CMS Expanding Patient Access to Data in Interoperability Proposed Regulation

CMS Expanding Patient Access to Data in Interoperability Proposed Regulation

Since the MyHealthEData Initiative was first announced by Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma during HIMSS18 in Las Vegas, the agency has been looking for opportunities to build on its announcement and improve patient access to healthcare data while advancing electronic data exchange and care coordination throughout the healthcare system. With its Interoperability and Patient Access Proposed Regulation, which was released on February 11th at HIMSS19, CMS has taken the next step by outlining opportunities to make patient data more useful and transferable through open, secure, standardized and machine-readable formats while reducing restrictive burdens on healthcare providers.

As part of the MyHealthEData Initiative, CMS launched the Blue Button 2.0 application programming interface (API) in its Medicare fee-for-service (FFS) system which has allowed beneficiaries to access their health claims information electronically through the application of their choosing. CMS currently has over 1,500 application developers building tools with this API, with 18 Blue Button apps using the CMS API in production. Given the fact that greater access to health information can be so useful to patients, and CMS wants to put patients fully in charge of managing their own health information, this proposed rule looks to utilize the same approach as Blue Button 2.0 and intends to require payers to make patient claims and other health information available to patients through third-party applications and developers.

Additional highlights from the CMS Proposed Regulation include the following.

Health Information Exchange and Care Coordination Across Payers

In our current healthcare system, patients move frequently between payers, and CMS thinks that patients should be able to maintain access to all their healthcare information throughout their entire patient journey. To help this effort, CMS is proposing to require Medicare Advantage (MA) organizations, state Medicaid and Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers in Federally Facilitated Exchanges (FFEs) to implement, test, and monitor openly published Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®)-based APIs to support electronic exchange of data for transitions of care as patients move between these plan types.

The agency notes that this data would include information about adjudicated claims, including diagnoses, procedures, tests, and providers seen and would give insights into a beneficiary’s health and healthcare utilization. CMS states that by ensuring patients have access to their information, and that information follows them on their healthcare journey, this provision will help to reduce burden, eliminate redundant procedures and testing, as well as give clinicians back valuable time so that they can focus on improving care coordination, and ultimately health outcomes.

Revisions to the Medicare and Medicaid Conditions of Participation (CoPs) for Hospitals

The Medicare and Medicaid CoPs for hospitals and critical access hospitals set basic health and safety standards for how effective care transitions for discharged patients should occur. In this proposed rule, CMS is looking to require some Medicare- or Medicaid-participating hospitals, to send electronic notifications when a patient is admitted, discharged or transferred to another health care facility or another community provider. These admission, discharge, and transfer (ADT) messages would only be required for those hospitals which currently possess electronic health records (EHR) systems with the technical capacity to generate information for electronic patient event notifications, recognizing that not all Medicare- and Medicaid-participating hospitals have been eligible for past programs promoting adoption of EHR systems. The use of electronic patient notifications has been shown a proven tool for improving transitions of care between settings as well as patient safety.

Public Reporting and Prevention of Information Blocking

CMS notes that those practices that unreasonably limit the availability, disclosure and use of electronic health information undermine efforts to improve interoperability. CMS suggests that it would benefit patients and caregivers to know if individual clinicians, hospitals and critical access hospitals have submitted a “no” response to any of the three attestation statements regarding the prevention of information blocking in the Promoting Interoperability Programs. Through this transparency effort, CMS hopes clinicians, hospitals and critical access hospitals will be motivated to refrain from information blocking.

API Access to Published Provider Directory Data

Through health plan provider directories, patients can find in-network providers and allow healthcare professionals to locate other providers for access to medical records, referrals, transitions of care, and care coordination. To help make sure patients and providers have easy access to this information, CMS is proposing to require MA organizations, state Medicaid and CHIP FFS programs, Medicaid managed care plans and CHIP managed care entities to make their provider networks available to enrollees and prospective enrollees through API technology. The use of APIs would allow up-to-date information to be available for all patients and providers to use by developers building tools in support of beneficiaries.

