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FHIR Patient Access: Health Plans Between a Rock and a Hard Place

08/10/2020

Tom Gaither, Vice President of Marketing

Several months have elapsed since the release of the new CMS and ONC regulations on FHIR Patient Access, and currently less than a year remains until the regulations take effect on July 1, 2021 (the extended deadline announced by CMS due to the COVID-19 pandemic).

Earlier this summer, Diameter Health sponsored a webinar with AHIP, moderated by President and co-founder John D’Amore, which featured a free-wheeling panel discussion with Mike Baillie from UnitedHealth Group, Hayes Abrams from Health Care Service Corporation, Tracy Rico from Superior Health Plan, and Jonathan Copeland from Centene Corporation.

During this conversation, we polled the audience several times to assess the readiness of attendee organizations to meet the new CMS requirements.  While not a statistically significant study, the directional results are revealing.

The poll results tell a cautionary tale.  When asked “How would you assess your organization’s readiness to meet the new CMS Patient Access regulations?” 41% responded they were either on or ahead of schedule.  59% responded that they were behind or didn’t know.

How would you assess your organization’s readiness to meet the new CMS Patient Access regulations?

Of greater concern were the results of the second question, “How would you assess the quality of clinical data that your organization receives?”

How would you assess the quality of clinical data that your organization receives?”

Just 19% of responders to this question assessed the quality of information received as even “pretty good.” Implementing the FHIR standard not only requires mapping data from previous standards (C-CDA variants, HL7 v2, etc.)  to the new FHIR (R4) resources, but also requires the refinement of legacy data to (among other things) normalize data and correct common vocabulary and syntax errors.

The experience from other industries (e.g. airline frequent flyer programs) where individual data was provided to consumers for the first time, should signal health plans that they should expect more member questions and complaints than appreciation when the clinical data starts to flow in July 2021. Without refinement, members will be unable to interpret the data provided, likely leading to increased member call center volume i and lower member satisfaction ratings.

As health plans charge forward (and charge they must, as there’s no time for delay) to meet the technical requirements of the CMS deadline, attention must also be paid to both the mapping of legacy data to the new standard as well as the usability of the clinical data itself.

[i] Gartner Research, Prepare for CMS Interoperability and Patient Access API Compliance for U.S. Healthcare Payer; 15 June 2020

 

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