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Could A New Interoperability Wrinkle Solve Healthcare's Biggest Challenge? There has been much debate on the possibility of mandating providers to participate in health information exchange activities to stay in Medicare.

For a few years now--from the latter part of the Obama administration through the first 18 months of Trump's presidency--federal health officials have been adamant about moving from an era of EHR (electronic health record) adoption to one in which these technology systems will make it easier for providers and patients to share health data across the care continuum.

Of course, healthcare interoperability has been a great pain point to date with one of the primary barriers being the lack of a true business incentive to compel providers and EHR developers to be "open" with this ever-so-important data. To this end, in recent proposed regulations, federal health leaders have clamped down, perhaps harder than ever before, in their ongoing effort to guide stakeholders to a world in which seamless health data exchange is the norm, rather than a rarity.

There may have been no greater evidence of this than the Centers for Medicare & Medicaid Services' (CMS) proposed updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) in April. In the rule, CMS proposed to re-name the federal EHR Incentive Program, or meaningful use, choosing to now call the program "Promoting Interoperability." But just how far the federal agency will go beyond "promotion" is what's particularly fascinating.

CMS wrote that it will be seeking public comment, via an RFI (request for information) on whether participation in the government's Trusted Exchange Framework and Common Agreement (TEFCA) initiative--a federally-constructed plan released in January to jolt interoperability among providers--could be used as a vehicle to mandate providers to share data.

Indeed, more specifically, in the proposed regulation, CMS said it will be soliciting feedback on if the agency should revise its "Conditions of Participation" for hospitals that would require them to perform health information exchange activities such as: electronically transferring medically necessary information upon a patient discharge, sending discharge information to a community provider via electronic means; and making information available to patients or third-party apps. And if providers did not meet these Conditions of Participation, if they were to be revised, the consequence would be that they would not be able to participate in Medicare.

HOW ARE STAKEHOLDERS REACTING?

As one might imagine, seeking comment on whether or not interoperability should be a requirement for Medicare participation has elicited a wide array of responses across the sector. Comments on the RFI were due to CMS by the end of June, and there was no update from the agency when it published the final Promoting Interoperability rule in early August on what the next steps might be. But as one health IT expert, Jeff Smith, vice president of public policy at the Bethesda, Md.-based AMIA (the American Medical Informatics Association), points out, it could be some time before there are actual interoperability mandates.

"You have to keep in mind the realities of the process. What you need to remember is that the Conditions of Participation aspect of the [proposed rule] was specifically called out as an RFI. And the RFI tries to get information that the agency could consider for potential future rulemakings," explains Smith. In other words, CMS did not include the potential Conditions of Participation revision as part of the proposal; rather, the RFI is the step leading up to a potential proposal. And "potential" is the key word to keep in mind, Smith says.

Nevertheless, health IT trade groups were keen to give their feedback on the RFI in their public comments. While some stakeholders were adamantly against the possibility of revising Conditions of Participations to revive interoperability, others were strongly in favor.

Kelly Hoover Thompson, CEO of SHIEC (the Strategic Health Information Exchange Collaborative), a national collaborative that represents health information exchanges (HIEs) and their partners, believes that imposing regulatory requirements is not the best solution to the interoperability problem. "I don't think it has to go as far as what CMS [could be proposing], but I do think that it's an indication to the industry, on a good level, that so many people are [thinking about] how to make things better," says Hoover Thompson. Other major industry trade groups, such as AMIA, the American Hospital Association (AHA) and the College of Healthcare Information Management Executives (CHIME), similarly attested in their comments that CMS is taking the wrong approach.

That said, others feel differently. A letter signed by more than 50 organizations, representing plans, providers, patient groups, ACOs (accountable care organizations) and health IT companies, has called on CMS to take more aggressive action to promote interoperability and advance health information exchange. Some of these signed groups include prominent industry names such as Beth Israel Deaconess Care Organization, Blue Shield of California, the New York eHealth Collaborative (NYeC), and Aledade.

Valerie Grey, director of one of the signing organizations of the letter--the New York eHealth Collaborative--says that NYeC supports potentially changing the Conditions of Participation with an incremental step. Grey says that more vendors and providers have been willing to make data available for shared patients, but further progress is necessary.

More broadly, though, Grey points out that not every hospital can afford the EHRs that are enabling some of that interoperability today. However, being that NYeC's role is to promote and enable information exchange, it is natural for the organization to support efforts that seek to promote information sharing, she says.

WILL BUSINESS INCENTIVES CHANGE?

In the end, just as the previous administration changed incentives to encourage EHR adoption, the current one will have to find ways to inspire the next stage of interoperability: the efficient movement of health data. But it's a delicate balance and it becomes a question of where to apply the pressure and how to incentivize the kind of behavior that is desired, AMIA's Smith says.

Another piece of the puzzle is an information blocking rule from the Office of the National Coordinator for Health IT (ONC), which was originally expected in April, but now has been delayed until September [and has not been published at the time of this story]. It's this rule, coupled with TEFCA, that experts believe could move the needle on incentivizing providers and EHR developers to interoperate.

"The hope was that the information blocking rule would be the definitive answer to the business incentive piece to the interoperability puzzle," says Smith, noting that there are plenty of questions that need to be answered even within that rule itself. For instance, he contends, "data availability--when it comes to matters of life and death--are issues of public health. But data availability for non-matters of life or death, or matters of an individual, comes down to more business questions--such as do I need to share the data for everyone who asks for it?"

Regarding TEFCA, officials are likely to put out a second draft version and another public comment period will follow, says John Kansky, the CEO of the Indiana Health Information Exchange, and appointed member of the Health Information Technology Advisory Committee (HITAC), which has had a lot of influence in making TEFCA recommendations to ONC. "It's fun to think about and I feel privileged in having a front row seat in helping advise ONC, but we don't know how the regulation will evolve," Kansky admits.

That said, it's not helpful or informative that opinions on TEFCA are all over the board, he adds. There are two buckets of folks that are thinking about and opining on this regulation, Kansky says: those who are strongly in the camp of advocating for consumer access and being in control of their data; and those who have been working on creating industry interoperability, be it through EHR vendors or HIEs, and trying to make it a reality. "Those two groups tend to have different views on regulation," he points out.

Going forward, Smith asserts that the key will be how these policies that the industry has been expecting for some time now will intertwine with one another. "What I am hoping beyond hope is that the reason these policies are not yet publicly available is because the powers that be are still trying to make sure that there is harmonization and a logical inter-reliance across them," he says.

Meanwhile, Kansky believes that the interoperability space is "ripe for bold change and opportunity. "A few years into the future, he predicts, between the EHR interoperability approaches that will be prevalent, in addition to HIEs and regulations like TEFCA, the ecosystem will find a way for everything to work together. "Even when one sees the other as competition or making the way of life more challenging, this is what we do in the free market in the U.S.," he says. "We throw a bunch of different approaches at a problem and sometimes we make a mess, but in the end we figure out a solution. And the solution isn't one thing, pure and simple; oftentimes it's a complicated ecosystem--but it works."

BY RAJIV LEVENTHAL
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Title Annotation:TREND: The New World of Interoperability
Author:Leventhal, Rajiv
Publication:Healthcare Informatics
Date:Sep 1, 2018
Words:1494
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