Five industry interoperability efforts every payer should know


Wednesday, February 5, 2020 | By Adele Allison, Sr. Director of Economics and Digital Health Strategy

Five industry interoperability efforts every payer should know

Interacting with meaningful healthcare data to fix real-life problems should be your interoperability end-game.  Industry and government leaders have been hard at work identifying the most significant types of data and potential uses to solve the most common problems we have in healthcare.  Are you familiar with these efforts?

This blog series has covered the types of data that payers must make available to consumers, what it means to connect to a Trusted Exchange Network, and the importance of appropriate use cases to stay on track as you move forward. Now let’s move on to the industry initiatives you should leverage as you plan for interoperability, which entails the effective use of standardized data sets and priority use cases.

Here are five key efforts with which all payers should be familiar: 

  1. CMS Blue Button 2.0 – CMS is pushing for larger goals for electronic health record (EHR) interoperability in relation to health plans. The original Blue Button initiative began in 2010 and used claims information available through an online portal, but was deemed “hard to understand” by end-users.  Blue Button 2.0 is the next-generation initiative and will use API standards to allow Medicare beneficiaries to link their claims data to other secure apps, services and research programs, including EHRs.  The hope is to truly begin to engage beneficiaries as active participants in their care, such as allowing them to share complete medication lists with their doctors. With both claims and clinical data moving to APIs, this represents a significant step forward in data convergence between administrative and clinical information.

    Why is this important? CMS is releasing Blue Button data for Medicare Parts A and B.  Any Part C and D payer will likely have to follow suit with what CMS is doing.

  2. U.S. Core Data for Interoperability (USCDI) – As discussed in the first blog, CMS named the USCDI as a priority data set for the exchange of clinical data between plans and providers.  This information was developed by the U.S. Office of National Coordinator (ONC) through a consensus process used to arrive at a standardized data set that would be contained in all EHRs. The USCDI version 1—meaning there will be a version 2, 3, etc.—is broken into data classes and data elements.  A data class is a collection of data elements, grouped by theme or use case.  Data elements are the individual pieces of data available for exchange. 

    Why is this important? Certified EHRs will all contain and be able to produce these common and expanding data elements to support health information exchange.  Integration of clinical and administrative data promises increased care precision, outcomes, and even, affordability.  Understanding this evolving dataset provides strong strategic positioning.

  3. The CARIN Alliance – Created in 2016 as a bipartisan effort to advance consumer-directed exchange of health information, CARIN has workgroups and members that include some heavy hitters in technology and healthcare, like Microsoft and Humana.

    Relative to health plans, CARIN has been developing a common payer consumer data set (CPCDS) to align with the Blue Button 2.0 interoperability data set available through the traditional Medicare fee-for-service program, including an implementation guide for Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs) that payers can display to consumers.  Blue Button—initially used for veteran access to EHR data—is driving the White House MyHealthEData initiative and the CMS and ONC interop proposed rules, which have aggressive timelines for health plans. 

    Why is this important? I predict that the data set for payers in the final rule will likely include CPCDS—as written by CARIN. 

  4. ONC FHIR At Scale Taskforce (FAST) – The ONC converted its original Payer and Provider FHIR Taskforce to FAST in 2019 to identify FHIR scalability gaps and potential solutions to promote predictable anticipation and mitigation of scaling challenges. This taskforce comprises 7 Tiger Teams including the Ecosystem Use Case Tiger Team that is focused on creating 5-10 summary use cases, publicly available to you for review.

    Why is this important? These will be common use cases adopted by the industry. Since they will already have the needed specifications, you can leverage this work rather than creating your own from scratch.

  5. The HL7 Da Vinci Project – The ONC and CMS are collaborating with HL7 through the Da Vinci Project, launched in January 2018, to use FHIR as the Internet-based data standard to support integration and interoperability between payers and providers.  They have 17 use cases, many with associated implementation guides, including use of FHIR interoperability to:

    • Streamline the preauthorization process through FHIR enabled algorithms
    • Expand population health management, risk scoring and outcomes-based payment
    • Perform 30-day medication reconciliation and data exchange to support HEDIS and STARS. 

    Why is this important? Pre-designed use cases will be available, developed by cross-functional industry experts. Providers and payers have worked together to prioritize and identify any prerequisites for the implementation of specific use cases, such as prior-authorization. This business framework is important to all stakeholders.  Da Vinci is also planning to field test these use cases, making them proven capabilities.

In summary

Whether you are trying to understand the data requirements, compliance, use cases or technologies needed to achieve interoperability, domain expertise will be necessary to carefully and thoughtfully plot your course forward.  As with other aspects of healthcare, you can count on constant movement, barriers, and hopefully, progress towards succeeding with data liquidity.  Think about how this new capability might solve problems unique to you and your members. 

We hope you have enjoyed this blog series and found it helpful. You can catch up on all blogs via our website, and watch our webinar: Interoperability and you: How will you succeed under the new direction? for additional insight. I also recommend that you sign up for our biweekly eBriefing to get the latest news, articles and whitepapers, along with information on webinars and other upcoming SS&C events. Please reach out at any time for a personal conversation.



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