Final Interoperability and Patient Data Access Rules Will Challenge Providers, Benefit Consumers

Gevik Nalbandian, VP of Software Engineering, NextGate
MARCH 30, 2020
interoperability

Since the beginning of the digital revolution in healthcare, providers have been in search of tools to connect disparate systems and deliver seamless, secure and timely patient data directly to the point of care. Our public health crisis is a sobering example of just how desperately information sharing capabilities are needed.

As a byproduct of the nation’s substantial investment in EHRs, the market has become inundated with applications and tools to collect, store, analyze and exchange massive amounts of health information.

Despite the best of intentions, however, this saturation has created a highly fragmented landscape with few shared standards, volumes of duplicate records, limited patient access to data and perceptions of information blocking that have pitted many of the industry’s biggest players against each other.

On March 9, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) took a big step toward improving these circumstances by finalizing two landmark rules to expand interoperability and ensure that patients maintain control over their own electronic health information.


Major Provisions Will Enhance Access and Accountability

The two rules contain a number of important provisions intended to improve the appropriate flow of data through the nation’s disjointed health information exchange pipelines, including actions to combat information blocking, support for value-based care, and laying the groundwork for enhanced standards-based data exchange.


Addressing Information Blocking for Payers, Providers and Vendors

Information blocking, or the practice of controlling data access rights to create a competitive business advantage, has been widely condemned by stakeholders across the industry.  ONC’s final rule establishes guidelines around what constitutes information blocking and how to avoid it in accordance with requirements in the 21st Century Cures Act.

For example, health IT vendors will be required to enable meaningful and actionable sharing of the US Core Data for Interoperability (USCDI), which includes critical elements such as clinical notes, patient allergies and medications. The USCDI also includes demographic data elements that are vital for patient matching across care settings—a key competency for patient safety and continuity of care.

Physicians and other clinicians participating in the CMS Merit-Based Incentive Payment System (MIPS) will need to attest that they have not knowingly engaged in activities designed to limit interoperability. What’s more, they must ensure they have responded as quickly and comprehensively as possible to requests for the retrieval or exchange of electronic health information.

The penalties for failing to meet these guidelines will include public reporting on patient-facing websites and potential monetary fines or other consequences to be established through future rulemaking.

Payers will also need to ramp up their data exchange capabilities with their peers. Medicare Advantage plans, Medicaid managed care plans, CHIP managed care entities and participants in the federal exchanges will need to provide USCDI data to other payers for up to five years after a member has disenrolled.


Establishing ADT Notifications As a Condition of Participation for Hospitals

As value-based care takes hold across the country, hospitals will now be required to send electronic admission, discharge and transfer (ADT) notifications to primary care providers when a patient experiences a qualifying event. Organizations that do not comply with this new rule will be unable to participate in the Medicare or Medicaid programs.

Hospitals only need to send a few key data elements to their community partners, not a full patient record. However, even basic information about patient activities can help primary care providers follow up quickly and manage patients more effectively to improve outcomes and reduce costs.
 

Leveraging APIs for Patient Access to Personal Information

Application programming interfaces (APIs) underpin some of the world’s most popular consumer apps and internet services. Now, healthcare providers and payers will need to take the same approach to giving patients access to their own data.

ONC has decided to adopt HL7 FHIR Version 4 as the standard mechanism for creating apps and allowing patients to choose which types of data can be shared with specific healthcare entities. 

HHS imposed the requirement on Medicare Advantage, Medicaid and CHIP health plans starting in January of 2021. 

The adoption of a unified standard will allow healthcare organizations and third-party developers to create consumer-friendly tools so individuals can actively participate in secure data exchange and make their personal health records more portable. 
 

Enhanced Data Exchange Makes Patient Identity Management More Important Than Ever

These challenging new requirements, along with many others in the lengthy twin rules, are designed to keep healthcare data moving quickly and securely while bringing immediate benefits to consumers. 

As information begins to flow more freely, stakeholders will need to pay even closer attention to questions of data quality and data integrity. Efforts to improve interoperability will not have their intended effect if information is incomplete, outdated or difficult to access when it reaches its destination.

Robust patient identity management tools will be critical components of the new interoperability toolkit to ensure that the right data are associated with the right consumer. With that, providers will be able to view all the available information about each individual in a timely manner.

Reducing duplicate records, creating comprehensive longitudinal patient profiles and presenting this information in a user-friendly manner at the point of care will support better outcomes, more value for consumers and improved opportunities to proactively manage patients.

Over the coming months, CMS and ONC will continue to work with stakeholders across the industry to put these rules into action. In light of COVID-19, the administration is currently considering relaxing the timeline. However, as the industry struggles with the pandemic, meaningful data exchange and a longitudinal view of patients' health is essential to track confirmed cases, test results and outcomes and ultimately change the course of the spread.

About the Author: Gevik Nalbandian is the Vice President of Software Engineering for NextGate, a global leader in healthcare identity management.

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