Is Interoperability the Key to Whole Person Care?

In February 2019, the Centers for Medicaid and Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) issued related proposals for policy changes which are designed to improve interoperability and increase patient access to their own electronic health information (EHI).

Under the CMS rule, which applies to Medicare Advantage (MA) organizations, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers, payers would be required to:

  • Create and maintain an Application Programming Interface (API) in order to “make patient claims and other health information available to patients through third-party applications and developers”
  • Ensure that patients can maintain access to their EHI when moving between different payers and plan types
  • Provide provider directories to both current enrollees and prospective enrollees through API technology
  • Participate in “Trusted Exchange Networks” in order to improve interoperability

The ONC proposed policy changes focus primarily on data blocking and Electronic Health Record (EHR) certification.

  • Data blocking is defined more precisely, and seven exceptions are outlined in order to help organizations better understand how to be compliant with data blocking regulations
  • EHR certification will be changed to an ongoing process in order to give vendors more flexibility to update their software

So, what exactly does all of this mean? And, more importantly, how does it impact patient experiences and health outcomes? To better understand these proposed rules changes, it is helpful to look at some of the individual pieces.

What is Interoperability?

The realm of health and human services is made up of a variety of different providers and payers that each use one of any number of software applications designed to manage both their business needs and the needs of their patients. This situation has created an environment where EHI is generated in silos and not easily transferable from one entity to another. The solution to these silos is interoperability, which is defined as the capability of two or more health information systems to digitally share health data and other information using common standards.

What Is an API?

An API is a common method for electronically sharing data and is designed to simplify the process and increase accuracy. If an organization chooses to create an API feed and then grant access to a third party, both parties can be confident that the data will be read correctly because it is formatted based on a set of shared standards. A variety of API standards exist across different industries and for different applications. In the case of the newly proposed rule, CMS will require the use of the Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) based API.

What is a Trusted Exchange Network?

Health information is confidential and specific types, such as behavioral health or substance abuse history, are even more closely regulated. As a result, it is essential that any data sharing only happen between verified parties. Trust exchange networks exist to help solve this problem. As a member of one of these networks, providers and payers have access to the technical capabilities and legal agreements to securely share EHI between other members and their various software applications.

What Is Data Blocking?

Data blocking is the practice of intentionally preventing a patient from having access their own EHI. This may be done for a number of reasons, but the most common example is that a payer or provider may refuse to transfer health records to a competitor in order to maintain their own client base. Another example of data blocking is when an organization intentionally charges unreasonable transfer fees in order to dissuade a patient from requesting the data.

Data blocking has been addressed in previous policies and legislation, but the newly proposed ONC rule seeks to better clarify what has often been a vague definition. For example, under the new rule charging patients to access their own EHI would be strictly prohibited. However, organizations will be allowed to withhold data if the process of extracting the information would be overly burdensome.

Why Is This Important?

Promoting interoperability and restricting data blocking are both essential to allowing patients control over their own information. When patients can transfer their own data, it allows them the freedom to easily move between both providers and payers. Not only is this positive for the patient, but some would also argue that it is beneficial for the healthcare industry because it creates a more competitive environment.

Providers having the ability to access a patient’s full EHI is also essential to improving the quality or their care. Whole person care coordination is only possible when providers have access to a complete view of their patient’s history. This is particularly true in the case of individuals with complex health needs since they are most likely working with a variety of health and social service providers.

The ability to securely share data is essential to make true coordination possible. For example, if a provider gives a referral for additional services but has no access to track their patient’s progress, it creates a potential barrier to the treatment being a success. However, if the provider has access to a closed-loop referral network they can digitally monitor their patient’s progress.

The availability of complete EHI is also essential when moving to new providers. Many patients change payer or provider networks multiple times throughout their lives and this transition can result in the loss of health information. If this problem is solved through interoperability, new providers will be able to make decisions using their patient’s complete history, which will increase the likelihood of positive outcomes.

There are still technological and logistical challenges to overcome before the health and human services sector becomes truly interoperable. However, each step in that direction is a positive one because having full access to a patient’s EHI is an essential step in achieving whole person care.

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