The journey to interoperability: A healthcare industry-wide transformation

The journey to interoperability between payer and provider systems in healthcare has been bolstered by several key pieces of legislation. These create the conditions to support aspects of healthcare interoperability and, collectively, allow the transition from segregated, monolithic, proprietary solutions toward more accessible, interoperable, modular solutions.

HITECH Meaningful Use (July 2010)

From a legislative point of view, interoperability began with the Health Information Technology for Economic and Clinical Health Act (HITECH Meaningful Use). Targeted at providers, the HITECH Act was created to drive the adoption and “meaningful use” of electronic health records (EHR) technology by United States-based healthcare providers and their business associates. Meaningful use requires healthcare providers to show that they are using certified EHR technology in a way that can be measured in both quantity and quality.

This bill introduced a series of payment incentives and penalties to strongly encourage hospitals and eligible practitioners to modernize their infrastructure with EHR systems that were certified to meet specific standards of data.

The concept of meaningful use rested on the “five pillars” of health outcomes policy priorities:

  1. Improve quality, safety, efficiency and reducing health disparities
  2. Engage patients and families in their health
  3. Improve care coordination
  4. Improve population and public health
  5. Ensure adequate privacy and security protection for personal health information

Seven Conditions and Standards (April 2011)

The Centers for Medicare and Medicaid Services created “Seven Conditions and Standards” that are fundamental to receiving enhanced federal funding of payer applications. These conditions and standards are:

  1. Modularity
  2. Medicaid Information Technology Architecture (MITA) Condition
  3. Industry Standards Condition
  4. Leverage Condition
  5. Business Results Condition
  6. Reporting Condition
  7. Interoperability Condition

Although only 11 pages long, no other single document has had such an impact on federally funded healthcare systems development in the past 20 years. A system’s qualification for enhanced federal funding of system changes or replacement was directly tied to showing that the modification aligned to these conditions and standards.

The Medicaid Management Information System (MMIS) certification process and qualifications changed to reflect these rules. Modularity and use of industry standards became paramount considerations in evaluating systems. Companies in the industry responded by adopting the principles when building or enhancing applications within their portfolios.

Operation Rules (January 2013)

The Operating Rules, introduced in 2013 and required by the Affordable Care Act, are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”

The Operating Rules focus on existing defined standard EDI transactions between providers and plans, and they mandate the business rules and specific required usage related to these transactions. This moved the transaction from a standard with many optional interpretations to a semantically interoperable data exchange, affected all entities covered under HIPAA, and required industry-wide transformation to make common usage of these data exchanges.

This is arguably the single biggest success of industry interoperability to date. The technological transformation to meet these conditions laid the foundation across many provider and payer systems for even greater data interoperability.

21st Century CURES Act (December 2016)

The introduction of the 21st Century Cures Act has had a wide-ranging impact on healthcare delivery and funding. Designed to help accelerate medical product development and bring new innovations and advances to patients faster and more efficiently, the act has been the legislative backbone for system and solution transformation. It required the Office of the National Coordinator for Health Information Technology (ONC) and responsible agencies to set up processes to define and monitor solutions supporting interoperability.  Specifically, this legislation is the authorization for the U.S. Core Data for Interoperability (USCDI); the Trusted Exchange Framework and Common Agreement (TEFCA) and the Interoperability Standards Advisory (ISA).

NPRM on Interoperability and Patient Access (February 2019)

While all the previous legislative changes have been important for interoperability, the most recent development has turned the focus on the value of healthcare data to the patient. The NPRM for Interoperability and Patient Access to Health Data seeks to give patients and their healthcare providers secure access to health information and new tools, allowing for more choice in care and treatment. It calls on the healthcare industry, including health plans, to adopt standardized APIs for the exchange of a patient-directed common dataset of healthcare information. These FHIR (Fast Healthcare Interoperability Resources)-based APIs allow patients and authorized third-party applications to access a common set of administrative and clinical healthcare data.

The journey

The journey to interoperability affects the entire healthcare industry and will require organizations to deploy innovative, modular healthcare solutions that can respond to the rapidly evolving landscape. Both the Centers for Medicare & Medicaid Services (CMS) and the ONC, which are developing complementary rules on interoperability, understand that to advance the objectives of improving health outcomes and reducing costs, interoperability of healthcare data will be imperative. Furthermore, interoperability will help to advance another core healthcare objective — achieving patient-driven care.



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