A New Era of Patient Engagement and Information Sharing

January 14th, 2021 by April Todd

Directory Assistance: The one thing payers and developers need before the full potential of the Final Interoperability and Patient Access Rule will be realized.

This summer, when the Centers for Medicare and Medicaid Services (CMS) issued the Interoperability and Patient Access Final Rule, they opened the door to a new era of patient engagement and information sharing.

The rule is designed to allow Americans to track their health insurance claims, prior authorizations, labs, scans and related information using commercially available mobile apps. Under the rule, when a member changes health plans, he or she will be able to use the app to share this information with the new insurer.

In addition to empowering patients with greater information about their claims, coverage and health history, the rule will facilitate better decision-making, care coordination and, in turn, health outcomes.

Yet, to make all of this a reality, one important piece is missing.

The CMS rule requires plans and app developers to use Fast Healthcare Interoperability Resource (FHIR) application programming interfaces (APIs) to share information. The FHIR standard was developed by the industry to allow thousands of disparate systems and apps to communicate with one another.

For this new ecosystem to work, payers and app vendors will need to be able to quickly and accurately find the digital address of the other parties with whom consumers want to share their health information. Today, there are more than 300,000 possible connections and, without a directory of FHIR endpoints, each plan or developer would have to find, catalogue, verify and maintain these addresses on its own.

The parties involved have recognized that this is a significant challenge, and the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) FHIR at Scale Task Force (FAST) determined an endpoint directory is needed to advance FHIR implementation.

CAQH, an alliance of plans and other healthcare stakeholders, was established 20 years ago to address just this kind of industry-wide challenge by streamlining and improving provider data management, coordination of benefits, health plan directories and other essential business functions. CAQH has also brought the industry together to develop the common operating rules that allow administrative information to flow seamlessly across the healthcare industry.

In close collaboration with a broad range of industry partners, including the technology company Edifecs, CAQH is developing an endpoint directory to build on the ONC FAST foundation and simplify the exchange of data between health plans and third-party app developers. CAQH presented a prototype at several recent industry events, including the HL7 FHIR Connectathon, to gather feedback and ensure that the solution effectively meets the task at hand.

At ONC’s “Accelerating APIs in Healthcare,” CAQH announced that it would continue to engage implementers and industry experts with the goal of launching a beta version of the directory in early 2021.

This timing is critical. Among other deadlines in the CMS rule, plans are required to implement the patient access APIs in January 2021 and a process for payer-to-payer exchange by 2022. The CAQH directory will enable plans to meet these aggressive deadlines.

It may be several months before consumers begin to manage their healthcare on their phones and claims history flows smoothly between health plans. However, with an endpoints directory at hand, that day is drawing near, and we may just be about to enter a new era in consumer-driven healthcare.

About the Author: April Todd, Senior Vice President, leads the CORE and Explorations initiatives for CAQH. She is responsible for leading multi-stakeholder collaborations driving the creation and adoption of healthcare operating rules for electronic administrative transactions, researching opportunities for further administrative automation, and establishing a common foundation for new interoperability initiatives.

Infographic: 5 Steps To Simpler and More Secure Healthcare Endpoints

March 18th, 2020 by Melanie Matthews

Healthcare endpoints are distributed and extremely costly to manage and maintain and high spend doesn’t equal high quality patient care with optimal outcomes, according to a new infographic by Igel.

The infographic provides five ways to simplify and secure healthcare endpoints.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical OutcomesAs healthcare moves out of the brick-and-mortar traditional setting into patients’ homes and their workplaces, and becomes much more proactive, the University of Pittsburgh Medical Center (UPMC) has been expanding its remote patient monitoring program. The remote patient monitoring program at UPMC has its roots in the heart failure program but has since expanded to additional disease states across the integrated delivery system’s continuum of care.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical Outcomes delves into the evolution of UPMC’s remote patient monitoring program from its initial focus on heart failure to how the program was scaled vertically and horizontally. Click here for more information.

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Infographic: Secure Health IT Asset Disposition

March 16th, 2020 by Melanie Matthews

Information lifecycle management (ILM) is a precursor to successful digital transformation (DX), according to recent Frost & Sullivan research highlighted in a new infographic by Iron Mountain Incorporated.

The infographic examines the maturity and readiness of ILM within organizations, the general state of DX within organizations and the relationship between ILM and DX capabilities.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results documents the accomplishments of CHS’s 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.

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Infographic: 2020 Top 10 Healthcare Industry Trends

March 13th, 2020 by Melanie Matthews

The Healthcare Executive Group exposes widely divergent readiness and perspectives among payers and providers around value-based care, consumerism, interoperability, and more, according to its new infographic based on the results from its the 10th Annual Industry Pulse Report.

