Going Beyond Compliance: How Payers Can Embrace Healthcare Interoperability

Remember the big picture

It is easy to get lost in the details of healthcare interoperability. However, payers should not focus so closely on the technical specifications and regulatory requirements that they lose sight of the overarching vision.

Why are payers pursuing interoperability? Why is this a priority for CMS, HHS, ONC, and the healthcare industry at large?

“CMS’s big vision on interoperability is to provide a secure, connected healthcare system that empowers patients and their providers to access and use electronic health information to make better informed and more efficient decisions,” a CMS spokesperson answered.

Todd categorized the overarching goals of interoperability into two buckets.

“One bucket is to definitely engage patients more in their own healthcare, making that data available so that they can be more active and engaged in their healthcare and improve their health,” Todd told HealthPayerIntelligence. 

“The second piece of this is making data more available across the ecosystem: facilitating data sharing between plans and between plans and providers in a more simplified, streamlined way so that everyone who is engaged in a patient's care can more effectively coordinate that care.”

Lloyd agreed that consumer access to personal health information was a key aim for this effort.

At AHIP, Lloyd and her team recently conducted an exercise with payers that sought to identify the motivation for and overall goals of interoperability efforts within payer organizations. The outcomes underscored that increasing consumer access to their own information was at the heart of this movement as well as maintaining consumers’ privacy and security.

Chennuru noted to HealthPayerIntelligence that the coronavirus pandemic spotlighted gaps in data-sharing capabilities industrywide, particularly in relation to immunizations and testing.

“We still have a long way to go to achieve the Anthem desired goals to improve but I would say every step we are taking is really to simplify this whole process,” Chennuru added. “It always comes back to trying to simplify the healthcare for our consumers.”

Involve consumers

Although consumers will never see what happens in the background—the contracts, the technological development, the actual exchange of data— ultimately, interoperability is oriented around them.

With that in mind, Anthem has made an effort to incorporate consumer perspectives directly into its interoperability strategy.

“Allow the consumer to have a voice in the process to ensure that the digital solutions provide a flexible, safe, and a secure ecosystem that provides options to enable the patient to improve their health through the use and access of their health information,” Chennuru urged. “Be open for either questioning the processes or open for feedback.”

Chennuru enumerated three ways in which Anthem has engaged consumers in the movement towards interoperability.

First, Anthem invited consumer involvement in its interoperability strategy through workgroups. The payer was engaged in consumer forums where it could receive consumer input. Chennuru noted that third parties sometimes arranged these workgroups because provider organizations were the entities with access to the necessary data.

The payer also received consumer feedback through its mobile app, Sydney. The public’s responses to this app and other digital, consumer-facing Anthem tools can inform Anthem’s strategies around data-sharing.

Third, the payer engaged its own employees as consumers.

“When you look at it, everyone is a healthcare consumer, so we all have feedback for it,” Chennuru said.

Thus, the payer sought to simplify healthcare for its 60,000 employees in order to assess processes and tools to simplify healthcare for consumers.

“Allow the consumer to have a voice in the process to ensure that the digital solutions provide a flexible, safe, and a secure ecosystem that provides options to enable the patient to improve their health through the use and access of their health information.”

Do not recreate the wheel

Developing secure, CMS-compliant tools for transferring consumer health data is a challenging endeavor.

But payers do not have to produce all of these components from scratch. Resources exist to help reduce payers’ burdens in certain areas of preparation. In its best practices and burden reduction aids, CMS has highlighted the CARIN Alliance Code of Conduct and ONC Model Privacy Notice as particularly useful for supporting privacy and security efforts.

“There are some things where payers do not have to recreate the wheel,” Todd said. 

“There has been a lot of work within the industry—amongst FAST, the CARIN Alliance, DaVinci, and others, and our endpoint directory as well—that has created some industry-standard ways of doing things. Payers can sign onto those. That can just take one hurdle off their plate and they can focus on some of the harder stuff around the FHIR circuit work.”

Quickly establishing endpoints is one major barrier for payers to overcome with such a tight timeline, but Todd emphasized that CAQH designed an endpoint directory to help payers facilitate these connections.

The directory acts as a matchmaker between payers and vendors. It asks participating health plans a number of questions essential that vendors will need to know, and it poses questions to vendors that payers would want to ask of a potential partner. 

The directory then enables health plans and vendors to see these responses in order to find the ideal interoperability partners. Importantly, the participants have the responsibility of reaching out, making the connections, and vetting potential partners. 

However, this tool—which CAQH developed in response to an ONC-identified barrier to interoperability—aims to cut down the time needed to identify partners and scale interoperability efforts.

“In terms of not recreating the wheel, what we're trying to do with the endpoint directory is create one place of information, source of truth, about other plans and app vendors that the health plans can use,” Todd explained. 

