brendan Keeler

Why healthcare organizations are stuck on legacy infrastructure

For many healthcare leaders, the prospect of upgrading core systems comes with serious risk. A system of record, like an electronic health record, acts as an operational heartbeat of a business. Once implemented, these systems act like cement.

What is the true cost of switching your system of record?

As Brendan explains, the challenge of replacing a legacy system is not a linear one – it's an exponential one. There are three types of gravity making this transition difficult:

1. Data gravity: The sheer weight of historical information stored in the system.
2. Workflow gravity: The entrenched habits of employees who have built their daily tasks around the software's quirks.
3. Integration gravity: The complex web of surrounding applications tied to the core system.

Because of these forces, some leaders balk at the idea of undertaking this challenge.

“Even though there's outsized gains to be had, it's easier to say, well, let's go change how this department's organized, or let's go slap some AI on top of it, right?” Brendan explained. “That's an easier, more palatable equation for most leaders.”

How does digital identity solve healthcare interoperability challenges?

A foundational requirement for secure data exchange is knowing exactly who is on the other side of the transaction. Without strong digital identity verification, counterparties lack the trust required to share sensitive clinical or financial information.

Justin highlighted Judi Health’s partnership with Clear as a step toward streamlining this trust process. And as Brendan added, establishing verified digital identities unlocks the next layer of interoperability.

"It's foundational in the sense that appropriately knowing that I am Brendan Keeler unlocks the ability to much more easily have trust between counterparties and share things that could be sensitive."

What should health tech leaders watch for in the next two years?

The regulatory landscape will continue to rapidly evolve. Brendan specifically points to the Office of the National Coordinator for Health Information Technology (ONT) and their upcoming HTI 5 rule. This rule is expected to change the contours of information blocking and deregulate parts of the EHR certification program.

Following that, the ONC has alluded to an HTI 6 rule, which would introduce new regulatory requirements and potentially push the industry toward the next level of interoperability networks.

“The government is uniquely positioned to push everyone along, and so I'm excited for that,” Brendan said. “I'm excited to see the CMS continues to cook, and they will not stop cooking...But my feeling is they'll continue to come up with new things and put more shots on goal, and again there's opportunity to make things better in those changes.”

The Future of Frictionless Healthcare

We are moving toward a future where patients can access their clinical data with the same ease that providers exchange records today. Digital identity tools are one key example of that.

“Well, now we're pushing forward and seeing not ubiquity, but signs of future ubiquity in terms of you using digital identity -- using Clear, or ID.me, or Persona, proving who you are and pulling your clinical data to use in a personal health record to pull and underwrite life insurance, to go and use with OpenAI, to do all the things that you might want in the same way that providers are able to exchange data pretty frictionlessly today. That's awesome.”

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Disclaimer

This podcast is for informational and entertainment purposes only. The views expressed are those of our guests, do not constitute professional advice, and may not represent Judi Health's/Capital Rx's position on any matters discussed. We make no representations or warranties regarding the accuracy or completeness of the content; information is subject to change and may not be updated.

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