Interoperability is a complex and challenging thing for the healthcare industry today. Different information systems, devices, and applications can access, exchange, integrate, and utilise the data beyond the boundaries to optimise global health needs
This is an exclusive interview conducted by the Editor Team of CIO News with Ankit Kumar Agarwal, Director – IT Delivery Services at NewWave Telecom & Technologies Inc.
The US healthcare system is a complex network of private and public institutions that provide medical care and services to the American population. The system is often described as a hybrid model, with a mix of private and public healthcare providers, health insurance plans, and government programs.
The healthcare system in the US is often criticized for being fragmented, inefficient, and expensive. Unlike many other developed countries, the US does not have a universal healthcare system, and many Americans are uninsured or underinsured. Healthcare costs in the US are among the highest in the world, and medical debt is a significant problem for many Americans.
According to data from the Centers for Medicare and Medicaid Services (CMS), national health expenditures in the US were $3.8 trillion in 2022, or $11,582 per person. This represents approximately 17.7% of the US gross domestic product (GDP). Healthcare spending in the US has been increasing steadily over the years and is expected to continue to rise in the future.
The US healthcare system faces several challenges, including:
- Access to Healthcare: Despite being one of the wealthiest nations, many Americans do not have adequate access to healthcare. Around 30 million Americans are uninsured, and many others are underinsured or have limited access to healthcare due to cost or geographic barriers.
- Rising Costs: Healthcare costs in the US are among the highest in the world, and they continue to rise. This puts a significant financial burden on individuals, families, and the government. The high cost of healthcare also makes it difficult for employers to provide comprehensive health insurance to their employees, which can result in more Americans being uninsured.
- Inequities and Disparities: Healthcare inequities and disparities are persistent problems in the US. There are significant differences in health outcomes between different racial and ethnic groups, income levels, and geographic regions. These disparities are influenced by factors such as access to care, social determinants of health, and implicit bias in the healthcare system.
- Lack of Health Data Interoperability: The healthcare data is fragmented, and the lack of standards for data sharing across various stakeholders makes it challenging to provide improved health outcomes for the members and reduce the significant investment in healthcare services.
Our research team analysed the current trends and referenced research material from various industry experts. We referenced the article from “Ankit Kumar Agarwal” (dated December 12, 2022). Challenges Faced by Healthcare Organizations in 2022 – This article was published at https://distilinfo.com/healthplan/challenges-faced-by-the-healthcare-organizations-in-2022/
We also referenced the article from “Ankit Kumar Agarwal” (dated December 22, 2022). 4 Data Security Challenges for Healthcare Organizations in 2022 – This article was published at https://hitconsultant.net/2022/12/22/data-security-challenges-healthcare-organizations/
Need for FHIR based Health Data Interoperability
When the internet was in its infancy, computer systems were required to have their own protocols for interacting with and reaching the networks, as there was no such thing as a universal standard for how their systems were different. Every time disparate systems needed to communicate with another system, each one needed special software. System developers need specialised and unique software for each server type. For disparate systems to establish communication channels, new stacks needed to be written for each purpose. These processes often obstruct interoperability when networking is at its initial stage.
The US federal government set up a standard to establish interoperability between the systems. The idea was to ease the flow of network communications across multiple systems, arrive at the right destination, and prevent obstacles in the early networking stage.
Healthcare today is at a similar stage, just like the early internet networking years. Data is the king in almost every business, organization, and entire process flow. When seen through the lens of the healthcare industry, data is a backbone for making better clinical decisions, processing claims, and managing critical record systems. When we talk about critical record systems, it doesn’t always make it easy to share the information between the providers, labs, and payers.
Interoperability is a complex and challenging thing for the healthcare industry today. Different information systems, devices, and applications can access, exchange, integrate, and utilise the data beyond the boundaries to optimise global health needs.
We referenced the article from “Ankit Kumar Agarwal” (dated December 19, 2022). US Health IT within the Context of Interoperability, FHIR, and Data Exchange – This article was published at https://distilinfo.com/healthplan/us-health-it-within-the-context-of-interoperability-fhir-and-data-exchange/ . This article beautifully lays out the ground rules for the FHIR-based healthcare interoperability journey.
There are various rules and regulations that have a direct impact on FHIR-based healthcare interoperability.
The Burden Reduction Rule paves the path for healthcare interoperability.
Patients tend to receive care from multiple providers, leading to fragmented patient health records where various pieces of an individual’s longitudinal record are locked in disparate, siloed data systems. With patient data scattered across these disconnected systems, it can be challenging for providers to get a clear picture of the patient’s care history, and patients may forget or be unable to provide critical information to their provider. CMS is focused on breaking down silos and handling the key issues of electronic prior authorization, payer-to-payer data exchange, and payer-provider data exchange to reduce healthcare waste and improve healthcare outcomes.
