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Payers are working to meet deadline for interoperability mandate

The majority of health plans say they do not feel ready to meet the new FHIR interoperability standards mandated by CMS.

Susan Morse, Managing Editor

Health insurers face a July 1, 2021 deadline to meet Fast Healthcare Interoperability Resources, or FHIR, interoperability standards for patients to access their clinical data through a member application such as a mobile device.

Many payers are nervous about having a plan in place by October or November to have time to deploy new technical systems and to make decisions with vendor partners, according to Terry Boch, chief commercial officer for Diameter Health, which helps insurers get clean data. 

It's a big task. There are an estimated 4.1 million clinicians documenting care in over 100 electronic health record systems and the flow of clinical data is increasing rapidly. Plans are spending hundreds of millions in chart retrieval.

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Payers have used paper data forever, so they are now learning that if data is not National Committee for Quality Assurance-certified, it could be deemed not valid, which means losing ratings and dollars, Boch said.

"As if the CMS (Centers for Medicare and Medicaid Services) mandate isn't enough, they're trying to address the pandemic," Boch said. "In the midst of this pandemic, the times of going in and pulling manual charts just doesn't exist anymore. There will be a new norm on the heels of COVID and with a digital chart."

On an enterprise-wide basis, insurers are thinking differently about the flow of clinical data so as to meet interoperability standards and move to a process that will allow for real-time access through a digital chart, Boch said. 

Yet as payers welcome the move to a broader digital system, the majority do not feel ready to meet interoperability standards, according to a Diameter Health poll released during America's Health Insurance Plans' Institute and Expo Online 2020. On plan readiness, 58% of health plans said they were behind or didn't know, and 71% said the quality of their clinical data needed work.

"We know some of the largest national plans are looking to comply with this, but complying is part of broader interoperability strategy for them, like supporting FHIR as a standard," Boch said. 
 
FHIR is only part of solving the interoperability mandate as FHIR makes the information pipeline bigger, she said.

WHY THIS MATTERS

The flow of clinical data right now is at an unprecedented rate, according to Boch. 

There has been an exponential growth in clinical data over the past five years. Much of it is inaccurate.

For instance, Diameter has found that 80% of allergies are not coded correctly and 40% percent of medications don't have the right coding to apply for quality purposes.

Data must be clean to reduce errors, help avoid payment delays and minimize potential audits or fines. 

Data must also meet NCQA healthcare accreditation for health insurance companies. NCQA-certified data is used for Healthcare Effectiveness Data and Information Set reporting. HEDIS is a comprehensive set of standardized performance measures that can be used to compare health plan performance.

Diameter, which began in 2007, works with 22 health information exchanges nationwide and several national payers, processing 1.5 billion transactions a day to produce clean data.

Other solutions include Zyter, which recently released the Zyter CMS Interoperability solution to provide the required standard FHIR-compliant application programming interfaces that work with disparate systems.

THE LARGER TREND

On March 9, the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology finalized the Interoperability and Patient Access final rules. These rules establish technical, content and vocabulary standards to ensure clinical information is more easily available to patients through third-party applications using standard based FHIR APIs, provider directories and payer-to-payer data exchanges. 

On May 1, the Department of Health and Human Services published revised final rules on interoperability and information blocking that included an enforcement date of July 1, 2021.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com