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Readying for Interoperability, Patient Access Compliance Amid COVID-19


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.

On March 9, the Office of the National Coordinator (ONC) and CMS finalized 2 rules focused on interoperability. The rules require CMS-regulated payers to implement and maintain a set of secure standards-based application program interfaces (APIs) over the course of the next 2 years. The rules are intended to give patients unprecedented, secure access to their health information.

These rules will also be a catalyst for a major shift in how health plans operate and engage with their members. Compliance with the new rules will require plans to create, deploy and sustain a robust data strategy that entails far more than traditional claims management. A far cry from a one-off project plan, plans will need to assess needed large-scale information technology (IT) investments and determine how they will manage and share data beyond 2021—taking into account consent, privacy, and comprehension on behalf of their members.

Unlike past federal efforts aimed at driving digital transformation, such as meaningful use, incentives for plans are not forthcoming. Instead, compliance with these rules is required to maintain payers’ contracts with the CMS. Compliance will require proper planning and coordination with key stakeholders enabling them to empower members with data and avoid disruption to their business.

Organizational Transformation

Until now, health plans have enjoyed the luxury of focusing data strategies on internal initiatives such as risk stratification and care management, but now their organizational culture will need to be completely upended to accommodate new external demands. While many plans may be relieved that CMS delayed enforcement of the rules until July 2021 due to the pandemic, there is little time to waste in such a significant endeavor. Lessons learned from provider struggles to implement and adopt certified electronic health record and health IT systems as part of incentive programs should serve as a warning to payers that they cannot afford to take the challenge ahead of them lightly.

In just 1 year, plans must have the ability to allow members to easily access their claims and encounter information, including costs, as well as a defined sub-set of their clinical information through third-party applications of their choice. The next milestone, which goes into effect January 1, 2022, will enable payer-to-payer data exchange using the data classes outlined in U.S. Core Data for Interoperability (USCDI). This milestone will provide access to a wider set of a member’s encounter data and allow members to take their information with them as they move from payer to payer over time.

Members will also expect the shared data to be understandable and protected. That means payers will have to translate medical jargon into consumer terms more diligently than ever and put in place a system for tagging sensitive data so that it can be shared appropriately and in compliance with consent rules.

The Impact of COVID-19

While the coronavirus disease 2019 (COVID-19) pandemic has slowed the timeline on enforcement, it has also highlighted the urgent need for quality data that is readily available and easily exchanged. In the face of unprecedented pressures on our nation’s health care system, payers had to be innovative in providing access to care and engaging their members in new ways.

Efforts such as waiving costs for testing and treatment of COVID-19, expanding telehealth options and refilling prescriptions off cycle, has led to a reckoning on the parts of payers of the value of strong data governance. Only with a data governance process in place can systems be remedied quickly, and data made shareable on the fly.


All these actions needed to happen rapidly, and they involve multiple departments across a payer organization that rely on much of the same data. That data is typically not centrally sourced within payer organizations making quick solutions harder to implement, inconsistently applied and hard to track the results. The solution lies in plans rethinking their data strategy, which is exactly what payers will need to do in response to the CMS/ONC interoperability rules as well.

Forward-thinking payers are taking steps now to prepare, including building strong data governance strategies that take into consideration process, technology and personnel. These organizations understand too well that creating a true single source of truth for their data will be business-critical going forward and, in many cases, are turning to trusted third parties to ensure a timely implementation. Looking toward the future, payers would be wise to acknowledge a need for external expertise in other areas as well, including mapping data to standards and extracting data from unstructured text that they will need to be successful.

For a breakdown of how payer organizations are preparing for this entirely new stage of data-sharing and harnessing the power of advanced technology to make that data useful, check back in a few weeks for a follow-up post.

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