Payer

How Payers can enable member-centered interoperability using a FHIR enabled Data Activation Platform

Sandeep Gupta
Tue 28 July 2020
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Healthcare consumerism is growing at an unprecedented rate, and health plan members are keen to access their healthcare data. When the data is relayed in a way that is easy to comprehend, with limited intricate technical terms, members can make prudent choices. Imparting information does not only empower the members, but it is also mutually beneficial. Along with healthcare data, if payers provide members with additional information about other health plans with lower out of pocket expenses, lower premiums and more coverage they can enable them to pick the most suitable plan and thereby instill brand loyalty. 

An informed and savvier member can potentially contribute to improving the quality of care, reduce excessive resource utilization and decrease costs. When members are in the thick of their healthcare journey, they can pinpoint if there is any duplication of tests and they can have educated conversations with their physicians about their medical history. Some members might even internalize their health data and pursue improved behavior and lifestyle choices apart from making informed decisions about whether and where to seek care.

Interoperability challenges in patient access to healthcare data

There are endless benefits of providing members with their healthcare data and guiding them in their decision making. However, until recently, there have been limited initiatives toward patient data access. There are certain interoperability challenges that stand in the way. Health IT solution providers switched from legacy, server-based systems to cloud-based, opening doors to incremental success in interoperability. However, there are some significant challenges yet to be resolved:

  • Different interfaces for different systems combined with a lack of standard and basic schema of EHRs results in every EHR being tackled separately. 
  • The growing number of healthcare data systems for care management, population health management, and others used in a hospital setting has created challenges in reconciling the outcomes. 
  • Lack of a uniform data exchange standard leads to sending and receiving data and can result in unforeseen consequences. 
  • An increase in cyber attacks in healthcare has warranted a security and confidentiality overhaul to protect patient health information. 

Initiatives by CMS and ONC to facilitate member-centered interoperability

To put an end to the interoperability barriers, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS) each issued rules to empower patients and improve data exchange arrangements under the 21st Century Cures Act. The rules support increased interoperability and facilitate patient access to electronic health information. The amendment will also strengthen the MyHealthEData initiative, allowing patients to manage and make their own healthcare decisions.

Implications of payer interoperability mandates per CMS 9115-F

The ONC rule has made it mandatory for healthcare insurers to share electronic health data with patients, which will enable them to participate more in their healthcare decisions. Members should be able to link any third-party application with their integrated health plan information and EHR data through a standards-based API. These APIs will have to use FHIR R4 for data access. Having access to their health data, patients can change providers if they aren’t satisfied with the care they receive. Patients can even change plans if the care experience does not meet their expectations.

However, transmitting information across third-party platforms, especially sensitive healthcare data, needs to be approached with the utmost caution. The rule compels API developers to leverage the highly secure protocol, OAuth 2.0, putting privacy and security concerns to rest. ID Connect, an overlay developed for the OAuth 2.0 protocol, allows authentication of health plan member information utilizing an authorization server. 

Payers regulated by CMS also have to make provider directory information accessible publicly through standards-based API. 

Leveraging Innovaccer’s FHIR-enabled Data Activation Platform

Innovaccer can help payer organizations achieve member-centered interoperability and provide greater access to healthcare data with its one-of-a-kind FHIR- Enabled Data Activation Platform. 

The platform can help payers accomplish the following:

  • Interoperability beyond compliance needs: Beyond support for Patient Access and Provider Directory APIs, and other CMS requirements, the platform supports customized workflows and cross-system connectivity.
  • Fully managed, developer ready deployment: Its managed services model ensures outcomes are achieved, with an interactive developer sandbox and a marketplace hosting environment to support the true platform ecosystem. 
  • Two-way interoperability: Payers can directly integrate data from EMRs, and export it through FHIR or any standard format for true bidirectional exchange of high-quality data.
  • Enterprise security: Payers can leverage PHI/PII security beyond OAuth and Open ID authentication, including ACL and security-specific attribution for access control, as well as HIPAA, ISO compliance with regular compliance vendor validation.

Future of patient access to healthcare data

Enabling patients to take control of their healthcare journeys is a great way to fulfill quality and cost objectives while accelerating the momentum of the value-based care movement. CMS will add more fuel to this movement. Beginning on April 1, 2022, states will be required to share Medicare and Medicaid enrollment data with its beneficiaries daily. Not only will the accessibility of this data ensure better care coordination for the member population, but it will also allow patients to monitor the services they receive and the costs they incur. These rules will eventually weed out inefficient practices and establish cost transparency and fair competition in the healthcare space.

To learn how to improve member-centered interoperability with the industry’s most comprehensive Healthcare Data Platform for payers, click here.

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