"Digital health is about applying data in a smart way into interactive user experiences"

Q. Russ, tell us a little about Availity.

Russ: The company’s been around for 21 years now, so, we’re two decades old. We have been in healthcare technology since arguably before it was termed healthcare tech.

At our core, we connect health plans and providers for their business transactions and enable data exchange so they can run their respective businesses more efficiently. What that means in practical terms is that we’ve got two million providers on one side of our two-sided network, and on the other side, we have every health plan. Between them then, we transact roughly 13 billion transactions a year, including claims.

If you look at the aggregate claims and value their network, it’d be claims around USD 2.5 trillion billed through the Availity network on an annual basis. So, there’s a lot of economic and business activity between two of the critical stakeholders in the health care ecosystem. We see a lot of things paying off now.

Q. Availity sits in the middle so neither party really gets to see the other’s data, but eventually has the ability to use the data in ways that create business value for both sides. Is that correct?

Russ: Who owns what is I guess core to that question. So, a provider would say, “When we create a claim, the work that goes into the creation of that claim is our work. So that is our data.”

We send that data through Availity to the health plans. They receive it in the form of a claim. The payer would then say, that at that point the claim becomes theirs and so does the corresponding remittance or response. But then again, when the provider gets that back in their system, now suddenly, that’s their data.

We don’t typically get into the debate around who owns what between health plans, providers. Generally speaking, I think the industry has been fairly practical about these ownership rights when it comes to business workflows. It’s been more focused on getting the workflow automated than haggling over data rights in the context of “Is it claims data? Is it medical data? Who owns it?”

Q. With regard to medical data, is EHR data specifically, also part of the datasets covered?

Russ: Historically, we’ve been moving almost purely administrative data. However, over the last several years, we’ve begun to move more and more medical data which is what we use generically for clinical data in various forms ACT, CCD and variety of formats.

A little over a month ago, we closed on the acquisition of Diameter Health, and we’re very excited about that. If people think that structured X12 data is very standardized — unless you work with it every day wherein you realize that it’s not really as standardized as previously thought – they must see one payer implementation. They’re all different when it comes to clinical data given it’s still very much the Wild West in terms of how data is facilitated, created, transacted, named, or even identified. There’s still a lot of opportunity to provide a structure around clinical data so that it can be used and automated into workflows, which is where we are. We’re very much focused on that.

Q. Is there a HIPAA consideration here? What would be one or two top considerations when it comes to this kind of exchange of data?

Russ: It plays a bit to our strategy. We’ve never sold data and we have a lot of claims data. While remittance data and a lot of very valuable data flows through our networks, we’ve always felt that it’s better to be a trusted data steward than a data broker. So, just like any firm that resembles ours, we take secure information along with security, and privacy, very seriously.

The fact that we have not been in the business of selling data has enabled us to strengthen trust with both sides of the equation — payers and providers — which we think is going to let us create some interesting use cases for data in that business workflow.

But to your specific question, you have just your core underlying concern of “Let’s make sure the data about the right person is going to the right person at the right time.” Our network, like any health care network, is constantly under some form of assault by people trying to breach it or get into it. So, we spend a small fortune on information security and privacy.

Beyond that, it’s about where you’re going. Once you move from those standard business transactions, which everybody opts into to how do you really use that clinical data to create a better health care system, then, you’ve got to be super careful about data rights, both in terms of the payer, provider, and patient who some would say ultimately, owns all the data.

Q. With regard to your recent acquisition, what does Diameter Health bring to the table?

Russ: I’ll use a few analogies to explain this. There’s considerable clinical data being mined out there in the market, many aggregators, and data collection sources as well drilling for oil so to speak, in this case, drilling for data. What we’ve noticed missing is, the ability to take that raw crude and turn it into a usable fuel.

Diameter Health is the data refinery that receives data from a variety of sources. They don’t actually have endpoints into provider systems to gather any data so are wholly dependent upon their customers to create those endpoints. That’s one synergy they have with Availity, which creates endpoints for data all day, every day.

Diameter Health pulls that data in from all these disparate sources and refines it to a particular client’s standard whether that client is a payer, an HIE, works in the government sector, etc. They have a variety of different customers with use cases for clinical data to drive better health outcomes and enable cost reductions, everything we want to see happen.

However, given how fragmented this data is, our ability to automate its flow into a utilization management system or a care management, encounters gaps making it hard to achieve the required scale. Diameter Health applies their tech to raw data and upcycles or standardizes it to create a structure by applying clinical knowledge to the data. Clinicians at Availity — nurse practitioners and Pharm Ds– work on these data structures so that when we flow it back to the end user client, it can be pushed into an automated workflow.

