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As HEDIS hibernation thaws, spotlight shines on data access revolution — and roadblocks

By Carley Thornell | February 8, 2021

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As the medical community grapples with the concurrent challenges of treating COVID-19 patients and vaccinating them, now more than ever it’s important to streamline healthcare processes. A Centers for Medicare & Medicaid Services Interoperability and Prior Authorization rule finalized last month intends to do just that, aiming to enhance patients’ access to their own data and phase out largely manual practices to collect information across the healthcare continuum. But the measure presents a dual challenge for payers, many of whom would have to enhance technology quickly while managing gaps in data due to difficulties accessing clinical records during the pandemic.

Connecting the dots across the continuum

The new rule builds upon CMS’s information blocking regulations, which were finalized just as the pandemic was declared a public health emergency. By focusing on prior authorizations —which many payers require for medications, procedures, and physician referrals — insurance companies have more oversight when it comes to the most clinically and cost-effective treatments. But it also means that providers must submit documentation and, in many cases, still wait on the phone or use fax machines. (EHR Intelligence notes that 46 percent of clinicians still submit authorization requests by fax and 60 percent are made over the phone.)

“Each element of this proposed rule would play a key role in reducing onerous administrative burden on our frontline providers,” said Seema Verma, administrator of CMS under the previous White House administration. “Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients.”

Lukewarm response to change during the public health crisis

The authorization management and interoperability rule was initially met with mixed reactions from the American Hospital Association. AHA supported efforts to enhance patient care by making the prior authorization process easier, but expressed disappointment that Medicare Advantage plans were left out. The rule requires that payers — but not plans on the federal exchanges — make prior authorization decisions within 72 hours, or a week for standard requests (more than a quarter of physicians polled in 2019 by the American Medical Association say they have waited “at least three business days” for prior authorizations). The new rule also requires payers to integrate new application programming interfaces (APIs) developed by Medicaid and other federally supported plans.

America’s Health Insurance Plans, an industry trade group representing payers, contests the timing of the newest interoperability rule, with overtaxed IT teams still combatting the health crisis. Even with “HEDIS hibernation” — a temporary reprieve in quality reporting for 2020 — COVID-19 still rages on and payers are anticipating gaps in data. It’s likely that only the most digitally minded organizations will be enabled to thrive when faced with the challenges of navigating the pandemic.

However, the effects of patients delaying care or avoiding in-person doctors’ visits altogether in terms of reporting may be somewhat mitigated by the rapid uptick in virtual care across the healthcare continuum. Not the least of those embracing the measures is the National Committee for Quality Assurance (NCQA), the body that administers the Healthcare Effectiveness Data and Information Set that is used by more than 90 percent of U.S. health plans to measure performance. “We understand the important role telehealth has played in making care available amid an unprecedented national lockdown,” said NCQA president Margaret E. O’Kane, “and that it will continue to be an important part of the healthcare system going forward.” That means both new reporting requirements and new opportunities. 

Digital tools are the building blocks for a new, stronger foundation

Ushering in a new digital era with more longitudinal interaction, virtual preventative visits, and data-driven decision-making may ultimately reduce costs for chronic care patients and others — while also minimizing the spread of infectious diseases like COVID-19, say scientists. Virtual visits for preventive care help keep patients with less serious conditions out of hospitals. And for health plans,  the availability of new and evolving tools to exchange medical data digitally help staff avoid costly trips to brick-and-mortar offices to gather paper charts, as detailed in a recent athenahealth webinar

Philadelphia-based Jefferson Health President and CEO Dr. Stephen Klasko said in a Becker’s Hospital Review interview that his post-pandemic predictions largely focus on advancements in access to data, interoperability, and relationships. “Think about how the pandemic would have been handled differently if we had continuous data coming in from patients through their wearables and other sources as it related to temperature, respiratory rate, etc.,” he said. 

“The COVID-19 crisis will accelerate a disruption in how healthcare is delivered, paid for, and perceived,” Klasko said, adding that he anticipates “closer strategic alignment” across the healthcare continuum. For some, that alignment includes vaccine distribution at sites like grocery stores and pharmacies; and for payers like Humana, drive-through patient testing at many Walmart Neighborhood Markets.

Such innovative models spotlight the need for a robust flow of data for care outside of traditional settings and between myriad geographies, say researchers like Dr. Trish Perl, chief of infectious diseases and geographic medicine at the University of Texas Southwestern Medical Center. She writes that as respiratory diseases like COVID-19 and SARS, whose first major outbreaks were in China, or Ebola (Western Africa) continue to become more prevalent and can spread rapidly through travel, patient travel histories should be integrated into EHRs. The result could be warning signs or protective measures to limit the spread of disease, and further support for provider decision making at the point of care. An effective patient data exchange and improved interoperability would facilitate sharing that information if Perl’s suggestion is implemented.

Learn more in this presentation with Eddie Ross, athenahealth vice president of payer strategy.