Over the past several years, the phrase “care continuum” has entered HME industry parlance with increasing frequency. It’s an expression that truly describes the state of care in the country.

Where healthcare used to be a somewhat “siloed” environment, where patients moved between different care providers — doctors, specialists, surgeons, hospitals, recovery, therapists, and yes, HME providers, as well as others — as though they were entering different worlds of care, U.S. healthcare is now trying to bring those disparate entities to work in concert.

A key impetus for this change is the drive by CMS, and more specifically Medicare, to focus on outcomes-oriented care. The goal is to have various care professionals involved in a patient’s care work together more efficiently in order to cut costs and improve outcomes. That strategy has since been adopted by private payor insurance carriers, who are also looking to ensure their beneficiaries get optimal care for the money spent on reimbursement.

Not surprisingly, information technology has come to the fore in this environment. The more that various care providers can share information the more they can fine tune a patient’s care and drive the sorts of efficiencies that cut costs and improve outcomes.

However, healthcare providers operate on a variety of disparate computer systems, and therein lies the challenge: how to create the kind of IT interoperability that will drive this improved care infrastructure? This is the challenge and opportunity that care providers across U.S. healthcare have been experiencing for the past several years, and now that interoperability imperative is finding its way into post-acute care, and more specifically, the home medical equipment industry.

What is Interoperability?

Let’s start by defining some terms — what exactly does healthcare interoperability mean, and how did it spread from a business imperative in the ambulatory and acute care setting into post-acute care spaces, such as home medical equipment? The Healthcare Information and Management Systems Society (HIMSS; himss.org) is a massive association of health IT companies and experts, and in 2013 its board defined healthcare interoperability as the ability of different information technology systems and software applications to communicate, exchange data and use the information that has been exchanged.

Nick Knowlton, vice president of Business Development for Brightree, has a more simplified definition.

“I just like to say that healthcare interoperability is getting the right healthcare information in the right place at the right time,” he says.

Of course defining healthcare interoperability and making it happen are two different things. In the early days of developing and implementing healthcare interoperability, Knowlton helped assemble the CommonWell Health Alliance (commonwellalliance.org) while working for Greenway, a company that makes HER systems for the physician practice area. He was a lead representative from the five founding companies that put the company together, and the alliance was focused on making interoperability happen.

It quickly became apparent that creating health system interoperability if anything was about solving tricky technical problems, while creating a system that met real-life demands.

“When we put together the CommonWell Alliance, one of the biggest drivers was the need to manage patient identity across domains,” Knowlton explains. “One of the hardest things in enabling interoperability across the country is to know if a patient in provider location A is the same patient in provider location B.

“We founded the alliance with the intent to solve the patient identity problem, and we very quickly realized that the systems we were operating in at the time — mostly hospital and physician practice — it was a very important problem to solve,” he continues. “But not physician has ever said, ‘I need better patient identity management.’ What they say is, ‘I need the healthcare records on this individual, so that I can better advise their care.’ So what we decided to do is build this network on top of it to make it ‘real.’”

So the main problem that the alliance could solve was when a patient comes to a healthcare provider’s office and the provider is able to quickly and easily get that patient’s information. But that was not the end game.

“It was intended to spread across many more care settings,” Knowlton says. “So while ambulatory and acute [software] vendors were feeling the need to do it, everybody recognized that it was going to extend out.”

And that meant post acute, pharmacy, lab and similar providers. While those arenas were under consideration at the time, Knowlton says it wasn’t until Brightree joined in and pushed hard for their consideration that the post acute space really started to make in-roads in this new interoperable environment.

At about this time, HME software company Brightree LLC had already joined CommonWell, and was advocating that the HME industry and similar post acute care arenas needed to be included in interoperability efforts. Knowlton was attracted to join Brightree specifically because he saw that interoperability was starting to creep into the post acute care space and that he could continue his work there.

“It’s a good feeling to have a seat at the table and say that we’re taking infrastructure that was developed for other needs and being able to apply it to problems might be a little unique to our neck of the woods,” he says.

Why Interoperability?

Of course this begs, the question, why is there this push for interoperability? Why did the healthcare IT world conclude it needed to undertake this massive effort? It turns out that the goal goes far beyond simply sharing information.

The drivers for this trend came from both the public and the private sector, according to Knowlton.

“The office of the national coordinator for health information technology has a rolling vision for how health information technology affects care delivery in the United States,” he says. “Their 10-year vision has called for a great number of steps in terms delivering the best care to patients at the point of care.

