Originally Published On: January 25th, 2023 Susan Bellile’s blog, published last year, dives into the importance of enhanced interoperability. She discusses how the now-finalized CMS Interoperability and Prior Authorization Rule (CMS-0057-F), released on January 17, 2024, will affect health plans, payers, providers, and members. Explore her insights to gain a comprehensive understanding of the implications for these stakeholders. |
I have worked with healthcare data for most of my career, supporting both provider and payer organizations. Over time, one thing has become very clear to me. When it comes to clinical data, providers have more depth of information while payers have more breadth.
Let’s look at the records at my primary care provider’s (PCP) office. They host clinical detail from my examinations, laboratory tests, immunizations, and even questions I posed through a patient portal. But my health plan, using information gathered primarily through claims, knows that I consulted a specialist two years ago, that I did or didn’t fill my prescriptions, or that I may have visited an emergency room in another state. I access my information using multiple patient portals because my provider and specialist don’t use the same electronic health record (EHR). I also access information from my health plan through their member portal.
Giving patients the ability to download data from different portals into a smartphone application was the vision behind the Patient Access API, one of the interoperability rules that went into effect in July 2021. Sounds appealing, but health plans have seen a low volume of downloads from their Patient Access APIs. This suggests that only a minority of consumers are doing that today.
In a previously published blog, I discussed the limited adoption of the Patient Access API. I also expressed hope that the payer-to-payer data exchange rule would help streamline members’ healthcare history when they switch plans. The Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule further advances meaningful sharing of member data maintained by payers. The proposed rule:
These are all important steps toward easier exchange of the payer’s more comprehensive view of a member’s healthcare history. However, these new ways of sharing information put an additional burden on payers. Creating a single, comprehensive, and coherent view of each member’s data – to be made accessible via Fast Healthcare Interoperability Resources® (FHIR) APIs – is the biggest challenge to meeting these new proposed rules.
While the FHIR standard facilitates healthcare data exchange between different systems, it does not address the underlying data quality. If the source data is incomplete and inaccurate, the compiled record will be as well.
Even with the challenges, I am optimistic that we will make progress. Availity has the expertise required to meet this challenge with Data UpcyclingTM. This five-step process includes normalizing, enriching, reorganizing, and summarizing raw clinical data to turn it into a standards-based, interoperable asset. Availity looks forward to continuing this interoperability journey with our payer and provider partners.
Interested in learning more about upcycling technology? Download “Why FHIR is Not the Holy Grail of Data Interoperability” Insight Brief.