A Roadmap to The Patient Financial Experience of the Future. Part I of a Five Part Series

Transcription

1 A Roadmap to The Patient Financial Experience of the Future Part I of a Five Part Series HIMSS Revenue Cycle Improvement Task Force March by the Healthcare Information and Management Systems Society (HIMSS) Page 1 of 18

2 EXECUTIVE SUMMARY As of this writing, it has been nearly two years since the HIMSS Revenue Cycle Improvement Task Force (RCI TF) challenged itself to take a fresh look at healthcare revenue cycle management (RCM) through the lens of a changing world. At the time, the main driver for this effort was an increasing trend towards consumerism in healthcare, a trend that has only continued to accelerate. RCM systems and processes were built to optimize processing of commercial and government medical claims with little inherent capability to address the type of functionality required in a more patient-centric world. This paper provides a detailed view of each component of the envisioned Patient Financial Experience of the Future behind a new, improved RCM model for the industry. It follows the patient s journey from pre-care, treatment, and coordination of care, ending with patient satisfaction, and identifies suggested technical solutions, streamlined processes, and potential gaps in the current typical patient experience. Realization of this vision will require widespread adoption of a full range of tools to support patient decision-making, scheduling, registration, administrative simplification, price transparency, and effective consumer payment methods. As the RCI task force has worked to consider the implications of a more patient-centered approach to RCM and to articulate a proposed vision for improving the patient financial experience, the industry has realized the challenge to be even greater than originally expected and the solutions much more complicated. The growth in consumer financial responsibility has led to the expected billing and collections challenges that were known to be weak points of most legacy RCM systems and processes; however, what many didn t consider was how much more information a patient with greater financial responsibility would come to expect. Traditional models for accessing and sharing health insurance, financial and clinical information and a lack of interoperability between the systems that support these models are insufficient to meet the increasing demand for real-time information and price transparency. As individuals assume increasingly larger amounts of direct financial responsibility for their healthcare, they begin to view healthcare as more of a retail experience. As such, they may transfer expectations of a typical retail experience to their healthcare experience. In those situations where it is possible to do so, more and more patients research their healthcare options before deciding where to go for care. They expect to be able to use their smartphone, for example, to determine the level of care available to them through their health plan s provider network, to have pricing and quality or patient satisfaction information at their fingertips and to be able to use this and other information to compare providers in the same way they might compare producers of other products they would purchase online. And, they expect their financial obligations to be addressed in one single bill or statement, just as they receive one consolidated bill for buying a vehicle or remodeling a room of their home, even though there may have been multiple parties involved in producing the final product. Industry stakeholders have acknowledged the need for health plans and providers to share information with consumers in a more coordinated Patients expect to be able to use their smartphone to determine the level of care available to them, to have pricing, quality and patient satisfaction information at their fingertips 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 2 of 18

3 fashion to enable improved consumer financial activities. Perhaps more importantly, it has become very clear to the RCI TF, as you ll see in the detailed findings that follow and in the RCI task force deliverables referenced within, that linkage between healthcare financial and clinical systems is absolutely critical to re-engineering RCM and the patient financial experience in healthcare. These systems will need to be able to share information seamlessly, regardless of which system, module or version of a system is being used. There are already a number of examples emerging across the industry of significant efforts to improve components of the patient financial experience. However, even broader industry engagement in the envisioned goal and commitment to the level of secure data sharing and interoperability is essential to enable the optimal consumer-friendly revenue cycle and provide for the financial wellness of our healthcare delivery system. Our hope is that you will read this paper through the lens of a patient, and that if you are an industry stakeholder you will walk away inspired to leverage your engagement in the healthcare delivery system to help all of us realize the task force s vision for the Patient Financial Experience of the Future by the Healthcare Information and Management Systems Society (HIMSS) Page 3 of 18

