Interoperability: Improving the healthcare consumer experience

Understand the opportunities and risks to drive engagement and growth

What is interoperability?

Interoperability seeks to remove barriers and breakdown silos to facilitate the exchange of health information, while still protecting individual privacy. The goal is to ensure that healthcare IT systems can improve their ability to exchange, process and interpret shared health information between devices, applications and systems across the entire healthcare landscape. It also aims to drive innovation and new entrants and ultimately, to build a more connected, consumer centric healthcare system.

What does interoperability mean for healthcare providers and payers?

As consumerism, innovation and value-based care increase, consumers desire easy access to their health records and want to know their data is protected. The seamless and secure access, exchange and use of protected consumer health data has become increasingly important.

The Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) finalized rules to address this. The ONC Cures Act Final Rule and CMS Interoperability and Patient Access Final Rule aim to eliminate barriers to health information interoperability and put individuals in control, shifting the industry from one in which you may share data in accordance with HIPAA, to one in which you must share data at the behest of the individual.

The implementation timeline requires rapid mobilization and execution. Among several other new capabilities, the rules will require providers and payers to share personal health data with consumers through application programming interfaces (APIs) based on Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) Release 4.0.1 as a foundational standard.

Leading health systems are capitalizing on regulatory mandates to amplify and evolve their consumerism strategy. Key considerations to take your interoperability program to the next level:

  • Have you leveraged the requirements as a jumping off point for your broader organization strategies?
  • Is your organization going beyond what your HIT/EHR vendors currently provide?
  • Have you established longer-term goals to enhance consumer engagement, digital tools and evaluate risk management strategies for the use of data?
  • Has your organization integrated information blocking with existing compliance mandates, e.g. HIPAA incident response practices, investigations and complaints?

Interoperability requirements and impacts:

  • Providers to make admission, discharge, transfer, and emergency visit event notifications available to the patient’s designated care providers, and make transparent their stance on information blocking.
  • Payers to share historic claims, clinical, and encounter data with members and other payers and expose their provider directories through APIs. Contact Mike Lee for a deeper conversation on the implications of interoperability for payers.
  • Third-party developers must disclose to consumers what they will do with their data and are generally expected to disrupt the ecosystem with data-powered innovations and new market plays with unprecedented access to patient / member / consumer data. Contact Zach Sachen for a deeper conversation on the implications of interoperability for third-party developers.

Five keys to a successful interoperability program

Interoperability’s aim for a more seamless data exchange can reduce redundancies and gaps that patients, providers and payers face.

The result? A more productive, coordinated, safe and accurate patient experience that enables providers to access data from disparate sources to more holistically understand the patient’s medical history and inform treatment decisions. Fewer hospital losses and clinical errors can reduce costs and increase industry margins for payers, with greater likelihood of retaining consumers.

The implications of interoperability span across industry stakeholders. Payers and providers need whole organizational responses to prepare for the changing regulatory environment, with key consideration towards: the right leadership, a review of business partnerships and agreements, new processes and data needs.

An effective interoperability implementation requires a cross-functional approach

Strategy and governance

How should we define, refine, align and monitor our interoperability program? How do we get buy-in and alignment?

  • Strategy & program stand-up:
    • Interoperability is more than a core compliance concern and carries deep strategic implications. Understanding the impact to strategy will require a holistic review that takes into account an organization’s market position, explicit and implicit business priorities, applicable use cases, and acceptable risk tolerances
    • Creation or adaptation of the right governance model that aligns stakeholders. This will oversee the program structure that coordinates and prioritizes planning, funding, integrated roadmap and implementation that meets both compliance and strategic requirements
  • Program management and change management: Support and execute interoperability program and implement change management, in coordination with use case delivery, to help drive awareness and organization alignment
  • Value management and business adoption: Identify business value drivers to support Interoperability Business Case. Develop KPIs and dashboard to help track and monitor program value delivered and business adoption

Program design

Program management to coordinate cross-functional delivery teams, decision making and escalation, and performance tracking.

  • Support and execute the interoperability program and implement change management, in coordination with use case delivery, to help drive awareness and organization alignment

  • Program management to coordinate with cross-functional delivery teams, IT, risk, compliance and business, decisions making and escalation and performance tracking

  • Establish a core management function that can inventory and coordinate all of the in-flight projects affected, new projects needed, and any dependencies, synergies across the portfolio, and risks

  • Align on an integrated work plan, a delivery method, and ways of working can provide both flexibility and visibility across all projects and teams

Operational readiness

  • Interoperability requires buy-in and commitment from all business areas. Policies, processes, and procedures will have to be updated.

  • Both employees and customers will have to be educated on the benefits—and the risks—of sharing data, whether among providers and payers or among patients sharing data with third-party apps.

  • The introduction of new business activities and third-party developers will require new processes and workflow changes to comply with regulations and develop additional business value

  • Multiple functions will certainly have roles in measuring and monitoring adoption, performance, and compliance.

Technology and data

What underlying technical capabilities/platform do we need to make interoperability a reality (e.g. data ingestion, integration and sharing considerations, including controls and infrastructure)?

  • Technology/vendor assessment: Identify and assess technology capabilities and vendor support required to enable interoperability (e.g., API mgmt., consent/identity mgmt., clinical data mgmt., etc.)
  • Clinical data exchange design, implementation, and proof of concept: The designing of capabilities that enable the future scalability and retrieval of multiple data types and sources will be at the forefront of this infrastructure. Design and develop Clinical Data Exchange to support interoperability and access of patient and member data, including data management services such as ingestion, normalization, and standardization to enable longitudinal health record
  • Data governance management: Assess and deploy Data Governance program framework, capabilities, and effectiveness prior to exposing data quality issues and ingesting external data via APIs

Privacy and security

The Interoperability Rules rely on the precedents of HIPAA and HITECH, along with a patchwork of state laws, in order to address the privacy and security considerations which are illustrated below. Further, organizations must understand the broader implications of the Interoperability Rules and their impact on current capabilities.

Implementation stages

  • Discover and analyze: Identify and classify relevant data, systems, and processes impacted by health information, and then analyze readiness for an interoperable data strategy enhancement
  • Assess and recommend: Assess readiness to comply with the Interoperability Rules against existing capabilities, identify remediation needs, and align these with organizational and operational goals
  • Strategize and plan: Establish the ongoing governance structure to coordinate, operate, and execute remediation activities for a successful implementation of interoperability requirements
  • Design and build: Implement interoperability requirements, mitigate identified gaps, and establish sustainable program controls
  • Operate and monitor: Manage ongoing “business as usual” compliance mechanisms to promote continued accountability through periodic compliance assessments and internal audits

Key considerations

  • Health information holdings: Does the organization have a thorough accounting of its health information holdings? This will be foundationally crucial for operationalizing healthcare interoperability
  • Readiness to comply: Is the organization ready to comply? Does the organization identify its capabilities and gaps for implementation purposes?
  • Project management plan: Implementation can be a multi-stakeholder cross-functional endeavour, does the organization have a clear path forward and plan?
  • Project implementation: Does the organization have the resources available with the knowledge to successfully execute the project plan?
  • Drive sustainability: Once implementation has occurred does the organization have the capabilities to monitor the interoperability practices and protect its investment?

Contact us

Thom Bales

Thom Bales

Principal, Health Services Sector Leader, PwC US

Mike Lee

Mike Lee

Managing Director, Health Services Payer, PwC US

Zach Sachen

Zach Sachen

Principal, Cloud & Digital, Integration Platforms Leader, PwC US

Jeremy Diebling

Jeremy Diebling

Principal, Health Services Cybersecurity & Privacy, PwC US

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