The Burden Reduction Rule places new requirements on Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS’ drive towards interoperability in the healthcare market. This rule also adds a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS. These policies, taken together, would play a key role in reducing overall payer and provider burden and improving patient access to health information.
The rule requires that, beginning January 1, 2026 (for Medicaid managed care plans and CHIP managed care entities, by the rating period beginning on or after January 1, 2026, and for QHP issuers on the FFEs, for plan years beginning on or after January 1, 2026), impacted payers would be required to make information available to patients via the Patient Access API about prior authorization requests and decisions (and related administrative and clinical documentations), including, as applicable, the status of the prior authorization, the date the prior authorization was approved or denied, the date or circumstance under which the authorization ended, the items and services approved, the quantity used to date, and, if the request was denied, a specific reason for the denial, no later than 1 business day after the payer receives a prior authorization request for items and services (excluding drugs) or there is another type of status change for the prior authorization. Beginning January 1, 2026 (for Medicaid managed care plans and CHIP managed care entities, by the rating period beginning on or after January 1, 2026, and for QHP issuers on the FFEs, for plan years beginning on or after January 1, 2026), impacted payers must make prior authorization information (and related administrative and clinical documentation) available to patients via the Patient Access API for the duration it is active and at least 1 year after the last status change. These proposals would apply to MA organizations, state Medicaid FFS and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs.
In order to meet the January 1, 2026 timeline, the payers would have to implement the key functionality by December 31, 2024, in order to meet certain CMS reporting requirements for the fiscal year 2025. CMS expects that the electronic prior authorization implementation duration for the majority of the plans could be between 18 months and 24 months.
Similarly, it is going to be a time-consuming effort to implement payer-to-payer and provider-to-payer data exchange. It is recommended that all of the plans start the planning exercise in Q1 2023 with a plan to start the design phase towards the middle of 2023 in order to meet the CMS-mandated timelines.
We referenced the article from “Ankit Kumar Agarwal” (dated January 6, 2023). How Burden Reduction Rule Will Transform the FHIR Interoperability Space – This article was published at https://distilinfo.com/healthplan/how-burden-reduction-rule-will-transform-the-fhir-interoperability-space/ . This article provides step-by-step guidance to various healthcare entities on how to implement burden reduction-based interoperability rules and its impact on business outcomes.
21st Century Cures Act and its Impact on Healthcare Interoperability
The 21st Century Cures Act is legislation passed by the United States Congress in December 2016. The act aims to accelerate the discovery, development, and delivery of new treatments and cures for diseases, as well as to improve the nation’s mental health system. It also aims to modernise clinical trials, provide funding for medical research, and speed up the FDA drug and medical device approval process.
The act includes several provisions related to healthcare information technology and data sharing, including:
- The establishment of the interoperability and information blocking provisions, which aim to promote the interoperability of health information systems and prevent information blocking,
- The creation of a national patient identification system, which aims to improve patient matching and reduce medical errors
- The establishment of the Office of the National Coordinator for Health Information Technology (ONC) to promote the development of a nationwide interoperable health IT infrastructure
- Provisions that support the use of FHIR (Fast Healthcare Interoperability Resources) as a standard for exchanging healthcare information
- Provisions that support the use of APIs (application programming interfaces) to enable secure and seamless access to electronic health information
Overall, the 21st Century Cures Act aims to promote innovation and improve patient outcomes by modernising healthcare information technology and supporting the development of interoperable systems that enable the secure exchange of healthcare data.
We referenced the article from “Ankit Kumar Agarwal” (dated February 6, 2023). 21st Century Cures Act and its Impact on FHIR Interoperability – This article was published at https://distilinfo.com/healthplan/21st-century-cures-act-and-its-impact-on-fhir-interoperability/
TEFCA’s Impact on Healthcare Interoperability
TEFCA (Trusted Exchange Framework and Common Agreement) is a framework developed by the Office of the National Coordinator for Health Information Technology (ONC) in the United States to promote interoperability among electronic health record (EHR) systems and other health information technology (HIT) systems. The goal of TEFCA is to facilitate the exchange of health information between different systems and providers in order to improve the efficiency, effectiveness, and quality of healthcare.
TEFCA sets out a set of technical, operational, and legal standards and requirements for the exchange of health information. It also establishes a common agreement between participants in the exchange, outlining the roles and responsibilities of each party. By establishing a common framework and agreement, TEFCA aims to create a more seamless and secure environment for the exchange of health information, which can ultimately lead to better care for patients.
