February 2021 | Point of View

Why healthcare interoperability regulations are an opportunity for health plans

The clock is ticking. This is how health plans can slingshot beyond minimum compliance.

Why healthcare interoperability regulations are an opportunity for health plans

Within the next two years, the 21st Century Cures Act and CMS Interoperability and Patient Access Final Rule will transform how health information is shared among patients, providers, and payers. By putting universal requirements in place around data accessibility and sharing, these legislative orders will significantly advance the healthcare industry’s longstanding movement toward interoperability and lay the regulatory groundwork for a more integrated health data landscape.  

We’ll examine what this means for health payers specifically, and how well-planned efforts at meeting deadlines for compliance can—and should—be part of broader data management and governance strategies designed expressly for a healthcare system characterized by greater efficiency and effectiveness. 

Key deadlines and critical steps for CMS interoperability 

The clock is ticking. Key deadlines were pushed back in Q4 of 2020 to allow for flexibility around the COVID-19 response, but one item remains certain: While the situation is more straightforward for health plan organizations than for health systems and providers, payers still have a lot to do in a short amount of time.

Faced with the need to have information blocking ceased by April 5, 2021, Patient Access and Provider Directory APIs ready to go by July 1, 2021, and Payer-to-Payer Data Exchange capabilities established by January 1, 2022, the most pressing challenges for healthcare organizations right now boil down to planning, developing, and deploying new capabilities in the allotted time and managing the organizational impact. 

To keep things as simple as possible as organizations work to approach these challenges, we suggest following three organizing principles: galvanize your strategy, capitalize on the opportunity, and hit the dates. 

No matter where your organization is in terms of progress against these deadlines, these principles are essential to your success.  

Galvanize your CMS interoperability strategy with quick assessments and defined solutions 

The decades-long path toward interoperability in the U.S. has been much more like a meandering stream than a superhighway. But CMS has recently suggested that notable progress is being made.  

Still, while some payer organizations have had seats at the rule-making table, most have limited visibility into what has been determined and how it will impact them. Either way, the top priority is admittedly the most obvious: Get smart about the rules and what they’ll mean for your particular organization. This entails not only absorbing the requirements and available tools but also taking stock of your current organizational and operational landscape, existing capability gaps, and—perhaps most importantly—how your overall business strategy and IT portfolio may be impacted. It’s likely that most organizations are well on their way toward ceasing information-blocking and setting up patient access and provider directory APIs, but there’s still time for those who aren’t.

The key to success in galvanizing your strategy is moving quickly to secure the necessary funds and resources and establish a clear, definitive plan. 

Speed and agility are going to be key regardless of where you are in the process. To those ends, it may be time for a rapid assessment. Ideally, this would have taken place in conjunction with your annual planning process to inform portfolio planning to evaluate the work needed to meet interoperability requirements in the context of other planned projects, and to secure necessary funding—all of which will significantly aid decision-making in both the near and long terms. Conducting one now that the enforcement year is well upon us can still be a good idea to make sure your projects are on track and to identify opportunities to expand beyond minimum compliance. 

On the strength of that assessment, you’ll be able to define your solutions by creating a conceptual architecture, capability inventory, and high-level plan in order to ensure that what you’re proposing meets business goals and provides the expected value. Solution definition will also make selecting the right solution partner easier—especially if encountering difficulties doing the development work in-house.

Capitalize on the opportunity CMS's interoperability policies are presenting 

While our main call to action here is about seizing the opportunities presented by interoperability regulations to slingshot ahead both technologically and operationally, it’s entirely understandable if your organization’s plan has been focused on the minimum required to achieve compliance. Generally speaking, these are not the easiest asks for most organizations. Likewise, the payer community at large has not viewed the information blocking rule especially favorably, and there are obvious and legitimate concerns around security and privacy. There also is a historic tendency among health payers to view member information as if it were intellectual property and to protect it as such, both for security/privacy purposes and to maintain competitive advantage. 

But while member data is obviously endemic to the essential functioning of a health payer’s business, viewing it as intellectual property is wrongheaded.

Rather, in the context of interoperability, a health plan’s IP will be the extent and manner of its enrichment of member data. By taking full advantage of this information exchange, payer organizations will strengthen relationships with members—as well as providers and other payers—and support the provision of better care. 

Those elements are where real competitive advantage will reside, and much the same can be said about provider network management, which is often riddled with inefficiencies and inaccuracies that affect providers and patients alike. Complaints about burdensome administration, low reimbursement, and lack of access to meaningful clinical and administrative data can negatively impact provider satisfaction, which can in turn impact negotiation and network design. But with cleaner, more regularly updated provider data as a fundamental, standardized requirement, health plans will be better able to innovate around what next-gen provider lifecycle management should look like.  

So be careful not to sell yourself—and your members, provider network, and other stakeholders—short. A minimalist strategy stands to miss a golden opportunity to rally around some game-changing initiatives across your organization and make progress on truly transformational projects that would impact not only your business but the industry as a whole.

Think ahead to market-relevant opportunities

As stated on CMS.gov, federal interoperability measures are aimed at improving “health information exchange to achieve appropriate and necessary access to complete health records for patients, healthcare providers, and payers.” Those healthcare organizations inclined to seek out the strategic possibilities for broad, long-term impact will come out of the next few years with a decided advantage. To that end, wherever you are in the process—whether you’re still planning and gathering requirements or you’ve moved to development—be sure that questions like these are top-of-mind as you execute against your strategy and look to the future:

  • If patient data is to be shared freely among members, providers, and payers and a variety of third-party app developers also gain access, how will this alter consumer access and engagement strategies?  
  • What opportunities do you see to exceed employer and member expectations by creating easier access to consumer health data via a host of secure, self-service apps and digital tools?  
  • As new market entrants develop innovative products and capabilities, how will the emerging extended care management ecosystem take advantage of those products and capabilities?  
  • Could your organization differentiate itself by extending traditional care management programs to include features like on-demand scheduling, home speaker integration, remote monitoring, or programs that address social determinants of health?  
  • What strategic provider partnerships might be possible through increased information-sharing, richer data, and seamless connectivity? 
  • Could changes made to meet new regulatory requirements introduce new capabilities that differentiate the provider experience and advance value-based care programs?  

