We are all frustrated when there’s a glitch with our online banking, or if bandwidth problems interfere with streaming the movie we want to watch. Imagine how individuals will react when the results of a cancer screening don’t find their way into Apple Health or Google Health, where such information is supposed to be easy to find. Or worse, if an individual is given the wrong information about a cancer diagnosis.
An individual’s first call about missing health data or claims is going to be to their health plan, not the digital health application. Next summer, health plan customer service personnel could be fielding thousands of calls every week from members who can’t find test results, pharmacy receipts, claims documents, and a range of other vital information. This, despite them, using a sophisticated digital health platform to manage their data.
Many health plans are woefully unaware of a possible looming problem that is coming when the CMS Interoperability and Patient Access rule is in effect, and individuals will finally be able to access their complete health data. Moreover, health plans may run afoul of state laws regarding HIPAA and consent management. Insurers will face these tough realities if they do not approach the upcoming mandate with the right strategy in place.
Health plan CIOs should be employing a plan that treats the mandate not as merely the latest hurdle to jump through, but as a jumping-off point to transform their business and create a better member experience.
Complexity of the Mandate
Because of the pandemic, health plans have been offered an extension on the deadline to make the valuable health information they are holding available quickly and easily to the individuals who ask for it.
But any CIOs breathing a sigh of relief are likely miscalculating the enormity of the job ahead. For health plans, July will come soon enough.
Since the mandate itself is still being finalized, compliance with it remains a moving target. For this reason, any data system currently in development could be scrapped as the guidelines change.
Consent for the sharing of health information is another layer of complexity. CIOs need to factor this in as they put together a strategy for compliance. Since the federal government has declined to pass a preemptive rule on consent, state rules are in effect. This means that insurers with multi-state operations will need to be able to manage differing local compliance requirements.
Preparing for this will be complicated, but violating any law—whether state or federal—means paying fines. Furthermore, the inadvertent release of personal health data to an unapproved person or source could expose health plans to additional government regulatory compliance violations and even civil suits.
Employing a data system that merely “checks the box” on meeting the CMS mandate instead of using these requirements as a catalyst for improving member experience could mean frustrated individuals and overwhelmed customer service lines.
This is why CIOs need to have the right considerations in mind—and know where the pitfalls lie—as they decide whether to partner with a technology developer to meet the interoperability requirement or to build the necessary infrastructure in-house.
Planning for the Future
Some health plans will meet the interoperability requirement by building their own infrastructure to share information easily with their members. Others will choose from a field of potential technology partners that have created solutions to ingest, manage and share data.
Here are some considerations CIOs should keep in mind whichever approach they settle on:
– Don’t build a system that merely conforms with a “compliance checklist.” The interoperability requirements are likely to change, so building to the requirement today, could mean rebuilding later.
– Take full advantage of the ability to share data to improve the member experience, and build modules that will take advantage of digital health applications now…and those coming down the road.
– Ensure that your systems can follow the data from a digital health application to a provider visit so that your customer service representatives have a complete view of member data, and thus can answer members’ questions.
Partnering with a technology company
– Avoid those who simply set up an FHIR-compliant server, add consulting services, “fire up the widgets” and then step back. The right technology partner understands the complexity of the mandate and designs flexibility into it.
– Choose vendors with deep security expertise in order to avoid compliance issues, especially if dealing with multi-state requirements.
– Find a partner that understands the discipline of healthcare, and the responsibility that comes with getting the right information, to the right patient, at the right time, and understands the mandate is merely a jumping-off point to improve the member experience.
Whether CIOs choose to partner or build, rolling out a system that merely conforms to a checklist would be a missed opportunity. And it could lead to costly mistakes.
CIOs should think bigger when it comes to interoperability. As sharing data will open up a new type of interaction between health plans and members, this is the chance to improve and even remake the member experience.
Health plans need to embrace this opportunity but know that meeting the mandate is more than checking a box.
About Minal Patel
Minal is a serial physician entrepreneur who founded Abacus Insights to serve payer needs around data integration and insight generation. Prior to this he has held senior roles at payer organizations most recently serving as SVP and Chief Strategy Officer of Horizon BCBSNJ.
About Laurent Rotival
Laurent Rotival serves as the SVP, Strategic Technology Solutions & CIO of Cambia Health Solutions. Laurent leads Cambia’s development of next-generation technology solutions that will help create a more person-focused approach to health care. Laurent brings 25 years of senior leadership experience in IT business strategy and growth from some of the most well-known global brands and Fortune 10 companies.