Connecting Care Providers: Building a Digital Platform for Health

Imagine a world where care providers can spend more time focusing on patients, as payers alleviate burdensome paperwork. Imagine care providers being able to better coordinate care with their patient and the broader team through the ability for all parties to access the patient's latest health information.

Imagine care providers getting near-real-time, up-to-date health data so that they can focus on the patients who need them most, while driving the best outcomes possible. Imagine care providers being alerted of potential care gaps and receiving patient insights driven by artificial intelligence (AI) within their current workflows and tools — rather than logging into or learning another system.

That includes bringing together complex and siloed data sets — such as admission, discharge, and transfer (ADT) notifications; electronic health record (EHR) changes; and social drivers of health (SDOH) information — AI, and independent technology systems to help increase care affordability, quality, access, experience, equity, and, most importantly, outcomes. All the while, administrative burdens are further reduced and care providers are more enabled to practice at the "top of their license."

With our digital technology platform — Health OS — care providers will be better enabled to deliver exceptional care experiences without having to leave their current EHR. Health OS is a payer-agnostic, clinical data platform designed to connect directly with EHRs, health information exchanges (HIEs), third-party data aggregators, and immunization registries. With that direct connection, it will allow for centralizing these sources into one longitudinal patient record (LPR) to improve care and reduce overall administrative burden.

This platform supports care providers with the infrastructure to change the way care is delivered. We are building Health OS to facilitate and enrich collaboration between care providers and payers with more complete and timely clinical data sharing, bidirectional consumer insights, automated processes, and industry-defined application programming interfaces (API) that allow for data exchange. These platform integrations and capabilities work together to:

  • Enhance value-based care arrangements.
  • Improve quality performance.
  • Reduce administrative burden.
  • Create a vertically integrated care network.

Health OS is connected to almost 200 health systems to date,1 with a continued focus on increasing connectivity to all major health systems that serve our consumers.

Independent Technology Integration

Being EHR-agnostic enables Health OS to break down data silos and make connections across a patient's care experience. To create this hyperconnected experience, Health OS has developed numerous technology partnerships and integrations to meet care providers where they are. This capability reduces the administrative burden of connecting care providers and payers to obtain information and increases the quality of the data provided. Health OS' capabilities allow clinical patient data to be captured on a different EHR, such as an ADT hospitalization alert, and delivered back to the care provider at the point of care in near-real-time.

Vertically Integrated Care Network

Across the country, few healthcare organizations deliver integrated care effectively — the most notable exception being fully integrated delivery systems with capitated payment arrangements, where the payer and care provider are two sides of the same coin. This type of integrated system tends to close care gaps more effectively, consistently achieve high-quality scores, and report better patient outcomes. This is made possible by a closed-loop system that has a single "front door" with one EHR for all clinics and hospitals, an integrated pharmacy, and connections to health plan administrative data for out-of-network care.

The question is, can we create a virtual, vertically integrated system that mimics the fully integrated model without owning significant aspects of the delivery system? If so, what capabilities are required to succeed?

Elevance Health is uniquely positioned to take this on, given its strengths and its strategy of partnering with care providers. Vertically integrated care with independent care providers requires connectivity. Integrated systems have spent billions on Epic implementation to facilitate data sharing.2 Our strategy is to use Health OS to connect with care providers to integrate clinical and administrative data to achieve similar outcomes — to:

  • Close care gaps more effectively.
  • Deliver better clinical outcomes.
  • Enhance quality.
  • Integrate formularies into the prescriber workflows.
  • Manage utilization.
  • Improve risk adjustment and performance on Medicare Star measures.

Building a vertically integrated virtual system as a strategic alternative where practices are partners rather than owned entities is complex. While our affiliated health plans' networks are strong, their influence and ability to enforce standards is positioned differently than others. As a result, we pursued a multistep, prove-and-advance strategy to help ensure success.

