New federal regulations are pushing for interoperability, but insurers say the 2020 deadlines are unrealistic.

Jan Greene
Contributing Editor

It’s been a decade since Congress pledged $35 billion to drag America’s health care system into a digital 21st century by paying for thousands of hospital and physician practices to dump their walls of paper files and move the data into computers. A big chunk of that federal cash went to states to set up information exchanges to share patient data less clunkily. And yet, the fax machine, that relic from the 1980s, still clutters the counters of most medical practices. Patients continue to struggle to get paper copies of their medical records, much less being able to pull them all together in one place online—an unmet promise getting dusty with age.

Recognizing both technical and business barriers to the speedy exchange of patient medical information, in February two federal agencies goosed the health care industry with a pair of proposed regulations. The regulations—one issued by CMS and the other by the Office of the National Coordinator for Health Information Technology (ONC)—go after some of the main barriers to sharing information: conflicting technical standards and the reluctance of some providers to share data because in health care, data is a treasured asset, more often hoarded and hidden than shared.

The new rules would require health plans working with federal programs to move ahead right away with allowing their databases to connect with consumer-facing apps.

They would also put some teeth into rules against “information blocking”—providers hanging on to patient information for their own financial gain. They could light a fire under hospitals, medical practices, and health plans by requiring them to make it easy for patients to get their own data electronically.

The rules are lengthy and complex, going on for hundreds of pages, but nothing in them is a big surprise. They carry out what Congress mandated in 2016 in its 21st Century Cures Act, a catch-all bill that also included language to further “interoperability.”

Ben Moscovitch

ONC’s attempt to remove some of the barriers to sharing information is “a key turning point,” says Ben Moscovitch, of the Pew Charitable Trusts.

Advocates of interoperability (which is pretty much everybody but a few naysayers with privacy concerns) say they welcome the CMS and ONC proposals. “I view these rules as pretty groundbreaking,” says Anne Phelps, U.S. policy and regulatory leader at Deloitte consulting. “They contain very laudable goals. The idea is that patients will have more ... access to all the information about them, whether that’s claims information or medical records, so as they move around the health care system they are able to share that with every touch point.”

Ben Moscovitch, who directs the Pew Charitable Trusts’ health information technology initiative, calls the ONC proposal “a key turning point.”

Mike Funk, Humana vice president in the office of the chief medical officer, says the proposed rules will help ease the way for value-based care and the multiple sources of patient information that need to be collected and shared. “You have hospital claims, clinical information, labs, data from personal devices, all collected in the EMR,” Funk says. “Along with the social determinants of health, that provides a longitudinal view of the patient’s health. That’s the great potential we see.”

Unrealistic deadline

It’s not all sunshine and light. Insurers are worried about meeting the 2020 deadline for application programming interface (API) software that will allow their data­bases to share information with third parties, such as mobile apps. The CMS rule requires Medicaid, CHIP, Medicare Advantage plans, and qualified health plans on the exchanges to provide enrollees with immediate electronic access to medical claims and other information, starting in 2020.

America’s Health Insurance Plans (AHIP), the health insurer trade organization, issued a cautious statement that insurers strongly support providing patients with meaningful access to their health information as long as it remains secure and private. But AHIP added that the proposed deadlines are not feasible and would pose significant compliance burdens on health insurers. Standards for the technical part of sharing are still being developed, AHIP said, and once they’re done, insurers will have to build and test new standardized technology and ensure that third parties will be able to connect. All of that takes time.

The rules get into the nitty gritty of making information systems talk with each other and making health care organizations adopt business policies to share patient information. The documents mention insurers only a few times in passing, but health plans would definitely be affected by their approval, particularly in making their data accessible via APIs within a year or two.

Other sections of the rules:

  • Define what kind of patient information must be made available
  • Prohibit information blocking (with seven specific but limited exceptions, such as preventing harm and protecting privacy)
  • Encourage sharing of data through “trusted” exchanges
  • Require payers to provide additional resources on privacy and security
  • Suggest how APIs and apps could be used to extract and transport data for whole patient populations, not just individuals
  • Address how providers and plans can charge reasonable fees for packaging and sending data to other organizations.

