Interoperability: The first pillar of payer data priorities
Why acting now to improve data access can help health plans stay ahead of evolving interoperability standards and policies.
This article is the first in a three-part series on payer data priorities. Future articles will address using data to advance payment integrity and the member experience.
For years, health plan leaders have lamented the lack of structured clinical data needed to capture quality metrics and inform a robust population health management strategy across their enterprise.
Fortunately, better clinical data is finally on the verge of transforming the industry, thanks in large part to the Trusted Exchange Framework and Common Agreement (TEFCA).
Building on interoperability advances set in motion by the 21st Century Cures Act, TEFCA’s voluntary framework gives plans, providers and other healthcare stakeholders a glidepath for broader clinical data exchange. TEFCA leverages the technical capabilities and expertise of qualified health information networks (QHINs) to broker queries for payers and their delegates.
TEFCA's implications
As TEFCA’s framework shifts from concept to reality, plans should prioritize establishing the robust infrastructure, partnerships and expertise needed to move their digital strategy forward.
Here are five proactive strategies for health plans to set the stage for better clinical data exchange with their partners.
Review the plan’s legacy data infrastructure to ensure it is ready for the next phase of interoperability. To keep pace with interoperability requirements, payers require a sophisticated, scalable infrastructure with sufficient technology to share clinical data via FHIR resources. A cloud-based infrastructure — either within the plan’s existing environment or through a managed services approach — can provide the scalability that health plans need to expand connectivity.
Currently, many health systems are not yet using FHIR to share data with payers, nor are they mandated to participate in TEFCA. As such, plans should be equipped to accommodate data partners’ capabilities from a technical standpoint when developing point-to-point connections. For example, plans may opt to use Integrating the Healthcare Enterprise (IHE) integration profiles to identify members and retrieve clinical documents. As some organizations may not have the bandwidth to implement a direct connection, plans can offer a secure web-based portal that enables clinical data to be uploaded by the site. Taking these actions will help plans avoid leaving valuable data on the table.
Set aside enough time and resources to execute or modify data use agreements where applicable. When executing data use agreements (DUAs) with data partners, health plan leaders may underestimate the effort required to identify and align the various stakeholders in complex provider organizations. These include HIM, legal, compliance, security and IT. Getting started now can ensure that plans have adequate time to execute these agreements and implement direct integrations with providers and other data partners when needed.
Consider joining a QHIN. As an alternative to creating one-off DUAs and direct integrations with health systems, plans may opt to join a designated QHIN under TEFCA to support data exchange on a broader scale and gain access to accurate clinical data more quickly and affordably. When plans take steps to onboard with a QHIN, they should ensure their provider contracts specify a response to all QHIN queries for data, not just for treatment and individual access exchange purposes.
Plans also have the option of querying a QHIN through a delegate partner. Trustworthy delegate partners should have a solid industry track record and value transparency regarding the data that is available across their entire network, outside of the QHIN. This includes a willingness to share updated participant lists with tax identification numbers and national provider identifier numbers, when available. Ideally, delegates also should offer analytics and the capabilities to leverage the data for multiple use cases, such as quality reporting, risk adjustment and payment integrity.
While critically assessing potential partners is important for plans of all sizes, this due diligence is especially critical for smaller and midsized health plans that have deep market penetration in specific regions of the country. For such plans, a well-established health information exchange in their market may be an untapped resource to help plans implement modern interoperability protocols and monitor the results over the long term.
Get listed in the recognized coordinating entity’s TEFCA’s directory. Regardless of how plans opt to obtain data from a QHIN (either directly or via a delegate partner), they must become listed in the recognized coordinating entity directory. The Sequoia Project is responsible for implementing TEFCA as the recognized coordinating entity, and becoming a listed participant in the directory is one of the first steps payers must take to access the data.
Be mindful of upcoming API deadlines. Plans are already required by CMS to support a patient access API. By Jan. 1, 2027, plans will also be required by CMS to make information available to patients about prior authorization requests. In addition, plans must implement a provider access API and a payer-to-payer API by the same deadline.
Although developing these FHIR-based APIs simultaneously may seem daunting, plans can likely build on their previous success implementing the patient access API and tap the same project team to meet these looming deadlines. In addition, ONC recently released the new Health Data, Technology and Interoperability: Patient Engagement, Information Sharing, and Public Health Interoperability (HTI-2) proposed rule for public comment. Focused on improving data exchange among patients, providers, payers and public health authorities, the new rule provides voluntary certification criteria for health IT vendors who support payer-provider interoperability. The criteria were developed in coordination with CMS to support the technical requirements included in the Interoperability and Prior Authorization final rule, with the intention of making it easier for payers to exchange information.
Prioritizing interoperability
Even though TEFCA has the potential to meaningfully advance payer interoperability, participation is not mandatory and, therefore, the framework is not a silver bullet solution.
As evolving policy developments improve payer access to data in the coming months and years, leaders can stay ahead by critically reviewing their infrastructure, protocols and partnerships. Prioritizing interoperability is a complex undertaking and plans that take these proactive steps will be better positioned to meet their strategic goals.
Katie Devlin, DHSc, MS, CPHIMS, is vice president of interoperability for Cotiviti.