Developing the Future of Care

Q&A with CEO and Founder Adam Sabloff and Vice President of Product Management Marcus Caraballo. 

The healthcare industry is evolving. As more and more organizations seek to implement a value-based care approach, many are realizing the importance of data interoperability, whole-person health, and the need to address and solve for social determinants of health (SDOH). To get the inside scoop on how VirtualHealth is addressing these challenges in 2023, we sat down with CEO and Founder Adam Sabloff and Vice President of Product Management Marcus Caraballo.

VH: VirtualHealth has been working on a lot of innovation lately, but what’s coming for 2023?

Adam: 2023 is an incredible opportunity to help healthcare organizations level-up their care management, and utilization management and better close the gaps in health equity.

We are finally seeing an increased pace of innovation industry-wide, and we see that trend continuing into this year and beyond. But, considering all that needs to be upgraded in healthcare, the key is to remember things take time to truly materialize.

A continuing area of focus is closing the loop on SDOH. Until that is commonplace, we will only have “potential”, and healthcare experiences, health outcomes, and true healthcare equality won’t be where they need to be.  We are also actively searching for integration partners to augment the whole-person view and provide more tools and resources within HELIOS. Additionally, we have multiple new state-of-the-art modules coming to market such as reimagined utilization management capabilities and pharmacy.

Marcus: We’ve got a few things in the works for 2023. One of our biggest projects right now is close to finishing and will help support organizations in meeting CMS interoperability standards. Other projects in scope for next year relate more to the care management and utilization management side of things as Adam mentioned.

And then finally, we are really pleased that recently HELIOS was selected for Amazon Web Services (AWS) Health Equity Program and will receive computing credits and technical expertise from AWS to further reduce healthcare disparities and advance health equity.

VH: We’re hearing a lot about FHIR® as well. What is it? Why is it important? How is VH addressing it?

Adam: FHIR® stands for “Fast Healthcare Interoperability Resources” and is the latest attempt to create an industry-wide interoperability standard. The Office of the National Coordinator for Health Information Technology defines the standard as:

“The HL7® FHIR® (Fast Healthcare Interoperability Resources 1) standard defines how healthcare information can be exchanged between different computer systems regardless of how it is stored in those systems. It allows healthcare information, including clinical and administrative data, to be available securely to those who have a need to access it, and to those who have the right to do so for the benefit of a patient receiving care.

The standards development organization HL7® (Health Level Seven®) uses a collaborative approach to develop and upgrade FHIR.” [See here for more information.]

Fortunately, we are seeing mass adoption of this initiative, and with regulatory tailwinds accelerating it, we have an industry-changing opportunity to modernize the entire healthcare ecosystem tech stack.

Marcus: What’s great about FHIR® is that organizations across the healthcare continuum are starting to collaborate off a common data model. In medical management, organization-specific data acronyms and labels can be challenging to navigate. FHIR® is helping organizations speak the same language, streamlining not only interoperability, but collaboration, innovation, and speed to value for customers and patients. These developments coupled with VirtualHealth’s unique market positioning and experience with interoperability have us aggressively staying at the forefront of CMS FHIR® requirements as well as general FHIR® enablement for all HELIOS data categories.

VH: Why is continuing to address data interoperability so key?

Adam: Data interoperability is essential to eliminating some of the biggest obstacles in healthcare, and more specifically, to health equity, solving SDOH issues, and ensuring healthcare is appropriate, necessary, and accurate for the right person, at the right time.

What we see in the industry is that lack of communication and collaboration can significantly harm health outcomes and drive costly inefficiencies on the back end. Not having a singular source of truth for member views is also problematic for healthcare payers and care producers across the spectrum. Part of why we continue to innovate HELIOS is the knowledge that a whole-person view with clinical and non-clinical data is an essential part of developing and delivering value-based care that accounts for the member’s entire being – incorporating both their medical data as well as the behavioral, social, and economic data that may impact a member’s ability to obtain, receive, or adhere to care instructions and regimens.

VH: You mentioned utilization management above. Can you tell us more about that and why it’s important for Medicare/Medicare Advantage payers?

Adam: So historically, utilization management (UM) and care management (CM) have been viewed as separate modules and disciplines. This siloed approach can result in higher costs, slower care delivery, and poor member experiences. In the fall we launched HELIOSum as a reimagined approach to utilization management and fully integrated within the HELIOS ecosystem. HELIOSum joined the HELIOS ecosystem of products, which already includes CM, disease management, care coordination, population health management, and behavioral health, all designed with seamless workflow across functions in mind.