ONC also recognizes another sticky problem holding up exchange of information—the ability to know for sure two different records with the same name belong to the same individual. The agency is asking for advice on how to proceed to improve patient matching.

In a separate but related request for information, CMS asked plans and providers to offer ideas about how to share their negotiated rates and costs with the public. Phelps sees that price-transparency rule as something of a sleeper issue that will dovetail with the data-sharing rules.

Another open question is how patient data will be protected as it gets passed from place to place. Particularly concerning is the fact that HIPAA privacy protections apply only to health care organizations, including providers and payers. They don’t apply to third parties that develop digital apps such as Apple, for instance, and are not considered part of the health care system.

A Senate panel’s March 26 hearing on inter­operability ended up focusing largely on this disconnect, with senators and experts alike noting the need to fix the gap.

Pow-FHIR-ful tool

On the optimistic side, the CMS rule also recognizes strides being made by cooperative private sector initiatives such as the Da Vinci Project, which has providers, payers, and heath IT vendors working together to promote specific “use cases” of information sharing to solve stubborn technology problems using a technical standard known as FHIR (also strongly endorsed by ONC). While Da Vinci has been around less than a year, it has already made progress on two use cases: a simple workflow that care providers can use to show that a 30-day medication reconciliation was done for a particular patient on a specific date, and coverage discovery, which allows care providers to request and receive information on health plan coverage requirements at the point of service.

Jocelyn Keegan, the project’s program manager, describes FHIR as “a really powerful tool” that allows developers to create “really great recipes” from a well-stocked larder. “You bring in the smartest people and build the best recipe you can to make pasta,” she explains. “You could also take that base recipe and then make tortellini or ravioli. And you can make sure you get exactly the same pasta as someone else who is making it across the country.”

Da Vinci has several more use cases in development and wants to move fast to get them going, Keegan says.

Insurers are motivated to make these data-sharing technologies work because without them, value-based payment models will stall. “We have competitors sitting side-by-side on calls trying to solve these table stakes kind of issues so the market can compete on differentiating factors, not just how to make data flow from point A to point B,” she says.

Phelps at Deloitte encourages both payers and providers not to look at interoperability as just an IT department problem or a compliance issue. “Look at it from a strategic point of view as well,” she urges. While insurers will first be reading the final rule—potentially out this summer—with an eye to how to avoid running afoul of federal bureaucrats, they will also be thinking about how to make it work for them, Phelps says.

Phelps urges her clients to look at the big picture of where federal health care agencies are pushing the industry, with interoperability and with MACRA’s alternative payment mechanisms carrot-ing and stick-ing providers into measurably efficient care.

“We’ve been talking about these issues for a long time—value-based care, improving quality, giving patients more information,” she says. “This is all a road map of how they want us to do it, where the future of health care is. I’m not saying it’s easy, it’s going to be bumpy and the timelines are short, but these are the goals.”

Leonardo’s list

37 organizations are participating in the Da Vinci Project, an effort to iron out hard-to-solve health IT problems.

  • Allscripts
  • Anthem
  • ATI Physical Therapy
  • Blue Cross Blue Shield Association
  • Blue Cross Blue Shield of Alabama
  • Blue Cross Blue Shield of Michigan
  • Blue Cross Blue Shield of Tennessee
  • Blue Cross of Idaho
  • Cambia Health Solutions
  • Casenet
  • Cerner
  • Cigna
  • CMS
  • Cognosante
  • Edifecs
  • Epic
  • Guidewell
  • Health Care Service Corp.
  • HealthLx
  • HL7
  • Humana
  • Independence Blue Cross
  • InterSystems
  • Juxly
  • MultiCare Connected Care
  • NCQA
  • Oregon Health & Science University
  • Optum
  • Rush Medical
  • Surescripts
  • Sutter Health
  • Texas Health Resources
  • UnitedHealthcare
  • Virence
  • Weill Cornell Medicine
  • ZeOmega


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