Care Coordination through Trusted Exchange Networks

The ability of payers and patients to communicate with each other as well as with health care providers will considerably improve broader access to data, reduce provider burden, and reduce redundant and unnecessary procedures. Trusted exchange networks allow for broader interoperability beyond simply one health system or point-to-point connections among payers, patients, and providers. These networks help establish “rules of the road” for interoperability, and with maturing technology, such networks are scaling interoperability and gathering momentum with participants, including several federal agencies, EHR vendors, retail pharmacy chains, large provider associations and others. CMS proposes to require, beginning January 1, 2020, that payers in their programs participate in a trusted exchange network which would allow them to join any health information network they choose and be able to participate in nationwide exchange of data. This would allow the information to flow securely and privately between plans and providers throughout the healthcare system and ultimately improve interoperability.

At the beginning of 2018, the Office of the National Coordinator for Health Information Technology (ONC) released its draft Trusted Exchange Framework for public comment, in which many commenters noted that existing trust networks operating successfully be leveraged in further advancing interoperability. Note in this proposed rules, CMS notes it is considering in the future an approach to payer to payer and payer to provider interoperability that leverages existing trust networks to support care coordination and improve patient access to their data.

Improving the Dual Eligible Experience by Increasing Frequency of Federal-State Data Exchanges In the proposed rule, CMS is proposing to update the frequency with which states are required to exchange certain Medicare/Medicaid data on dual eligible beneficiaries from a monthly exchange to a daily exchange to improve benefits coordination for the dual eligible population. This data exchange will include files of all eligible Medicaid beneficiaries by state, as well information about states that are using Medicaid funds to “buy-in” for Medicare services for certain beneficiaries. Also in the proposed rule, CMS seeks comments on future rulemaking on how they can achieve greater interoperability of federal-state data for dual eligible beneficiaries.

Provider Digital Contact Information

Technology, such as electronic addresses, allows providers to exchange data faster while improving interoperability and could help eliminate the need for fax machines in the exchange of health information. CMS thinks that a centralized directory of provider electronic addresses for data exchange could ensure the flow of patient information and the needed provider-to-provider communication is seamless for all users. Under the 21st Century Cures Act, the Secretary of the Department of Health and Human Services (HHS), is required to create a provider digital contact information index, and as of June 2018, the National Plan and Provider Enumeration System (NPPES) has been updated to include one or more of the pieces of digital contact information that can be used to facilitate secure sharing of health information. To help ensure that NPPES is updated with this information, CMS proposes to publicly report the names and National Provider Identifiers (NPIs) of those providers who have not added digital contact information to their entries in the NPPES system beginning in the second half of 2020.

Advancing Interoperability in Innovative Care Models

CMS is looking to utilize the Center for Medicare and Medicaid Innovation to test ways to promote interoperability across the healthcare spectrum. CMS thinks that Innovation Center models provide an important lever to advance progress toward interoperability, as these models offer unique opportunities to engage with health care providers and other entities in innovative ways and to test concepts that have the ability to accelerate change in the broader health care system, including to promote interoperability. CMS is looking for public comment on examples of how they may focus on interoperability related-issues in future model development which may include models that: incorporate piloting emerging standards; leverage non-traditional data in model design (for example, data from schools, regarding housing and on food insecurity); and, leverage technology-enabled patient engagement platforms.

CMS is also looking for comments on the following general principles around interoperability within Innovation Center models for integration into new models, through provisions in model participation agreements or other governing documents:

  1. Provide Patients Access to their Own Electronic Health Information
  2. Promote Trusted Health Information Exchange
  3. Adopt Leading Health IT Standards and Pilot Emerging Standards

Requests for Information

CMS is looking for ways to facilitate private sector work on a practical and scalable patient matching strategy. Together with the Office of the National Coordinator for Health Information Technology (ONC), CMS is requesting feedback on how it can leverage its authority to improve patient identification and safety to encourage better coordination of care across different healthcare settings while advancing interoperability.

Moreover, CMS characterized transitions across care settings as common, complicated, costly and potentially hazardous for individuals with complex health needs. Despite the need for functionality to support better care coordination, discharge planning and timely transfer of essential health information, interoperability by certain health care providers such as long-term and post-acute care, behavioral health, and home and community-based services continues to lag behind acute care providers. To help solve this lag, CMS is asking for comment on potential strategies for advancing interoperability across care settings to inform their future rulemaking activity in this area.

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