“They do not each, individually need to be asking these questions of other payers and of the third-party apps. They can just pull that information from one source and know that we are going to be updating it and maintaining it, verifying the identity of these organizations so that they do not have to do that on their own. Hopefully, that will make things easier and quicker for them and they can focus on the things that are specific to their systems.”

Document the interoperability effort

Payer readiness for the interoperability rules varies widely. When CMS bumped the first deadline from January 2021 to July 1, 2021 due to the coronavirus pandemic, the industry expressed some relief. But even CMS still characterized the new deadline as “aggressive.”

As the compliance deadlines approach, payers lean heavily on their legal teams to ensure readiness, Lloyd told Healthcare Strategies, and payers will need to make sure that those efforts are well-documented. 

Legal teams are critical for establishing regulatory compliance with CMS and ONC standards. However, such a team’s role also encompasses securing contracts with vendors and subcontractors, ensuring compliance with state regulations, and keeping payers aware of how interoperability efforts fit into other regulatory movements such as price transparency.

As payers work with their legal teams and other departments to prepare for interoperability, they will want to have strong evidence of their efforts.

“It has been very trying with the evolving landscape of the standards,” Lloyd acknowledged to HealthPayerIntelligence. “One piece of advice I would give is: document, document, document. In the event that you just happen to not quite make that deadline, you want to be able to show that there was a good faith effort to get there.”

“One piece of advice I would give is: document, document, document. In the event that you just happen to not quite make that deadline, you want to be able to show that there was a good faith effort to get there.”

See interoperability as an opportunity for differentiation

Initially, the motivation for payers’ interoperability efforts stemmed from the need to satisfy regulatory demands. The shift is so massive that it can be difficult to think beyond checking the boxes that CMS and ONC have established.

However, after several years of working toward this goal, Chennuru and his team at Anthem have embraced a perspective that looks beyond compliance.

“In the past, not being the front runners was okay because it was more about: let's do the minimum of what is needed to look at it more from a compliance or a mandate perspective,” Chennuru recognized. “But now, the more you invest, this can become a differentiating capability that consumers do pay attention to.”

This is true both for the interoperability effort and the movement toward simplifying healthcare in the US overall: in each case, if payers start to think beyond compliance, they may stand out from their competitors.

Next steps

Establishing data privacy and security is a major barrier to progress in healthcare interoperability. Chennuru named this as one of the biggest challenges for Anthem.

“Providing access on an individual basis when subscriber accounts are typically family-based results in complexity when adding authentication and consent for personalized representatives, or even caregivers and authorized minors or minors with legal standing,” Chennuru shared.

Privacy and security have to be at the forefront of payers' minds, he stressed.

CMS has compiled resources to answer payer questions on the issue and to clarify the interoperability rule’s privacy and security requirements.

However, even in these resources, it is clear that, as much as payers must prepare defensive mechanisms technologically to reduce risk to patient information, a key part of the strategy to overcome these challenges will depend upon consumers.

It is already important for payers to involve consumers in the process of building out interoperability strategies. However, this will be even more crucial in the coming phase as payers pivot from technology and infrastructure to strategy and communication.

Payers will need to communicate clearly with consumers, educating them on how to keep their information safe.

“A lot of the privacy and security components of this rule really are going to come down to the patient level, so health plans can do a good service for their members by making that information available to their members in an easily accessible way,” Todd said.

Additionally, as payers move beyond the July 1 deadline, they will have to coordinate interoperability efforts with other regulatory movements, such as price transparency.

Specifically, some health plans will be responsible for both interoperability compliance and price transparency compliance. However, whereas the interoperability movement focuses largely on third-party vendor apps, the price transparency movement is oriented around payer apps and providing access to pricing for 500 shoppable services.

“There are so many different policies out there; how do we get more of a cohesive approach, a more consistent approach?” Lloyd asked. 

“How do we make sure that we are thinking about who is the best source of that data? And, from a technology perspective, what is the best way to share it and how do we make sure that we have a standard base approach that's fully interoperable, regardless of these rules, to seamlessly share that information?"

“A lot of the privacy and security components of this rule really are going to come down to the patient level, so health plans can do a good service for their members by making that information available to their members in an easily accessible way.”

Although the regulatory landscape is complex, recognizing the shared goals between interoperability and price transparency could ease the process for payers.

“Under the theme of simplifying healthcare and improving outcomes, knowing the price upfront or providing the transparency is going to be critical,” Chennuru said.

He also saw opportunities to advance interoperability alongside blockchain, a decentralized database.

In 2019, Anthem joined a blockchain that created health utility networks alongside Aetna and Health Care Service Corporation (HCSC) with the goal of creating a secure platform for data exchange. The endeavor is still young but Chennuru expressed confidence that it would yield greater accessibility of personal health information for members.

Recognizing the overarching vision for interoperability will help payers go beyond compliance to establish themselves as industry leaders and embrace the future of healthcare.