Making Interoperability Privacy Standards Work for the Real World

The announcement of the CMS Interoperability Framework holds much promise and opportunity for patients, providers, and our national healthcare system. With renewed support from the federal government to address barriers to seamless data sharing and access and an invitation to innovate and collaborate quickly, we also have an opportunity to revisit standards and processes. Now is the time to update them to best uphold the high security and privacy standards that work in the real world.

One lesser-known element of interoperability that is vitally important is the on-ramp for providers under Trusted Exchange Framework and Common Agreement (TEFCA) standards. To participate in TEFCA, which works in alignment with the CMS Interoperability Framework, providers must be vetted to have access to and share patient information. This approval process is not only foundational to the security of national interoperability, but also to establishing trust in a national network of high-quality providers and the community being built. 

Entities have been denied, discouraged or delayed from participating due to vetting criteria that do not hold up to the realities of real-world use cases. For instance, consider free health clinics, which provide an invaluable service. Due to the vetting process focusing on covered entities that execute covered transactions, by providing free services, these providers don’t produce the billing transaction that verifies them as a covered entity. Or consider a pediatric practice with multiple locations. When an organization’s headquarters is identified differently from an individual practice, it can be cause for rejection. These issues also extend to the broader social services ecosystem. Confusion around qualification and inclusion of other care providers with different licensing structures, such as Licensed Professional Counselors (LPCs) and Licensed Master Social Workers (LMSWs), are also barriers to inclusion.

This is more than a data qualification and verification issue. For healthcare providers, this is impacting care delivery, putting more administrative burden on clinicians and their teams, and creating redundant tasks for everyone involved in the verification process. Critically, exclusion from TEFCA carries downstream consequences: Disenfranchised providers are unable to share critical clinical information, patients face fragmented care, and the public’s trust in the promise of nationwide interoperability is diminished. 

To continue to improve these processes and fully realize the trust, transparency, and equitable access the interoperability community is working to achieve, here are some ways we can prevent repeating history while also harnessing the resources and support offered through TEFCA and the CMS Interoperability Framework: 

• Reduce the burden for providers to participate in interoperability by modifying the vetting criteria to make it easier for healthcare providers to onboard. We can also add provider types that are currently excluded, such as concierge medicine, free clinics, behavioral health providers, and certain assisted living facilities that may not meet the HIPAA “covered entity” definition, making TEFCA participation challenging.

• Increase transparency for providers. Based on the existing structure, this recommendation includes transparency into the role of the Recognized Coordinating Entity (RCE) in the review process, as well as the creation of a participant oversight board that includes community-based providers and consumer advocates.
• Publicly track and report key information and metrics. This should include tracking and publishing onboarding timelines, denials, and participant demographics, as well as evaluating success based on who is benefiting and how from these actions, not just technical compliance.

We are currently experiencing an inflection point for progress in interoperability. Without meaningful reform to reflect the real world, the system risks repeating and even accelerating historical patterns of exclusion — leaving vulnerable patients behind. Let’s use the engagement, energy, and invitation of the CMS Interoperability Framework to design and implement community standards that reflect the diversity, realities, and values of the healthcare ecosystem it aims to connect. We can’t afford not to.

Photo: marian, Getty Images

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