4 BACKGROUND Healthcare s revenue cycle management (RCM), the administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue 1, is currently undergoing a transformation as far-reaching and revolutionary as that occurring in the clinical space. Two important initiatives, payment reform and patient consumerism, have emerged as among the chief concerns of the RCM transformation and are moving forward at distinctly different rates of change. Payment reform, the transition from fee-for-service to a value based payment model, involves changing the core revenue model and redirecting an entire industry, requiring changes in business rules and processes, solution applications and technology. Currently the speed of this change is being driven largely by government programs with compliance as the primary benchmark. In January 2015, U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell announced that by the end of 2016, thirty (30) percent of all Medicare payments made to hospitals and physicians will be based on pay-for-value payment models, and that by the end of 2018 that number will be increased to 50 percent. In addition, Secretary Burwell said that the remaining fee-for-service payment arrangements would be adjusted so that 85 percent of Medicare hospital payments would be tied to quality or value by the end of 2016, with an increase to 90 percent by the end of Despite the aggressive goals established by HHS, it is important to note that this transition will be extremely complicated as most of the industry s legacy revenue cycle technology was designed in the fee-forservice era and does not include the functionality required to support a value-based payment system. In addition, patient consumerism is an initiative involving requirements and capabilities that have not previously been required from healthcare or have not matured to the level demanded by consumers accessing other service industries. Patient consumerism, or health consumerism, is a movement that promotes patient involvement in their own healthcare decisions. It advocates for patients to partner with, rather than defer to, their physician. Under patient consumerism, the patient becomes more educated about healthcare issues they may be facing and the treatment options available to them. This empowers them to be more involved in the decision-making process 2. Increasing patient consumerism is driving healthcare stakeholders to define cultural and business requirements that have never existed before. Increased patient financial accountability has triggered new patient expectations for retail-like service levels and increased value for their healthcare spend. Patient consumerism has accelerated as a result of several industry drivers. Increased patient financial accountability has triggered new patient expectations for retail-like service levels and increased value for their healthcare spend. Incorporating patient satisfaction with their overall healthcare experience, beyond return to wellness, has been elevated by many payers and providers to a top priority. The need for service price transparency continues to be a key requirement for patients who simply want to understand what they are being asked to pay for, how much they are being asked to pay and how the price they are being charged by one provider compares to the price charged by another provider for what appears to be the same service. Patients also want to know if there is more than one 1 Healthcare Finance Management Association definition of revenue cycle management as referenced by Oregon Health Science University. 2 Definition of health consumerism by the Healthcare Information and Management Systems Society (HIMSS) Page 4 of 18

5 treatment option available, and not only how effective each of these treatment options is, but how they compare in terms of cost. In addition, patients need to understand the available financing and payment options, including available electronic payment functions. Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) are examples of healthcare self-funding options available today. Even though these taxadvantaged programs have been available since the 1970s in the case of FSAs and 2003 for HSAs, continued increases in direct patient financial responsibility have led to a rise in their popularity. As consumerism and patient financial responsibility also continue to rise, financial institutions have the opportunity to offer patients additional products tailored to meet a broadening range of healthcare financial needs. As patients continue to bear more and more of the financial burden for their healthcare, providers will be serving increasingly well-informed, knowledgeable and motivated patients who are well-positioned to make their healthcare decisions based on both real and perceived value. Convenience and ease of doing business will also be important to the patient who will increasingly expect real-time paperless transactions and instant access to healthcare information sources when and where they need it. The patient encounter, whether face-to-face, through a traditional call center, via the internet, by a service kiosk, or from a smartphone app, will need to demonstrate responsiveness, simplicity, convenience, and the capability to answer all of the patient s clinical and financial questions in a single encounter. Customer service applications that can facilitate this sharing of information will be needed if healthcare service response levels are to equal those provided by other retail and service industries. As patients continue to bear more and more of the financial burden for their healthcare, providers will be serving increasingly well-informed, knowledgeable and motivated patients who are well- positioned to make their healthcare decisions based on both real and perceived value. The competition for patients in this evolving healthcare marketplace may no longer be based on return-to-wellness or patient clinical outcomes alone, but on a provider s ability to deliver a total healthcare experience the patient judges to be fully satisfactory, including the financial components of that experience. ROADMAP TO THE FUTURE Since 2011, the HIMSS Revenue Cycle Improvement Task Force (RCI TF) has addressed the emerging dynamic of healthcare consumerism and the patient experience related to the provider s financial and administrative performance and service levels. In July 2014, HIMSS directed the RCI TF to focus its energies on creating a vision for the next generation of revenue cycle management tools and processes that keep administrative cost containment, interoperability, and patient engagement front and center. In 2015 the HIMSS Revenue Cycle Management task force created an infographic depicting their vision for the Patient Financial Experience of the Future. The work of the RCI TF is underpinned by a specific set of Guiding Principles. The group agrees that the recommendations of the task force must involve solutions that: are patient-focused; support transparency of information; reflect process driven, non-duplicative business practices; leverage existing and emerging technologies; 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 5 of 18

