Interoperability—the seamless flow of healthcare information between providers, patients, and payers—has been a long-term goal in the healthcare industry.1 This is because the lack of interoperability has too often prevented healthcare providers (HCPs) from obtaining patients’ medical records when needed for treatment decisions. Medical records’ lack of accessibility, and the resulting challenges of coordinating care across multiple health networks, often results in duplicated tests and treatments. This is estimated to cost the nation more than $210 billion annually in unnecessary treatment and often results in significant delays in care.2,3 To ensure the best possible care for patients, true interoperability is essential.3
In this article, we explore how interoperability has evolved over the years. We also discuss how payers can lay the foundation for optimal payer-provider interoperability by focusing on tools that facilitate clinical data exchange.
The initial focus of interoperability was provider-to-provider. This level of interoperability is essential to ensure continuity of care for patients and to provide clinicians with access to individuals’ care history so they can make informed clinical decisions. The growth of provider-to-provider interoperability existing in the United States is the result of a lengthy series of legislation, rules, and initiatives. Although it is difficult to pinpoint the precise starting point of the journey to interoperability, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 is one of the key launch points.3
Interoperability has been an overarching goal of the U.S. healthcare industry since this act—part of the American Recovery and Reinvestment Act of 2009 (ARRA)—was passed in 2009. The goal of the HITECH Act was to stimulate adoption of electronic health records (EHRs) and to support technology to improve the safety, quality, and efficiency of patient care. To do so, it established an incentive payment program for eligible physicians and eligible hospitals that demonstrated “meaningful use” of Certified Electronic Health Record Technology (CEHRT) and interoperable health information technology (HIT). This Act also established future payment penalties for eligible providers and hospitals who had not yet met the requirements for the meaningful use of EHRs.3-5
Two additional rules were issued in 2010 to aid in the execution of these programs. The Centers for Medicare and Medicaid Services (CMS) issued a Final Rule titled “Medicare and Medicaid Programs: Electronic Health Record Incentive Program.” (The Electronic Health Record Incentive Program came to be known as Meaningful Use.) The Office of the National Coordinator for Health Information Technology (ONC) in the HHS published the Final Rule titled “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology.” The CMS Final Rule defined how an EHR system had to be used to qualify for the incentive program and avoid future penalties. The ONC Final Rule defined what an EHR system must be able to do, by establishing certification criteria required for EHRs in order to support meaningful use.5,6
In 2012, the development of the HL7 FHIR standard was initiated.7,8 HL7 is an international, nonprofit, ANSI-accredited standards development organization and the global authority on interoperability for healthcare information technology.7-9 Development of the FHIR standard began because of the need for faster, easier, and better methods to exchange healthcare data. FHIR was built using Internet standards and technologies that were already used by industries outside of healthcare. FHIR provided a way for healthcare information to be exchanged securely between different computer systems even if those systems were using different methods to store the information.9
Over time, however, the focus of interoperability became provider-to-patient information exchange.
Historically, a lack of seamless data exchange in healthcare has decreased the quality of patient health care, leading to higher costs and less than desired health outcomes. Unable to access their health records, patients were unable to take their healthcare information with them from one provider to another.10 One of the first concerted attempts to rectify this situation was the 21st Century Cures Act.
Among the many important elements of this legislation, the 21st Century Cures Act addressed advancing interoperability and implementing penalties for data blocking, or the practice of preventing patients from accessing their health information. It called for all electronically accessible health information to be made available to patients without special requirements from the user.11
One tactic used to promote interoperability was identifying HL7 FHIR as the foundational standard to support data exchange using secure application programming interfaces (APIs).10 Other key elements of this act recently went into effect, such as the requirement for payers regulated by the Centers for Medicare and Medicaid Services (CMS) to implement a secure API that allows patients easy access to both their medical information and claims information. The goal is for both claims and clinical data to be available to patients and their providers, to offer a broader understanding of the patient’s interactions with the healthcare system. This will allow better decision-making and, ultimately, better outcomes.10
In 2018, CMS renames and revamps the Meaningful Use program, originally introduced in the HITECH Act of 2009. Renamed the Medicare and Medicaid Promoting Interoperability Program, this update brought other changes as well. This overhaul was designed to prioritize interoperability and patient access to their healthcare information. In addition to incentives, it added consequences—reduced Medicare payments—for hospitals and clinicians that failed to give patients electronic access to their health information.12,13
Designed to put patients in control of their healthcare data, this initiative enabled patients to take their health information with them on their healthcare journey. It helped to break down barriers that prevented patients from having electronic access to their health information, so that patients could share their health information with whomever they desired.1,14,15
At the same time, Medicare’s Blue Button 2.0 program launched with the goal of making claims data available to patients to serve their health needs. It provided Medicare beneficiaries with a new, secure method for accessing and sharing their personal health data in a universal digital format. CMS used the introduction of Blue Button 2.0 to provide a model for healthcare insurers, calling on them to follow their lead by granting patients access to their claims data in digital format.1,14,15
CMS added another specific application to interoperability with the Discharge Planning Final Rule. This rule required that hospitals ensure patients’ rights to access their medical records in electronic format. It required the ability for seamless exchange of patient information between different healthcare settings, so that patients’ healthcare information could follow them after their discharge from the hospital.12
