Interoperability in healthcare moving forward despite challenges

Photo: Al David Sacks/Getty Images

Interoperability has been a longstanding goal for healthcare: The promise of being able to exchange data seamlessly between health information networks has been a goal the industry has been working toward for years, and now payers and healthcare organizations have to wrangle with rules, passed by the Centers for Medicare and Medicaid Services, governing how such exchanges will occur.

There's a sense of confusion around the rules, but also a sense of optimism, as advances in technology have brought the healthcare industry closer to true interoperability.

Mariann Yeager, CEO of the Sequoia Project, a nonprofit focused solely on advancing interoperability, noticed there wasn't a lot of clarity as to how to implement CMS' rules for exchanging payer-to-payer information in particular.

Working through her organization, she formed a work group co-chaired by two payers – Evernorth and Medica – and they're currently meeting monthly to discuss progress and share a dialogue.

"How do you mobilize a health plan to start figuring out this payer-to-payer information exchange? You need a leader in the organization who can build buy-in and cooperation across business units," said Yeager. "They also need to have the authority to move the organization forward. You need to galvanize the organization and find someone who can be that champion."

She'll speak about the topic at length in a session, "Interoperability Developments to Improve Care and Outcomes," September 24 at 5:40 p.m. CT at AHIP's Consumer Experience and Digital Health Forum in Nashville, Tennessee.

CMS' rules, she said, are fairly generic and direct organizations to follow certain standards without necessarily explaining how – leaving an opportunity for the private sector to come together and brainstorm.

Under CMS' final rule, passed this year, payers are required to implement and maintain certain HL 7 Fast Healthcare Interoperability Resources application programming interfaces to improve the electronic exchange of healthcare data, as well as to streamline prior authorization processes.

It affects Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program, fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges.

CMS is requiring that impacted payers implement and maintain a Payer-to-Payer API to make available claims and encounter data (excluding provider remittances and enrollee cost-sharing information), data classes and data elements in the United States Core Data for Interoperability (USCDI), and information about certain prior authorizations (excluding those for drugs).

Payers are only required to share patient data with a date of service within five years of the request for data. This will help improve care continuity when a patient changes payers and ensure that patients have continued access to the most relevant data in their records, CMS said.

While payers and other healthcare organizations have questions, they've still been making progress.

"We're seeing advancements on a number of fronts," said Yeager. "There has been tremendous success in a private sector approach to interconnected networks."

Interoperability framework company CareEquality, for example, has put around $1 billion into building connectivity for treatment purposes between and among networks.

"When you have a trust framework … parties that want to share information agree to the rules of the road, they sign a contract, pledge to support standards," said Yeager. "That is a great enabler. That has worked tremendously to allow the exchange of information to treat patients."

And then there's the work the Office of the National Coordinator for Health IT has been undertaking regarding TEFCA, implemented by Congress in the 21st Century Cures Act to enable and facilitate data exchange in and among networks. According to Yeager, there needs to be governance around this effort – a "floor of policy" – and it needs to be easier and simpler for individuals to access their own health information.

"It's built on a foundation of experience from the private sector," she said, "and has the broader goal of allowing an exchange for a broader set of purposes. Payers haven't been participating in national networks. TEFCA's really focused on that. They need a uniform set of expectations. They need to have assurance everyone's operating under the same rules of engagement."

With seven designated qualified health information networks, TEFCA is already live, and just published a use case and implementation guide to support healthcare operations – a development that Yeager said is forging new ground and getting community buy-in.

These efforts will ultimately be worth it, she said, because of the potential benefits to both patients and healthcare organizations.

"From a patient perspective, it's helpful to have access to your information more readily," said Yeager. "And caregivers – folks who have a heightened interest or need to access their health information – they need to have more visibility. The benefit is, instead of having to implement point-to-point interfaces, you have one standardized way to interact with the ecosystem. The real value of TEFCA is that you sign one agreement and you can do all these things. This is a single connection, and you can do all of these things through your network of choice."

Making further progress is going to require diligence and focus, she said. 

"There are lots of opportunities to advance interoperability," said Yeager. "It's a long game. We have a commitment for the long haul."

AHIP's 2024 Consumer Experience & Digital Health Forum is being held Sept. 24 - 26 in Nashville, Tennessee.
 

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.