Electronic Data Interchange - The Blood Viens of Healthcare

In healthcare, Electronic data interchange (EDI) in healthcare is a secure means of communicating information between hospitals, clinics, insurance payers, and patients using specific messaging standards and formats. Having an EDI streamlines day-to-day operations at hospitals as well as associated organizations like health insurance companies and clearinghouses. 

But it was not always standardized. Different manufacturers developed their own data formats for transmitting medical data among compatible health systems. There was a time when there were about 400 standards of data used for exchanging information. It meant that the staff at a healthcare organization using one type of system had to ensure that the information they transmitted to another organization was compatible with that organization’s system. If not, then there was an elaborate series of measures to ensure interoperability.

Needless to point out, this increased the possibility of errors in the conversion of the data, posed risks to the privacy and integrity of the data, and generally resulted in higher IT overhead. However, the HIPAA EDI (Health Insurance Portability and Accountability Act) regulation meant that hospitals, payers, and others in the healthcare ecosystem had to use uniform standards for all kinds of medical information exchanges. This not only speeds up the process of pulling up medical information but also ensures its security and integrity. 

The integrity of patients’ medical data is paramount when it comes to delivering care. Doctors need a complete picture of the patients’ health situation before they can prescribe proper medication. Doing so without full knowledge of patients’ health might have adverse consequences. For example - if there is a patient who’s been in an accident and has a history of diabetes, it is important for the treating doctors to know about diabetes before performing certain procedures or administering drugs. It goes without saying that diabetes introduces additional layers of complications, depending on its severity.

EDI transactions in healthcare eliminate the need for reformatting or sifting through data standards. It is important for different stakeholders in healthcare to invest in electronic data interchange software to engender smooth operations. Let’s explore the healthcare EDI transaction list - 

Healthcare claim payment (835) -  This transaction is used by insurance payers to pay and transmit an explanation of benefits to the providers. 

Healthcare claim transaction set (837) - It allows provider organizations to communicate healthcare claim information and data about the overall doctor-patient encounter.

Healthcare eligibility inquiry (270) - This set of EDI transactions in healthcare is used by providers and healthcare organizations to communicate inquiries for healthcare benefits and the eligibility of the subscribers to financial institutions and government agencies.

Healthcare service review information (278) - This is used by provider organizations to request authorization from insurance companies.

Healthcare Eligibility response (271) - As per the above-mentioned transaction set 270, this set is used to respond to inquiries about the health plans or benefits of subscribers. It is also used by hospitals, ambulatory care centers, and clinics to transmit data to financial institutions and government organizations.

Electronic data solutions coupled with medical electronic data processing systems accelerate the exchange of vital medical information among stakeholders in healthcare. It’s not news that American healthcare is extremely complex with layers of regulations and guidelines. EDI medical solutions go a long way in helping providers, payers, and even patients get the most out of this system.