Industry Voices—Achieving true interoperability: The impact of CMS' interoperability and patient access final rule

Doctor computer medical records
If COVID-19 taught us anything, it’s that clean, deduplicated data (the process of eliminating multiple copies of the same clinical data), is critical to achieving a high-value health system, Julie Smith writes. (Getty/BrianAJackson)

When I worked as an emergency room nurse, having access to a complete patient health history was not always guaranteed. I would need to retrieve patient records from outside the facility on a daily basis—whether that patient walked in, was wheeled in, or even carried through the door.

Some patients could provide the missing information for us on things such as allergies and underlying conditions, but for patients unable to communicate, the risk of administering medication or a treatment that may have adverse effects was high.

Unfortunately, this is the reality for too many healthcare providers due to a lack of interoperability—the exchange of healthcare data between providers, payers, and patients. The lack of accessibility to outside health records and the challenge of coordinating care across several networks often forces patients to repeat tests, costing the nation upwards of $210 billion on excessive and unnecessary treatment. This, in turn, results in significant delays in care.

If COVID-19 taught us anything, it’s that clean, deduplicated data (the process of eliminating multiple copies of the same clinical data), is critical to achieving a high-value health system. True interoperability provides the level of clean and shared data along with a full longitudinal view of the unified care record that can be accessed anywhere at any time. True interoperability is foundational to ensure the best possible care for a patient across the entire care continuum. In short, it saves time—and lives.

This level of interoperability has been an overarching goal of the U.S. healthcare industry since the implementation of the HITECH (Health Information Technology for Economic and Clinical Health) Act in 2009. The intent of this act was to stimulate the adoption of electronic health records (EHRs) and the supporting technology in the United States while improving the safety, quality, and efficiency of patient care. However, more than a decade since it passed, healthcare interoperability has yet to be fully realized in the U.S.

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

This month, the first requirements of the Centers for Medicare & Medicaid Services' (CMS) Interoperability and Patient Access final rule (9115-F) go into effect—a new set of federal guidelines that grant patients increased access to their health information and improves interoperability while reducing the burden on payers and providers.

While these federal guidelines are a step in the right direction towards true interoperability for all, meeting these new requirements may not be a straightforward and easy process for payers and providers.

The CMS rule has a number of deliverables rolling out over the next two years. First—and perhaps most challenging—are the two standards-based application programming interfaces (APIs): the Patient Access API and Provider Directory API.

Patient Access API (applicable Jan. 1, 2021)

There is no question that healthcare organizations are under incredible strain to meet the needs of members and patients across the continuum of care, especially in the wake of the COVID-19 pandemic. The new rules put forth by CMS mean that for the first time, CMS-regulated payers are being pulled into the fold to make healthcare data truly interoperable by putting records into the hands of patients and members in a meaningful way.

To accomplish this, healthcare organizations must align on the use of standard terminologies for clinical data through the use of USCDI v1 and claims data with the use of the CARIN profiles.

However, while the rule is now final, many of the implementation guides for the "how" are still under development, and payers specifically have a steep learning curve to address clinical data format and access needs.

RELATED: CMS issues Medicaid guidance for states on implementing interoperability rule

Transforming the incoming data from disparate sources into a streamlined, standardized format can be particularly challenging given the complexity of terminologies required that must be navigated and the ultimate conversion into Fast Healthcare Interoperability Resources (FHIR) that must be achieved.

Partnering with an established HIT vendor with a depth of experience in this space provides a key acceleration boost given the tight timelines required. Once the data is in the proper formats, making it accessible to members while meeting the OAuth 2.0 and OpenID Connect standards for sharing to third-party applications of the members’ choice requires confidence that the tools used meet the privacy, security, and safety needs of the organization and membership.

Provider Directory API (applicable Jan. 1, 2021)

With the new CMS rules, provider directory data must now be available to the public through standards-based APIs. This creates several unique challenges, including the need to move standards quickly when time and expertise may be lacking.

RELATED: Providers, payers struggling to comply with interoperability mandates amid COVID-19 pandemic: survey

While payer organizations have historically maintained internal provider directories, converting these to standards-based publicly accessible directories may be daunting. Existing data may be far from the recommended FHIR standards, requiring extensive resourcing to map and transform it. Furthermore, the Provider Directory API requirements define a number of new data types, including what may be an entirely new pharmacy directory to payer organizations. Thus, getting this data aggregated quickly to meet the deadlines may be best addressed through leveraging HIT expertise outside the payer organization. 

In the long term, the CMS rule, in conjunction with its ONC Cures Act counterpart, will ultimately streamline data across provider and payer organizations while simultaneously placing the data in the hands of patients. While the lift is significant, the positive gain for patient care is equally so.

Having standardized data that can be communicated between organizations and applications gives patients better control, choice, and transparency. That said, both payers and providers play equally important roles for healthcare organizations to successfully address the challenges and meet the requirements of the upcoming CMS interoperability rules.

As the originators of clinical data, providers must ensure they capture information accurately. Payers must ensure they share benefit, claim, and provider data while simultaneously offering price and provider transparency. The two combined empower patients to manage their health throughout the care continuum.

Only with true interoperability where providers are equipped with better access, portability, and the ability to easily exchange records can the healthcare industry dramatically make a difference and improve care for patients throughout the country.

Julie Smith is clinical product manager at InterSystems is a leader in strategy and product management at the juncture of healthcare delivery, clinical informatics and software development.