Interoperability Investments Pay Off When Planned and Properly Prioritized

By  Jocelyn Keegan,  Practice Lead, Payer/Practice

Interoperability means different things to different people. For healthcare payers, it means solutions that improve technology infrastructure to reach across data silos, reduce burden on payers and providers, improve the member and provider experience, enable value-based care programs and meet federal regulations. It can also provide competitive advantages.

46% of payers state that current regulations and policies will facilitate innovations in interoperability.¹ When asked what challenges are currently limiting interoperability, 50% of payers said technical infrastructure and 43% said lack of industry standards.²

While 2022 is bringing new regulations, compliance should not be the only consideration when assessing an investment that will improve interoperability. Standards are essential and, even more critically, they are being developed concurrently with or being named in federal regulations to enable real-time, interoperable data exchange here and now. HL7 Fast Healthcare Interoperability Resources (FHIR) standards enable the use of application programming interfaces (APIs). The Da Vinci Project, one of several HL7 FHIR Accelerators leveraging FHIR, is currently developing a patient cost transparency use case and implementation guide that provides the “recipe” for how to use FHIR to communicate an advanced explanation of benefits prior to scheduled service or upon request to the patient.

Some innovative payers, rather than checking the box on compliance deadlines or holding back until the standards are adopted by all, are assessing interoperability investments based on how they can benefit patient outcomes and experiences and help their provider network provide better care with reduced burden. Payer organizations don’t have to be giants to approach interoperability planning more strategically.

We advise our clients to consider three key factors when establishing their goals for interoperability and prioritizing their implementation plans: opportunities, risks, and resources.

Opportunities: How Can Interoperability Reduce Burdens and Improve Care?

Interoperability solutions are reducing administrative burdens and improving care with electronic prior

authorization (ePA). According to a 2021 American Medical Association study, 93% of physicians reported delays in care associated with prior authorizations (PAs). 88% of physicians described the burden associated with PAs as high or very high.³

ePA helps to reduce this burden and streamline workflows by automating form completion, verifying clinical documentation, and providing real-time authorization at the point of care. Health systems and providers using ePA have reported a reduction in median wait time for a decision by more than two-thirds, from 18.7 to 5.7 hours.⁴

Another example of interoperability improving patient care is when payers partner with health systems and associations to champion a particular preventive care measure, such as screenings. Some payers help enable electronic enrollment into pharmaceutical companies’ patient support programs, triggered by coverage approval of a specific prescription. The sharing of data — from prescriber to payer to patient — requires interoperability powered by APIs.

Risks: Are There Compliance Issues or Other Consequences for Staying with the Status Quo?

Regulatory requirements are often the catalyst for investing in new technology infrastructure, and the current federal regulation landscape is bringing unprecedented changes. The inclusion of the NoSurprises Act driving patient cost transparency is triggering regulator action by the Department of Health and Human Services (HHS) and the Unified Agenda is signaling a return of the stalled Centers for Medicare and Medicaid Services (CMS) PA burden reduction proposed regulation.  

The proposed CMS rule on PA and burden reduction requires payers to build and implement FHIR APIs to, among other things:

• Alert providers of the specific documentation required for PAs
• Streamline the documentation process
• Enable providers to submit PAs directly from their EHR (without going outside of workflow
• Set a maximum of 72 hours to issue a PA decision
• Increasing patient access to health data and ability to port their data to a new payer (including previous PA approvals)

These expected regulations, paired with the existing 2021 Patient Access API rules from CMS in coordination with the Office of the National Coordinator for Health Information Technology, reflect a trend encouraging the adoption of APIs for ease of data sharing and improving patients’ ability to access and manage data. CMS regulation of payers under their purview already requires them to meet certain data exchange standards for sharing data with patients, providers and other payers. Technical standards developed by HL7 Accelerators and the growing FHIR community with significant support from CMS and HHS that can help you create a path and timeline for complying with regulations with resources are found here.

Member, employer and provider demand are also driving the switch to API-based data systems as patients expect access to their data and the ability to make price comparisons. Forward-thinking organizations are planning beyond this year’s compliance requirements and looking at the risks of falling behind competitors by not providing the levels of interoperability that today’s healthcare market demands.

Resources: How Does Our Current System Align with New Technologies and Standards?

Organizations should take inventory of their current data systems using quantifiable criteria to assess how their current resources meet the industry’s rapidly advancing standards. It is important to establish return on investment, prioritization and a clear understanding of value of investments to help determine the necessity and sequencing of your interoperability implementation plan. These rankings should include levels of readiness for regulatory timing, technology requirements and alignment with business partner systems.

Point-of-Care Partners provides the in-depth health information technology (health IT) analysis and clear understanding of the use cases that require advancement to offer assessments that identify key opportunities within payer and provider organizations. We bring nationally recognized expertise concerning standards, health IT and interoperability to facilitate your evolution.

We are working to advance interoperability by putting in the hard work to make real-world advancements of standards across the spectrum of health IT. In addition to program management for Da Vinci, our experts lead the Patient Cost Transparency and Consumer Real-Time Benefit use cases and are working on value-based care performance metrics sharing. Outside of the FHIR community, we are driving the discussion forward on eConsent and putting National Council for Prescription Drug Programs Foundation dollars to work modernizing transactions. Let us put our expertise to work for you in the evolving healthcare landscape.

To learn more about creating or validating your own interoperability plan to achieve business successes and not just checking a compliance box, please contact jocelyn.keegan@pocp.com. To learn more about FHIR Accelerators and the patient cost transparency use case, reach out to vanessa.candelora@pocp.com.

References:

1. HIMSS State of Healthcare Research. healthfinancenews.com

2. Barriers to health data sharing in the U.S. in 2020, by healthcare actor | Statista

3. American Medical Association. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

4. SureScripts 2021 National Progress Reports. https://surescripts.com/docs/default-source/national-progress-reports/2021-national-progress-report.pdf?sfvrsn=71fcbe15_14