On May 1, 2020, the Centers for Medicare and Medicaid Services (CMS) published the Interoperability and Patient Access Final Rule, designed to enable a connected healthcare system where a streamlined flow of information breaks down siloes, enhances decision-making and ultimately improves health outcomes. To enable this seamless flow of data, CMS specified Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Release 4.0.1. as the data exchange standard.
Three years (and one pandemic) later, where does this initiative stand?
CMS has exercised enforcement discretion around certain provisions and deadlines, so not every state has made the same level of progress. Some, however, have taken the leap and are setting up to adopt the next set of regulations, including new payer-to-payer APIs and planning for prior authorizations.
Through Gainwell Technologies’ experience guiding 15 states to full compliance with the original Final Rule — and currently supporting five more states in their journeys — we have compiled a set of lessons learned to ease the burden of future implementations while maximizing flexibility and project outcomes.
- Prioritize Consistent Data
Even though states are working with essentially the same kind of data, it’s not consistently maintained — neither within nor across state systems. Even if formats started out the same among agencies, so many differences have been introduced over time that there’s now a great deal of variance within the data.
Sound, data-driven decision-making relies on a foundation of accurate and complete information. Any compliance effort should start with ensuring that all systems have access to consistent, clean data.
- Ensure Quality Through Rigorous Reviews
The importance of comprehensive and granular quality reviews cannot be overstated. In fact, we’ve transformed our own quality assurance processes based on what we’ve learned over the past several years.
Conducting more reviews up front helps to uncover issues that might slow down the process later. Identifying each source of data, then mapping and documenting how it will be digested by the various systems, is crucial to ensuring a seamless flow of accurate data.
- Leverage Standards to Speed Compliance
FHIR provides a standard endpoint for a state’s data sources and is absolutely critical for enabling interoperability between systems. FHIR provides a foundation for a truly interconnected healthcare system, but it also allows agencies to build out exciting new capabilities.
We’ve encouraged our clients to think of the FHIR standard as an enabler of innovation — and as the race to interoperability continues, we recommend they look at Transformed Medicaid Statistical Information System (T-MSIS) data the same way.
Using T-MSIS as the standard format for data is one of the reasons our clients moved forward so quickly. Taking an existing format and leveraging it for input into FHIR is allowing states to accelerate their compliance efforts.
- Build, Then Grow
Once states have properly implemented FHIR, they’ve effectively established a beachhead from which to expand. Many have already been able to make enhancements to the platform and are considering additional ways to innovate, such as importing and analyzing data on social determinants of health. And once states are compliant with the current government regulations, they will have the ability to more easily adapt their existing systems to support future regulations.
- Consider New Perspectives
States are the undisputed experts on their Medicaid programs, but bringing in a different perspective can also speed modernization projects.
Gainwell, for example, has worked with so many states over the years that we have built up a wealth of institutional knowledge — knowledge that allowed us to step up to the challenge of the Final Rule and will enable us to address future regulations for our clients.
- Embrace the Future, Today
By starting early, we’ve had time to work through challenges with our clients, and we know what we’re looking for now. Accordingly, our clients are now much farther down the road to interoperability.
CMS has not strictly enforced compliance, but that could always change. And the lift could also be heavier with the next round of regulations.
The best time for states to accelerate their compliance efforts was three years ago. The next best time is today.
About the Author
Rajesh Sharma is a vice president and general manager overseeing Systems Integration, Interoperability and Data Analytics Product Offerings at Gainwell Technologies.
Ignatius Cruz is director of Interoperability Solutions for Gainwell Technologies.