The health care industry started its work towards true interoperability in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act was established to enable access to a patient’s comprehensive health history, improve the workflow of health care providers and payers, and empower patients to manage their health.

The next chapter in health care interoperability opened with the Centers for Medicare and Medicaid Services' (CMS) Interoperability and Patient Access final rule going into enforcement as of July 1, 2021. The rule requires the safe exchange of patient data across health systems and compelling qualified organizations to provide patients complete access to their personal health information.

The goal of the new CMS rule is to modernize the health industry’s data-sharing capacity, which relies on health systems and payers to adopt advanced application programming interfaces (APIs) to facilitate access to valuable health information. While CMS continues to scope out guidelines to meet the new measure, partnerships with experienced patient education providers can help health systems comply.

What is the new CMS Interoperability and Patient Access rule?

The rule requires qualified health plans, including Medicaid, Children’s Health Insurance Program (CHIP), and Medicare Advantage, to ensure that enrollee data is made available in secure formats suitable for access on patients’ phones or preferred devices.¹ These capabilities require robust privacy and security measures to protect personal information.

Requirements of the CMS rule:

1. Patient access – Payers and providers must implement and maintain a secure standards-based API allowing patients to easily access claims and encounter information and cost of care.¹
2. Provider directory – Payers are required to make provider information accessible to the public using a standards-based API.¹
3. Admission, discharge, and transfer notifications – Hospitals will have to send electronic notifications of patient events, including admissions, discharges, and transfers to another provider.¹
4. Payer-to-payer data exchange – Payers will be required to implement a process that allows patients to take their information with them when they change payers to maintain a complete health record.¹
5. Public reporting and information blocking – Clinicians and hospitals will be publicly reported if they block information from being shared, undermining patient access to electronic health information.¹
6. Digital contact information – Providers that do not list or update their digital contact information (including secure digital endpoints) will be publicly reported.¹

What guidelines can help you attain true interoperability?

As your hospital or payer organization scopes out how to comply with the new CMS Interoperability rule, here is what you need to know.

1. Mass amounts of existing data from electronic health records (EHRs) must be aggregated, reformatted, and elevated to FHIR (Fast Healthcare Interoperability Resources) standards.
2. True interoperability requires your organization to commit to the deduplication of data (eliminating multiple copies of the same data), align on the use of standard terminologies for clinical data, and adopt standards-based APIs that are accessible anywhere, anytime.²

The CMS rule’s primary deliverables rest on the Patient Access API and Provider Directory API. To complete these tasks, however, enormous disparate data must be streamlined and incorporated within the deadlines imposed by the rule.

Why you need a HIT partner to meet new CMS requirements?

A steep learning curve – and a lot of planning – are associated with FHIR technologies needed to format and access clinical data (often integrated with EHR systems), which are then incorporated into Patient Access and Provider Directory APIs. Working with experienced health information technology (HIT) professionals will ensure your organization fulfills CMS rule requirements.

HIT vendors can guarantee that your data-sharing activities meet all third-party application standards, as well as all privacy, security, and safety requirements. And for payers that now must convert their internally maintained provider directories into publicly accessible directories, a partner with HIT experience will ensure the payer organization remains transparent about benefits, claims, and provider information under the rule.²

Leveraging HIT expertise through a partner agency is the best approach to help organizations correctly capture, transform, and map large amounts of data quickly to confidently meet federal standards and deadlines.

What are the benefits of the new CMS rule?

Advanced data-sharing standards facilitate the seamless flow of health information along a patient’s entire health journey, improving communication among patients, doctors, hospitals, and insurance companies. Access to valuable health information is further essential for making meaningful decisions regarding a patient’s treatment; to coordinate care across diverse health needs; and to avoid excess or unnecessary costs, like duplicate tests or other inefficiencies.³ Additionally, public reporting and access to provider information are useful for patients in helping them choose a provider whose care practice is based on coordinated care and who moreover support patient access to their health information.

The new CMS rule holds payers and providers to a higher standard of data sharing while protecting patient privacy. Krames can assist you in meeting the new CMS requirements and help get your organization one step closer to true interoperability today.

References
1 Landi H. CMS’ new interoperability rule requires major changes for payers, hospitals. Fierce Healthcare Web site. https://www.fiercehealthcare.com/payer/cms-interoperability-rule-requires-major-changes-for-payers-hospitals-here-are-key-timelines. Published March 9, 2020. Accessed September 6, 2021.
2 Smith J. Industry Voices – Achieving true interoperability: The impact of CMS’ interoperability and patient access final rule. Fierce Healthcare Web site. https://www.fiercehealthcare.com/tech/industry-voices-achieving-true-interoperability-impact-cms-interoperability-and-patient-access. Published January 4, 2021. Accessed September 6, 2021.
3 Nelson H. What Providers Should Know for CMS Interoperability Rule Compliance. EHR Intelligence Web site. https://ehrintelligence.com/news/what-providers-should-know-for-cms-interoperability-rule-compliance. Published June 28, 2021. Accessed September 6, 2021.