6 demonstrate a sustainable return on investment; have standards-based architectures; are intuitive and include simplified user interfaces; and are designed with the full revenue cycle business process flow in mind. In 2015, the task force applied these principles to the development of an overarching vision for the patient financial experience of the future. This vision was shared in a White Paper, Rethinking Revenue Cycle Management. The vision was further articulated in an infographic that illustrated the task force s vision for a simple, pre-planned office visit. In 2016, the task force is analyzing the technical functionality required to execute their vision for the patient financial experience of the future and comparing that functionality against what is known to exist today to identify potential gaps that will need to be addressed to realize the vision. These gaps include not only technical functionality, but the development of national standards and uniform operating rules to support things such as accurate patient matching and the ability to share complex data in a meaningful and actionable way. The purpose of this paper is to share the outcome of that analysis. The analysis begins with the recognition that there is a broader set of national goals this task force is not addressing that must be met to address core industry issues. The success of the task force s vision depend on these goals being met; however, these activities are being addressed by other bodies, including the Office of the National Coordinator, and are not within the scope of the task force s work. These goals include: national standards and uniform operating rules for the secure electronic exchange of healthcare information. wide-spread adoption of electronic health information exchange. highly accurate matching of patient data and/or identification of patients. wide-spread adoption of healthcare cost transparency. industry adoption of uniform quality of care metrics. interoperability among vendors, providers, payers, and financial institutions that will allow them to share their information in realtime. emerging reimbursement methods that will not complicate patient financial experiences. This initial analysis is conducted from a patient s perspective and follows the patient s journey from pre-care through treatment, coordination of care, and follow-up care, as shown in Diagram 1. The task force s next step will be to conduct a similar analysis from the provider perspective). That work will begin in March Diagram 1: Patient Journey To identify potential gaps, the task force examined each step of the patient s journey, considering specific activities involved in each of the steps as envisioned in the Patient Financial Experience of the Future. The group reviewed the technical functionality required to support these activities and identified potential gaps between the functionality that exists today and the functionality that will need to be developed to realize the task force s vision. The following is an overview of the potential gaps identified for each step of the patient journey by the Healthcare Information and Management Systems Society (HIMSS) Page 6 of 18

7 Category I: Pre-Care The first step in every patient s journey is to choose a provider. This choice may be based on an existing relationship between the patient and the provider, the provider s reputation, the convenience of proximity to the patient s location or the severity of the patient s condition. Patients tend to choose their provider based on their specific health plan. A technical connectivity solution with the ability to determine and match the details of the health plan, such as provider network, healthcare benefits, copay, and deductible with the patient s immediate healthcare needs and geographic location will simplify this task. A solution that provides pertinent information such as hours of operation, languages spoken by the medical office staff, physician specialty, quality rating and charges for an initial office visit further enhances the patient experience. Once a patient has chosen a provider, the Patient Financial Experience of the Future envisions the patient being able to make an appointment and complete a registration form on-line. A single point solution where the patient s medical information, including a complete medical history and list of medications currently being taken as well as the name of the treating or prescribing provider will feed into the portal of the provider with whom the patient is scheduling an appointment and auto populate appropriate fields. The only information the patient will need to insert will be relevant to their current medical need. While there are progressive technology solutions available today that deliver pieces of this vision, none provide the full level of functionality described here. As a part of scheduling and registration, the patient would have the ability to authorize appropriate parties to retrieve and review the patient s medical records. This cannot happen without the adoption of national standards and uniform operating rules for patient matching and the transfer of this data. Diagram 2: Pre-Care In the Patient Financial Experience of the Future, patients will have the opportunity to submit payment or make payment arrangements prior to or at the point of care. To be able to do so will require a tool that estimates and communicates patient financial responsibility (or liability) in realtime at the moment the patient or provider requests it, including information about payment options and access to financial counselors. In situations where the patient is required to complete pre-visit activities, such as fasting or having lab work done prior to seeing the physician, patients will have the option of receiving information about these requirements in whatever manner they choose via cell phone, through an , etc. Information provided will include patient s financial responsibility, if any, for these services. The final step of the pre-visit activity is for the patient to receive an automated appointment reminder for the visit. There are technology solutions such as and text platforms for appointment 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 7 of 18