Healthcare organizations using HELIOS can now support both UM and CM needs in a comprehensive, seamless, fully integrated, and intuitive manner.

HELIOSum helps improve utilization management to reduce healthcare costs (for payers, providers, and members), improve patient care and outcomes, as well as reduce denial of claims. An integrated and collaborative approach is enabled by a 360-degree view of the patient record that supports an intuitive workflow for both UM and CM.

From Medicare Advantage payers to scaling healthcare organizations and community health plans, HELIOSum was designed to help them expedite authorizations; streamline utilization reviews, appeals, and grievances; reduce the risk of human error due to manual entry; drive more efficient data management without duplication of effort across teams (better resource deployment); help improve plan satisfaction ratings and ensure regulatory timelines are met; and deliver higher quality and more comprehensive data around members, health plan benefits, and resource usage.

Marcus: Yes, Adam covered most of it. HELIOSum is a UM solution that comes natively integrated with our industry-leading HELIOS care management platform. It also supports flexible integration with external systems and interconnected workflows.

With HELIOSum we saw an incredible opportunity to enable care management and utilization management collaboration; provide more detailed patient views that will support better member healthcare, service, and satisfaction, as well as to help organizations reduce operational and organizational costs related to UM inefficiencies so they can then transfer those hours and funds towards member-health associated efforts.

We applied the same configurable rules model that we built for HELIOS to HELIOSum to adapt to organization-specific needs. By bridging UM and CM together, we have advanced HELIOS to empower care managers to take an even more proactive care approach (they can now address some UM-related issues and begin key educational, or outreach activities related to UM items sooner and more effectively).

VH: Finally, what are the key trends in healthcare for 2023 that you believe are important to address/solve?

Adam:  Closing the loop on SDOH initiatives, meaning a bi-directional exchange of community resources and service providers. It needs to be captured in real-time at point-of-care (POC).  And it needs to be streamlined in the care management workflow. This is something we have had at the top of our minds for a decade and are continuing to innovate within HELIOS to achieve better outcomes and provide more comprehensive care support and tools to users.

Other themes for 2023 will be data interoperability with a big push on FHIR<® and remote patient monitoring (RPM) data usage. I personally hope to see more in the way of connected devices, home sensors, and wearables incorporated into whole-person care, but in many cases, the cost of acquisition can be prohibitive.

We can’t buy everyone an Apple Watch, but for those who have one, we need to be able to not only take the data it provides but make it actionable.

I also expect to see the continued growth of value-based care. Aligning incentives for payers and providers and compensating based on outcomes is why I started VirtualHealth. Policy changes alone won’t fix our system. What we need is to hold healthcare payers and providers accountable. Reward them for being efficient and improving member outcomes and penalize reactive behaviors and increases in risk profiles or hospital admissions (the main driver of our healthcare costs).

Marcus: This year I expect to see a continued push for automation. Organizations that can streamline clinical and administrative processes with streamlined UM and CM efficiencies see improved productivity and member outcomes. Configurability and automation will play a key role.

I also expect to see significant development in the role of artificial intelligence (AI) as modeling technology matures and research advances on the benefits of predictive measures and to enable more accurate and proactive diagnosis and care delivery.

VH: VirtualHealth is constantly listening to the needs and challenges of our clients and trying to find innovative ways to solve them. What are our clients talking about for 2023 as their largest challenges?

Adam: I think healthcare is ready for real-time bi-directional data exchange.   For too long healthcare has been reliant on claims that are 30-60-90 days old.  Obviously, the infrastructure needs to be there and that’s where we come in.  Clients increasingly want real-time POC data as it provides meaningful seamless integrations with EHRs, home care EVV+, and hospital ADTs.

We need to stop looking at healthcare as acute and post-acute and start to look at it with the whole journey in mind. All that changes is the physical location of the patient.

Marcus: Lately our discussions with our customer success and sales teams have revolved more and more around increasing interest in SDOH-related integrations. We’ve had more customers and prospects asking about how they can better solve gaps in transportation, access to nutritious foods, and health literacy. This is why we’ve worked hard to build (and continue to build) a robust  who focus on supporting SDOH initiatives.

We’re also seeing a desire to elevate UM programs and creative initiatives to improve member engagement, experience, and satisfaction.

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