MedCity Influencers, Health IT

How will the interoperability rule transform value-based care?

The intent of Interoperability and Patient Access regulations is not to wash your hands of them. A more empowering viewpoint is that they give organizations a chance to champion the patient and make healthcare better.


Over the past two years, we’ve seen API requirements apply to providers, hospitals, and other entities across the healthcare system for the first time. If you think about the way the US works with regulations, it’s different than any other country:

  1. The government creates a mandate.
  2. Departments within the government write policies that are meant to turn those mandates into reality.
  3. The private sector then decides how those policies will be implemented.
  4. Companies create tools and products that leverage those new policies and methods.

For hospitals and payer organizations, the Interoperability and Patient Access final rule made January 2022 the deadline to allow patients to access their data. Today, the healthcare industry is kind of stuck between steps 3 and 4.  We know the rules, we know the policies, but how we interact and build on these new policies is still being debated.

Innovation in cost of care and in better outcomes.

Innovation is starting to come into play around value-based care, since VBC hinges so much on quality care-coordination. Newly unsiloed records are giving risk-bearing groups the chance to grab nearly real-time longitudinal data on their populations. With this information, any provider can find and get ahead of their most at-risk patients by calculating better risk scores, finding gaps of care, or just getting the most recent lab result on the patient. The end result is treating sicker patients early…with less resources… which is a win-win.

Providers are already taking notice.

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There are tons of incentives, both on the provider side and patient side, to use a patient data API. Innovative health companies are adopting technologies to cushion their risk-taking. Multiple VBC providers, for example, are enabling better treatment of at-risk patients by pulling health records and using them to provide early, personalized care.

Company size will impact what their API adoption looks like.

Big behemoth payers will take this opportunity to focus on cost savings by switching their data collection from fax to API. It’s natural to connect these rules to how they can drive savings in administrative burden, but nimbler players can do a lot more.

Smaller organizations are already thinking with a data-first mentality. Generally speaking, ancillary payer solutions that are more focused on innovation than cutting costs will be faster to recognize the changing environment and will create unique value propositions. The organizations that leverage innovative solutions and acquire patient data early in the game will inevitably find a way to change how clinicians and patients interact by bringing data driven decisions to the forefront.

We’re still developing nationwide payer data exchange.

In this case, ensuring minimum necessary data access in a trusted network is the sticking point.

Each new rule that mainstreams data sharing increases the incentives and pool for interoperability. Every accessible record lowers the barrier to interoperability bit by bit. But getting the providers and payers to play along is not so straightforward. It will be a chicken-and-egg problem before we see ubiquity.

Healthcare payer requests for data typically fall under what’s called the Operations Purpose of Use. Under HIPAA, this is a protected class of data exchange which could be anything from claims adjudication to risk adjustment. As other key interoperability rules mature – TEFCA and Anti-Information Blocking – there will be less friction to fill these requests, and payers will benefit by moving from fax-based data collection to APIs.

There’s still plenty of room for payers and startups to build solutions. As late as 2021, only 24% of leading healthcare organizations used APIs, according to a Change Healthcare study. One reason many healthcare organizations don’t use APIs, the authors speculated, was because the main driver for healthcare tech adoption has been regulatory compliance. The primary driver in other industries (those with a little more of a competitive nature, perhaps) was improving efficiency and customer experience.

Well, the regulatory changes are here.

So organizations that don’t just manage these regulations, but take early advantage of them can start to differentiate themselves — by the creation of new value propositions, reducing the cost of care and improving outcomes across the board.

And considering what we know about interoperability — from Apple devices to Plaid API-enabled banking apps — we can be certain that APIs are just getting started. If you understand the potential of APIs, you’ll be able to own your market.

The intent of Interoperability and Patient Access regulations is not to wash your hands off them. A more empowering viewpoint is that they give organizations a chance to champion the patient and make healthcare better.

Troy Bannister is the CEO and co-founder of Particle Health. After spending 15 years in healthcare as an EMT, medical student, clinical researcher and early stage investor, Troy found a gap in patient rights & paper processes that digital solutions could fill. Troy is incredibly optimistic about the future, particularly as it relates to legislation and emerging data standards.