The shift from fee-for-service healthcare to a value-based care (VBC) model has transformed the way healthcare is delivered. Health systems require data to deliver higher-quality care at a lower cost.
Although the bidirectional exchange of data between disparate healthcare organizations is essential for coordinated care, population health management, and quality reporting, interoperability is lagging.
The number of hospitals engaged in interoperable exchange increased from 2018 to 2024; however, only 43 percent of hospitals routinely engaged in interoperable exchange, and 78 percent integrate information into electronic health records (EHR).
“When we think about success in value-based models, interoperability is a fundamental requirement,” says Megan Zakrewsky, vice president of product for clinical data exchange payer solutions at Veradigm.
“Most of the value-based financial arrangements rely on complete and timely data [and] without interoperability, systems can’t talk to each other and coordinate the complexity of all the healthcare information.”
The Cost of Fragmented Data
Providers need clinical data to make treatment decisions, track patient outcomes, and submit claims, while payers depend on data to evaluate prior authorization requests and assess medical necessity. Despite the need for timely and precise data, providers use fax, mail, or other manual methods to exchange 100 million medical records requests annually. This practice is costly, time-consuming, and error prone.
“The bidirectional exchange of data is critical [in value-based care] so payers and providers can efficiently and effectively collaborate on the information each party is collecting,” says Zakrewsky. “It’s required for the best patient outcomes.”
While the volume of health data has surged, it has resulted in isolated data silos. The lack of interoperability hinders care coordination and population health management, impedes innovation, increases administrative complexity, and affects value-based reimbursement. It also costs the U.S. healthcare system $30 billion annually.
“If you're not investing in interoperability, you run the risk of…care gaps,” Zakrewsky says. “We also run the risk of again duplicative tests and interventions, and higher medical spend, [and] we all take accountability in a wasteful healthcare system from a financial perspective.”
Interoperability Drives ROI
In healthcare organizations, investing in system connectivity yields multiple benefits including reduced administrative overhead, improved provider engagement, increased member retention, and enhanced HEDIS/STAR quality measures.
Studies have found that data exchange reduced the number of CAT scans, x-rays, and ultrasounds by up to 35 percent and resulted in cost savings up to almost $2,000 per patient. The largest returns on investment (ROI) were identified among systems that paired incentives with strong governance and deep technical integration, including the embedding of interoperability into clinical and administrative workflows.
Value-based care requires that health organizations have access to timely, accurate and standardized data to evaluate performance and improve outcomes. Interoperability supports that. As a result, it has a direct impact on quality scores.
Standards such as the Trusted Exchange Framework and Common Agreement (TEFCA), the National Committee for Quality Assurance (NCQA), and the CMS Interoperability and Prior Authorization Final Rule are aimed at improving healthcare interoperability.
“[Organizations] have various requirements around what's required for the exchange of data to enable faster reporting and compliance. If information is locked inside of a provider's EHR or just not being captured, those quality measures can't be accurately reported to the reporting bodies like NCQA,” says Zakrewsky. “From a reporting perspective, it creates lags in what's truly going on with any given patient, which could impact things like STARS measures or overall performance and we're talking about impact to patient outcomes and the financial bottom line.”
Legacy systems can make interoperability difficult and costly, but accurate, timely data exchange is a factor in meeting regulatory reporting requirements. Regulations like Zakrewsky acknowledges, “regulatory pressure seems to be the best mover of anyone to change their existing processes,” and the technology exists to make it happen.
Veradigm integrates with various EHRs and digital health platforms using Fast Health Interoperability Resources and other established standards to facilitate bidirectional data exchange and support to ensure a seamless transition.
“What we're trying to sell for in the industry is no longer a tech problem,” she adds. “We think the tech is there. It's more about supporting the people that are using the tech and making sure that it's…useful and meaningful and helps expedite the problems they're trying to solve.”
