Healthcare Interoperability Benefit #3: Improved and Consistent Patient Healthcare

Jun 29, 2021

In final rules issued on March 9, 2020, the CMS Mandate for healthcare interoperability requires a patient to have instant access to their medical information via a third-party application. Effective July 1, 2021, convenient patient access to personal medical records as mandated by the Patient Access Rule enables patients to directly engage their own treatment plans, and access important health information, real-time. Patients can also directly share their records with new providers, who can then access the medical information to provide quality care from a holistic perspective immediately.

The Payoff

There’s a huge payoff to the mandate in the name of technology, as it gives developers access to healthcare information to easily develop third-party apps that are beneficial to patients. Patients will be able to access their longitudinal medical records or utilize apps that specifically help them monitor chronic conditions. For example, consider the potentially life-saving benefit found in a smartwatch, which can submit an EKG directly to your cardiologist based on the readings detected from the watch.  This is accomplished via third-party apps, easily accessible to patients.

FHIR® and API, Oh My!

There are some complexities in the build-out required to exchange the information gathered from various source systems securely. However, the rule requires specific areas for data sharing and compliance with specific technical standards, using HL7® FHIR® Release 4.0.1 (FHIR R4) as the standard for exchanging healthcare data. FHIR® standards provide consistency in how the data is designated and arranged while allowing the real-time exchange of important health information. Once the data is standardized, it’s exchanged via an Application Programming Interface (API), a software intermediary that allows two applications to talk to each other. In other words, the FHIR® standard “extracts” the data, and then that data is delivered via an API.

FHIR® standards have been utilized on the provider side for several years. However, the CMS Mandate now brings the opportunity to health plans to leverage solutions like our CAVO® platform that streamlines the record exchange process. Here at TREND, our solutions are connected to multiple EMRs that allow us to successfully extract clinical knowledge and convert unstructured medical records into FHIR standards. These standards allow health plans to provide important medical information to their members via API and apps.

Generating An Automatic Feedback Loop

One of the great benefits of the interoperability mandate is the possibility for streamlined and consistent sharing of important medical information payer to provider, payer to payer, and payer to patient, ultimately benefiting the patient.

Giving medical information access to developers allows them to develop apps that benefit providers and plans that create an automatic feedback loop via automation. Da Vinci FHIR® Documentation Template Rules (DTR) specify how providers can execute payer rules to meet documentation requirements. Using this FHIR® standard reduces manual data entry, reduces provider burden, and ensures that payer documentation requirements are fulfilled.

The DTR works in conjunction with another FHIR® Implementation Guide (IG) called Coverage Requirements Discovery (CRD). This IG queries payers to notify providers of documentation requirements for specific items such as medications, procedures, and other medical treatments. The query allows the payer to return Clinical Decision Support (CDS) cards to the provider, containing information about the documentation requirements.

The failure of providers to conform to payer requirements has enormous financial and quality of care implications on the healthcare system, which ultimately affects the patient by increasing out-of-pocket expenses, lacking consistent treatment, having to make changes to already ordered therapy, and even increasing the number of office visits. By utilizing standards like DTR, CRD, and others, an automatic loop of information is generated, assuring consistent care is maintained and meeting insurance coverage expectations and lowering health costs.

The Art of Collaboration

CMS is leveraging a collaborative industry effort to streamline workflow access to coverage requirements in an effort to reduce provider burden, reduce improper payments and appeals, and improve provider-to-payer information exchange. The payout for items and services is only rendered when the provider’s medical record documentation meets all payer coverage and coding requirements. There are several APIs and sharing standard opportunities that commercial plans should consider utilizing in order to deliver on their end of the collaboration that provides information to their members while also diminishing provider burden.

Enter the exciting world of APIs:

  • Documentation Requirement Lookup Service Initiative (DRLS) API. Although in its infancy, this API will include a list of items and services for which prior authorization is required. In simple language, this will help providers know what documentation is required from a specific payer for procedures and treatments at the time of service within their EHR or practice management workflow.
  • Prior Authorization Support (PAS) API. This new developing API will allow providers to submit prior authorization requests and receive payer responses immediately. The exchange of this information maintains HIPAA compliance and assures that all treatments administered adhere to the patient’s policy coverage while meeting payer authorization requirements.

These APIs will shorten prior authorization timelines so that a patient can receive consistent and approved treatment for both urgent and standard requests.

It’s About The Patient

The Patient Access Rule is designed to give patients their health information via third-party apps in a format that the patient can easily understand. While the onus is on payers in the CMS requirements to standardize clinical data and build out systems to meet all the interoperability requirements, benefits will be felt across the healthcare ecosystem – with patients empowered with data throughout their healthcare journeys.

  • Patient Access API. This API allows the exchange of medical information between a payer and their member, via 3rd party apps, and will include: prior authorization details, share claims, clinical data, and more.

For patients who have experienced challenging health issues that have required evaluation and/or treatment from additional or various specialists, or changing health plans, gathering their healthcare data can be overwhelming, if not seemingly impossible, at times. This rule prevents arbitrary information blocking of data, meaning it limits the ability of third parties to silo data covered in the mandate, giving patients control over their health treatments. In addition, this means that when payers and providers work together, utilizing the incredible technological advances of FHIR® standards and APIs, everyone wins…including the patient.

We’re on the precipice of some of the most exciting opportunities to streamline our entire healthcare system, improving the working relationships between payers and providers while diminishing administrative burden, lowering health costs, and providing patients with consistent and better health care. The CMS Interoperability Mandate is leveraging technology to massively improve our systems, and ultimately, our health.

As a technology company focused on improving processes and efficiently exchanging clinical data, we ensure that interoperability requirements are met with health plans, members, and EMRs. TREND is fully supportive of patients having access to their health information, as well as the ability to share it in real-time with their health plans and care providers, as needed.