The Interoperability and Patient Access Rule is Here

September 18, 2020

Here’s what you need to prepare for

There’s nothing like landmark regulation, released during a time of great uncertainty.

On May 1, 2020, the clock began ticking for health plans, providers, and IT developers to implement the Interoperability and Patient Access Rule. For all of us struggling to cope with the COVID-19 “new abnormal” there is more at stake with this coming wave of interoperability than may meet the eye. Now is the time to plan and take action.

What is the Interoperability and Patient Access Rule and why does it matter?

Put simply, individuals will have the option to take greater ownership and accountability for a broader and consolidated set of electronic health information (EHI) and, with individual consent, share that information with their health plan and providers. This will be supported by the creation of a system of regionalized data brokers who arbitrate the exchange of electronic health information with and from CMS-regulated health plans, providers, and IT developers according to defined patient consent parameters. This new approach – the Trusted Exchange Framework and Common Agreement (TEFCA) – is still being considered by regulators but will likely follow the National Information Exchange Model (NIEM), a proven federal approach for the exchange of data within and across industries, including Homeland Security.

This means a likely future in which:

  1. Data brokers (Qualified Health Information Networks- QHINs) will arbitrate the parameters for all patient EHI transfer – including B2B from developers to health plans/providers
  2. Federally certified IT developers will have access to the same core data set as health plans and providers and be focused on creating value for patients through the development of new digital products that will enable more transparency, efficiency, and choice
  3. Individuals will move through the healthcare ecosystem with their EHI based on tiered levels of consent, with a core data set that is opt-out for exchange, but with higher tiers of confidential EHI that patients must opt-in for sharing.

Make no mistake, the new rule will create disruption in the healthcare marketplace. Federal regulators are doubling down on the idea that creating a more open system of exchange to a publicly owned virtual clearinghouse of claims and clinical data will force competition and innovation that is good for healthcare consumers. When the wave breaks, the healthcare landscape will look very different from today.

What does this rule mean for patients?

At its core, this rule is about transparency and giving individuals the ability to move across health plans and providers and have both their clinical and administrative information move with them and be accessible throughout their journey. Bottom line, certified IT developers will empower individuals to actively engage in their healthcare in an unprecedented way, through a seemingly limitless set of new use cases, such as these, at the highest level:

  1. Before patients decide where to buy insurance coverage, they can see if their doctor is in a health plan’s clinical network, and have a better way of comparing across multiple health plans offered by a variety of payers as a means of comparison shopping
  2. Through a single application, patients can access current and historical health insurance data, and clinical data from all visits, regardless of a doctor’s EHR so the patient can see things like scheduled appointments, lab results, diagnoses, referrals, prescriptions, authorizations, deductibles and copays.
  3. When a patient arrives for a new specialist appointment, they do not need to fill out the same paperwork for the umpteenth millionth time and instantly transmit 5+ years of cumulative EHI through an authentication process between their phone and the specialist’s EHR
  4. Patients, providers and health plans will have better information to navigate the health care system, and through this, reduce the risks to the patient that come from incomplete information.

Why is interoperability particularly important to health plans?

Historically, health plans (and providers) have been understandably reluctant to share information both for competitive and regulatory reasons. However, as the new rule is implemented, consumers will exercise increasing control as to how and with whom their EHI is shared. This will usher in unprecedented risk including risk to privacy as third-party developers are able to directly access patient data, and risk to monetization of data with the rise of new applications that circumvent traditional regulatory gatekeeping policy. Understandably, the costs to establish, maintain, audit, and retain EHI will be borne by health plans, providers and potentially patients.

To stay relevant, health plans will need to embrace this new reality via a consumer-focused strategy and not just check the box.Survival requires not just getting on board with these newly defined needs but getting out in front of them by putting the member at the center of value creation, while transforming how you track and manage data. This may take some deep, authentic introspection, and asking questions like:

  1. How do we seamlessly identify and capture member consent for data exchange so that we can remain viable for my members and have the information to support high quality care?
  2. Where do our members and their families most often get stuck trying to navigate care and advocate for themselves—both within and outside our clinical network—and how can we help?
  3. How do we safely and securely support the right level of transparency for our members to get the right care at the right time?
  4. What customer experience tools and incentives can we provide our members and group plans to help us prioritize and better target our population health programs?
  5. How can we use the new rule to build a relationship with providers that puts the patient at the center and moves us away from being at odds?

What to expect

In the near term, the industry will continue to lobby for scaled back regulatory requirements and a longer implementation timeline​. There will be operational pressure for health plans and providers to comply by adopting new technologies, workflows and governance models​, as well as new investment and rapid growth of third-party developer solutions combined with a race to prototype, test and market these products.