8 reminders, but they have not been universally adopted. Wide-spread adoption of these tools will help provide patients a consistent healthcare experience, regardless of where they live, what provider they are seeing or what insurance coverage they have. Category II: Treatment The task force envisions a future in which patients present for treatment and may be checked-in using an automated electronic process. As with the on-line registration process and sharing of information, this solution will require the adoption of national standards and uniform operating rules related to patient matching to ensure that the right information is being associated with the right individual. Electronic awareness and connectivity by means of mobile phones and related applications is an opportunity that can increasingly be leveraged. After the patient checks in and vital signs are taken, the medical history/reason for visit is reviewed. The vital sign capture could be expedited through the use of wearable technologies that could be programmed to transmit an individual s vital signs to a treating physician in real time. In spite of having some technological solutions in place today, there is still the lack of the ability to access and share patient medical history between multiple providers and multiple health systems. In the Patient Financial Experience of the Future, the provider s office will have realtime access to the patient s healthcare benefit information including any patient financial responsibility such as co-pays or deductibles, the provider network associated with the patient s health insurance coverage and pricing information, and be able to share that information in a meaningful way to allow the patient to make the most informed treatment decisions possible. This will include the ability to compare both the Diagram3: Treatment efficacy and costs of different treatment options. The provider will also be able to provide information about payment options for the patient s financial responsibility, and be able to facilitate payment arrangements at the point of care. The challenges in realizing this vision for the future are two-fold. The current healthcare system not only lacks the technical ability to share the level of detailed information identified herein and the business processes to support the scenario described, there are cultural challenges as well. Many providers are not accustomed to including financial considerations in the discussion of treatment options with their patients. Some are concerned that doing so may discourage the patient from choosing what the provider believes to be the best possible treatment, based on clinical considerations only. From a patient perspective, however, deciding on what they consider to be the best course of treatment may include consideration of their financial situation and the amount of social support available by the Healthcare Information and Management Systems Society (HIMSS) Page 8 of 18

9 Diagram 4: Coordination of Care When medical staff and patients agree on a plan of care, the plan of care will be captured electronically and shared with the patient and any providers involved in the execution of that plan. Although many providers are able to facilitate such communications between themselves and their patients, fewer are able to extend this capability to include other providers involved in the patient s care, particularly providers who may not be directly affiliated with the primary physician s medical organization. In situations where the initial office visit is also the last office visit, providers will be able to provide patients with a final bill, including an accurate statement of the patient s financial responsibility, before the patient leaves the office. They will also have the ability to process whatever form of payment the patient chooses to satisfy their portion of the bill at that time. Health plans must find a way to determine and communicate patient financial responsibility in real-time in order for this vision to be realized. This could happen through newly designed benefit structures created to support alternative payment models that make it easier to predict patient financial responsibility, through revised business processes related to claims adjudication, or through the development of technical solutions aimed at providing real-time claims information among all affected parties. For those situations requiring follow up care or a referral to another provider such as a specialist, appointments will be able to be made before the patient leaves the referring physician s office and all applicable patient information will be automatically shared between providers without the need for patient facilitation. While the major EHR s assist with this functionality to some extent, there is still a lack of a universally adopted scheduling tool and wide spread information exchange, especially between non-affiliated providers. Category III: Coordination of care When a patient arrives at an ancillary service or other healthcare provider s office for treatment or services, all of their pertinent personal and health information will be available to that provider. The patient will not have to repeat their full medical history. Sharing this type of information among all providers involved in an episode of care, including those who are not associated with the same medical facility or healthcare system, will require the establishment of national standards and uniform operating rules related to the sharing of personal healthcare information and widespread adoption of electronic health information exchange capabilities by the Healthcare Information and Management Systems Society (HIMSS) Page 9 of 18