“The first step that they wanted to bite off was ‘electronifying’ the industry,” he continues. “The second step was — which we’re in now — … getting the systems to talk to one another. And where they’re going with this is that they would like the ability to aggregate and analyze information for best practices, but also being able to eventually drive clinical support back down to the point of care.”

So, where interoperability now stands is that healthcare IT world has determined a format that makes data “liquid,” and has also figured out a way to share it between systems. Now that world is figuring out how they can make the most use of that ability.

And the upsides are many. They include better care coordination, information analysis, determining the best treatment approaches, establishing best practices for disease states, or isolating specific patient populations with specific symptoms across various providers.

On the private side, trends such as Accountable Care Organizations and value-based reimbursement models replacing fee-for-service reimbursement models are pushing the need for different physician groups needing to talk to one another, according to Knowlton.

“All the drivers around payment reform, and accountable care, population health management, and care coordination — that’s all what’s feeding this,” Knowlton explains. “And to have systems out there available to plug-in and be able to leverage standards that the rest of the industry has developed as ways that they can communicate with the outside world, a lot of that is what’s feeding the opportunity here.”

Interoperability’s Imperative & Promise

And of course these same pressures are being felt in the post acute care world, as well.

“We all know that interoperability is being driven by the payor sources,” says Rob Boeye, executive vice president of HME for Brightree. “And they’re trying to improve patient outcomes and reduce readmissions. So if you look at that overall, our HME providers need to be able to share this information bi-directionally with the acute care and physician practices, and that’s really going to have to happen in the next 12 to 24 months.

“If providers can take advantage of the electronic sharing of information, they will become relevant in the discussion of the patient’s outcome,” he continues. “… It’s also going to improve their stickiness with their referral sources.”

Essentially, the ability to share data becomes a differentiator. If physicians, and hospitals and other referral sources find it easy to work with a provider and share information, and are getting a good deal of usable data that they can put toward their patients’ care, why would they need to go with anyone else?

So how does this work in the real world? Sleep is perhaps the best example of how HME providers are making the most of interoperability and data sharing. The ideal scenario sees providers working to put sleep therapy patients on intelligent PAP devices that constantly record how the patient is doing during their sleep. Important respiratory events are recorded and the data is then shared with physicians who can start to model the patient’s sleep apnea behavior and adjust their therapy accordingly. That free flow of data is a win-win-win between the patient, provider and referral partner, and the manufacturers of those systems are striving to make that scenario the everyday reality for their providers.

“The possibilities for sleep and respiratory care are significant. From our own experience with respect to the home medical setting, we have seen a dramatic increase in the number of medical devices available with remote monitoring capabilities, in sleep especially,” says Rob Levings, vice president of ResMed’s Healthcare Informatics Global Business Unit.

ResMed is a key player in the sleep data market. A December report from Berg Insight identified sleep breathing therapy as the largest growing sector of connected devices in the past year, with ResMed as the largest player in not only the sector, but also the single largest provider of connected healthcare devices overall with 1.3 million connected sleep therapy devices.

“In addition to connected devices, we make interoperability a key focus to ensure that the device data can get where it needs to go,” Levings says. “Our ResMed Data Exchange enables interoperability with third party applications to ensure that end. The best part is that this technology can go far beyond sleep: We view all of the products that we offer, from diagnostics to therapy and beyond, as part of an interconnected suite of solutions.

“At ResMed, this means when we’re designing a new CPAP device, we’re thinking about how data from that device could deliver value to a physician using an EHR application, or to a DME that is managing a large population of patients, or to a patient that wants to monitor their own sleep therapy, for example,” he continues. “Interoperability is a key part of that because our systems need to talk to other systems to fulfill that vision.

Interoperability in the Real World

Interoperability was a real-world challenge for Patty Mastandrea, chief operating officer at hospital-based HME provider MedCare Equipment Company (Greensburg, Pa.) owned by eight health systems in the Pennsylvania. Being a for-profit business unit, MedCare’s challenge was how it could insert itself into the care continuum and be a key player in ensuring the right patient outcomes. That meant knowing who is involved in the care being provided across these disparate organizations.

So in 2008, MedCare was approached by another health system that had its own DME and was asked if they could help work with them managing their services. But other health systems also involved with MedCare did not have their own DME. Working under a philosophy that MedCare couldn’t simply “get” the business, but instead had to earn the business, the challenge quickly became, how do they differentiate from other providers?

“It all came down to the continuum of care,” she said. “… So we asked what makes us different? We identified that you have the patient — who technically owns the protected health information — you have a doctor, you have a long-term care facility, you have a hospital, and you have the DME. And we all want the exact same thing; we want it to be easy. But the question is how do you do it?”

