To meet interoperability mandates, providers and payers should build API expertise

Drew Ivan, chief strategy officer at Lyniate

Photo: Courtesy of Lyniate

The recent Centers for Medicare and Medicaid Services proposed Interoperability and Patient Access proposed rule is designed to provide patients with easier, more useful access to their health information, according to Drew Ivan, chief strategy officer at Lyniate.

It's one of a dozen mandates for interoperability, he said, but to Ivan most of what healthcare does is about interoperable systems: Between EHRs and billing, between medical devices and EHRs, between providers and patients, and between providers and payers.

"We have a really broad interpretation of interoperability," Ivan said of Lyniate, a company that specializes in the field. With few exceptions, providers and payers are compelled to share clinical and claims data, upon request, in a format specified by the requestor.

This includes Fast Healthcare Interoperability Resources Application Programming Interfaces (FHIR APIs), which are now mandated and which all certified technologies must support, Ivan said.

Mandatory APIs seem to be the biggest paradigm shift for most providers, he said. But the Office of the National Coordinator has been talking about an interoperability infrastructure based on APIs for over a decade.

"This shouldn't come as a surprise to anyone," Ivan said. "This has been in the works for a long time, and we expect it to reduce the special effort required to access patient data."

WHY THIS MATTERS

To meet interoperability demands, Ivan recommends health systems and payers get good at APIs and do more than the minimum required to meet compliance. Healthcare organizations need to take control of their data, he said.

"It's time to build a platform for servicing requests for data from payers, providers, other third parties and healthcare consumers," Ivan said. "It's generally a bad assumption that all mandated or relevant data lives in a single system, and it's not guaranteed that the vendor of that system will do a good job of implementing APIs. The best approach is to take control of your own technical environment and own the interoperability components required to deliver data."

He added, "If you treat it like a compliance mandate and you do the minimum, then it's just a cost. If you treat interoperability as a strategic initiative, then it can improve data liquidity for internal projects, reduce costs associated with workflows across organizations, such as prior authorization, enable participation in value-based care and even turn into a profit center if data can be effectively and appropriately shared with researchers."

Organizations that do the minimum don't get great outcomes, Ivan said. Those that drill down into the intent of the rule, and then solve for that problem by building a solution, do better. 

"It's much harder but it's more valuable," he said. But compliance is an unfunded mandate, he said.

"I haven't seen a study on what it costs providers or payers to implement solutions to the Cures Act, but there are large penalties for noncompliance, up to getting kicked out of the Medicare program, so compliance is surely cheaper," he said.

Rarely does CMS apply the carrot approach. An exception was meaningful use when CMS offered higher reimbursement for compliance, but that "carrot morphed into a stick," Ivan said.

Providers must publish machine-readable files containing in-network negotiated prices, out-of-network prices and allowed rates for their services. Payers are required to maintain an up-to-date provider directory accessible through APIs. 

A recent study by Defacto Health shows that only about half of payers are fully compliant 18 months after the enforcement deadline.

Providers must contribute their Direct Address to the National Plan and Provider Enumeration System (NPPES). 

THE LARGER TREND

TEFCA, the Trusted Exchange Framework and Common Agreement, defines the current interoperability environment, Ivan said. TEFCA's overall goal is to establish a universal floor for interoperability across the country. TEFCA reached a milestone in February when the ONC announced the first six organizations to be onboarded as Qualified Health Information Networks (QHINs), for working to create a nationwide interoperability network under the 21st Century Cures Act. 

After the 21st Century Cures Act was signed into law in 2016, the Office of the National Coordinator for Health Information Technology (ONC) released a final rule on meaningful use that was designed to provide secure electronic access to health information.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org

Dr. Vin Gupta will offer more detail during his HIMSS23 session "Keynote: Healthcare Disruption: Accelerated Opportunities for Care Delivery Alternatives." It is scheduled for Wednesday, April 19, at 8:30 a.m. - 9:30 a.m. CT at the West Building, Level 3, in the Skyline Ballroom, room W375.