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Interoperability and the Patient Access Final Rule - are you ready for it?

Over the last two decades of the internet and smartphones, we have created a gateway to accessing what feels like unlimited knowledge.

Looking for a new healthy recipe that your kids will actually eat? Easy.

Maybe you want a video to help you finally learn how to play that dusty guitar sitting in your office? No problem.

Perhaps you’re trying to compare the latest and greatest tech before you buy it? Look no further.

Endless knowledge constantly flowing right to your fingertips from any source in the world.

Well, almost endless. Individual’s wanting to access his or her personal healthcare data has historically been a different story. Patient data has existed in silos – single pods of information, only accessible one at a time. Every primary care doctor, specialist, hospital, and urgent care has its own silo for every patient they see, and the information remains in each silo unless requested to be shared. A patient logs into one member portal for results on bloodwork, another portal for the notes of a recent specialist visit, and another application for information about his current medications. And on and on this goes – a patient can access his or her information, but not all of it in one moment with a single click.

But all of that is about to change, leaving many in the healthcare ecosystem wondering if we are ready for this shift.

The Interoperability and Patient Access Final Rule

Back in May 2020, the Center’s for Medicare and Medicaid (CMS) issued the Interoperability and Patient Access final rule with the focus on completely changing how patients have access to their own health and medical data. The goal laid out by CMS is this: to give patients easy access to and therefore more control over their own medical data through interoperability.

The idea behind this ruling makes sense. If we can have 300 ways to quinoa on a single Pinterest page, why can’t patients have all their data hosted in a single place as well? So many other industries have capitalized on hosting information in one place with many doors. If a patient could see every medication he has been prescribed from all of his providers, every diagnosis he's received and all the recommendations he has for any risks he faces, he is at the center of his own care and empowered to make educated choices to manage his own health.

While this ruling has not been enforced since its announcement, CMS has been leaving breadcrumbs that leniency on this ruling will soon be a thing of the past. The Interoperability and Patient Access Final Rule is not an option, and payers and providers need to be ready for this huge change in healthcare.

But, what about the people whose responsibility it is to adhere this rule? What does this ruling mean for them? And what do they need to be ready for?

Interoperability: Ending the Silo Approach

To understand who these ruling impacts and what is being asked of them, we first need to discuss a critical word from this ruling: interoperability.

Oxford Languages defines interoperability as “the ability of computer systems or software to exchange and make use of information.”

Imagine you’re in another country, one that you don’t speak the language. You want to communicate with a local, but she only speaks her language. You pull out your smart phone, open Google Translate and it begins translating your conversation in real time. Suddenly, two people who would have not been able to communicate have a successful exchange of information.

That’s interoperability. A pathway of communication between two systems and the ability for them to understand each other. For systems who once could not work together, interoperability brings them together

Up until now, there has been little to no interoperability within the healthcare ecosystem. A specialist’s EHRs doesn’t share data outside of its practice. A payer doesn’t share claims data outside its member portal. And there is no single source of truth that hosts all of someone’s health information in one place. To create this single source of truth, payers and providers are finding themselves needing to adhere to the Interoperability and Patient Access Final Rule, including

  • Medicare Advantage (MA) plans

  • Medicaid state agencies

  • Medicaid managed care plans

  • Children’s Health Insurance Program (CHIP) agencies

  • CHIP Managed Care entities

  • Issuers of qualified health plans in Federally-Facilitated Exchanges, except for stand-alone dental plans.

The new ruling states, “patients should have the ability to move from payer to payer, provider to provider, and have both their clinical and administrative information travel with them throughout their journey” and with the new interoperability standard using the Patient Access API, a patient should be able to choose and use a commercial application where they can find his data.

Apple Health. Google Health. Samsung Health – these are all apps downloadable to a smartphone and all avenues where, according to the new standard, a user should be able to see every facet his or her health care data, historic and current.

Every doctor visit, every prescription, every claim, all accessible with the simple logging into an application. And your current system must be ready to start communicating to all of them.

Along with this ultimate hub of patient data for each person, users must also have access to a provider directory, also provided by your organization.

Currently, to access a provider directory, a member or patient needs to log in to that specific payer or patient portal and then begin the search. Again, we see no set standard for how these provider directories look or operate – each directory is unique to its owner. With the Interoperability and Patient Access Final Rule, payers and providers will need to share their provider directories on the same commercial app as the patient data.

A user could login to Apple Health, see PCP visits, test results and care management notes and decide to see a specialist as recommended. Within that same session, the user loads up the provider directory for his area and find a specialist in network. The whole interaction happens in a matter of minutes and the patient is in control of each step.

Sounds futuristic, right?

We’ve been taking the silo approach to healthcare data for so long, it’s hard to imagine anything different. But with the implementation of FHIR and the Patient Access API, CMS is taking this into reality. Interoperability Starts Now

While 2020 was the original launch year for the Interoperability and Patient Access Final Rule, the pandemic put the world on hold, along with the enforcement of the new ruling. In 2022, CMS announced that it would exercise discretion in its enforcement of the ruling with payers. But here we stand at the tail end of 2023 and enforcement is here. Compliance for this ruling may feel overwhelming. But it doesn't have to be. We at Vernier are the solution. We are an end to end answer to the Interoperability and Patient Access Final Rule. Within 90 days, organizations will be CMS compliant with minimal heavy lifting on their end. Through Vernier, health plan members with have access to all of their health information, including all adjudicated claims within 24 hours, through any commercial platform. For the entire CMS Interoperability and Patient Access Final Rule, click here.

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