The Impact New CMS Guidelines Could Have on Interoperability, Patient Care

There is some anticipation and uncertainty had over the new Interoperability and Patient Access final rule (9115-F)the Centers for Medicare and Medicaid Services (CMS) will be releasing in 2021. This new guideline is aimed to empower patients and improve interoperability while reducing the burden on payers and providers. However, the process to meet the requirements will be challenging, according to Don Woodlock, vice president of Healthcare Solutions at InterSystems, a global data platform provider that supports over 1 billion patient records.

True interoperability has been a major goal of the U.S. healthcare industry for more than a decade, Woodlock says.

In 2009, Congress passed the HITECH (Health Information Technology for Economic and Clinical Health) Act to encourage the adoption of electronic health records (EHRs) and supporting technology across the country, while improving the safety, quality, and efficiency of patient care. However, this goal has yet to be obtained, he adds.

The new Interoperability and Patient Access final rule put forward by CMS is an effort to improving overall interoperability, which is the exchange of healthcare data between providers, payers, and patients. This outcome will be achieved by freeing up patient data through CMS’s authority over Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). Most importantly, the CMS final rule empowers patients by giving them greater access to their health information so that they can use it effectively in their own care. The first requirements of the federal guideline will go into effect in January 2021.

While efforts have been on-going for years to provide further access to health information and create a smoother process in delivering care, COVID-19 helped expose the lack of interoperability in the U.S. healthcare system, underscoring the need for payers, providers and federal agencies like CMS to work together to obtain greater access to healthcare data, Woodlock says.

Guidelines proven to be needed for interoperability may face some challenges in the process to meet the requirements, though.

The CMS final rule will roll out new standards and guidelines over the next two years, but there are two standards-based application programming interfaces (APIs)—the Patient Access API and Provider Directory API—that will prove to be the most challenging for organizations to meet, Woodlock says.

"Part of the immediate challenge is that the implementation guides on how to actually address clinical data format and access needs have yet to be finalized," he says. "Taking incoming data from different sources and placing it into a standardized format can be especially difficult because there is a range of complex terminologies that must be navigated in order to complete the conversion into Fast Healthcare Interoperability Resources (FHIR). In addition, the CMS rule requires that provider directory data must be available to the public through standards-based APIs, which can be challenging, particularly if expertise and time are in short supply."

Woodlock says in order to meet the tight timelines of the new CMS rule, organizations should partner with experienced HIT vendors that have the expertise to transform data into FHIR to make it accessible and ensure the tools being used align with the privacy, security, and safety needs of the organization and membership. HIT vendors can also help organizations work towards greater interoperability by aggregating, normalizing and deduplicating data across multiple systems so that organizations can use it effectively.

One of the challenges with the clinical data requirement of the Patient Access APIs is that it puts forward a variety of brand new data types such as vital signs data collected by payers that don’t use a standard set of terminology, he says. Leveraging the experience of an HIT vendor from the provider and clinical side of the business can help payers get this data aggregated quickly and efficiently.

At InterSystems, they are helping customers meet the new guidelines with their HealthShare® CMS Solution Pack™. The Solution Pack leverages InterSystems expertise in interoperability and bundles together solutions, including technology, hosting, focused implementation and pricing solutions, all geared towards helping organizations meet the obligations of the new CMS rules as quickly and painlessly as possible.