For a virtual, vertically integrated network to compete, our health plan affiliates are focusing on launching a digital health maintenance organization (DHMO) product. This product couples virtual and physical care, ensures that data moves seamlessly between care providers using Health OS, and that high standards of care are met through virtual primary care provider (PCP)-driven referrals and care gap closures. While the product launched on January 1, 2023, the framework is a great example of how the "digital front door" is truly brought to life and connected with care providers to deliver seamless, hybrid care.

Enhancing Value-Based Care

Health OS will virtually connect a network of care providers to manage patient care effectively under value-based payment arrangements. This important care management function is enabled by the platform's Digital Chart Retrieval capability that allows health plans to source charts from connected EHRs to ensure completeness in a person's risk profile, which is important for appropriate reimbursement rates, high-risk patient engagement, and driving care plan adherence. Leveraging Health OS enables care providers in value-based payment arrangements to target the most pressing needs across their patient panel with near-real-time information and make the right referrals or the right intervention.

Improving Quality Performance

Health OS enables care providers and care managers to convene around patients for a more cohesive, coordinated care experience. The multiple data-sharing capabilities within Health OS will enable improved quality performance, such as HEDIS and Star quality performance measures.

First, the clinical data exchange capability provides clinical data that is not found in traditional sources, like claims, but is necessary to close HEDIS-measure care gaps. Through Health OS, the data is received closer to real-time than claims data, enabling consumer and care provider outreach programs to be more effective in targeting patients with true care gaps.

Second, Health OS-enabled consumer insights notify care providers of open patient care gaps within EHR workflows, allowing those care providers to address gaps at the time of a patient's visit, increasing the likelihood that the gap is closed.

Finally, Health OS provides consumer ADT notifications to care providers to enable timely post-discharge follow-ups, which is a hospital transitions of care measure, new to HEDIS in 2022, and a Star ratings metric.

Spotlight: Health OS in Action

A Southern U.S. health system recently implemented Health OS for their Medicare Advantage (MA) population of roughly 10,000 patients. Of this population, 9,274 MA patients had their data received through Health OS, and it was leveraged to improve care gaps, cost-of-care savings, and prior authorization digital conversion rates.

Care Gaps

The system's MA population had 1,120 consumers with outstanding adherence care gaps with a total of 1,331 gaps. Health OS' digital connectivity enabled care providers to close 116 gaps in care, for an 8.7% response rate, up from a baseline of 1%.3

Prior Authorization Rates

The independent technology integrations within Health OS led to improved prior authorization rates. Utilizing Epic Payer Platform (EPP) integration, which also allows for clinical data attachment, the system saw a 40% digital conversion rate for prior authorizations.3

The implementation of Health OS at this health system was so successful that they decided to expand their membership to include lines of business beyond Medicare.

Ultimately, Health OS is being built to enable our consumers and their entire care teams by delivering predictive, proactive, and personalized care experiences. Coupling the data and technology integrations within our system with traditional networks creates the foundation for a digitally led care network that helps address physical needs and improve experiences for health plans, care providers, and patients. Health OS will enable us to elevate and advance healthcare, one medical record at a time.

Forward Together

We have already seen evidence of the benefits of Health OS' ability to partner and integrate with other technology platforms. One key example is Epic, one of the most widely used EHR systems in the American healthcare landscape. We have integrated EPP into Health OS to further standardize the clinical data exchange between our operating system and each care provider connected to EPP. With the EPP integration, we expect to be able to quickly scale Health OS bidirectional consumer insight capabilities, such as diagnoses and care gap exchanges, to those connected to EPP. The EPP integration also enables the digitization and automation of prior authorization requests and responses right in the care provider's native Epic EHR workflow.

Similarly, we are collaborating with other EHR partners to build these deeper integrations and deliver incremental value to care providers and their patients. Although we have made a lot of progress, we still have much to do in partnership with care providers.

1 Internal data (2022). 2 Forbes, The Billionaire Who Controls Your Medical Records (April 8, 2021): forbes.com. 3 Internal data (2022).