Interoperability and the Connected Health Care System
The COVID-19 pandemic exposed many shortcomings in our health care system, especially the ability to quickly share and use reliable data to better understand the health needs of all people across the country. This need for more accessible data is why the Centers for Medicare & Medicaid Services (CMS) remains committed to making health care data flow more freely and securely among payers, providers, and patients by laying the foundation to foster a more connected health care system.
CMS is working toward this goal by increasing and advancing health care data exchange functionality to better inform decision-making for patients and their providers, support and improve patient care, and reduce the administrative burden on providers and payers. The Biden-Harris Administration is committed to increasing health data exchange and investing in interoperability – the ability for computer systems to exchange information between devices and software systems. These goals are key components of our strategy to promote a more equitable and efficient health care system.
On May 1, 2020, CMS published the CMS Interoperability and Patient Access Final Rule, establishing policies that advance interoperability and access to health information for all stakeholders. This rule made sure patients can have convenient access to their health care data through a personal health app. Specifically, CMS requires certain payers to build standardized Application Programming Interfaces (APIs) that allow for a more secure data exchange process between the payer and a patient’s chosen personal health app. This rule is just one step in a larger journey toward achieving a health care system where patients, providers, and payers can easily exchange information to bolster better care outcomes.
This rule also established a requirement for certain payers to build standardized APIs to exchange data with other payers, with the goal of enabling patients’ health data to follow them if they switch health insurance plans. While we are excited about what payer-to-payer information exchange can do to accelerate the flow of such data, it is vital that: 1) the policy supports patients in the ways they need, and 2) payers are able to effectively and successfully implement these new features. To that end, CMS heard concerns from the payer community about operational challenges and risks to data quality in the absence of specific data exchange requirements and standards, particularly the lack of a requirement for a standards-based API. Accordingly, to ensure payers are in a position to effectively contribute toward our shared goals for interoperability, CMS recently exercised enforcement discretion with regard to the payer-to-payer data exchange provision, meaning the agency will not take any action against payers should they not meet the original deadline until CMS can improve the policy through future rulemaking. This step will also give payers more time to come into compliance with the provision when a new rule is published.
While CMS works to develop and finalize new rulemaking regarding payer-to-payer information exchange, we are engaged in several additional efforts that continue to lay the groundwork for the future of interoperable data exchange. For example, we are exploring how health care directories, such as those patients use to find information about their providers, such as names, addresses, phone numbers, can further strengthen interoperability for health care and public health systems and what role CMS should play in managing these directories. Additionally, we are working closely with the Office of the National Coordinator for Health Information Technology (ONC) on its USCDI+ initiative to advance CMS’s use of interoperable datasets for quality measurement and other areas. The United States Core Data for Interoperability (USCDI) standard sets the foundational set of data for health information exchange, clinical care and patient access. In July 2021, ONC published USCDI version 2, which included some significant updates such as the addition of social determinants of health, sexual orientation, and gender identity data elements to support efforts to advance health equity and improve outcomes for minoritized, marginalized, and underrepresented individuals and communities. The USCDI+ initiative builds on that foundation to establish, harmonize, and advance the use of interoperable datasets that extend beyond the core data in the USCDI. USCDI+ efforts for quality measurement and public health are starting with Centers for Medicare & Medicaid Services and Centers for Disease Control and Prevention. The goal is to continue to improve data exchange across the health care ecosystem, including public health systems, for better coordination of care, enhanced clinical decision making, and a higher quality of care for patients.
We are also exploring with ONC how the Trusted Exchange Framework and Common Agreement | HealthIT.gov (TEFCA) nationwide network can be used to support a variety of CMS use cases. Finally, we also continue to examine ways in which we can use technology tools streamline processes like prior authorization to make them less burdensome on patients and providers.
CMS is also exploring the use of a standards based API, using the HL7® Fast Healthcare Interoperability Resources® (FHIR) standard for our price transparency efforts, including the Advanced Explanation of Benefits (AEOB). FHIR is already being used to support electronic data exchanges among providers, payers, and patients, and may allow a consumer friendly AEOB to be produced that could encourage important discussions between patients and their care teams regarding cost and value. The use of FHIR is critical to enabling payers to send data to patients, and to providers for a seamless exchange.
We appreciate everyone’s enthusiasm for improving information exchange and feedback on CMS’ efforts. We will continue to work together to build a data connected health care system that better supports patients and enhances the health and well-being of all people.