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7 CMS Interoperability Policies and How Zen Helps
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Seamless data exchange in healthcare has a direct impact on patient care. If limited it can lead to higher costs and worse health outcomes. In order to address this, the CMS interoperability and Patient Access final rule laid the groundwork and established policy that improves interoperability and spurs innovation.
These interoperability and patient access rules are attempting to push healthcare toward a future of data free-flowing securely between payers, providers, and patients. The Office of the National Coordinator (ONC) is taking center stage in helping move all healthcare organizations to successfully achieve compliance.
“The Office of the National Coordinator for Health IT is gearing up to help organizations succeed with all phases of the interoperability rule, focused mainly on moving a range of health IT levers in unison in both the short and long term, according to the newly appointed national coordinator for health IT, Micky Tripathi, PhD, MMP.
Whether it is information blocking, patient data exchange, or interoperability, Tripathi said ONC’s goal is to “pull all of those levers so that they’re working as an orchestra” by correctly pulling them at the right time, and most importantly, in the same direction.”¹
Definitions around privacy, security, and messaging standards are laying the groundwork to ensure that data formats keep up with the times. Health Level 7 (HL7) and Fast Healthcare Interoperability Resources (FHIR) have been identified as the foundational standards for healthcare data exchange via API’s. For some of our clients, this is a costly and time-consuming proposition to support with their existing infrastructure. However, Zen is proving to be a valuable resource for these organizations by acting as a bridge between legacy technology and FHIR or IHE based exchange, two models that are gaining traction as organizations look to achieve compliance with the new rules.
Let’s take a look at some of the new policies as outlined in the Interoperability and Patient Access Fact Sheet from CMS.gov:
#1 Patient Access API:
CMS-regulated payers, specifically MA organizations, Medicaid Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP FFS programs, CHIP managed care entities, and QHP issuers on the FFEs, excluding issuers offering only Stand-alone dental plans (SADPs) and QHP issuers offering coverage in the Federally-facilitated Small Business Health Options Program (FF-SHOP), are required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1) API that allows patients to easily access their claims and encounter information, including cost, as well as a defined sub-set of their clinical information through third-party applications of their choice.
Claims data, used in conjunction with clinical data, can offer a broader and more holistic understanding of an individual’s interactions with the healthcare system, leading to better decision-making and better health outcomes. These payers are required to implement the Patient Access API beginning January 1, 2021 (for QHP issuers on the FFEs, plan years beginning on or after January 1, 2021).²
As a way to increase visibility for patients, this patient access API requirement forces payers to push data to a patient-facing API that supports FHIR data standards. One specific adjustment to the deadline listed above: CMS has recognized the challenges faced by payers during COVID-19 and have elected to refrain from enforcing these new requirements until July 1st, 2021.
Zen specializes in helping organizations meet these data standards by translating the existing data standards healthcare organizations already have in place to support the new FHIR based API standards and can help them be fully compliant before the July 1st deadline.
#2 Provider Directory API:
CMS-regulated payers noted above (except QHP issuers on the FFEs) are required by this rule to make provider directory information publicly available via a standards-based API. Making this information broadly available in this way will encourage innovation by allowing third-party application developers to access information so they can create services that help patients find providers for care and treatment, as well as help clinicians find other providers for care coordination, in the most user-friendly and intuitive ways possible.
Making this information more widely accessible is also a driver for improving the quality, accuracy, and timeliness of this information. MA organizations, Medicaid and CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities are required to implement the Provider Directory API by January 1, 2021. QHP issuers on the FFEs are already required to make provider directory information available in a specified, machine-readable format.²
Similar to the Patient Access API, the Provider Directory API requires data to be made available via a standards-based API. Organizations will run into similar road bumps if their legacy systems aren’t set up to push data to the API in the required formats.
#3 Payer-to-Payer Data Exchange:
CMS-regulated payers are required to exchange certain patient clinical data (specifically the U.S. Core Data for Interoperability (USCDI) version 1 data set) at the patient’s request, allowing the patient to take their information with them as they move from payer to payer over time to help create a cumulative health record with their current payer. Having a patient’s health information in one place will facilitate informed decision-making, efficient care, and ultimately can lead to better health outcomes. These payers are required to implement a process for this data exchange beginning January 1, 2022 (for QHP issuers on the FFEs, plan years beginning on or after January 1, 2022).²
The Payer-to-Payer rule ensures that patients have better access to their cumulative health records as they move to various payers over their lifetime. Payers will need to make at least the defined USCDI data set of a patient’s health record data available to exchange with fellow payers.
Zen is familiar with the USCDI data set and can help payers successfully implement payer to payer exchange using tools like the Gemini Integration as a Service Platform with the Stargate IHE Gateway. Zen believes that both FHIR and IHE type exchange will be used as models to meet the payer-to-payer data exchange rule.
