Where Are We Really With Interoperability?


New interoperability rules could require significant changes for healthcare organizations, but everyone will benefit from these improvements.

The writing is on the wall: Interoperability is coming, whether or not your organization is ready for it. In 2020, the Centers for Medicare & Medicaid Services (or CMS) published the Interoperability and Patient Access Final Rule to progress interoperability and health information access for all stakeholders.

Although the rule was supposed to go into effect January 1, 2021, enforcement of the Patient Access and Provider Directory provisions was delayed six months, while the payer-to-payer provision was left unenforced until a new amendment was released. So, where does this leave us? How close are we, as an industry, to achieving interoperability?

What Is Interoperability in Healthcare?

CMS defines interoperability as “the ability for computer systems to exchange information between devices and software systems.” Interoperability is a key part of CMS’s goal to make healthcare more equitable and efficient.

Interoperability is a far-reaching goal. The scope of interoperability proved too broad for adoption by the original timeline. A Deloitte Center for Health Solutions survey found that only half of hospitals were prepared to meet interoperability guidelines. CMS will not enforce the payer-to-payer data exchange portion of the rule, but other provisions have been in effect for the past 18 months.

CMS has been responsive to working with payer organizations to address interoperability challenges. Its goal is to improve data exchange across the healthcare ecosystem for better care coordination, enhanced clinical decision-making, and a higher quality of patient care.

What Can You Do Now to Prepare?

We know that a revised interoperability rule is coming from CMS, so it makes sense to be proactive. The big question for all payers and providers at the moment is: Will your current technology and systems be able to support interoperability in the years ahead? If the answer is no, then you need to start onboarding translation technology or new systems.

The Office of the National Coordinator for Health Information Technology (known as ONC) published an interoperability road map to help meet the demands of interoperability. As you work with your tech vendors to address interoperability, consider the following:

  • Look for data transfer systems that are widely used in the industry and are vendor-agnostic. Many health plans using proprietary technologies have discovered that some of those technologies were intentionally designed to inhibit data sharing between systems. ONC advocates for data transport that requires as few protocols as possible.
  • Another key consideration as we move forward will be data matching. As we head into the era of interoperability, we will routinely pull health information from multiple sources. Technology must meet this demand to ensure the correct data always links to the right patient.
  • Providers should look closely at their workflows and practices to determine if they support timely information sharing. For example, ONC noted the closing of referral loops as one particular pain point. Make sure you have systems and processes to update patient information quickly for each encounter.

Many of ONC’s recommendations and CMS’s goals focus on placing the patient at the center of healthcare. One of the major goals of interoperability is to equip patients with knowledge and access to be active contributors to their care. During encounters with patients, make sure they know they have access to an application programming interface and encourage them to use the API to manage their care.

As patients grow accustomed to managing their healthcare, they expect access to all their health data. Payer organizations will play huge roles in achieving this outcome. The ONC's Trusted Exchange Framework and Common Agreement (or TEFCA) was published earlier this year as a blueprint for a national network of electronic health records. TEFCA offers a valuable road map to interoperability for payer organizations, with actionable recommendations such as applying to join a Qualified Health Information Network to enable data sharing.

Interoperability might require significant changes, but everyone will benefit from these improvements. Patients gain better transparency to manage their healthcare and increased flexibility to take their data with them if they switch plans or providers. Payers and providers gain more access to information and can share it quickly and efficiently. Providers will also get a holistic view of patient care, enabling more effective encounters. When we are all connected, we all win.

Jon Wasson is the senior product director at Episource, which provides services and products to simplify the way Medicare, Commercial, and Medicaid health plans manage their risk adjustment and quality programs.

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