CMS' new interoperability rule requires major changes for payers, hospitals. Here are 6 key elements

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A new Centers for Medicare & Medicaid Services rule requires Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and qualified health plans to make enrollee data immediately accessible by January 2021. (turk_stock_photographer/Getty Images)

The Centers for Medicare & Medicaid Services' (CMS') new interoperability rule will require major changes for payers and hospitals to provide patients access to their health information.

The Interoperability and Patient Access final rule will require, among other things, that Medicaid, the Children’s Health Insurance Program (CHIP), Medicare Advantage (MA) plans and qualified health plans make enrollee data immediately accessible by January 2021.

CMS Administrator Seema Verma said the rule will help bring the health system’s data-sharing capacity out of the "stone age."

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It was one of two rules issued by the Department of Health and Human Services Monday to implement interoperability and patient access provisions of the bipartisan 21st Century Cures Act. 

"These rules begin a new chapter by requiring insurance plans to share health data with their patients in a format suitable for their phones or other device of their choice. We are holding payers to a higher standard while protecting patient privacy through secure access to their health information. Patients can expect improved quality and better outcomes at a lower cost," Verma said.

Justine Handelman, senior vice president of the Office of Policy and Representation for the Blue Cross Blue Shield Association, said the group supports the Trump administration's efforts to achieve an "interoperable healthcare system."

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“Blue Cross and Blue Shield companies believe empowering consumers with the right information at the right time, and in a secure way, is critical to driving positive health outcomes. This starts with the seamless flow of health information among patients, doctors, hospitals and insurance companies, stronger privacy and security measures to protect personal health information, and more advanced data sharing standards to improve and simplify the healthcare experience," Handelman said.

Speaking with reporters Monday, Verma said she believed CMS developed fair and realistic timelines for payers and hospitals to implement the rules.

"Patients can't wait for their health information. This is a matter of life and death. We're seeing this with the situation with coronavirus and patients coming into a hospital and providers are stressed with dealing with sick patients and they have no time to gather patient information in order to have a complete medical record. These rules will make a difference to help provide safe and high-quality care all across the country," she said.

Here are key requirements and timelines in the CMS rule:

  1. Patient access: CMS-regulated payers, specifically MA organizations, Medicaid fee-for-service programs, Medicaid managed care plans, CHIP fee-for-service programs and CHIP managed care entities will be required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1) API that allows patients to easily access their claims and encounter information, including cost, through a third-party app of their choice. Payers are required to implement the patient access API beginning Jan. 1, 2021.
     
  2. Provider directory: CMS-regulated payers will have to make provider directory information publicly available via a standards-based API by Jan. 1, 2021. 
     
  3. Admission, discharge and transfer event notifications: CMS is modifying conditions of participation to require hospitals, including psychiatric hospitals and critical access hospitals, to send electronic patient event notifications of a patient’s admission, discharge and/or transfer to another healthcare facility or to another community provider or practitioner. The policy will go into effect six months after publication of the CMS rule.
     
  4. Payer-to-payer data exchange: Payers will have to exchange certain patient clinical data, specifically the U.S. Core Data for Interoperability, at the patient’s request. Organizations will have to implement a process for this data exchange by Jan. 1, 2022. This will allow the patient to take their information with them as they move from payer to payer over time to help create a cumulative health record with their current payer, according to CMS.
     
  5. Public reporting and information blocking: Beginning in late 2020, and starting with data collected for the 2019 performance year, CMS will publicly report clinicians, hospitals and critical access hospitals that may be information blocking based on how they attested to certain Promoting Interoperability Program requirements. Knowing which providers may have attested can help patients choose providers more likely to support electronic access to their health information.
     
  6. Digital contact information: CMS will begin publicly reporting in late 2020 those providers that do not list or update their digital contact information in the National Plan and Provider Enumeration System. This includes providing digital contact information such as secure digital endpoints like a direct address and/or a FHIR API endpoint. Making the list of providers who do not provide this digital contact information public will encourage providers to make this valuable, secure contact information necessary to facilitate care coordination and data exchange easily accessible, CMS said.

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