Q. Have you started tapping into individual data?

Russ: We’ve never had a direct-to-consumer strategy because we’re direct-to-provider and the providers ultimately source a lot of the data that the health plans need and vice versa. A direct-to-consumer strategy then, feels like a pretty big lift and one that, frankly, for the use cases that we are bringing to life, includes a lot of patterns. There are many low hanging fruit. To automate workflows like authorization, care management etc., the data required by the plans lies in the provider systems so, that’s where we’re really focused on data capture.

Q. You mention authorization and that’s one of the biggest friction points in healthcare. What is the competitive landscape like for you?

Russ: In that particular one and in others where you have the payer partnering with Epic, we serve as the gateway for the payers that have been identified. We’re big fans of automation, whether it comes in an Epic system or any other application, so we help automate data and workflows.

That said, the biggest pain point between providers and health plans today, is one that frankly has not been solved at scale. I really like what Epic’s doing with the Epic Payer Platform and driving all the automation there. That’s going to be an important source. Frankly, we’ll be a catalyst for a lot of other innovation around over the next few years.

Q. Can you share a couple of use cases coming out of the Diameter acquisition that enhances the value of your business?

Russ: Let’s start with Auth because I really have very personal reasons for wanting to solve the Auth problem. I just think it’s bad not only for business but also, for patient care. Any time a patient’s left standing at a doctor’s front desk waiting for an Auth to be approved, that is not good for patient care. That, to me, is one great example of where even though we’ve got some great tech that’s being applied to the Auth problem itself, you still have to empower data in a consistent, logical way so that it can be transacted into the payer system. One of our helpline partners is Elevance. And to that point, even they’re right. You’ve got to be able to push the data into their systems in a consistent and automated way.

One example of where we will put the Diameter technology to work is upcycling that clinical data that gets used in a Auth UM workflow both, for Auth determination as well as ultimately, the second phase of that process, which is medical necessity determination. If you can get an Auth and still not have medical necessity approved, you have got to have a way to pull that clinical data into the system so that you’re solving both problems at once. So, starting Auth is a great example of that.

I’ll bucket it under the general heading of chart retrieval, for various purposes. Today, the chart retrieval process is still a very manual process with thousands of people sitting in the bowels of health systems looking at paper records all day and scanning them into some OCR system and then, pushing them through. Ultimately, the plan is not to look for that entire medical record. They’re looking for data elements that are in that medical record to approve whatever it may be right for, whether it’s a medical necessity determination, etc. That’s another area where we think there’s just a ton of room with what we’re doing with Diameter Health to bring that data to life.

Everyone knows the data is there but it’s how you bring it to life in an automated way that needs to be seen. One of the comments I was going to make about Elevance is, there’s a lot of really smart people there, but one, in particular, who uses the term “auto adjudication” instead of just “automation.” He talks about auto adjudication in context not just of claims but everything from provider directory data. When a provider updates a piece of demographic data, how do you auto adjudicate that all the way through the planning system to clinical data? It’s a great example as well of getting clinical data and being able to then, auto adjudicate that through whatever multitude of systems the plan may need. That is where we think the real value of Diameter Health is and where you can start to really prove ROI. We know the large costs entailed when a human has to intervene in a chart review. So, that’s a couple of great examples of how we’re going to do it.

Q. What about the other side — health outcomes? What is the role of your data set and platform?

Russ: I love the idea of bringing disparate data sources to life around total care management but the one thing that frustrates me about the U.S. health care system is, it’s by and large, a reactive health care system. We treat symptoms, diseases, and specific diseases. We don’t treat real conditions of human health.

I’m personally very interested and trying to get a lot smarter around things like longevity. What can we do to prolong?

Q. Didn’t that come up with a supplement that does that anyway?

Russ: Yes, but one of the reasons that we aren’t more proactive in managing care and paying for the management of care proactively is, it’s really hard to prove returns on investment. We know all day long that if somebody has high blood pressure, then, treating it with a pharmaceutical product is going to help and if it’s high cholesterol, treat with a statin. But we don’t do anything to get at the underlying conditions which are causing that. So, I’m very excited about the notion of being able to go out and get a lot of differentiated data on people and bring it into this central repository.

