How payers and providers can address the CMS interoperability mandate

In March of this year, the Centers for Medicare & Medicaid Services (CMS) announced a new rule regarding health IT interoperability and a patient’s right of access to their health data. The mandate will have a major impact on the entire healthcare industry, but it will particularly affect the payer market in the U.S.

Payers will be expected to make a patient’s data available to them electronically through a variety of electronic channels, including mobile applications, by allowing for secure access to data through interoperable application protocol interfaces (APIs). Compliance must be achieved by July 1 of next year.

Many payers are not certain what to do to meet the requirement, and the clock is ticking. How can organizations get up to speed quickly on the necessary requirements?

The first step is to understand exactly what is being mandated. CMS is requiring payers and providers to deliver longitudinal health records. These records give patients access to their data and allow them to move that data either to third-party applications or to other payers.

This rule has two main elements.

The first involves claims information and clinical data. In the same way CMS’ Blue Button project lets participants get their claims information and share it with whatever applications, services or research programs they want, the new rule requires private payers to do the same.

The second element calls for the use of open APIs. With APIs, third-party applications will be connected so patients can answer questions about a range of topics, such as if their doctor is in-network, and which doctors are in-network within a 10-mile radius of their house. This access gives consumers the power to make informed decisions about which plan is best for them.

Considerations for a Smarter Implementation
We need to keep in mind three key elements to successfully implement these rules:

• Plan Adequately for Data Mapping: Don’t underestimate the effort involved in mapping, particularly if you’re probably looking at a facade type implementation where your APIs need to reach back into your data services to present data to your consumers. Making large volumes of data available on-demand on a 24/7 cost basis will be cost-prohibitive. One way to simplify this process is to work with a vendor that already has experience mapping data elements in your data lake to FHIR. This will speed up your process and help you ensure optimal customer service.
• Leverage Open Standards: Whenever you can, leverage open standards for your implementation. Leverage standards like OAuth 2.0, which is an implicit part of the specification for FHIR and SMART on FHIR. This decreases your burden for achieving interoperability.
• Look to the Cloud: Placing your solution in the cloud allows you to more quickly stand up compliant solutions and scale them as needed. By partnering with a cloud provider who can deliver this scalable platform as an entire solution, you allow payers to reduce their time to compliance. Consider teaming with those that have thought about how to wrap all services together into a cohesive solution.
• Understand the Scale – CMS is requiring that data going back to January 2016 is made available. This is a lot of data, and the data must be housed in platforms that leverage interoperable APIs. This also involves controlling access to it and managing the community around it. Understand that you are going to have a rapidly growing data store. It is not just five years of data. In another five years, it is going to be ten years of data! Be ready.

These are just some of the things to consider as you develop your solution. Of course, issues such as identity management, leveraging open standards and budget constraints will also be of great importance.

Stronger as a Community
Finally, don’t get overwhelmed! Everyone is struggling to meet the aggressive deadline for these new rules.

Many healthcare leaders express that these rules are taking them into unchartered territory. For example, many are not used to interacting with third-party commercial applications. Also, they are not accustomed to patients requesting to connect data to a new application without special effort.

I encourage every healthcare entity to consider how we can best work together as a community. We can and should leverage smart strategies and best practices that have been implemented by other organizations in terms of data mapping, or in working with organizations that are building cloud solutions that can be applied across our industry.

Photo: JamesBrey, Getty Images 

 

 

 

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