By Susheel Ladwa, CEO, Onyx Health

December 2023 – Ask any doctor or nurse what part of the day they dislike the most, and the answer is unanimous – the burden of paperwork. According to an AMA study, physicians spend 27 percent of their total time on direct clinical face time with patients, while a staggering 49.2 percent is devoted to EHR and deskwork activities. This means that for every hour spent in direct clinical face time, physicians invest nearly two additional hours on EHR and deskwork. This burden also extends to payer demands of spending considerable hours reading PDF documents for prior authorization and risk adjustment. The result is a system drowning in paperwork, compromising the quality of care and slowly succumbing to the perils of “Death by Clicks.”

Let’s see how we got here.


Grandpa’s Healthcare – Healthcare 1.0

In Grandpa’s day, the U.S. healthcare system operated on a paper record foundation, characterized by:

  • Manual Documentation: Every aspect of Grandpa’s medical journey, from prescriptions to diagnoses, was documented on paper.
  • Tangible Health Trail: Health history was physically preserved, creating a tangible trail of medical records in the form of handwritten notes and carefully stored files.
  • Limited Accessibility: Despite the thoroughness, the paper-based system posed accessibility challenges, making coordination of care among different healthcare providers cumbersome.
  • Fragmented Information: Health information was scattered across various offices, hindering physicians’ ability to access a consolidated view of his medical history promptly.
  • Personalized Touch: Despite its inefficiencies, there was a certain charm in the personalized touch of this era, where medical care was recorded with care and attention to detail in the pages of a patient’s physical health dossier.


The Perceived Modern Healthcare – Healthcare 2.0

In the era of perceived modern healthcare, colloquially labeled Healthcare 2.0, the adoption of EHR software ushered in a new age of digital documentation. Key features included:

  • Digital Transition: Healthcare 2.0 marked a shift from paper to digital documentation, where medical information was stored electronically in EHR systems.
  • Efficiency Expectations: The introduction of EHRs promised increased efficiency, with instantaneous access to patient records, test results, and treatment plans.
  • Interconnected Challenges: However, this reality introduced its own set of challenges. The interconnected nature of EHRs presented issues of data security, interoperability, and a learning curve for healthcare providers.
  • Physician Burnout: The burden of navigating and inputting information into electronic systems contributed to physician burnout, as the administrative demands often encroached on valuable time for patient care.
  • Fragmentation Concerns: Despite digitization attempts, healthcare information remained fragmented across different EHR platforms, posing challenges for comprehensive and streamlined patient care.
  • Tech Integration Dynamics: The perceived modern healthcare system showcased the dynamic interplay between technology and healthcare, raising questions about striking the right balance between digital innovation and the human touch in medical practice.

Healthcare 2.0 has created more electronic information than mankind has ever seen before but making it useful has been a significant challenge. It’s death by clicks!


The Future We Get to Design – Healthcare 3.0

In envisioning the future of healthcare, coined Healthcare 3.0 for reference, a pivotal focus lies on the adoption of FHIR (Fast Healthcare Interoperability Resources) based interoperability standards. Think of FHIR as a new medium of communication in healthcare, one every system can potentially understand and exchange data with seamlessly (at least in part).  Key points include:

  • FHIR Integration: Healthcare 3.0 marks a transformative shift towards FHIR-based interoperability, facilitating seamless data exchange in the digital healthcare landscape.
  • Burden Reduction: The objective is to alleviate the burdens associated with fragmented systems, promoting a more interconnected and streamlined healthcare experience.
  • CMS Regulations: The Centers for Medicare & Medicaid Services (CMS) spearheads crucial regulations to advance interoperability. Initiatives like the Interoperability and Patient Access final rule, Advancing Interoperability and Improving Prior Authorization Processes proposed rule, and the 21st Century Cures Act are information blocking mandates aimed at dismantling data silos and empowering patients with unhindered access to their health information.
  • Patient-Centric Approach: The push for interoperability aligns with a patient-centric approach, ensuring individuals have comprehensive access to their health records, fostering more informed decision-making.
  • Balancing Technology: Healthcare 3.0 strives to strike a delicate balance between technological innovation and preserving the human touch in medical care. It emphasizes leveraging technology to enhance, not hinder, the healthcare system.

