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Q&A on opportunities presented by new federal interoperability rules


March 22, 2021

Mike Lee
Managing Director, Health Services Payer, PwC US
James Lin
Director, Health Industries, PwC US
Fran Grabowski, Jr.
Director, Risk and Regulatory, PwC US

New federal rules requiring providers and payers to free patient data from behind their own organizational walls for patient apps and broader data sharing could power forward a more consumer-centric healthcare system.

As the rules force organizations to liberate patient health information, some companies will sprint ahead of their rivals by earning consumer trust, synthesizing the data and providing innovative products and services. HRI spoke with managing director Mike Lee, director James Lin and director Fran Grabowski about the strategies that healthcare organizations should consider.

PwC Health Research Institute (HRI)

HRI’s fall 2020 executive survey found that only 24% of healthcare executives view the interoperability rules as a strategic opportunity. The remainder see it as a compliance issue. Can you talk about why a strategic approach might position companies better?

James Lin, PwC director

For the organizations that are not thinking about this strategically, or even defensively, there is a potential for them to actually lose market share in a pretty significant way if certain innovations start to drive the market to a competitor.

Mike Lee, PwC managing director

The patient is going to be able to access so much more data. You can imagine if a member’s claims data, and then encounter data, is sent to some sort of app on someone’s phone that says, “Are you getting the best bang for your buck in healthcare? Send us this data and we tell you that for your age, background and the diseases you have, you’re overspending by 30%. You should change your plan.” That’s the kind of potential this has. Companies should be thinking what they should be shoring up today to blunt any efforts like that that might happen when some third-party company gets really smart and says, “Can I take this data and turn it into something really valuable?”

HRI: Most executives we surveyed (79%) said they are preparing for new processes to comply with the interoperability rules, but only about half had started mapping out their data to see what’s affected. What might companies be overlooking?

Fran Grabowski, PwC director

A data governance strategy is important and often overlooked or disconnected from new interoperability implementation. What controls or rules are in place to make sure that the data you’re putting out there to your customers and your competitors is high quality? The new application programming interfaces (APIs) are going to expose any potential gaps outside the organization.

James Lin: Health plans have been so hyper-focused on implementing the APIs from a technology perspective that they haven’t thought through the business process implications. This includes things like training member service staff to answer questions about interoperability and third-party apps, addressing potential security and privacy issues, and educating members on their consent.

HRI: The intent of these rules is to free healthcare data and ultimately improve care. Can you walk us through an example of how a more interoperable healthcare system can accomplish that?

Mike Lee: Right now, a lot of care coordination elements require somebody quarterbacking the process—ideally your primary care physician, as a patient goes through maybe an acute setting to a recovery setting and then home to be monitored. All those steps usually require conversations between the primary care physician and members of those different facilities to ensure that the patient is cared for in the right way.

When you have the required notifications in place, you take a lot of communication friction and coordination friction out of the picture and allow for greater accuracy and insight of patient status through that particular care journey.

James Lin: Today if I wanted a second opinion, or any information, I have to go to my doctor, get a printout of my medical records, get a CD of my X-ray images and hand all that to the next doctor’s office. In a more interoperable future, the assumption is that I should be able to use an app, get access to that information and blast that information out to three, four or five different physicians to get a second opinion very easily.

Once that information is more portable and I have that access in my app, it’s very conceivable for an academic medical center to create a second opinion app as a new service that is convenient for the patient and a brand new revenue stream for the health system.

HRI: How can interoperability help with COVID-19 vaccinations?

Fran Grabowski: The efforts to create a standard vaccination card that can be stored in your digital wallet may make third-party solutions more appealing to consumers––ultimately increasing adoption of the new required APIs.

What may be more transformational, however, is the real-world evidence in your soon-to-be interoperable health records. Collecting the health records seamlessly for clinical trials is a challenge. If R&D teams use interoperability-enabled apps to pull that data together, we should expect to see expedited research and development timelines.

HRI: What do you think our clients should be thinking about right now when it comes to privacy concerns?

Mike Lee: The leading participants in the space will really think through what privacy and security mean to the patient or the member experience. That may mean vetting and establishing trusted third-party apps where a payer could say, “If you want to understand affordability or shop around for doctors or whatever you want to do in this new world, we have a set of trusted partners with whom you can guarantee your information will be secured in the right way.” The leaders will be the ones that think through this problem in a way that improves customer trust.

James Lin: The focus of the law is to put the information into the consumers’ hands, just like consumers have access to social media and can enable other third-party applications’ access to that. But it’s their healthcare information. The only thing that a health plan or health system can do around that is just make sure that patients understand what they are opening themselves up to when they share health information with third parties. Education will be key.

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Mike Lee

Mike Lee

Managing Director, Health Services Payer, PwC US

James Lin

James Lin

Director, Health Industries, PwC US

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