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HealthAugust 30, 2019

The crack down on silos of patient data: CMS and ONC interoperability rules hit health plans.

In 2019, the Office of the National Coordinator (ONC) and the Centers for Medicare and Medicaid (CMS) proposed rules on interoperability, data blocking, and other activities as part of implementing the 21st Century Cures Act. The proposed separate but related rules would require that patients have easy access to their health data. As described by ONC, the rule would “support seamless and secure access, exchange, and use of electronic health information.”

With so much attention focused on requirements for health IT companies like EHR vendors and providers, like EHR interoperability, it’s easy to miss the huge potential impact the new rules are likely to have for health plans. But the decision to hold plans accountable for data sharing—just like hospitals, EHR vendors and others across the healthcare ecosystem—shows just how serious the agencies are in giving patients free access to their health information.

And it makes sense. While providers hold a vertical set of data about the patient relating to an episode of care, plans have the longitudinal data sets that follow the patient over a long period of time and across the healthcare ecosystem.

Here’s an overview of the proposed rules on information sharing and interoperability.

The ONC rule would require health plans to:

  • Support new criteria and standards comparable to proposed ONC certification criteria that provide open APIs and allow other software systems and modules to access, exchange and use patient data.
  • Adopt United States Core Data for Interoperability (USCDI) as a standard for data classes and constituent data elements capable of being exchanged with other payers or providers.
  • Implement the 21st Century Cures Act provisions on information blocking with exceptions to protect the patient and ensure the security and privacy of electronic health information. This would apply if a health plan met the definition of health information network.

The CMS rule would apply to health plans, state Medicaid and Children’s Health Insurance Program agencies—known as CHIP, and insurers that offer qualified health plans, Medicare Advantage plans, or Medicaid and CHIP managed care plans. The CMS rule would require these payers to:

  • Provide access to patient data and claims information via APIs.
  • Transfer patient data if that patient is changing their provider or transitioning to new health insurance with another payer or health plan.
  • Enable electronic access to provider directories via APIs.
  • Enable the participation in trusted exchange networks for exchanging data.

Impact of the ONC and CMS proposed rules

The final ONC draft rule is not expected to be available until later in the year and it’s possible a final rule won’t be seen until the first quarter of 2020 or later. While there is little information about CMS’ timing, it seems likely the agency will issue its final ruling in the same timeframe since much of it aligns with the ONC ruling, such as open APIs and the adoption of FHIR (Fast Healthcare Interoperability Resources, pronounced “fire”), which is an interoperability standard developed by Health Level 7 International (HL7).

Both ONC and CMS recognize that health plans will need time to adopt the technology and standards integral to interoperability. However, both agencies will push forward with the requirements as soon as possible. The onus is, therefore, on all stakeholders to consider what will be required of them for regulatory compliance in healthcare. 
For health plans, that means viewing interoperability through a much wider lens than what they’ve been accustomed to—and that means change.

It’s time to advance data practices

Regardless of how the rules ultimately take shape, it’s clear there is strong momentum to improve care and lower costs through a more transparent system. As such, ONC is likely to push all stakeholders in the healthcare ecosystem—including health plans—to achieve those twin goals.

Health plans will have to invest in modernizing their technology and systems architecture, including adopting master data management strategies, to enable interoperability in healthcare. They will need to make process changes to ensure the information isn’t siloed to enable information sharing. And they will have to do all of this very quickly to meet the deadlines currently set by ONC and CMS.

Now that data will be fully transparent and exchanged via a trusted network, allowing for broader interoperability beyond single, point-to-point connection, there is a crucial need for payers to ensure the data is accurate, clean and actionable.

Data standardization (keeping up with updates, establish a single source), creating relationships between data sources (across silos and domains) and leveraging unstructured text (80% of which is locked) will all be key for compliance in healthcare as we move into the future.

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Brian Diaz
Director of Strategy and Business Development, Clinical Surveillance and Compliance

As the Director of Strategy and Business Development, Clinical Surveillance and Compliance, Brian is responsible for business strategy, research, and business development.

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