#4 Improving the Dually Eligible Experience by Increasing the Frequency of Federal-State Data Exchanges:
This final rule will update requirements for states to exchange certain enrollee data for individuals dually eligible for Medicare and Medicaid, including state buy-in files and “MMA files” (called the “MMA file” after the acronym for the Medicare Prescription Drug, Improvement and Modernization Act of 2003) from monthly to daily exchange to improve the dual eligible beneficiary experience, ensuring beneficiaries are getting access to appropriate services and that these services are billed appropriately the first time, eliminating waste and burden. States are required to implement this daily exchange starting April 1, 2022.²
The goal of this rule is to improve the dual eligible beneficiary experience, ensuring beneficiaries are getting access to appropriate services on a timely basis and ensuring these services are billed appropriately the first time, eliminating waste and burden. States are required to implement this daily exchange starting April 1, 2022. The key problem Zen can help with here is implementing an efficient and scalable solution that is much more focused on real-time or small batch type processes versus the previous monthly “big batch” methods.
#5 Public Reporting and Information Blocking:
Beginning in late 2020, and starting with data collected for the 2019 performance year data, CMS will publicly report eligible clinicians, hospitals, and critical access hospitals (CAHs) that may be information blocking based on how they attested to certain Promoting Interoperability Program requirements. Knowing which providers may have attested can help patients choose providers more likely to support electronic access to their health information.²
CMS publicly reporting which participants are meeting Interoperability program requirements is in itself a very important incentive for organizations to meet those reporting and information blocking benchmarks. Since some payers actually directly own or manage provider practices today, this rule is absolutely relevant to many payers.
Hospitals and Provider practices will have to rethink their integration strategies from being primarily focused on a “how do our internal systems share data” to a “how do we share data with our healthcare ecosystem”. Zen is already working with provider type organizations to implement effective strategies. For example, Zen is a Carequality Implementer and has the tools needed to fill interoperability gaps often found in EHR systems.
#6 Digital Contact Information:
CMS will begin publicly reporting in late 2020 those providers who do not list or update their digital contact information in the National Plan and Provider Enumeration System (NPPES). This includes providing digital contact information such as secure digital endpoints like a Direct Address and/or a FHIR API endpoint. Making the list of providers who do not provide this digital contact information public will encourage providers to make this valuable, secure contact information necessary to facilitate care coordination and data exchange easily accessible.²
Providers will be required to have digital contact information made available, including FHIR API endpoints when applicable. This is going to greatly enhance the value of the NPPES database. In Zen’s experience, the NPPES database and the quality of that data have always been a pretty big problem. Moving forward, high-quality provider data is critical to ensure physician and healthcare organization identity is properly managed when exchanging data and in understanding patient-provider relationships.
In terms of managing a high volume of new FHIR endpoints, CAQH just recently launched their National Directory of FHIR Endpoints and Third-Party Apps. For both providers and payers, getting validated in directories like this one as soon as possible will be critical. We are excited about both this new rule and the CAQH initiative as it is a critical step needed to operationalize the new requirements.
#7 Admission, Discharge, and Transfer Event Notifications:
CMS is modifying Conditions of Participation (CoPs) to require hospitals, including psychiatric hospitals and CAHs, to send electronic patient event notifications of a patient’s admission, discharge, and/or transfer to another healthcare facility or to another community provider or practitioner. This will improve care coordination by allowing a receiving provider, facility, or practitioner to reach out to the patient and deliver appropriate follow-up care in a timely manner. This policy will be applicable 12 months after publication of this rule.²
Payers and patients alike pay the price when transitions of care are not managed correctly. The new ADT Event Notifications rule mandates the use of technology to facilitate better coordination of care post discharge. Zen has been helping HIEs successfully implement event notifications and we look forward to bringing that expertise to other healthcare organizations as this rule goes into effect as of May 2021.
Keep in mind that the rules detailed above are just the beginning. Starting in October 2022, some unstructured data must also be shared. The CMS interoperability rules will require a flexible approach to bring payers into compliance for mandated data exchange with patients, other payers, and providers.
Examples of flexible approaches include combining solutions such as Diameter Health’s FHIR Patient Access solution with Zen’s Gemini platform. Diameter Health ensures the quality of the data; Gemini brings the swiss army knife to the legacy data format problem.
For Zen clients, the Interoperability and Patient Access final rule has pushed forward their data interoperability projects to ensure they meet the new compliance rules and standards. Zen is filling gaps for them in their existing infrastructures to optimize their approaches.
If you are one of the many organizations struggling with how to meet the many new ONC interoperability rules, including FHIR API Patient Access, be sure to connect with us to see how we can fill those gaps to reach your compliance goals fast.
About Zen:
Zen Healthcare IT is an interoperability technology and consulting firm. Zen helps all stakeholders in healthcare – vendors, providers, payers, HIEs, and ACOs – simplify interoperability. Using technology tools and years of interface development and support experience, Zen’s solution architects and engineers design and build use-case driven solutions for health information exchange.
The Zen team solves problems ranging from data acquisition, data normalization and aggregation, and data delivery challenges. Zen’s national client-base leverages Zen’s broad range of services, on-demand engineering, and disruptive Gemini Integration as a Service platform helps overcome interoperability obstacles and creates sustainable health information exchange infrastructures. Learn more at www.Consultzen.com.
Reference Articles:
¹https://ehrintelligence.com/news/onc-leader-tripathi-offers-tips-for-interoperability-rule-success
²https://www.cms.gov/newsroom/fact-sheets/interoperability-and-patient-access-fact-sheet
Other Helpful Resources:
https://www.healthit.gov/topic/standards-technology/standards/fhir-fact-sheets
Best Practices for Payers and App Developers (PDF)
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