The infographic lists the top 10 priorities for healthcare executives as identified by the report.


Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in the coming year?

Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare Industry, HIN’s 16th annual business forecast, is designed to support healthcare C-suite planning as leaders continue to strive to improve healthcare quality and access and reduce costs as the industry continues its move toward a value-based system.

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Infographic: 3 Challenges That Affect Care Team Well-being

March 11th, 2020 by Melanie Matthews

Alarm fatigue, workplace violence and clinician burnout affect care team well-being, according to a new infographic by Spok Inc.

The infographic compiles recent statistics about the number of alarms in hospitals, the issue of workplace violence, and clinicians’ perception of burnout.

Yale New Haven Health System (YNHHS) takes an on-site, embedded face-to-face approach to coordinating care for its highest-risk, highest-cost patients—whether identified within its own employee population, inside a patient-centered medical home (PCMH), or among the geriatric homebound. The Connecticut-based health system believes this vision of care management is the most direct path to success in a value-based healthcare industry.

3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients across the Continuum examines YNHHS’s three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care.

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Infographic: 3 Strategies To Improve Healthcare Performance in 2020

March 9th, 2020 by Melanie Matthews

Working to meet evolving patient expectations while also trying to manage day-to-day operations can be challenging for healthcare organizations, according to a new infographic by Kaufman, Hall & Associates, LLC.

The infographic demonstrates why insights from improved data and analytics across multiple dimensions will be critical for successful performance improvement in the years ahead.


Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in the coming year?

Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare Industry, HIN’s 16th annual business forecast, is designed to support healthcare C-suite planning as leaders continue to strive to improve healthcare quality and access and reduce costs as the industry continues its move toward a value-based system.

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Infographic: How IT Helps Healthcare Organizations Put Patients First

March 6th, 2020 by Melanie Matthews

Working to meet evolving patient expectations while also trying to manage day-to-day operations can be challenging for healthcare organizations, according to a new infographic by Insight.

The infographic looks at health IT best practices and trends that are helping healthcare organizations provide personalized care, reduce costs for both patients and providers, track inventory and data, and ensure security compliance.


Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in the coming year?

Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare Industry, HIN’s 16th annual business forecast, is designed to support healthcare C-suite planning as leaders continue to strive to improve healthcare quality and access and reduce costs as the industry continues its move toward a value-based system.

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Infographic: Trends in Specialty Drugs

March 4th, 2020 by Melanie Matthews

In recent years, innovation has vastly increased the number of specialty drugs. There were just 10 specialty drugs on the market in 1990; by 2008 that number had reached 200 and stood at 300 in 2015, according to a new infographic by Oliver Wyman.

The infographic examines the top 10 most expensive specialty drugs and specialty drug spend by: route of admission, therapeutic class and type of condition addressed.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk PopulationsWhen it comes to medication management for Medicare beneficiaries, there are more than 25 different factors that can complicate proper use of prescribed medicines—from affordability issues, even among the insured, to fear of a drug’s side effects to potential dangers from high-risk medications or health conditions.

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

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Infographic: What is Fair Market Reimbursement?

March 2nd, 2020 by Melanie Matthews

Fair market healthcare reimbursement establishes a reasonable range of reimbursement rates that all providers within a local market receive from a commercial insurer or another payer, according to a new infographic by Ancore, LLC.

The infographic examines how providers can better understand the rates that have been negotiated with other groups and use this information along with their own cost and quality performance data in payer negotiations.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Insights on Mental Health

February 28th, 2020 by Melanie Matthews

Poor mental health is more common than thought, according to a new infographic by McKinsey, based on the results of its national survey that sought to understand the impact of unmet social needs on consumer health outcomes, utilization and preferences.

The infographic examines the impact of mental health status on healthcare utilization and unmet healthcare needs and social needs.

2019 Healthcare Benchmarks: Social Determinants of HealthOne-third of Americans are grappling with stress tied to meeting their basic human needs such as stable housing, adequate food, and reliable transportation, according to the results of a new national survey from Kaiser Permanente. The survey, Social Needs in America, also found that Americans overwhelmingly want healthcare providers to be involved in identifying and addressing these non-medical social needs.

2019 Healthcare Benchmarks: Social Determinants of Health is the second comprehensive analysis by the Healthcare Intelligence Network of programs aimed at addressing social determinants of health (SDOH), including populations prioritized for SDOH screening, preferred screening tools, interventions, results and ROI.

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