These questions point to the kinds of market-relevant opportunities health payers have to enrich their portfolios and improve three- and five-year strategic plans when they actively seek to do more than the minimum to meet interoperability requirements. Operationally and organizationally, moreover, this all comes at a time when the need to break down longstanding internal silos and bring business and IT units into far greater cohesion is as great as ever. Establishing a culture of transformation with balanced priorities, a business-driven technology approach, and strong change management will are the keys to setting your organization up to meaningfully participate in the increasingly digital, connected healthcare landscape.

Plan your calendar accordingly to meet official deadlines 

Time is of the essence. Here are four points to guide you:

  1. Stay on top of critical milestones by working toward interim dates for development and testing. Think back from official deadlines to assess where you stand. For instance, if FHIR-based APIs will be required starting July 1, 2021, then deployment must be complete by the end of May at the latest. That means testing and validation should be done by April, and development should have started in February, meaning architecture would have been done back in December 2020 and your entire plan laid out since October/November—at the latest. Here’s a visual of this sample timeline, which we put together back in August 2020 to illustrate the sense of urgency around the quickly-approaching July 2021 deadline.

2. Stay engaged in and informed about technical implementation specifications as they are being developed and refined by enterprise data scientists and architects. 

In addition to mandating exchange of the USCDI clinical data classes, the rules for patient access and provider directory information are requiring health IT developers to support standards-based APIs for certain transactions and prohibit information blocking. CMS-regulated health plans will have to provide access to claims, encounter, and clinical information via FHIR APIs, access which includes third-party consumer health apps.

The ONC recently released new tools and guides to aid tech development, and many implementation resources are available on CMS.gov. Those organizations that are on or ahead of schedule are likely to have some influence on implementation standards as they’re further refined, and they should also be in position to gain essential expertise that will enable faster solution architecting, development, and deployment while avoiding costly rework down the road.

3. Drive iterative and incremental development, testing, validation, and deployment to meet official mandates.

The key here is to avoid getting lost in the details or burying yourself (and your teams) by trying to do too much, too fast—lean on your solution partner for business and technical expertise as they drive the day-to-day iterative development, testing, validation, and deployment work within your prescribed timeframes. This partner will be your transformation catalyst, helping you avoid missteps and keeping your initiatives on track.  

Elsewhere, we’ve summarized the need to rethink your enterprise operating model, design an optimal user experience, and define a coordinated technology strategy as you move toward interoperability. While it may be enticing to have your IT teams build data integration and warehousing capabilities in-house, your best bet for meeting official deadlines is to leverage technology that’s compliance-ready right now—starting from scratch is simply too risky and too slow, not to mention no longer an option if you’re behind schedule. Technologies that meet CMS interoperability standards out of the box are going to give you a major leg up on the competition and put you in much better position to meet (and exceed) federal requirements in time. 

4. As suggested above, pick the right solution partner for your organization. If you didn’t pick them early or are feeling the crunch now, you can still minimize challenges for the rest of the road ahead.  

No matter where you stand in relation to the deadlines, that partner has to be well-versed in what’s required, able to determine the best path forward for your particular set of circumstances, and also have the real-world chops to execute. To those ends, West Monroe actively cultivates external relationships with leading technology companies in order to couple our assessment framework and proprietary data integration and warehouse automation service with best-of-breed, interoperability-ready solutions. This confluence of advanced capabilities is more than a nice-to-have. It is essential to turning regulatory compliance into a market-differentiating opportunity. 

Backed by a rapid diagnostic approach designed to quickly develop a go-forward plan aligned to your organization’s particular business and IT landscape, West Monroe and its technology partners are focused on enhancing data warehousing capabilities, setting up true interoperability data architecture, and drawing business and IT functions into greater alignment around an operating model that fosters collaboration both across the enterprise and broader healthcare capabilities. By providing a tremendous head start with our pre-built accelerators, our aim is to help health payer organizations satisfy federal requirements (on time) and capitalize on the opportunities at hand to improve consumer access and engagement, extend the care management ecosystem, and foster strategic provider partnerships.  


The 21st Century Cures Act and CMS Interoperability and Patient Access Final Rule has clear intentions: to give patients fuller access to their health information, improve the visibility and accuracy of provider information, and create effective payer-to-payer exchanges of health data as a catalyst to move the healthcare system toward greater efficiency and effectiveness. 

Meeting the challenges posed by these regulations means facing a host of technical, operational, and business challenges that require partnerships with IT, business, clinical, and customer experience stakeholders to accelerate value beyond basic compliance.  

Efforts to meet and exceed minimum compliance represent a huge opportunity to slingshot forward and leapfrog less visionary competition while contributing to the overall advancement of our national healthcare system. In other words, if you’re already going under the hood to mess with the engine, you might as well take a good look at how you can optimize performance, not only for your organization but for those with whom your work and partner.  

Time is of the essence, of course, but don’t let that keep you from thinking ahead to ways that an otherwise burdensome regulatory activity can be beneficial for your organization and the healthcare landscape at large. 

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