Earlier this year, as part of the podcast series, Chris interviewed Orion Health Vice President of Public Sector Solutions, Chad Peterson about the 21st Century Cures Act and specifically, the CMS Interoperability and Patient Access final rule as well as the Interoperability, Information Blocking and ONC Health IT Certification Program final rule published by ONC. Both were released in final form on 9 March and went into the Federal Register on 22 April 2020, however, implementation was delayed for many components due to COVID-19.

Chris and Chad discuss the long-awaited regulations and consider the role of health information exchanges (HIEs) when it comes to enabling payer compliance. For ease of discussion, the rules are referred to as the Patient Access Rule and the ONC Rule. The following summarizes a few key takeaways from their full conversation.

The role of HIEs in helping payers meet obligations

The Patient Access Rule requires payers to implement and maintain an applications programming interface (API) to support patient access to their health information, such as claims, encounters and some clinical information through a third-party app of their choice. This is termed the Patient Access API.

The relationship between HIEs and payers will be important when it comes to the Patient Access API. Leveraging data from the HIE will simplify the process for patients to access valuable and complete information. Chad describes the HIE “could really be [the] gateway to both the payer information in this requirement and also [on] the provider side of things” by being a “one-stop-shop” to help patients navigate between the numerous providers and payers they may see.

Under the new rules, CMS-regulated payers will also need to implement and maintain standards-based API access to make their provider directory available, termed the “Provider Access API”. HIEs could step in and help solve this problem, particularly between the national directory and payer directories like State Medicaid for example or other regional payers, and the provider directories that the healthcare systems are maintaining to make it into a ‘shared service’ for stakeholders within a region.

The ONC Rule and information blocking  

The Patient Access Rule enables CMS to publicly list clinicians, hospitals, and critical access hospitals that are determined to be engaged in information blocking based on information disclosed by clinicians and entities. Information blocking is any action that is likely to interfere with, prevent or materially discourage access, exchange or use of electronic health information.

This rule will be helpful for HIEs as aggregators of data. Many stakeholders and ecosystems already rely upon HIEs as a trusted partner and extension of them, but there is still some competition between providers over data. “I don’t know that it’s going to fix everything, but I certainly think it’s going to help get data moving and there will no longer be this excuse of ‘I’m not allowed to share the data’”, says Chad.

As part of the ONC Rule, health IT vendors will also now be required to develop via APIs to allow third-party connections to those API. This will change things for HIE vendors with business models that don’t accommodate this. Ultimately, aggregating data from multiple sources is a positive move for patients and population health, and vendors will need to think differently to avoid becoming information blockers themselves.

Achieving true interoperability

Look how far we’ve come since 2004. It’s amazing to me. It seems agonisingly slow at times and yet we’re right here at the cusp of what I hope is some real game-changers when it comes to getting us to real interoperability”, Chad says of the new regulations.

In the full podcast, Chris and Chad also share their thoughts on payer-to-payer data exchange and the USCDI, Admission, Discharge, and Transfer (ADT) notifications, and talk in more detail about the role of HIEs in enabling compliance with the 21st Century Cures Act obligations.