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Innovation Through Integration: Legislation Should Help Open Access to Patient Data

Eight-year-old standard finds fresh life thanks to new legislation meant to ease access to patient data across the health care ecosystem.
  • Gates Ouimette
  • April 2021
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As the current U.S. health care model becomes less sustainable, with administrative costs negatively impacting the industry, the public's awareness of health insurance availability and affordability increases. The COVID-19 pandemic, with its rapid spread, varying symptoms and overall unpredictability, has further accelerated this situation.

To specifically address a move from fee-for-service to a value-based care world, where patient outcomes will benefit, in 2020 the federal government passed legislation with short-term implications to providers and to payers. Despite having some short-term implications, longer term ramifications are significant. Combined, the CMS Interoperability and Patient Accessed Rule (CMS-9115-F) and the ONC 21st Century Cures Act are designed to increase access to patient data.

Since insureds often have multiple providers, including primary care and specialists, patient records can be found in multiple systems in multiple formats. While hospital systems struggle to rationalize patient provider data within their system, adding to this complexity are patient out-of-system encounters.

Patient data is most often viewed as being held within a provider's electronic health record (EHR), but there is a significant amount of insureds' data held within payers' systems. Insureds' payers can change as often as they change jobs, not to mention changes from family members transitioning to their own insurance. With a typical insured's provider and network continually evolving, so are isolated instances of their data. The federal legislation is designed to eliminate “all of the above” types of data silos.

New Rules

Under this legislation, insurers have new requirements. Access to a payer's provider directory must be provided by an API (application programming interface); payers must allow other payers to access patient/claims data through a payer-to-payer exchange. A third piece required of payers is a patient access API, where insureds can easily access their claims data.

To simplify this any-to-any data sharing, the Fast Healthcare Interoperability Resources (FHIR) standard, created more than eight years ago by the Health Level Seven International (HL7) for data exchange, is increasingly relevant. A foundational technology, FHIR can be the vehicle for EHRs, digital health applications, and insureds/patients to use and exchange structured health care data.

In this newly “open” world for patient data, each individual payer can implement their interoperability as they prefer. Some may focus on compliance implications, and the potentially significant cost to be incurred by payers. Others may focus on more strategic designs for this requirement, taking more of a leadership role on using individual patient data to enable personalized health management.

This more strategic approach can help a payer better manage, and even drive down their costs for providing health insurance. By themselves hosting the patient access API, payers can use near real-time data to augment patient histories. Earlier diagnoses can alter the types of treatments used, driving down costs for the payers, improving health outcomes for patients and growing positive payer brand perception.

The evolving role of data in insurance innovation is important, said Charlie Sidoti, executive director of InnSure Corporation. As a 501(c)(3) not-for-profit organization focused on fostering innovation in insurance and risk management, InnSure's guiding principle is “building and connecting confidence.” To achieve the requisite confidence within the insurance industry, data will play a critical role in how it helps industry constituents respond to disruptive forces. Nothing builds or breaks confidence as much as good or bad data, the company noted.

Going forward, the sharing of health care data will create new opportunities across the industry, and beyond health insurers to life writers and even to property/casualty insurers. Insurers considering the new possibilities, rather than focusing on privacy and cost concerns, can create the new normal with health care providers.


Best’s Review contributor Gates Ouimette is principal at ITconnecter. He can be reached at gateso@ITconnecter.com.



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