We talk at Availity about one patient health record. That is not just what’s happened to you retroactive to becoming sick. For instance, I’m ill and now I’m being treated. But how do we proactively enable providers to know what they need to know about you when you come in instead of just how you may be feeling today? My doctor will be able to look at a chart and say I’ll be ok because he’s been tracking the Hemoglobin A1C, and glucose levels for the last three months so can see where the spikes are. He can then talk about my diet in ways that we can do and test things to reduce those spikes. That to me is the health care system.

The question then, is, where does Availity play? For now, at least, Availity’s play in that is in a retrospective manner, but you ultimately have to have a way to measure what value we’re getting from that and total cost of care. I think that’s the way you look at it over time. So, our ability to look at claims and then, the analytics across claims is critical. I do analytics across claims and know what’s going on with the patient but after the fact is where you get a lot of that.

Q. Let’s talk about digital health. Digital transformation of healthcare data and analytics is super important in all of this. Can you do your work with digital health startups? How do you enable them? What should they know about you?

Russ: While I’m very opinionated on this topic here’s what I think. Digital is another highly overused term, not unlike population health and interoperability and that sort of stuff. To me, digital health is about user experience and it really is that simple.

How do we apply data? How do we make data smarter and apply it into an interactive user experience that drives as a high net promoter score, user satisfaction and gives people the answers to questions they need? That is by proactively anticipating the questions that are going to be asked and answering those questions in a very logical way in workflow.

The example I always use and not a lot people can relate to it is that, I’m a pilot and I’m flying what’s called a glass panel, which means I’m looking at a screen just like I’m looking at two computer screens when I’m in the cockpit. That has evolved over decades from six different devices and instruments to one glass panel that gives you all the information you need, as you need it, even before you need it. It is thinking ahead for you and preparing you for what’s coming next. It’s answering questions intuitively, applying analytics to the data that’s coming in to give you routing information. The truth or the same reason that we did it today in health care is that, I think, we’re still very analog in the way that providers and health plans interact with each other. So, where we’re investing as a company is in two particular areas.

We’re investing in data intelligence and data analytics. We’ve just hired Gigi Yuen-Reed, who was a Principal Data Scientist for IBM Watson, and is now, our VP, Data and Analytics and we’re building a team around her. Their job is going to be to take 13 billion data points and make them smart, more intuitive, more interactive to extract insights and knowledge from all the data flowing through our network.

On the other side, we’re investing in our user experience, not just our screens, but the way that we deliver data to our end users, whether that end user is in an Availity application or in an Epic application. That’s because we sell a ton of provider business through our partnership with Epic or in a nascent digital platform that some brilliant entrepreneur has independently developed.

I’ll give you two examples of where we have a budding partnership with Rhyme, which was brought off and is now run around automating the prior authorization workflow. Leveraging tech that Rhyme has built creates what I call nodal activity – it’s not a very good term. However, the problem with the auth workflow is not a transaction but a conversation between disparate systems and health systems in a payer system. So, Rhyme has really brought intelligence to that conversation so that they can actually speak the same lines. Rhyme is a great example of a partnership where we are bringing value to a young startup digital company to help them get scale.

The other is Vin who’s a very close friend and what Vin is doing with clinical data capture at the point of care is particularly valuable in smaller EMR and EHR systems. We are now leveraging Vin as our own point solution, if you will, which we will bring to scale, to extract and deliver clinical data and insights directly on the provider’s desktop.

Where we are investing is in building an underlying architecture in an API framework so that we can very easily stand up partnerships with some of these brilliant young entrepreneurs who are building applications and sitting there having built something really cool. But question arises, “How do I get scale? Where can I get to a network where I can actually interact with health plans and providers at scale?”

We think Availity should be a logical place for them.

Q. There’s the emergence of a lot of data consortiums – Truveta, HIEs, clearing houses etc. What are your high-level thoughts on the market right now?

Russ: I’ve been involved in HIEs since 2002, so I go back a long way with them and to your point, I think there are HIEs that serve very viable purposes. They’ve figured out a commercial model and are very relevant as data aggregators and local community voices that help create trust around data exchange. We love partnering with them. We’re partnering in Michigan and California. Now with Diameter Health, we’ve got a number of other places where we’re helping bring that data to life.

There’s no lack of data but what do you do with it? We’ll continue to focus on this. We didn’t last for 21 years by not having a good, sustainable business model and I do believe that we knew that some of these disparate, nascent data elements were going to become more and more important to us. Finding ways to consolidate that data into an existing workflow is an area where I think Availity can be very relevant and start creating real value for the end user. What we do today in just transacting claims and eligibility is highly commoditized but if you do it at scale like we do, it creates a phenomenal platform that you can build around.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.