In addition to providing ongoing support for interoperability, this final rule cracked down on information blocking with the promise of publicly reporting clinicians and hospitals that participated in information blocking. CMS began enforcing this portion of the rule beginning in March, 2021.10,16
This rule focused on driving interoperability and patient access to health information by making claims and clinical data available for 85 million patients.12 Two of the policies from this rule went into effect in 2021:17
This regulation’s goal is to benefit both providers and patients. It is intended to ensure that providers have access to patients’ care history, enabling them to make informed clinical decisions. It is also intended to increase patients’ access to their personal health information, so they might become more engaged in their care.18
Having clearly defined their goals for provider-to-patient interoperability, regulatory bodies have moved on to other goals. Now, the focus in interoperability is shifting toward payer-to-provider interoperability. Current regulations are intended to drive change in how clinical and administrative information is exchanged, supporting more efficient care coordination. When implemented effectively, payer-to-provider interoperability can also reduce the burden of certain administrative processes, such as prior authorization.17
CMS regulations include policies requiring payers to implement APIs to improve electronic sharing of healthcare data between payer and provider, or between two payers. These regulations include policies that may reduce burdens of the prior authorization process by increasing automation.17
This proposed rule really consisted of two rules tacked together. The first part furthers payer-to-provider interoperability to improve coordination of care for patients. It does so by requiring providers to be able to access patients’ healthcare information from payers using their Health Information Exchange (HIE) solution. It also requires payers to include information about patients’ pending and current prior authorization decisions as part of the information accessed via the Patient Access API as well as the information accessed via the Payer-to-Provider and Payer-to-Payer APIs. This gives both patients and providers direct access to prior authorization status information.19,20
The second part of the rule is an effort to automate and standardize the prior authorization process. CMS attempted to do this by requiring providers to build an FHIR-enabled Prior Authorization API—basically, an automated way to send requests for prior authorizations and receive back responses within their existing workflows. It also required affected payers to create an FHIR-enabled API that can be integrated with the provider’s HIE to automate the process of obtaining documentation for prior authorization requests.19,20
Both portions of this rule are targeted to have a January 1, 2023 compliance date.
Standards-based clinical data exchange is at the core of all healthcare data interoperability. The Integr8 platform from Pulse8 lays the foundation for payer-to-provider interoperability by facilitating clinical data exchange. Keep reading to learn more about Integr8, which:
HCPs receive more than 100 million medical record requests every year. About 90% of those are exchanged via manual methods such as traditional paper or analog fax.23 One study estimated that $248 billion was wasted annually in U.S. healthcare spending, attributable solely to administrative complexity. That’s because, typically, charts are pulled individually; driven or mailed to the health plan; and then each chart is reviewed manually.24
Integr8 facilitates payer/provider collaboration by automating the extraction of continuity of care (CCD) documents and patient medical record information. This eliminates the need for more costly and labor-intensive means of data collection such as medical record review (MRR), initial health assessments (IHA), hierarchical condition categories (HCC) bulletins, and so on.21
Integr8 also allows medical records to be retrieved more quickly and efficiently. If a chart needs to be pulled, providers can seamlessly and automatically provide the requested chart without disrupting their workflow. It also ensures security—the system sends patient information in an encrypted format. The system supports value-based reimbursement as well, aiding data collection for quality measures that impact reimbursement for value-based care models.24 This allows payers and providers to share data more efficiently and effectively.21
Integr8 uses the current standard for healthcare data exchange, HL7 FHIR. FHIR uses standardized APIs to create plug-and-play applications, removing the errors and gaps that exist in the current document-based system of information exchange. An application developed using FHIR can communicate with any FHIR-compliant EHR, allowing seamless exchange of information.10 This standard provides security in health data exchange.18
Integr8 provides nearly real-time verification of medical record documentation, which confirms claims and coding accuracy. This benefits the provider by reducing the risk of RADV audits—which benefits the payer as well, because the provider is then able to provide better quality care.21,22
Integr8 automatically extracts encounter data from the electronic medical records (EMR), claims data, and ancillary data as well. It formats structured Consolidated-Clinical Data Architecture (C-CDA) data in a format ready to drop into the Healthcare Effectiveness Data and Information Set (HEDIS®) Engine.
It also embeds advanced analytics into the provider’s workflow. Both Quality and Risk Analytics are processed to identify gaps and provide supplemental data for risk adjustment, which enable the payer to push alerts to the provider for closure of gaps in documentation, coding, and quality, while still in the clinical setting.21,22 Quality gaps exist in healthcare; by alerting the provider at the point of care, the payer can more easily close these quality gaps and make up for potential lost claims.21
Integr8 provides better care coordination as well: Rather than communicating with faxes or requiring medical office staff to log into another portal, Integr8 embeds analytics and alerts directly into the provider’s workflow, reducing the risk of things falling through the cracks.21,22
Integr8 EMR integration brings with it the connection to over 150,000 providers. With its partnership with NextGen Healthcare, Veradigm and Allscripts now has one of the largest EHR dataset currently available. Integration provides improved efficiency by automating the extraction of continuity of care (CCD) and medical record information. It also has the potential to improve quality of care due to faster turnaround times and better care coordination.21
Integration helps clinicians deliver higher quality care by embedding analytics and alerts directly into their workflow. It reduces the risk of RADV audits with near real-time verification of medical record documentation. At the same time, it offers improved provider relations, as EMR integration is the least intrusive method of collecting data from providers and returning insights.21
Want to learn more about how Integr8 can help you achieve your interoperability goals? View our webinar: The Push and Pull of Clinical Data Exchange: Laying the Foundation for Payer-Provider Interoperability.