Many consumers believe that they have access to their healthcare data. Historically, however, they’ve been beholden to the apps and portals that providers decide to deploy. In addition, most states don’t offer portals for Medicaid members, so these individuals don’t have electronic access to any of their data.
All of this is changing with the CMS Interoperability and Patient Access Final Rule. Interoperability represents a fundamental shift which puts consumers in control. To satisfy the CMS rules, the healthcare ecosystem must implement specified application programming interfaces (APIs) to transfer the data they store internally. Those APIs will give consumers ownership of their data and will enable technology companies to create applications that combine this data in new ways that meet people’s unique and varied needs.
The Interoperability Ecosystem
While consumer-facing apps are in important component of interoperability, they represent only part of the picture. To support those apps, healthcare organizations must build technical infrastructure. This “plumbing” serves three important purposes:
- Accessing data. The first part of interoperability is accessing the data itself. Consumers are interested in a wide variety of information ranging from claims data to clinical information, formulary data, relationship data around legal guardians, and more. The source systems for this data include Medicaid Enterprise Systems (MES), immunization registries, health information exchanges, and pharmacy benefit manager systems.
- Loading data into a Fast Healthcare Interoperability Resources (FHIR) repository. The next step is mapping data from source systems to the FHIR format and then loading it into a FHIR data repository and publishing it in the required API format. The apps will access these APIs from this repository to gather desired information and transform it into personalized healthcare knowledge.
- Making information available in a secure way via consent management. Authentication is crucial to ensure that APIs disclose sensitive healthcare data to the appropriate people. Consent management is more complex with Medicaid organizations, since they rarely have existing member portals with usernames or passwords for members. Complicated relationships, such as legal guardians, also make consent management more challenging.
Another critical element required for interoperability is the third-party developer ecosystem. Healthcare organizations must register app developers and give them access to the API endpoints. Gainwell’s Patient Access and Interoperability solution offers a developer console and API sandbox so third-party app development teams can work with the API endpoints and test them in a safe environment.
It’s important to keep in mind that API support for interoperability is quite complex, since multiple stakeholders are involved. When questions arise, coordination may be needed between consumers, third-party developers, and the API developers.
Why States are Choosing Gainwell’s Patient Access and Interoperability Solution
Gainwell has the most states committed to partnering for interoperability and more states live than any other vendor in the marketplace. Gainwell differentiates itself from other interoperability solutions in several ways:
- A deep understanding of FHIR technology which has its roots in the clinical space, as well as the Medicaid and payer landscape. Gainwell’s partnership with 1upHealth brings together clinical expertise and knowledge of government adjudication systems.
- A flexible solution with multiple implementation options. Extracting data from source systems can be challenging. Gainwell has pioneered a unique and highly successful approach using the Transformed Medicaid Statistical Information System (T-MSIS) format to get data out of many state systems.
- A complete end-to-end solution. This includes a developer ecosystem, integrated support model, payer-to-payer model, and a Gainwell app. The data that Gainwell makes available via its API endpoints is richer than that provided by other vendors. We make many optional fields from the Common Payer Consumer Data Set (CPCDS) standard available to third-party apps. The Gainwell developer ecosystem is also mature. Clients immediately get access to the third-party apps and developers in the ecosystem, giving members broader access to tools to manage their own healthcare.
To learn more about the infrastructure needed to deliver on the interoperability promise, please register for our upcoming webinar on November 22 – Decoding the Interoperability Ruling: Access When You Need It.