Longer term impacts will see:

  1. Incremental improvements in patient access to EHI and provider directory data leading to a higher level of discernment in customer product choice
  2. Higher precision in matching patients to clinical history, medical needs, social determinants of health and physical/digital location; significant data security risks ​and more reliance on strategic partnerships and trusted health information networks/exchanges for reliable sharing of EHI
  3. Increased market competition stemming from a need for digital products and strategies to attract and retain patients and networks​
  4. Improved care coordination, continuity and quality of care resulting from a portable, digital patient health record, better data standardization and improved B2B interoperability ​
  • Accelerated adoption of value-based payment models resulting from a growing cumulative patient record and corresponding ability to more accurately measure patient outcomes and risk stratify needs (medical, behavioral and social determinants)
  • Voluntary commercial insurance adoption of standards and rules
  • Further industry consolidation.

How should you respond?

First, it’s important to understand where you’re at and where you need to go. This includes launching a readiness assessment, governance, program planning and execution. Whether you’re a family practice in a retirement community or publicly traded insurance carrier with an MA plan, you’ll need to evaluate options, ensure you meet the requirements, and where possible, align resources to pivot to take advantage of the changes coming.

Key drivers for health plans

Following are some practical insights on how to approach this new challenge. Start with:

Customer Experience

Ensure your brand strategy is centered on trust and establishes an authentic emotional connection with your members. Every member acquisition and retention touchpoint should be crafted with care, not only providing the information required but finding ways to anticipate member and prospective member needs. Also be sure your digital products and services are effortless to use, removing all points of friction and finding opportunities to increase engagement by personalizing content via insight from customer data. A well-designed customer experience will build brand preference, increase conversion and result in long-lasting relationships.

Strategic Partnerships and Vendor Management

Understand your health information exchange and ensure you’re informed, proactive and strategic in how to collaborate with Qualified Health Information Networks (QHINs). Don’t just turn on FHIR APIs as a check-the box exercise. Develop short, medium, and long-term strategies to identify, vet, and partner with ONC-certified third-party developers to capitalize on innovative ways to improve patient experience and support better care coordination, both during a pandemic and in the new normal. Establish partnerships with QHINs and certified developers that enable a shift from seeking to control customer data, to a stewardship model that empowers member access. Prioritize digital product development and vendor selection roadmap to remain relevant/viable as a business.

Regulatory Compliance and Data Security

Have proven-effective compliance policies to inform third-party developer vendor selection.Ensure you have the right people, processes and technology for effective delegated entity oversight of interoperability technology vendors. Include new governance models for member consent, data sharing, patient privacy and data security, and monitor and audit systems and processes for:

  1. Data validation/verification
  2. Patient privacy
  3. Data security
  4. Information Blocking
  5. 3rd party IT developer / delegated entity oversight

Operational Integration as a Competitive Advantage

Have best in class operational and technological capabilities to support members in their care journey and operational and technological capabilities to support providers in care coordination. Build in the ability to adapt quickly to evolving federal trusted exchange requirements and ensure your member enrollment processes capture data-sharing consent. Include rapid risk stratification and predictive modeling at member enrollment and take a proactive approach to member outreach, coordination and care management. Improve quality measurement to direct Value Based Care VBP strategy and cost-containment investments.

Understanding the trusted exchange and how to work with it can provide you with a key strategic advantage. To stay relevant in the new normal, understand the evolving trusted exchange and interoperability rules and develop the infrastructure to integrate them into your business, invest in partnerships that enables best in class data as service to drive customer experience and optimize your relationship with trusted exchanges.

Aaron Lones, Susan Yeazel and Susan Kanvik are consultants with Point B, a consulting company that helps organizations in the areas of customer engagement, growth investments, workforce experience and operations excellence.

Lones’ 20 years of healthcare leadership experience includes an extensive background leading customers through high stakes, strategic initiatives. He’s led an array of programs in primary and dental care, behavioral health, care transitions, public/private partnerships, capital projects and population health.

Yeazel is an accomplished health insurance operations and strategy professional with extensive experience in the delivery of imperatives critical to the success of the business. She excels in strategic planning, design, development and implementation of integrated business and technology solutions and specialize in core health care operations including enrollment, eligibility, membership transactions, contact center, financial operations and renewal processing.

Kanvik has more than 40 years of experience in the health care industry with a focus on information technology and data/analytics to improve outcomes and operations. She serves as an advisor to healthcare clients nationally on health IT, data governance and BI/analytics.