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Challenges

• Patients find it extremely painful to constantly provide their medical information to multiple Providers. They also face difficulty accessing Patient information, inefficient medical and claim processes, managing care gaps and risks, and misdiagnosis.
• Payors are challenged by accessing Patient information across varying Providers, the lack of technical interoperability between Payors and other Payors, managing Patient care gaps and risks, data standardization, and data integrity.
• Providers are challenged by accessing patient information across varying Providers and Payors. They need to balance the pressures of providing the best care for Patients with the ever-increasing complexities of administrative, clinical, and regulatory standards, and requirements.

All of this results in poor Patient experiences and outcomes.

CMS rules, standards, and guidance

The U.S. government responded to interoperability and Patient access challenges negatively impacting Patient care outcomes by announcing that the CMS-9115-F ruling (CMS Interoperability and Patient Access) was to take effect in 2020 as part of the MyHealthEData Initiative.

• Payors are required to make a Patient’s claims and encounter data available to Patients in a user interface.
• They are also required to make a Patient’s clinical data available. This includes but is not limited to, conditions, medications, allergies, and labs.
• 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 Payor’s website.
• Part D Medicare Advantage plans must also make formulary information available via the Patient Access API. In addition, Medicaid and CHIP FFS and managed care must make preferred drug lists available. 
  
  For more information, you can check the CMS interoperability regulation guidelines.