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 1. Home
 2. HealthEdge Blog
 3. Interoperability Today: What Health Plans Need to Know


INTEROPERABILITY TODAY: WHAT HEALTH PLANS NEED TO KNOW

Published Date June 6, 2023 Author HealthEdge


 * 
 * 
 * 
 * 


WHAT HEALTH PLANS SHOULD KNOW AS INTEROPERABILITY CONTINUES TO CHANGE THE GAME
FOR HEALTHCARE

Interoperability has transformed every facet of the healthcare delivery system,
creating new opportunities to improve outcomes, reduce costs, and improve
efficiencies. It has also been the key to enabling healthcare technology
solutions to achieve their full potential.

By gaining a deeper understanding of the origins, current status, and future
potential of interoperability, health plans can seize the opportunity to
implement modern and innovative care management integration capabilities that
deliver results for digital payers.

Defining Interoperability

Interoperability in healthcare refers to the ability of various information
systems, devices, and applications to access, exchange, integrate, and
cooperatively use data in a coordinated manner, in order to provide timely and
seamless portability of information and improve the health of people and
populations around the world.

Interoperability is the basis on which healthcare providers are able to deliver
coordinated and comprehensive care to patients by accessing and sharing critical
patient data in real-time. It also enables health plans to streamline
administrative processes and reduce costs. As the healthcare industry continues
to evolve and adopt new technologies, interoperability will also become an
increasingly vital aspect of healthcare delivery and management.

Why Interoperability Matters

Interoperability can have significant positive implications across the
healthcare ecosystem. Key goals of seamless integration include:

 1. Advancing care coordination: Interoperability facilitates the sharing of
    member health information between payers, providers and systems, enabling
    better coordination and collaboration among organizations and teams.
 2. Improving outcomes: By providing care managers and healthcare providers with
    access to comprehensive and up-to-date patient information, interoperability
    can help care managers create effective care plans and improve patient
    outcomes.
 3. Streamlining administrative processes: Interoperability can reduce
    administrative burden, support new payment models, and ease claims
    processing.
 4. Reducing costs: Interoperability can help reduce errors, streamline
    processes, and save time, leading to overall cost savings for payers,
    healthcare organizations, and members.
 5. Improve member satisfaction: By improving data exchange, members have
    greater access to health and claims information, improving satisfaction and
    engagement.

The Beginning: Unlock the Power of Health Data through Interoperability

The need for interoperability originated as healthcare providers embraced
widespread adoption of electronic health records (EHRs). EHRs were intended to
revolutionize the way healthcare was delivered, enabling better coordination of
care, reducing medical errors, and improving patient outcomes. However, in
practice, EHRs created silos of health data that were not easily shared between
providers or patients. This lack of interoperability led to fragmentation of
care, duplication of tests, and unnecessary healthcare costs.

Recognizing the need to address these issues, the 21st Century Cures Act
mandated that healthcare providers make patient health information available to
patients and other providers in a standardized format through open, secure, and
standardized application programming interfaces (APIs). The Act also created new
provisions for healthcare data privacy and security, ensuring that patient data
is protected when it is shared between providers.

These interoperability standards were important for several reasons. First, they
empowered patients to take control of their health information and share it with
any provider they choose. This increases patient engagement and allows for more
comprehensive and coordinated care. Second, the rules helped to break down the
silos of health data that had developed, enabling providers to access complete
patient records, reducing the risk of medical errors, and improving the quality
of care.

Finally, the interoperability rules promoted innovation in healthcare by
encouraging the development of new applications and tools that can use
healthcare data to improve patient outcomes, reduce costs, and improve
efficiencies. Interoperability continues to be a priority for health plans and
organizations across the healthcare ecosystem.

New Regulation and Innovation: Key Drivers Influencing Interoperability Today

Today, new regulations and continued innovation are driving urgency for greater
interoperability. For example, the CMS Proposed Rule: Advancing Interoperability
and Improving Prior Authorization Processes will directly influence integration
priorities for many health plans. The proposed rule updates some of the policies
included in the Interoperability and Patient Access Final Rule of 2020 and
officially withdraws the December 2020 CMS Interoperability proposed rule. The
objectives of the policy are to reduce the burden on both payers and providers,
improve efficiencies, and advance patient access to health information. Some of
the conditions take effect immediately, while others require implementation by
2026. Given the scope, it is important health plans to take action now and
prepare their infrastructures for full implementation.

The proposed rule includes multiple requirements for payers that will directly
influence their interoperability strategies:

Patient Access API: The rule proposes to require regulated payers to include
information about patients’ prior authorization decisions to help patients
better understand the process and contribution to their care. The proposed
provision would also require impacted payers to report annual metrics to CMS
about patient use of the Patient Access API.

Provider Access API: The rule proposes impacted payers build and maintain an API
to share patient data with in-network providers where a treatment relationships
exists with the patient.

Payer-to-Payer Data Exchange on FHIR: The rule proposes to require payers to
exchange member data when a member changes health plans, with the member’s
permission. The data elements include claims and encounter data, those
identified in the USCDI version 1, and prior authorization requests and
decisions – only if the patient opts in to data sharing.

Improving Prior Authorization Processes: The rule proposes a series of policies
in an effort to improve the prior authorization process through greater
efficiency and transparency.

The rule also outlines CMS’s recommended use of certain implementation guides
for the APIs listed in the rule, but does not propose requiring their use.

The provisions outlined in the CMS proposed rule facilitate moving the industry
toward more streamlined communication and better information exchange that can
benefit members, payers, and providers. As organizations await the final ruling,
there are steps that can be taken now to prepare:

 1. Understand how the ruling will impact your health plan. Assess guidelines
    and determine which provisions will apply to your organization.
 2. Evaluate your current data management processes. Is all member information
    available in a single source in order to create the full record required? If
    not, what changes need to be made to maintain a record for each member?
 3. Evaluate your current interoperability strategy. How is member information
    exchanged between payers, providers, and patients today? How is prior
    authorization information managed and exchanged today? In what format are
    the data points being requested and can they easily be delivered via a
    Patient API or Provider API?
 4. Assess resource availability. Who will be responsible for implementing the
    new standards? Who will be responsible for ensuring data is available to
    patients and providers within defined timeframes? What processes will need
    to change in order to accommodate the new standards?

Future State: Interoperability Considerations for Digital Payers

The proposed rule could be considered just the beginning for innovation in
interoperability that will impact health plans moving forward. Rapidly evolving
regulatory requirements, new payment models, rising consumer expectations, and
new market opportunities will continue to drive payers to advance
interoperability. The results promised by continual digital advancements across
the healthcare ecosystem rely on seamless data exchange. In fact,
interoperability can be considered a prerequisite for many health innovations.

Digital payers should consider their care management system’s ability to meet
key requirements for modern and evolving integration criteria:

 1. Exchange a variety of data types: Health plans should ensure their care
    management system can access, ingest, and exchange various data types across
    other systems with industry interoperability standards.
 2. Support real-time data exchange: Informing decisions in a timely manner is
    critical when it comes to effective care management. Health plans should
    ensure care managers have real-time access to member information.
 3. Work seamlessly with other systems and data sources: Care management systems
    function as the core orchestrator of member care. But the most effective
    care plans rely heavily on data from multiple sources to inform optimal care
    plans. In addition, care management systems must work in tandem with claims,
    payment integrity, and other administrative systems to streamline processes
    and reduce costs.

GuidingCare® enables digital payers to meet these modern interoperability needs,
plan for future requirements, and support continued innovation. To learn more
about how about creating a successful interoperability strategy with
GuidingCare, visit the GuidingCare page on the HealthEdge website.


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