10 Many of the activities and gaps identified in the treatment category of activities, such as decision-making tools and payment options, apply to coordination of care as well. A major difference, however, will be the consolidation of financial information. In today s world, an individual who receives treatment for a single episode of care involving multiple providers in a variety of healthcare settings can expect to receive multiple bills and explanations of benefits. This creates a great deal of confusion and frustration for the patient, who simply wants to know, bottom line, who do they owe, how much do they owe them and what are their options for making payment. In the Patient Financial Experience of the Future, financial and clinical information will follow the patient throughout their episode of care and include real-time updates as they occur. The financial implications of this capability is that at the time the patient completes their final office visit and is released from care they will receive one final consolidated bill that includes charges from all providers involved in the episode of care and clearly states the patient s financial responsibility. Having received an estimate of their financial responsibility at the time treatment was chosen, the patient will have the opportunity to settle their portion of the bill at the time of care or automatically execute the payment arrangements made earlier in the process. Category IV: Patient Satisfaction In the Patient Financial Experience of the Future, the healthcare delivery system realizes the importance of patient satisfaction with all aspects of their interaction with the healthcare delivery system. Immediately upon leaving a provider s office possibly even before they leave the patient will receive a customer satisfaction survey, asking about all elements of their experience, from ease of finding a provider, to the simplicity of the registration process, to the patient s interaction with their provider, to how well they understood and were able to address their financial responsibility for the care received. This is not a new concept. The Centers for Medicare and Medicaid Services (CMS) has embraced this philosophy in practice through their Consumer Assessment of Healthcare Providers and Systems (CAHPS) program. CMS combines the results of CAHPS surveys with other quality measures to determine payment incentives for high performing healthcare providers. 3 Currently, the industry lacks a consistent approach to providing feedback to the patient or the provider regarding opportunities for improvement. The task force believes that for satisfaction surveys to be truly meaningful they must be consistent across the industry, constructive criticism must be acknowledged, and patterns must be tracked. Where patterns of extreme satisfaction exist, providers should be rewarded. EFFORTS CURRENTLY UNDERWAY Not all of the functionality required to support the Patient Financial Experience of the Future will need to be created from scratch. There are several efforts already underway that may fill gaps identified above or can be leveraged to do so going forward. The task force has done preliminary research to identify innovative solutions and initiatives. An overview of these findings can be found in the Appendix of this document. The solutions/initiatives included in our grid are in no way intended to be a 3 AHRQ Program Brief CAHPS: Assessing Health Care Quality From the Patient s Perspective. April by the Healthcare Information and Management Systems Society (HIMSS) Page 10 of 18

11 comprehensive inventory nor an endorsement by HIMSS. Rather, this step is designed to illustrate movement already underway in the industry that can be built upon to realize the Patient Financial Experience of the Future and fill some of the functional, technology gaps identified in this roadmap. The challenge going forward is to create the required interoperability and connectivity, coupled with security and access that result in a healthcare system that provides a seamless clinical and financial experience for patients while keeping administrative cost containment and patient engagement front and center, regardless of the reimbursement methodology being applied. CONCLUSION As the trend for increasing patient financial responsibility continues the healthcare industry must recognize the need for change in the patient experience. The processes and functionality outlined in this paper describes the HIMSS RCI task force s vision for the Patient Financial Experience of the Future, following the patient s journey from pre-care to treatment to coordination of care, ending with patient satisfaction. The vision identifies suggested technical solutions, streamlined processes and potential gaps in the current patient experience and related processes and functionality. Realization of this vision will require widespread adoption of a full range of tools to support patient decision-making, scheduling, registration, administrative simplification, price transparency, and effective consumer payment methods. Secure information sharing between a provider care team and patient is a must throughout the journey - from pre-visit, to diagnosis and plan of care exchange, to treatment summary and follow-up activities, providing care team access to patient medical record, eprescriptions, test results, patient health plan coverage, and provider price and quality information. A variety of electronic health information sharing arrangements will continue to exist as they serve different community needs. Realization of this vision is predicated on the development and deployment of robust, secure, and readily available applications. As an industry, healthcare leaders must support and advocate for the technology solutions which support the processes described in this vision for the future. Innovators have already proven that the needed solutions are technically possible. This is not the end of the process, but the beginning. Achieving the task force s vision will require a paradigm shift among all participants patients, providers, payers, vendors, and financial institutions. We need to take action to make this vision a reality. We need your help. Share your solutions! Submit a case study! Join our taskforce! Visit the HIMSS website and checkout our infographic, microsite and previous White Papers developed by this taskforce. We encourage you to get involved! 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 11 of 18

