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Contributor: 4 Data Sharing “Truths” for Health Plans


Karen Kobelski is the vice president and general manager of clinical surveillance, compliance & data solutions at Wolters Kluwer. She brings more than 25 years of experience to her position, which expands her previous leadership role over the Safety & Surveillance group to also include the Health Language portfolio of data normalization solutions.

The interoperability rules recently finalized by the Office of the National Coordinator for Health Information Technology (ONC) and CMS aim to achieve seamless exchange of medical information among health care stakeholders to improve health outcomes and reduce unnecessary costs. For information to flow freely across the health care system, it is critical that all players—providers, payers, and health IT vendors—adhere to the same rules and standards. It is also essential to ensure data can be provided to patients by third parties in a timely manner and in an easy-to-understand format.

Interoperability Hurdles

For health plans, compliance with these rules will be no small feat, requiring entirely new strategies for data management and significant IT investment. The rules require plans to provide patients access to their data via the FHIR Release 4 standard beginning January 1, 2021, as well as the ability to facilitate data exchange with providers or other payers using the data classes defined within the United States Core Data for Interoperability (USCDI).

Health plans have limited experience with these standards compared to providers, and after years of investing in point solutions, acquiring smaller plans, or expanding their services to support new member cohorts, most plans are managing multiple claims processing systems, analytics platforms, data warehouses and member portals that have created dozens if not hundreds of data silos.

Getting the Data House in Order

To get on the right path, and ensure regulatory compliance by 2021, plans must address data silos and embrace the following “truths” for efficient data-sharing in the new environment:

  1. Changing data standards necessitate a robust reference data management strategy. Beyond what is contained in claims data, plans must start incorporating clinical data, patient-generated data and even social determinants of health data. They must also be prepared to manage regular updates for procedures, labs and medications, as well as data from mobile health apps and devices. Managing the associated -- and highly dynamic -- data standards (e.g., LOINC, RxNorm, SNOMED, ICD-10, etc.) will be overwhelming for plans that lack formal data governance practices that span the entire enterprise. Plans would be wise to implement a management strategy now as reference data will only become more important as data assets increase over the next three to five years.
  2. Data normalization enables proper standards mapping. The ability to standardize data and convert it to something widely useable is perhaps one of the most critical elements of plans’ readiness for interoperability. Standards simplify the exchange of data but first it must be normalized and mapped to the required USCDI terminology to ensure it can be easily shared with other stakeholders. This is uncharted territory for most plans that may need to rely on third party experts to help them map local disparate clinical and claims data to the most appropriate standard codes. Plans can also look to advanced terminology tools and finely tuned matching algorithms powered by machine learning to enrich non-standard data before it’s mapped.
  3. Consumer-friendly descriptions make healthcare data actionable. Translating data into easy to understand formats will be required for consumer/members to make sense of and act on the data that is being shared with them. Plans must have the ability to translate clinical and claims data in paper-based communications with consumers as well as through patient/member portals and EOBs. This capability will not only put plans in regulatory compliance but also help them increase member satisfaction and empower members to be more engaged in their care.
  4. Sensitivity codes ensure member information is protected. Even with this call for more data access, sensitive information, such as substance abuse, mental health, family planning, genetic testing, HIV and STDs, must be properly safeguarded. With a set of specific codes in place, health plans can identify and filter sensitive diagnoses, procedures, labs and drugs to protect patient and member confidentiality. This capability will also enable plans to model, map, group, search, and distribute data throughout the enterprise for increased efficiencies without sacrificing privacy.

With enforcement around the corner, plans need to act now to address the data silos that will impede their progress, as well as transform how they collect, manage and share data going forward – all while ensuring member consent, privacy and comprehension. It is a lot to tackle in a relatively short period of time, but with the right preparation and partnerships, plans can get there.

Looking ahead, as data becomes increasingly transparent and exchanged via a trusted network, it will be crucial that payers are equally diligent in ensuring data is accurate, clean, and actionable for long-term success. The steps that CMS and the ONC have taken to press forward on interoperability represent only the tip of the iceberg.

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