Dive Brief:

• The Biden administration has been working on additional rulemaking to address issues with the payer-to-payer data exchange requirements set out in sweeping interoperability rules finalized in early 2020, and "we look forward to sharing this rule with you soon," CMS administrator Chiquita Brooks-LaSure told attendees at the HIMSS annual conference in Orlando on Tuesday.
• CMS decided not to enforce those provisions when they kicked in this year, after health insurers raised concerns about operational challenges and risks to data quality given a lack of specificity in the rule.
• The new rule will incorporate extensive public comment to try to address stakeholder concerns, and will standardize how payers exchange data through application programming interfaces, Brooks-LaSure said.

Dive Insight:

The CMS rule was published in tandem with a twin rule from the Office of the National Coordinator for Health IT in March 2020, meant to push the healthcare industry toward free and unfettered electronic data sharing between patients, payers and providers. Some requirements of the rules were delayed to free up resources during COVID-19, however, while others like the payer-to-payer exchange provisions have yet to kick in or be enforced.

The CMS rule requires plans participating in federal programs to provide patients with free electronic access to their personal health data, including medical claims and encounter information including cost. It also requires plans to make their provider directories available to current and potential enrollees through the API technology, with the hope insurers will carry over those practices to private plans as well.

Originally, plans were required to share certain clinical information with each other at the patient's request, allowing patients' cumulative health records to follow them as they transition between insurers and plans.

However, payers slammed that segment of the rule, saying it would be very difficult to implement and could result in a patchwork system of reporting, as there was no requirement for a standardized API for data sharing.

In December, CMS formally exercised enforcement discretion with regard to that provision, meaning it wouldn't take any action against a health insurer if they weren't exchanging data with other payers at a patient's request by the original deadline.

The agency is committed to requiring payer-to-payer data exchange, but "the policy that CMS finalized did not quite hit the mark," Brooks-LaSure said Tuesday. "Our interoperability rule wasn't interoperable enough, and left too many questions open about how data is exchanged."

As such, the agency has been working on taking the next rule "above and beyond" by weaving in extensive public comment and ensuring it includes requirements for a standards-based API, Brooks-LaSure said, such as a Health Level Seven FHIR-compliant API, which the government selected as the national standard in its interoperability work.

Agencies like CMS and ONC that are active in health IT are continuing to look at other ways to build on the interoperability regulations, mandated by the 21st Century Cures Act passed in 2016. Currently, CMS is working on outlining interoperability for healthcare directories and exploring what role the agency should play in managing those, along with thinking about how technology can be used to streamline prior authorization — a major source of controversy for payers and providers.

CMS is also working with ONC on updating the USCDI dataset that forms the backbone of what data types are required to be interoperable to be in compliance with the rules, Brooks-LaSure said.