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Electronic Health Records: Square Peg or Holy Grail
April  2019

Electronic health records (EHR), which capture health information on individuals in an electronic format using diagnostic codes,  do have the potential to disrupt life insurance underwriting. Used in combination with lab-free and automated underwriting programs, EHRs can help companies realize the vision of issuing a large percentage of applications without manual review, drastically reducing application time and cost while improving the customer experience and policy placement rates. However, effectively operationalizing EHRs into existing processes is a relatively new journey that requires comprehensive program planning and design and stakeholder buy-in from across an organization. 

An EHR underwriting solution involves multiple parties having to overcome multiple obstacles. We have a long way to go, but a growing number of life insurers and reinsurers are leveraging work being done outside the industry.

Carriers are piloting and assessing EHRs and EHR retrieval technology to complete protective value studies, cost benefit analysis and determine the complexity and effort required to implement EHRs in their underwriting process. They are evaluating the pros and cons of the various EHR data retrieval solutions available to determine best fit for their risk pool.  

At SCOR, we use the term “EHR data aggregator” to represent companies that perform EHR retrieval and aggregation of medical records from multiple parties in the health care industry. These companies contract with several health care data sources including health plans or provider networks to facilitate the data collection for the insurance carrier.

Below are  four categories of  EHR data aggregators in the life insurance space, but these lines are getting cloudy given new entrants (i.e., Apple and Google initiatives): 

Patient Portal Solutions: platforms that aggregate EHR data from multiple patient portals; it enables applicants to complete a search for their doctor/provider, log into each of their respective patient portals and provide electronic authorization to EHR data.

Health Information Exchanges (HIE): organizations that facilitate the exchange of health care information electronically across organizations within a region, community or hospital system. This is critical because systems must be able to exchange and present data in a way that can be understood by the user.

EHR Vendors: vendors that obtain EHR data for insurers from patient portals and provide electronic authorization.  A carrier builds interface to connect directly to EHR Vendor and extract EHR. 

Aggregator of EHR Vendors: platforms that enable acquisition of applicant-authorized EHR from contracted EHR vendors.

There are pros on cons to each approach. For carriers, the biggest concern around each appears to be EHR content, customer experience, hit rate and national footprint.

EHRs are a substantial collection of codified data which include physicians’ notes, vitals, records of allergies, medications, surgical procedures, lab results, as well as social determinants of health and provide a longitudinal health record rather than at one point in time.  

Market analysis, EHR study, and discussions with leaders in the life insurance and EHR Data aggregator space have provided insights into the gaps/hurdles and potential opportunities.

Table 1: EHR Gaps and Hurdles
​1 Limited accessibility: A national or even state-based data set does not exist; patient records are not easily available to providers and patients – and certainly not insurance carriers.
2 Low hit rates: Those working on these solutions are still growing their network of data contributors. 
​3 Incomplete information or limited percent of EHR records: The records may not include attachments (diagnostic tests), referral notes or work-ups from outside specialists. The lookback period may be limited or only include records after EHR system implementation.
4 Full EHRs not available in real-time: About 60-80% of EHR data is unstructured.
5 Patient-matching and data-matching not 100% accurate: The US does not have a universal patient ID, and no single access point; errors in data matching to patient files.
6 Other concerns: This includes issues around volume or redundancy of data, disparate formats and multipe authorizations.

Table 2: Potential Opportunities for EHR Implementation
​1 Records on demand
​2 Lower acquisition costs
​3 Improved throughput in automated underwriting
​4 Decreased review time 
​5 Digital data available for study/research and further build out into AI models
​6 Longitudinal information can give considerably more insight into the health of an applicant

Current State in Healthcare
While the health space is experiencing high levels of adoption (99 percent of hospitals and more than 60 percent of all office-based physicians)1 the landscape continues to struggle with interoperability as each EHR vendor has developed proprietary software and platforms and primarily related to ambiguity in data format requirements.  

Privately-funded exchanges and vendor coalitions have emerged to advance implementation of secure, interoperable nationwide or regional health information exchanges and to support multiple, independent health interoperability initiatives. Much work is still required by healthcare to make EHRs available and useful.

In a 2018 study by the Office of the National Coordinator for Health Information Technology (ONC)3, half of physicians surveyed said they were not satisfied with their access to patient data, noting lack of access to patients’ clinical history can impede care coordination and result in increased costs. In some instances, sharing EHRs between providers is still being done via fax with an average time of nine days. 

Barriers hindering scalability to nationwide, vendor-neutral interoperability today include: 
  1. The average person sees more than 18 providers in their lifetime
  2. Each provider has their own EHR(s) and other clinical data sources; current interoperability approaches simply don’t scale
  3. Health data information is still very siloed. Data blocking by providers/networks2
  4. Need to create tightly constrained standards for data sharing and patient matching
Proposed Regs Focus on Portability and Accessibility
EHRs still don’t do the necessary job of making patient records easily available to providers and patients. They were originally designed as a tool to help with billing and  are falling short in their ability to provide data in a portable and accessible format.

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) and the ONC released proposed rules that focus on ensuring that health information is shared across the entire care continuum, including with patients. This is great news for healthcare, patients and life insurance underwriting.

This increased focus/effort should result in access to more of the documents that underwriters need for risk assessment. Some of the top priorities included in the new rules are:
  1. Solve interoperability so patients and providers can access medical records across health systems, practices and portals (intra-coordination vs inter-coordination)
  2. Creation of national patient ID
  3. EHR quality
  4. Move from fragmented care to coordinated care
There are many favorable initiatives underway that could facilitate EHRs to earn the label of Holy Grail. The health industry is required to improve quality, quantity and access of EHR data, and the EHR data aggregators are focused on improving their national footprint and delivering quality formatted data. 

EHRs for Underwriting and Research
The life industry is heavily relying on the EHR Data Aggregators to “figure it out”. With some guidance from carriers and reinsurers, the aggregators can attempt to provide a more comprehensive solution that has a national footprint and high hit rate. Such a solution will  include needed medical information that is clean, formatted, easily consumable and can be utilized for risk assessment decisions by an underwriter or an automated system.

Given the low hit rates and limited networks of data contributors as well as  EHR gaps/hurdles, it is likely that using EHR data alone would produce  several instances where either no data is found, or where the data captured is incomplete. 

The efforts involved in using EHRs is substantial, but early adopters will benefit from use of the data in current underwriting and for research, which will inform model development and improvements. In addition, early adopters can assist EHR data aggregators in developing solutions and benefit from a tailored solution. The availability of healthcare information as a data stream is a critical advantage for insurers using rules-based decision engines for accelerated underwriting and data-driven decision making.  

EHRs are certainly not a “square peg,” and SCOR wants to do its part to move the industry forward and make EHRs a more complete solution. We are exploring the EHR space, and these efforts led us to invest in Human API, a San Francisco-based company that enables consumers to share their health data with the people and organizations that help them manage their health. This partnership supports SCOR's desire to accelerate the underwriting process through electronic health data and automated decision making. 

1 2016 ONC Report
2 2015 ONC Report
3 ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS)