Roland Therriault

The Centers for Medicare and Medicaid Services’ (CMS) 

21st Century Cures Act’s interoperability and information-blocking rule

, call for streamlining data exchange between healthcare providers, patients, and payers, while protecting stakeholders against “information blocking.”

The legislation, which goes into effect April 5, 2021, also calls for transitioning existing EHR specifications to the HL7 Fast Healthcare Interoperability Resources (FHIR) standard.

However, many healthcare stakeholders, as well as health IT vendors, aren’t prepared for FHIR implementation and still may not be by winter’s end. Out of the thousands of EHR vendors in the country, only about 680 have been certified as compliant with the most updated clinical data set. Furthermore, nearly 80% of providers, payers, hospitals, and vendors who participated in a 

 from the eHealth Initiative reported that the COVID-19 pandemic was hindering their ability to prepare for the forthcoming regulations.

And while many of these vendors are playing catch up, the industry standard will continue to evolve. By 2022, CMS has indicated that the current, de-facto HL7 standard, and its respective APIs, will likely sunset.

To keep from getting left behind, healthcare organizations need to ensure they have a plan in place for a smooth transition.

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While CMS and ONC have extended compliance deadlines from January to April, transitioning to FHIR (pronounced “fire”) won’t be as easy as flipping a light switch.

Since its release in 2014 as a “trial” standard by the Health Level Seven (HL7) International Organization, FHIR has been hailed as the driver of true interoperability. As the ONC noted on P. 115 of its final rule, “the HL7® FHIR® standard represents health information in what are called ‘FHIR resources’ [and] when it comes to logically organizing FHIR resources that relate to one another and share common properties, FHIR uses a concept called a ‘compartment,’” which links clinical, financial and other resources tied to that patient. The end result is an organizing framework [that] provides a potentially rich set of a Data Classes and Data Elements to consider for inclusion in the USCDI, including clinical, encounter, specialty, and financial data.”

Yet while FHIR’s success in enabling interoperability is hailed, healthcare leaders have expressed concerns over whether their EHRs will be able to support a more advanced organizing framework–especially if they’re part of an independent and/or small practice and lack the resources of a larger healthcare system.

There are also questions—and concerns—over whether care partners will adopt the same version of FHIR to facilitate data exchange, and how true interoperability will work if these partners aren’t keeping up.

Organizations that lack in-house health IT expertise may find the depth of the interoperability and information-blocking regulations overwhelming, and not know where or how to leverage their financial resources to ensure compliance.

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Healthcare providers don’t have to navigate the complex transition to FHIR alone, but they’ll still need three things: an EHR that’s compliant with the 2015 Edition Health IT Certification Criteria; a technology vendor partner that has their back; and a communications strategy for patients and partners about interoperability and information sharing.

The need for an EHR that meets the 2015 Edition Health IT Certification Criteria and associated Common Clinical Data Set is top priority, as FHIR can’t run without it. Healthcare organizations need to check with their vendors to ensure the organization’s EHR is certified and that there won’t be problems down the line in meeting regulatory requirements. If an organization is sunsetting a legacy EHR and shopping for a new system, these questions are still important.

But having a certified EHR is only the first step. Physician groups need a technology vendor partner that actively keeps up with regulations, and has a roadmap for rolling out, and upgrading, FHIR over the next few years as the standard evolves.

While patients and payers won’t need a lesson on FHIR, a broader communication strategy around interoperability and information sharing is essential.

Patients will be sharing a lot more data and may have concerns about how the data will be used. A gun owner might worry that their primary-care physician will find out they are seeing a psychiatrist. An individual who has an STD may fear that lab results will be shared with third-party vendors. Healthcare providers will need to be able to assure patients that HIPAA and other privacy protections remain intact, and that patients ultimately control who sees their health data.

The new interoperability legislation, and the adoption of FHIR, are a step in the right direction, as care coordination gains greater importance amid the pandemic. While some providers may not understand what differentiates FHIR from fire, having a solid roadmap for technology migration is the best way to ensure compliance in 2021.

Roland Therriault is president and executive vice president of sales with

. He has more than 20 years in healthcare and technology and manages all company operations, driving its go-to-market strategy and overseeing all sales activities.

Articles

What the new HL7 interoperability standards means for providers. 

This world is on FHIR

, 2020, healthcare providers are now required to submit Medicare claim transactions with Medical Beneficiary Identifiers (

). CMS’ goal with the unique patient identifier, which replaces the old Medicare card and use of a social security number (SSN): to improve patient safety and security through the correct identification of individuals at the point of care. 

Has your practice completely switched over to MBI numbers?

If you answered “no,” “not yet,” or “not quite,” you’re not alone. Medicare issued an estimated 150 million MBIs to active and archived beneficiaries over the last two years. Yet as the American Medical Association (AMA) reported in November, 20 percent of Medicare physician claims are still being submitted with old patient identifiers.

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Practices that don’t get up to speed quickly could face steep financial consequences and a disruption in cashflow, stemming from a rise in claim rejections. Given what’s at stake, now is the time to embrace the new Medicare card, ensuring your patients, staff, and vendor partners can adjust to MBIs with ease. 

CMS’ move to MBI numbers has been in the works for a few years as a response to the risks and vulnerabilities associated with using an SSN, such as identity theft and data breach. The shift to MBIs is an effort to protect patient information and address past vulnerabilities when verifying patient identities.

, more than 1,200 data breaches occurred in 2018, and nearly 10 million records were exposed in the healthcare/medical realm. Moreover, the total number of data breaches in all industries more than doubled between 2017 and 2018. 

The new MBI is intended to protect patients and the healthcare providers who care for them from incidents of identity theft and breach, which can also lead to civil and financial penalties.

Yet with any administrative change, challenges or pitfalls are unavoidable. 

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First, providers face workflow challenges. Ensuring administrative staff is up to speed with the new rules is challenging enough, considering the sea of regulatory and administrative burdens that practices have faced in recent years. And in the shift toward value-based care, many practices have borne the onerous task of having to accommodate multiple risk-based, shared-savings plans overseen by multiple payer partners. 

Providers also face technology challenges. Specifically, if technology such as an EHR or practice management system is not up to date, or has not been upgraded to accommodate the new cards and patient identifiers, billers and coders will have a harder time doing their jobs-and managing the increased workloads that will naturally result from denied Medicare claims.

For providers whose patients aren’t caught up, or who are experiencing issues with billing, coding, and/or reimbursement, here are a few best practices to consider:  

 Ensure your partners, including your EHR vendor, RCM partners, or other outside experts such as consultants, are not only up to speed with the new identifiers, but are also processing claims in accordance with Medicare’s rules. Ask your vendor partners: Have they bolstered or upgraded their technology to process claims with the new identifier? And are they monitoring claim rejections? 

Go over changes and exemptions with staff.

 Administrative staff is likely aware of the shift to MBIs and ready to process claims using the new cards. They also know that if you submit with Health Insurance Claim Numbers (HICNs), Medicare will reject your claims. However, there are some notable exemptions, as detailed by CMS. Make sure staff is 

 The best way to ensure you can process claims using the MBI is to have your patients’ MBI information on file-so ask your Medicare patients for their Medicare cards when they come for care. If your patients don’t know their MBI, you can look it up via the Medicare Administrative Contractors (MACs) 

. If they don’t have their card, hand them the “Get Your New Medicare Card” flier in 

Change is hard, and the shift to MBI numbers after years of using cards with social security numbers may be a bumpy one, especially if patients aren’t all caught up. But as with the transition to any new process or technology, the sooner you adapt to the changes, the easier it will be to run your practice.

 is President and Executive Vice President of Sales for 

. His experience in healthcare and technology includes more than 20 years of direct and channel sales, strategic planning and business development. Prior to joining InSync, Roland served as Vice President of Sales for MD On-Line, a provider of acute and ambulatory clinical and practice management solutions.

Practices could face steep financial consequences from claim rejections if not adjusted.