12 HIMSS wishes to thank the following authors to this white paper Ron Bissetta Partner Optimity Advisors Stuart Hanson Senior Vice President, General Manager, Consumer Change Healthcare, Inc. Payment Solutions (HIMSS RCI Task Force Chair) William Johansen President The Gunner Grayson Group Susan Tatara Associate Vice President, Advisory Services Jacobus Consulting, Inc. Sandy Wolfskill, FHFMA Director, Healthcare Finance Policy/Revenue Cycle MAP Healthcare Financial Management Association (HFMA) The authors wish to acknowledge and express our appreciation for the contributions of our fellow task force members, without whom this paper would not have been possible by the Healthcare Information and Management Systems Society (HIMSS) Page 12 of 18

13 APPENDIX EFFORTS CURRENTLY UNDERWAY Not all of the functionality required to support the Patient Financial Experience of the Future will need to be created from scratch. There are several efforts already underway that will either fill gaps identified in this paper or can be leveraged to do so going forward. The following tables illustrate solutions that currently exist in the marketplace. They are in no way intended to be a comprehensive inventory. Rather, this step is designed to illustrate movement already underway in the industry that can be built upon to realize the Patient Financial Experience of the Future. These examples demonstrate functionality while providing a proof of concept through the identification of specific, existing solutions to individual and often discrete issues within the revenue cycle. Clearly the challenges that remain need to address how solutions may be combined, integrated or repurposed to meet the identified gaps that exist for the successful implementation of the overall vision. To enhance the focus on functionality, we have divided the solutions into the following general categories: Patient Information Access and Exchange Patient Identification Patient Care Plan Alternative Site of Service Electronic Scheduling/Pricing/Payment Provider Selection, Payment & Explanation of Benefits (EOB) Standards Patient Information Access and Exchange Technology solutions in this category include concierge style tools to facilitate 24/7 access to benefit plan and provider information, in- network provider listings, price transparency and live support functions. Electronic sharing of a patient s pre-registration and electronic health record (EHR) information among providers, including referrals, clinical messages and test results is facilitated via tools designed to specifically support this type of data sharing. A number of EHRs now include a patient portal which allows the patient access to test results, scheduled future appointments, medication lists, etc. Some bolt on applications may also support medication information and reminders, so as to support patient compliance with medication instructions. Important to the information exchange needed for the future are solutions which not only facilitate data movement along the roadmap, but also across hospital systems, physician offices, clinics and any other care provider organizations that support the community or geographic area. Information exchange also provides a base for analytics necessary to support population health management strategies among various providers sharing a patient population by the Healthcare Information and Management Systems Society (HIMSS) Page 13 of 18

