With the introduction of HIPAA in 1996, interoperability has often taken center stage in the health care arena. Amid new federal regulatory requirements and an unprecedented global pandemic, the importance of the industry’s journey to achieve a truly interoperable and connected health care delivery system that supports improved patient care and quality outcomes has never been clearer.

Payers and providers have been working together for years, alongside health care interoperability collaboratives such as The DaVinci Project, CARIN Alliance, CommonWell Heath Alliance, Carequality, and The Sequoia Project, on the most effective ways to collect and share data. However, payers had not previously been mandated to exchange claims and clinical data with members–that is until March 2020  when the Centers for Medicare & Medicaid Services (CMS) released its Interoperability and Patient Access final rule requiring exactly that.

By July 1 of this year, all Medicare Advantage, Medicaid, CHIP and ACA plans are required to provide a FHIR®-based Patient Access Application Programming Interface (API) and Provider Directory API, as mandated in the final rule as part of the 21st Century Cures Act. By January 2022, health plans must also have in place an API in place to support Payer-to-Payer data exchange. When these new requirements are in place, health care consumers will have the ability to easily and rapidly access their own personal health care data and provider information.  In addition, they will benefit from their health care data being seamlessly shared between health plans should they move to another plan.

As we move closer the first compliance deadline this year, the next destination on the interoperability journey is clear for many health plans; however, for others the path may be less so. An industry readiness survey conducted by the eHealth Initiative in September 2020 found that 43 percent of respondents representing payers, providers, and vendors indicated they were most concerned with implementing and maintaining a Patient Access API. Further, a majority reported foreseeing major challenges associated with managing multiple APIs connected to different systems as regulatory timelines progress. Underscored by the COVID-19 pandemic, there was also consensus among respondents that having too many competing priorities was a top challenge impacting readiness to comply with the upcoming mandates.

The first regulatory enforcement deadline is fast approaching in July 2021 and many health plans are still grappling with significant considerations related to:

  1. Ensuring data accuracy, completeness, and mapping to required formats
  2. Security issues related to application authentication and consumer validation
  3. The need for deep expertise in FHIR®-based API development, maintenance and integration; patient engagement and the user experience; and much more

Price transparency requirements aim to further advance  and  inform consumer health care decision- making

The Interoperability Final Rule requirements are far from the end of the federal government’s efforts to establish a more connected and transparent health care delivery system. CMS finalized its Transparency in Coverage Final Rule on October 29, 2020  that aims to make health care price information easily accessible to consumers and other stakeholders including researchers, employers, and third-party developers. This will ensure they have crucial information to make informed health care decisions, improving patient outcomes. The rule builds off CMS’ Hospital Price Transparency Final Rule, requiring all U.S. hospitals to offer pricing information online starting January 1, 2021.

Compliance deadlines for the Transparency in Coverage Final Rule will come in phases similar to CMS’ API data-sharing mandates. The first deadline converges with the Interoperability Rule’s Payer-to-Payer Data Exchange API deadline of January 1, 2022, at which time health plans will also be required to make publicly available standardized data files, updated on a monthly basis, that provide:

  1. In-network provider negotiated rates
  2. Historical payments to out-of-network providers
  3. In-network negotiated rates and historical net prices for all covered prescription drugs

Beginning January 1, 2023, the second phase of the Final Rule comes into effect at which time health plans will be required to provide an online shopping tool allowing consumers to see the negotiated rate between their providers and their plans, as well as a personalized estimate of their out-of-pocket cost for 500 of the most commonly used items and services. By January 1, 2024, these online shopping tools will also be required to provide the costs for all remaining procedures, drugs, durable medical equipment, items, and services.

Looking beyond compliance to new, innovative ways to improve member engagement and meet consumers where they are

While these federal mandates largely represent a brand new world for the health care industry, which has traditionally lagged other industries in the realm of digital transformation, they also offer an incredible foundation for health plans to support a seemingly limitless number of opportunities to meaningfully engage with members and enhance the member health care journey while driving better health outcomes.

With the ability to gain essential information about which applications and online tools consumers are using, health plans will be able to employ this data to develop targeted strategies for engaging their members in a number of ways, including the ability to:

  • Empower care management teams with real-time patient-specific insights to help quickly identify high-risk members in need of intervention and prevent avoidable adverse events
  • Close critical clinical and quality gaps and reducing unnecessary hospital visits with member care reminders that support improved patient quality outcomes and risk score accuracy improvement
  • Engage high-risk members through tailored notifications and program alerts to help connect members to medical and supplemental benefit programs based on their needs in order to control chronic conditions faster
  • Simplify the care experience by informing access to care and helping members navigate the system and make more informed decisions

The path ahead is long, but the journey toward interoperability is accelerating

As we know, regulatory initiatives are only part of a much broader digital transformation that is now well underway in the health care industry. Organizations across the health care delivery system are all seeking innovative and yet practical approaches to work across organizational boundaries in order to improve patient care and experience while complying with new regulations. We are moving away from an era of “how do I get more information” on my member (or patient) to “how do I make sense of all this data,” “what insights really matter,” “how can I effectively share this data to better engage my members in their care,” and “how can I use this data to improve the health care outcomes for my members?”

Current circumstances are requiring us to accelerate this transformation– he nation’s nimbleness and ability to respond to COVID-19 provides evidence to the industry’s ability to accelerate advancement in interoperability. Health care data interoperability and real-time data exchange of relevant health care information between payers and providers improves not only the quality of care provided, but also the efficiency with which it is delivered in value-based health care ecosystems. FHIR®-based data standards also provide greater opportunities for data sharing across the care continuum and enabling organizations to leverage their existing systems to improve care delivery and patient outcomes.

Health care interoperability will continue to evolve and improve as new technological advancements are made, requiring organizations to pace themselves in order to succeed in the new interoperability-driven generation in health care. While the path ahead may be long, the journey toward enabling greater interoperability and connectivity across the health care system and empowering patients to be active stewards of their health and health care is a welcome and worthwhile destination.


About the author

Henry Archibong serves as associate vice president of innovation at Inovalon, where he oversees strategy development, execution, and sales commercialization of Inovalon’s Data Connectivity solutions. 

As a health care IT executive with over 18 years of experience in the technology field, Archibong has also held several executive roles for large health care provider systems over the last 10 years. He began his career with Johnson & Johnson (J&J) where he successfully streamlined IT project execution and resource management across all 250 J&J operating companies globally.

He transitioned into health care when he was tapped to join Cooper University Health Care, Camden, N.J. as its director of enterprise applications. He successfully led the system-wide implementation and adoption of the Epic Electronic Health Record (EHR) for the health system - a 635-bed academic hospital, Level 1 trauma center, and 630 employed physicians. Archibong subsequently led both the hospital and providers to successfully attest to Meaningful Use Stages 1 through 3, earning over $10 million in CMS incentives for the health system. Under his leadership the health system achieved Stage 6 on the HIMSS Analytics EMR Adoption model.  

He then joined Anne Arundel Medical Center (AAMC) in Annapolis, M.D. as its executive director and associate chief information officer (ACIO). There he led several technology advancements for the health system, including the launch of a new Enterprise Resource Planning (ERP) system, a Picture Archiving and Communication System (PACS), and deployment of Epic EHR across all ambulatory clinics. AAMC was recognized as one of the nation’s Most Connected hospitals by U.S. News & World Report, as well as named one of the nation’s Most Wired Hospital in 2015 and 2016 during his tenure.

Prior to joining Inovalon, he was the vice president and site executive for University of Maryland Capital Region Health in Prince Georges County, M.D.