Earlier this year, the Centers for Medicare & Medicaid Services (CMS) introduced new interoperability mandates for health plans that must be implemented by July 1, 2021. Technically the mandate goes into effect on January 1, 2021, but CMS won’t enforce the requirements until July 1, 2021, because of the COVID-19 pandemic.

CMS set down this new rule to make it easier for patients to access their health information by implementing new industry standards, including HL7/FHIR APIs and deterring information blocking. However, many payers say they don’t feel ready to meet these new Fast Healthcare Interoperability Resources (FHIR) interoperability standards, and the countdown clock to the deadline is ticking down…

Let’s take a closer look at why healthcare interoperability is so important, what the new FHIR standards are, why payers are struggling to meet these new standards, and how they can solve those challenges.

Why Interoperability Is So Important

The global healthcare interoperability market is exploding. Market research firm Frost & Sullivan project the market will reach $8 billion by 2024, (up almost 14% from $4.2 billion in 2019). A lot of that has to do with the exponential growth in clinical data over the past five years, but the more data you have, the more potential problems lurk within it, and the biggest issue? Much of that data is inaccurate. 

Medical data company Diameter Health, for example, found that 80 percent of allergies aren’t coded correctly, and 40 percent of medications don’t have the right coding to apply for quality purposes. On top of that, most of this healthcare data is sitting in silos, making it a herculean task to run simple analysis and get insights. 

Meanwhile, the countdown clock to the CMS deadline keeps on ticking…

Breaking Down the New Interoperability Standards

The FHIR mandate requires CMS-regulated health plans to offer access to provider and patient claims and clinical data through APIs. What exactly does that mean? APIs facilitate the rapid exchange of electronic health information, which gives patients access to their health information for free. (We wrote about the importance of APIs to EHRs earlier this year.)

Under the new standards, plans must ensure that their information systems can communicate with third-party users, including consumer health apps. The technical standard for APIs (finalized by the ONC) adopts HL7 FHIR release 4.0.1. 

Plans will also need to establish a secure and trusted connection with a third-party application requesting patient data to comply with the ONC’s implementation specifications for OAuth and OpenID. The access has to include authorization and authentication for API users with tokens for accessing data for a single patient, verifying the patient, and revoking access, all at the patient’s discretion. 

The key requirements for standardizing data access include: 

  • Giving patients access to their data through a patient access API
  • Sharing provider data more broadly with third-parties through a Provider Directory API
  • Facilitating patient information transfer between payers (through a payer-to-payer exchange)
  • Complying with information blocking and federal/state data exchange and event notifications 

Why Payers Are Struggling to Meet the Deadline

According to Terry Boch, chief commercial officer for Diameter Health, many payers don’t have a plan to deploy new technical systems and make decisions with vendor partners in time to meet these standards. Stats from a poll conducted by Diameter Health reveal that 58 percent of health plans said they were behind or didn’t know where they were when it comes to plan readiness, and 71 percent said the quality of their clinical data needed work. 

Rising to meet the challenge of these new healthcare interoperability mandates can be a struggle at the best of times, and “During a global pandemic” is not the best of times. So it’s understandable that organizations are at a loss for how they’re going to meet CMS’ deadline. 

Getting Started with Interoperability Standards 

The new CMS mandate has put healthcare interoperability in the spotlight again, but the lack of effective data exchange has been a problem for payers for years. We should know—Surety Systems has been assisting healthcare providers with their HL7 engine challenges for years, and we’re here to help with the FHIR mandate as well.

Our senior-level healthcare integration consulting team has the HL7 experience and skills you need to assist you in meeting these new interoperability standards. Contact us today to learn more and take your mind off the tick-tock of the countdown clock.