14 Example Products: Patient Information Solution A Solution B Solution C Solution D Large, successful health information network Spans 18 states, over 80 clinic system members, 4,500 physicians Services organizations for community-based clinics Analytics to track and improve population health Stores insurance, medication and preferred physician information Contains question/answer-based service to help patient connect to specialist Information exchange tool with a directory that allows data to be sent unambiguously to any identified system or organization in a variety of formats (HL7, X12, Direct Message, etc.) Allows information to be more easily interpreted for pre-care service pricing and identification of in-network care centers contracted under the benefits/insurance Gives patients controlled access to the same Epic medical records their doctors use, via browser or mobile app Includes test results, appointments, pre-visit questionnaires, statements, medications, allergies, prescriptions, and more Helps patients comply to care plans and achieve the greatest results from their procedure, without the need for higher utilization Provides patient engagement that can reduce post-acute spending and can get patients home quicker while still receiving the best of care Identifies patients at-risk for complications and provides help before patients enter emergency Access and Exchange Solution A Solution B Solution C Solution D Combined mobile app and live, 24/7 concierge scheduling access Personalized benefit plan and provider information Warm handoff to telemedicine Price transparency, advocacy support Patient preregistration information sharing Shared access to patient E H R Patient portal for easy access to lab, radiology services and results Patient tracking of medications and usage Store physician/insurance contact information Receive health tips based on their medical information Appointment/medication reminders Store important files/photos such as discharge instructions, plan of care Patient Identification One of the challenges to the sharing of patient-specific data across multiple entities through various technologies is the need for positive patient identification. Token based applications offer an identification solution that may be activated through existing, accepted forms of patient identification. Example Products: Patient Identification Solution Leverage patient existing ID (e.g. driver s license, payment/smart card, mobile device) Patient s ID information is tokenized and associated with the patient Patient s ID is read through e.g. a Point-of-Service terminal Unique token identifies the patient and the associated correct medical records 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 14 of 18

15 Patient Care Plan Patient understanding and compliance with a care plan is a critical component of all population health initiatives. Applications in this space provide content to help patients comply and achieve the best possible outcomes. Identification of high-risk patients and fostering patient/provider interactions, medication instructions, in a mobile platform, supported by text messaging and telephone calls are important tools embedded in these care plan support applications. Example Products: Patient Care Plan Solution A A patient outreach platform with content customization Easy procedure logistics and patient communications Patient s ID is read through e.g. a Point-of-Service terminal Document and share patient plan of care Includes interactive mobile apps, text message and phone calls Solution B Enables automated check-ins that helps monitor and guide patients Provide the right continuity of care, connecting patients, physicians and the hospital Helps patients comply to care plans and achieve the greatest results from their procedure, without the need for higher utilization Provides patient engagement that can reduce post-acute spending and can get patients home quicker while still receiving the best of care Identifies patients at-risk for complications and provides help before patients enter emergency Alternative Site of Service As employer plans move to narrow network designs, employees need to be able to connect quickly with physicians in the narrow network, as well as use a mobile app to obtain pricing information and make payments. Providing network information is critical to eliminating the surprise bills resulting from out of network referrals and services. Example Products: Alternative Site of Service Connects employees directly with doctors via app or phone Provides support related to insurance and billing Solution Electronic Scheduling/Pricing/Payment The ability to locate a physician in my network, identify physicians in my area and see appointment times all from a mobile application eliminates the need for lengthy telephone contacts to potential providers. At the same time, the patient is able to obtain pricing information and resolve copayment responsibility as part of either the scheduling or arrival process. Example Products: Electronic Scheduling/Pricing/Payment Electronic scheduling Website/mobile application Obtain pricing information and make payments Solution 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 15 of 18

16 Provider Selection Provider selection is typically based on a number of factors, including, but not limited to location, specialty, insurance network status, quality scoring, costs and availability, all in a mobile, user friendly application. Each of these features in one application reduces redundancy and allows the patient to choose quickly knowing relevant issues, including quality and patient satisfaction information. Example Products: Provider Selection Solution A Solution B Solution C Solution D Solution E National provider directory Search by location, specialty, insurance accepted, procedure Map to offices /locations Direct messaging, file sharing, referrals, and integration with EMR Census-based survey of providers - measures patient perceptions of care and used to create national experience outcome data Includes surveys such as CAHPS (Consumer Assessment of Health Providers and Systems Mobile app to assist patients in searching for best medical care Compare costs Find doctors and health systems near your location Helps patient choose a provider based on their health plan and geographical location Allows patients to view available providers quality, cost Make provider appointment and payment Integrated into provider for scheduling and payment Integrated with health plans for access to deductible data and HSA balances Payment and EOB Available functionality includes creating combined bills for multiple entities, providing price and payment options in an on-line environment which accepts multiple payment types, allows management of payment plans, provides access to detailed EOBs for multiple years and supports direct communication between the patient and the provider on billing matters by the Healthcare Information and Management Systems Society (HIMSS) Page 16 of 18

