The good news: 84% of specialty provider organizations have an electronic health record (EHR). The bad? Hardly any specialty provider organizations have health information exchange (HIE) capabilities—at last count, less than half could exchange data (see IT Spending Follows The Money).
Why is this bad news? Our team has written before why HIE is essential for specialty provider organization survival. It’s the key for participating in integrated care, whole person care, social determinants initiatives, and much more. But, HIE and more data sharing flexibility may become mandatory. Last year, the Centers for Medicare & Medicaid Services (CMS) final rule for the Medicare and Medicaid Promoting Interoperability Programs emphasized measures that require the exchange of health information between provider organizations and consumers (see CMS Finalizes ‘Promoting Interoperability’ Rule For Hospitals and CMS Shifting Data Control To Consumers: Are You Ready To Share?).
Now the other shoe has dropped: In February CMS issued another proposed rule that requires health plans to provide members with immediate electronic access to medical claims data and other electronic health information (EHI), such as diagnoses, procedures, tests, and the provider organizations/clinical professionals seen, by 2020. The rule affects Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, state Children’s Health Insurance Program (CHIP) agencies and CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) in the federally-facilitated health insurance marketplace exchange (FFE) (see CMS Proposed Rules Require New Consumer Data Sharing). The proposed rule requires that organizations do the following:
- Implement an openly-published Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API). This will make patient claims and other health information available to patients through third-party applications and developers.
- Support electronic exchange of data for transitions of care as consumers move between plan types (Medicare, Medicaid, CHIP, QHP issuers in the FFEs). This data includes information about diagnoses, procedures, tests, and the provider organizations/clinical professionals seen.
- Use an API to display and facilitate member search of the health plan provider organization network.
- Participate in a trusted exchange network with other health plans and with provider organizations which would allow them to join any health information network they choose and be able to participate in nationwide exchange of data.
What this means for stakeholders is a need to commit to finding a common understanding of what they are measuring and what measurements will provide value in the exchange of data. Most health plans already have mechanisms in place to provide this information electronically and chances are that this information could be made available to other health plans, health information exchanges, or other data sharing applications. OPEN MINDS Senior Associate Sharon Hicks noted that long-term success relies on reaching this common market definition of “value”:
The issue is less a technical data sharing issue than it is a question about what information is meaningful and useful. Paid claims information is not clinical information, it is simply a record of a clinical service that was delivered and proof of payment for same. It’s utility for medical decisionmaking has not been tested and may in fact be limited. We need to assure that we have a common language before we assume that sharing information will help improve health care.
To prepare, what should your management team do? OPEN MINDS Senior Associate Chris Williams explained that provider organizations need to start with an assessment of their current data sharing capabilities and a comprehensive review of the organizations they should be exchanging consumer data with in their market. In the new market realty, organizations need to understand who they need to connect with specifically and find the tech tools that enable that data sharing capability. He explained:
Which entities will you be required to connect with and share information—health plans? State payers? Other provider organizations? How will that process work? Understand at a deep level, how your reimbursement model functions within information exchange model. This is critical because under these new regulations, health plans will need to provide consumers access to every one of their claims. (Let that sink in for a moment.) Your starting point is to assess and understand the technology you have, compared to the technology you’ll need to comply, execute, and exchange information within your immediate network of payers and other provider organization partners—and potentially beyond.
EHRs, HIEs, and EHI are all critical to provider organization participation in the evolving health and human service system-critical for long-term sustainability. For more on meeting that challenge, check out these resources from the OPEN MINDS Industry Library:
- How To Be Operable In An Interoperable World
- Is Your Organization Data Reactive – Or Data Predictive?
- Moving EHR Investments From ‘Must Do’ To ‘Must Have’
- IT Spending Follows The Money
- You Have An EHR, But Can You Share Data?
- Health Information Exchange-Can Work, Isn’t Working
- Data Exchange Via Mail & Fax? In Today’s Market?
- Technology Adoption Varies By Specialty Health Care Market – Results Of A New OPEN MINDS Sponsored By Credible Behavioral Health Software
- Moving Out Of Your Comfort Zone: The VBR Technology Continuum
- Are You Strategically Interoperable?
For more, join me on June 6 for The 2019 OPEN MINDS Consumer Engagement Technologies Summit, featuring Andrea Auxier, Ph.D., Senior Vice President, Product Development, New Directions; Chris Thompson, Chief Operating Officer, Monarch; Davis Park, Executive Director, Front Porch Center for Innovation & Wellbeing; Larry Smith, Chief Operating Officer, Grand Lake Mental Health Center; and Neal A. Bowen, Ph.D., Chief Mental Health Officer, Hidalgo Medical Services.