Healthcare CMS Interoperability and Patient Access | Agnos

Policy changes designed under MyHealthEData Initiative were meant to improve patient access and advance electronic data exchange and care coordination across the healthcare system. The objective was to bring the focus to a value-based healthcare system that offers patients some level of control over their health data.

The MyHealthEData Initiative

The focus on interoperability became a pressing issue for the United States healthcare system since the US Department of Defense and Veterans Association were identified as not being able to interoperate and seamlessly exchange patients’ electronic health records from their members. To overcome such issues and offer better healthcare, a strict set of rules was proposed to drive the evolution of healthcare digital transformation by increasing transparency without compromising data integrity.

As part of the MyHealthEData initiative, the final rule (CMS-9115-F) focused on driving interoperability and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

In this particular case, the ruling applied mostly to payers and their ability to integrate, standardize and securely expose patient data. 

As a whole, the new regulation comprised of different aspects of Interoperability including:

• Patient Access API (applicable January 1, 2021)
• Provider Directory API (applicable January 1, 2021)
• Payer-to-Payer Data Exchange (applicable January 1, 2022)
• Improving the Dually Eligible Experience by Increasing the Frequency of Federal-State Data Exchanges (applicable April 1, 2022)
• Public Reporting and Information Blocking (applicable late 2020)
• Digital Contact Information (applicable late 2020)
• Admission, Discharge, and Transfer Event Notifications (applicable spring 2021)

Given the challenges posed by Covid-19, CMS offered enforcement discretion for the Patient Access API and Provider Directory API policies for MA, CHIP, Medicaid, and QHP issuers. 

What does this mean for Payers? 

This ruling means that non-compliance or inability to provide mandatory information may be interpreted as blocking the information exchange and this can lead to penalties.

According to the Cures Act, providers and vendors that have engaged in information blocking and have submitted a false statement of compliance would become subject to civil monetary penalties of $1 million per violation.

So, what does it take to become compliant, and is it a time-consuming process?

According to the CMS, there is a huge effort involved in becoming compliant with the new policies:

• “(...) we estimate 12 months of work or 2,880 hours (1,440 hours * 2) for administrators and network architects.” 

And when you add in the rest of the professionals needed to complete the project it comes to almost three-quarters of a million dollars.

• “For a low estimate, the first-year implementation will require a total of 8,400 hours per organization at a cost of $718,414.40 per organization (this number is obtained by adding the products of hourly wages and hours required (…) ) ”

How to get started?

Here's a checklist of items to keep in mind while preparing for compliance with CMS-9115-F:

• Payers are required to make a patient’s claims and encounter data available through patient access API. 
• Payers are also required to make a patient’s clinical data available including, but not limited to, conditions, medications, allergies, and lab data.
• Under this rule, MA organizations, Medicaid FFS programs, CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities are required to make provider directory information available via the Provider Directory API. This API must be accessible via a public-facing digital endpoint on the payer’s website.
• Part D Medicare Advantage plans must also make formulary information available via the Patient Access API. Additionally, Medicaid and CHIP FFS and managed care must make preferred drug lists available.

Who can provide policy guidance? 

CMS provides rules, standards, and guidance throughout the entire process including both technical and business guidance. If you want to embark on the journey of healthcare interoperability, you can find details on the CMS website that includes:

• The technical standards for data transmission
• The business standards for coding business objects such as “adjudications codes”
• Vocabulary rules
• Security rules around authentication and data handling
• The objects and how they relate to each other
• Implementation guides and downloadable sample implementations 
• End-to-end documentation

Healthcare Interoperability and Agnos 

Agnos has been working with patient data interoperability since 2017 and has extensive experience with FHIR and also HL7 v2, integration with Epic / Cerner, and CMS Blue Button 2.0. We have developed provider-facing applications for both single specialty and multi-specialty hospitals. The most recent product was built in partnership with Inovalon. It is a mobile-friendly application that seamlessly integrates with the payer’s website using FHIR APIs to securely display patient coverage, claims, and clinical information. 

Agnos brings global turn-key teams of highly skilled healthcare technology practitioners including Product and Project Management, Business Analysis, UX Design, DevOps, Quality Assurance, and Software Engineering.

Let Agnos help you in your interoperability drive!

References:

• Policies and Technology for Interoperability and Burden education
• Interoperability and Patient Access Fact Sheet
• US government doubles down on health interoperability at HIMSS
• PDF for reference