HEALTH CHAIN INSIGHTS

Future Proofing EHI Interoperability for Payers & Providers

July 12, 2023 | 5-minute read

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.

Focus	Hospitals Non-federal acute	Providers Office-based physicians
Electronic Health Records	96%	< 80%
Health Information Exchange (Send, Receive, Find, Integrate)	62%	16%

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 1/1/2026 Implementation	Current Health Chain Solution
FHIR-based Patient Access Application Programming Interfaces (APIs)	Health Data & Claims Data Information includes: 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) Information includes: 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
Payor-to-Payor APIs	Data Available to Patients Even After Changing Payers Information includes: Claims and encounter data (excluding cost information) Data elements identified in the USCDI version 1 Prior Authorization requests	Payer to Payer (P2P) Hub

Proposed CMS Rule
1/1/2026 Implementation

Current Health Chain Solution

FHIR-based Patient Access Application Programming Interfaces (APIs)

Health Data & Claims Data
Information includes:

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)
Information includes:

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

Payor-to-Payor APIs

Data Available to Patients Even After Changing Payers
Information includes:

Claims and encounter data (excluding cost information)
Data elements identified in the USCDI version 1
Prior Authorization requests

Payer to Payer (P2P) Hub

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.