CMS and the New Interoperability Rule – How and Why

Interoperability has been a goal of the US healthcare system for decades. But just as computing (phones) and cloud networks have transformed our consumer lives, computing and cloud networks will transform healthcare. How and why?  

The “How?” is increasingly being put in place by Congress and the Executive Branch. Interoperability at scale started with 21st Century Cures Act requirements for standards-based APIs so patients, providers and payers can get at the clinical data bunkered in EHRs. Now with the second iteration of CMS payer rules, patients, providers, and payers will start getting access to the administrative data such as claims and prior authorization which drives that care. The data enabler of this modern computing is the FHIR® healthcare data standard which leverages the learnings twenty years of modern Internet computing have provided on how to compute at scale servicing hundreds of millions of devices daily. The infrastructure enabler is cloud-computing which allows seamless combinations of data and the application programming interfaces (APIs) needed to capture, compute and then coordinate care with the new combo of clinical and financial data.

What about the “Why?”. Historically interoperability has been about filling in the blanks in the direct care of an individual patient. While that is still a valuable service, today interoperability is all about optimizing care for an entire population of patients. Key issues such as treating chronic illness, making prior authorization reasonable, prevention, addressing social determinants, and lowering costs of care are simply not soluble at an individual level. Addressing these issues effectively will require a stream of nuanced insights from an entire population of patients.  Importantly the entire healthcare system has to move to richly connected continuous care where patients, their phones and other devices, and their monitoring can become seamless 7 by 24 activities because unfortunately chronic illnesses can best be handled by 7 by 24 attention and ongoing consumer convenience. The days of half-yearly doctor’s office visits as the standard in treating illnesses such as diabetes, hypertension, and obesity are coming to an end.  

CMS increasingly realizes that this modern care requires all of the relevant parties to patient care – the patient, the providers and payers each need rich data flows to provide this modern care. CMS has just proposed the second version of its interoperability rules where the payers it works with are required to provide FHIR APIs for patients, treating providers and with transitions of care to other payers. CMS has provided a powerful statement that the vast federal spending on programs such as Medicare Advantage, Medicaid and CHIP will go to those payers providing and using modern APIs. CMS itself with Medicare Fee for Service already practices this discipline with FHIR APIs using Blue Button 2.0 and Bulk FHIR for participating ACOs.

And for payers today the third part is the “What?”. How can a payer effectively combine claims data that the payer already has infrastructure for with a modern compute environment that can both capture clinical data from providers and provide the APIs for this modern view of the world. That is where 1upHealth comes in. As the first FHIR-native cloud infrastructure 1upHealth provides payers with a massive scale cloud computing environment to capture both claims and clinical data, build the compute environments to measure quality, power prior authorization, and design efficient networks and finally power all of the APIs to use this knowledge with patients and providers on an ongoing basis.

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