Although CMS compliant interoperability regulations continue to evolve, the end-state objective is clear: ideally, all care-delivery partners will work together effectively consolidating, updating and seamlessly sharing data between patients, providers and payers, tools. The adoption of CMS standards, and advancement towards the ideal end-state vision is progressing, albeit unevenly, in the provider and payer ecosystem.
On the provider side, per the ONC 2022 Report on interoperability while significant progress has been made in terms of EHR adoption, the progress of robust health data exchange capability is lagging.
|Electronic Health Records
|Health Information Exchange
(Send, Receive, Find, Integrate)
On the payer side, achieving widespread interoperability remains an ongoing challenge. Factors contributing to the situation typically include:
Legacy system retirement or accommodation;
An organization’s stage of digital transformation;
Uncertainty about interoperability solution requirements and ROI; and
Differing rates of HL7 and Fast Healthcare Interoperability Resources (FHIR) standards adoption.
Research published by Gartner® on May 19, 2023, U.S. Healthcare Payer Interoperability Benchmarks, 2Q23* states: “FHIR data exchange with providers is in its infancy, but ADT and CCDA ingestion is becoming routine – although not necessarily at scale.”
To advance interoperability adoption to provide guidance to Medicare Advantage plans and other payers, CMS recently proposed new rules for FHIR-based data exchange between payers and providers.
The chart below illustrates that while many potential clinical data integration solutions providers may have these potentially CMS mandated technologies slated for inclusion in their IT roadmap for eventual release, Health Chain offers payers existing foundational solutions in place that can be easily enhanced to meet evolving requirements.
||Proposed CMS Rule
|Current Health Chain Solution
|FHIR-based Patient Access Application Programming Interfaces (APIs)
||Health Data & Claims Data
- Adjudicated claims (including provider remittances and patient cost-sharing)
- Encounters with capitated providers
- Clinical data, including laboratory results, as maintained by the payor.
|Omega Patient Access App
|Prior Authorizations (PA)
- PA status
- The date the PA was approved or denied
- The date or circumstance under which the PA ends
- The items and services approved
- The quantity used to date under the PA excluding PA decisions for drugs
||Data Available to Patients Even After Changing Payers
- Claims and encounter data (excluding cost information)
- Data elements identified in the USCDI version 1
- Prior Authorization requests
|Payer to Payer (P2P) Hub
*GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.
To learn more about how Health Chain is helping payers and providers deliver value-based care through advanced data integration and data accessibility platforms, please contact us.