As we journey towards Healthcare 3.0, there is optimism that interoperability standards and regulatory frameworks will evolve to create a more efficient and patient-friendly healthcare ecosystem. The goal is to avoid the pitfalls of the past, steering clear of what has been feared as “Death by Clicks.”


Let’s get Action Oriented

Let’s talk about what payers and providers need to plan for. Actions institute change, and CMS/ONC are putting their will into driving this change.

To transition to Healthcare 3.0, payers can take several key actions:

  • Implement Patient Access API Rule: Payers should prioritize the implementation of the Patient Access API rule, ensuring seamless access to health information for patients. This move aligns with the broader goal of empowering individuals with greater control over their healthcare data.
  • Adopt FHIR as an Interoperability Standard: Payers should proactively adopt FHIR as an interoperability standard within their organizations. Embracing FHIR enhances data exchange capabilities, fostering a more interconnected and efficient healthcare ecosystem.
  • Prepare for the Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule: Anticipate and prepare for the upcoming rule, recognizing its potential to automate electronic prior authorization, facilitate payer to payer data transfer, and offer providers an API for querying payers. Embracing these changes lays the groundwork for a more streamlined and automated healthcare workflow.
  • Explore Further Opportunities: Understand that these actions represent just the beginning. Payers should explore additional opportunities, such as leveraging HEDIS (Health Effectiveness Data and Information Set) quality reports, to further enhance interoperability. Ultimately, these efforts aim to liberate healthcare providers from the burdens of manual chart chasing and streamline processes for risk adjustment.

To accelerate the transition to Healthcare 3.0, healthcare providers can consider the following strategic initiatives:

  • Embrace g(10) Compliant EHRs: Prioritize the adoption of g(10) compliant EHR systems or upgrade existing ones to meet g(10) standards. Compliance ensures adherence to the latest regulatory requirements, setting the foundation for a more advanced and interoperable healthcare environment.
  • Invest in FHIR Infrastructure: Proactively invest in creating a FHIR infrastructure for healthcare data. As record release requests shift from PDF/eFAX to FHIR, having a robust infrastructure will be essential for seamless data exchange and improved interoperability.
  • Stay Informed on Regulations: Stay ahead of evolving regulations, particularly those related to electronic prior authorizations. Understanding how they can reduce administrative burdens and expedite approval processes is crucial. As interoperability efforts progress, being well-informed about regulatory changes positions providers to optimize their workflows effectively.
  • Prepare for Future Interoperability: Acknowledge that the journey to interoperability is ongoing. Prepare for future advancements by actively participating in initiatives that leverage emerging standards and technologies. Recognizing that we are only at the beginning of the interoperability evolution, healthcare providers can contribute to minimizing administrative burdens and optimizing healthcare delivery.


By working together to implement interoperable solutions and streamline processes, providers and payers can contribute to minimizing the digital complexities that have been associated with the healthcare system. Let’s slow down the Death by Clicks and make it a better experience for everyone.




About the Author

Susheel Ladwa is passionate about healthcare. He is the CEO of Onyx Health an organization driving Interoperability in the Industry. The team at Onyx built Blue Button 2.0 for CMS (the largest Global Interoperability platform supporting 53 million beneficiaries). Susheel was also ranked as one of the “Top 10 Most Inspiring CEO to Follow in 2023” by The IncMagzine and also won the Healthcare 2.0 leadership award. He did his Digital Health education from Harvard Online University.

He began his career at Texas Instruments before becoming part of the initial team that built Wipro’s healthcare practice, where he led the growth of the payer, provider, and medical device business. He then served as a client partner for major healthcare transformation projects at EDS, later acquired by HP.

Susheel played an impactful role at IBM, where he served as an industry leader for healthcare and life sciences for Cloud Application Services. He then took up the CEO role at Onyx Health, a healthcare company disrupting the industry by making data interoperable across the healthcare value chain leveraging the FHIR standards.

Besides his work at Onyx Health, Susheel is a contributing editor at DistilINFO Publications and has chaired the American Health Insurance Plans IT workgroup. He has also authored over ten books of quotes and sayings.





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