So MedCare started with sleep to start shaping its model for making things easy. In this scenario, a patient gets diagnosed as possibly having sleep apnea, so a sleep study is ordered. That data is then provided to MedCare as supporting documentation so that the patient can get the correct therapeutic equipment, Mastandrea explains.

MedCare then sets the patient up on a PAP device with a modem. This lets the physician dial in to see that the patient has been set-up, is using the device, and is either complying or not. Then MedCare started calling the patients to do any necessary intervention — and the doctor can see that the provider is taking these proactive steps thanks to the interconnected IT environment.

“The goal is that we’re all trying to provide quality equipment for quality outcomes,” Mastandrea says. “But we also have to make sure to continue to provide the service that we’re providing to the insurance companies, because it all boils down to how everybody’s getting paid. So we have to make sure that we are collecting the data that’s required by the different payors to qualify or disqualify that patient for the equipment.”

Using technology, MedCare ensured that there was a smooth, bi-directional flow of information between it and the board-certified sleep doctor. But it goes deeper than that. At all times, the data for any patient that was referred to MedCare is available to the ordering physician in order to manage that patient remotely.

“So that when that patient comes in or calls in, the physician has the ability to say ‘Let me look at this. You’re using your CPAP four hours a day at a pressure of X. Let’s increase your usage, but let’s also increase your pressure,’” Mastandrea says. “And we can effect all those changes remotely by using modem technology.

“In addition, we know the patients who aren’t complying with the guidelines of their care, so that we can do interventions, and can work very diligently with those patients to get them compliant,” she adds. “Because the insurance have already paid a significant amount of money for the testing and the equipment. They want the patients to be successful on that therapy, and we have the ability to intervene and get that to happen. And we have the data to say, ‘Okay you reached your criteria’ in order to drop a bill.”

And that technology also helps MedCare follow up with patients on resupply needs in order to prevent the kinds of infections that lead to readmissions, which saves everyone even more. These are the promises of healthcare interoperability, made reality smack dab in the realm of HME.

Making Interoperability Happen Across HME

Of course, sleep is just one segment of the industry. Interoperability needs to happen across the spectrum of home medical equipment. Bearing that in mind, what do providers need to do in order to ensure that they achieve interoperability with their referral partners? What needs to happen in the industry so that providers have liquid files that can move across the patient care continuum?

“Our area of the healthcare industry needs to advocate for its needs,” Knowlton says. “Over the short-term, we need to the meet the industry where it is. There is a lot of liquid data in the hospital and ambulatory physician practice systems, but their standards were built for their needs.

“There is a lot that we can do with that, but it’s not a perfect fit for the needs of the HME provider,” he continues. “For instance, for CPAP therapy compliance, there is no single standard for how you ship that from an HME provider to a physician practice; no one has developed one yet. So our industry has to advocate for that.”

But there are ways to use what is currently there to improve how providers share patient records with referral partners and tighten up efficiency in the how they communicate with their physicians.

“There are strides that can be made today,” Knowlton says. “We just need to help the rest of the healthcare industry understand the needs of our providers, as well.”

Going back to Boeye’s earlier comment about 12 to 24 months as a timeliness, what should providers be doing for themselves?

“The top HME providers are already starting to proactively leverage technology to not only make themselves relevant, but also attract more referrals,” he says. “By using technology, this allows providers to free up their resources to market and better communicate with a larger base of referrals. It makes it a lot easier to do business with someone who can already share the information electronically.”

ResMed’s Levings adds that it is critical for providers to not sit on the sidelines and wait for interoperability to come to them, but to start looking at how they can make it happen now.

“Technological capabilities in healthcare are evolving quickly and providers need to understand how the technology can benefit them and their patients,” he explains. “Many are aggressively taking steps to embrace technology, including the adoption of interoperability mechanisms … to exchange data with hospital systems, patients, partners, and others. The status quo is not an option. Smart application of technology will ultimately be a critical success factor.”

Truly, healthcare IT interoperability has become an imperative for HME providers, whether they have realized it or not. The rest of the healthcare industry has been evolving toward an interoperable environment for sometime, and if providers want to keep pace with their referral partners, they will need to adapt to this new technology landscape.

But fostering interoperability ultimately means so much more than being able to simply “talk” to other care providers’ systems. It means creating new possibilities for providing all new value in patients’ care and demonstrating that value across the care continuum. That’s a healthcare connection well worth making.