TEFCA is one of several initiatives aimed at improving interoperability in healthcare. Other efforts include the use of standards such as Fast Healthcare Interoperability Resources (FHIR) and the adoption of APIs (application programming interfaces) to facilitate the exchange of data between systems.
We referenced the article from “Ankit Kumar Agarwal” (dated January 24, 2023). Can TEFCA Transform Healthcare Interoperability. This article was published at https://distilinfo.com/healthplan/can-tefca-transform-healthcare-interoperability/
Impact of CMS Interoperability Phase II on Healthcare Interoperability
Electronic Prior Authorization
Interoperability is a complex and challenging thing for the healthcare industry today. Different information systems, devices, and applications can access, exchange, integrate, and utilise the data beyond the boundaries to optimise global health needs.
With the introduction of HL7 FHIR interoperability standards and the direct submission of prior authorization requests from EHR systems using a standard already widely supported by most EHRs, FHIR. To meet regulatory requirements, these FHIR interfaces will communicate with an intermediary who, when necessary, can convert the FHIR requests to the corresponding X12 instances prior to passing the requests to the payer. Responses are handled by a reverse mechanism (payer to intermediary as X12, then converted to FHIR and passed to the EHR). The direct submission of prior authorization requests from the EHR will reduce costs for both providers and payers (on average, $25 per prior authorization request), get rid of paper waste, and reduce greenhouse gas emissions. It will also result in faster prior authorization decisions, which will lead to improved patient care and experience.
When combined with the Da Vinci Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR) implementation guides, direct submission of prior authorization requests will further increase efficiency by ensuring that authorizations are always sent when (and only when) necessary and that such requests will almost always contain all relevant information needed to make the authorization decision on initial submission.
We referenced the article from “Ankit Kumar Agarwal” (dated December 27, 2022). Implementation of ePrior Authorization can help reduce 483 Million Pound of Greenhouse Gases and $1 Trillion in Healthcare Administrative Waste. This article was published at https://distilinfo.com/healthplan/implementation-of-eprior-authorization-can-help-to-reduce-483-million-pound-of-greenhouse-gases-and-1-trillion-in-healthcare-adminsitrative-waste2/
Patient Cost Transparency
Apart from electronic prior authorization, the burden reduction rule emphasises the implementation of patient cost transparency and a digital insurance card for their transparency and ease of use for health plan members.
Patient cost transparency refers to the practice of providing patients with information about the costs of their healthcare services and treatments, including the prices of drugs, procedures, and tests. This can help patients make informed decisions about their healthcare and potentially lower their overall costs.
Patient cost transparency can be a valuable tool for patients, particularly those who have high deductible health plans or who are paying for their healthcare services out of pocket. By providing patients with cost information, healthcare providers can help them understand the financial implications of their healthcare choices and empower them to make decisions that are right for them.
We referenced the article from “Ankit Kumar Agarwal” (dated January 11, 2023). Patient Cost Transparency and It’s Impact on Healthcare Interoperability. This article was published at https://distilinfo.com/healthplan/patient-cost-transparency-and-its-impact-on-healthcare-interoperability/
Digital Insurance Card
A digital insurance card is an electronic version of a traditional insurance card, which is a physical card that is issued by an insurance company to a policyholder. It contains information about the policyholder’s insurance coverage, including the type of coverage, the policy effective dates, and the policy limits.
A digital insurance card can be accessed and used electronically, typically through a smartphone or other mobile device. It can be used in place of a physical insurance card to verify insurance coverage and access healthcare services.
We referenced the article from “Ankit Kumar Agarwal” (dated January 17, 2023). Digital Insurance Card Benefits and Path to Implementation. This article was published at https://distilinfo.com/healthplan/digital-insurance-card-benefits-and-path-to-implementation/
After carefully evaluating all of these rules and their potential impact on healthcare FHIR interoperability, we felt the need to utilise Smart on FHIR and Patient Match capabilities along with these regulations to build a secured and scalable interoperable healthcare FHIR-based RESTFul API solution to exchange healthcare data between various stakeholders for improved healthcare outcomes and to reduce trillions of dollars in healthcare waste.
We referenced the article from “Ankit Kumar Agarwal” (dated January 31, 2023). SMART on FHIR and its impact on FHIR Interoperability. This article was published at https://distilinfo.com/healthplan/smart-on-fhir-and-its-impact-on-fhir-interoperability/
We also referenced the article from “Ankit Kumar Agarwal” (dated February 13, 2023). Magic of Patient Matching and FHIR. This article was published at https://distilinfo.com/healthplan/magic-of-patient-matching-and-fhir/
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