17 Example Products: Payment and EOB Solution A Solution B Solution C Solution D Solution E Consolidated statement for multiple provider visits over an episode of care Eliminates the need for multiple patient bills and EOBs Combines multiple charges from multiple entities into a single bill Offers multiple patient-friendly payment options, automates the processing reconciliation, deposit, and posting to patient accounts Providers get indepth reporting capabilities to utilize to make data-driven decisions to optimize their revenue cycle Patients get complete access to manage the financial portion of their care Offers a patient centric payment platform Allows the provider to electronically connect with their patients at every moment when the patient has a financial obligation to the provider Offers cost estimation along point of care payments as well as payment plans (virtual wallet, credit card, etc.) Trusted electronic communication relationships with their patients Informs patients about their financial responsibilities and responds to the provider s request faster offers point of care payments via mobile and online including payment plans Patient link to insurance company access deductible, max out of pocket Patient can access real-time balances for HSA, personal accounts and pay with same methods Optional integration of health systems provided payment options including credit card, debit card and payment plans Patient can make payment knowing impact on their Insurance deductible With patient's permission medical staff can access up to last two years of medical claims Receives EOBs from 300+ Insurance plans in real-time and presents to patient for payment, optionally receive and reconcile this with Health System bill, showing patient a single EOB Electronic check-in interview Signatures for consent forms and insurance information, administers relevant clinical assessments and ensures compliance with specific meaningful use criteria Offers a variety of payment options, including automated monthly payments and online payments Robust communication tool that allows a variety of communications and supports reminder notifications Displays eligibility and benefits Standards Functionality within the standards space includes patient matching, EHR certification and a defined set of industry standards to allow the secure exchange of healthcare information within mobile applications. Example Products: Standards Standard A Patient Matching: Innovator in Residence Program EMR Certification: Voluntary certification program Standard B Define industry standards for exchanging and securing healthcare information within mobile applications Phase 1: insurance information Subsequent phases: providing eligibility information back to the patient, enabling the exchange of health and prescription information, exchanging clinical summary forms and exchanging HIPAA privacy notification/acknowledgement forms 2016 by the Healthcare Information and Management Systems Society (HIMSS) Page 17 of 18

18 Standard C The three overarching themes of the roadmap are: Giving consumers the ability to access and share their health data Ceasing all intentional or inadvertent information blocking Adopting federally-recognized national interoperability standards Milestones: Between now and 2017 ONC intends to enable the sending, receiving, finding and using of health data domains with an eye on improving care quality and outcomes addressing secure transport of data, identity and matching, authentication and authorization, standard data formats and semantics, testing and certification ONC's next phase, slated to span , aims to expand data sources and increase the number of users to create healthier populations at a lower cost The ultimate goal is to build a learning health system by 2024, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access A variety of electronic health information sharing arrangements will continue to exist to meet the unique needs of different communities In an interoperable, interconnected health IT ecosystem, cyber threats will occur at an increasing rate and an intrusion in one system could allow intrusions in multiple other systems Privacy and security are key, proper permission to collect, share and use an individual s health info continues to be a complex legal issue; with clarity and computing power, individuals who want to document detailed, granular privacy choices will be able to do so The success of the patient financial experience of the future is predicated on the development and deployment of robust, secure, readily available and mobile enabled applications designed to support the patient focused, value based healthcare system. The technology solutions discussed in this section represent only the tip of the iceberg of what currently exists and what is possible to deploy in the future. As an industry, healthcare leaders must support and advocate for the technology solutions which support the processes described in the Roadmap for the Future. Innovators have already proven that the needed solutions are a technical possibility. The challenge going forward is to create the interoperability and connectivity, coupled with security and access that result in a healthcare system that provides a seamless clinical/financial experience for patients while keeping administrative cost containment and consumer engagement front and center, regardless of the reimbursement methodology being applied by the Healthcare Information and Management Systems Society (HIMSS) Page 18 of 18