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Episode 23: Staying ahead of interoperability to drive lasting impact

• Ilene MacDonald

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Join us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health.

Katie Devlin, DHSc, MS, CPHIMS, vice president of interoperability at Cotiviti, returns to RISE Radio and is joined by Adam Gilbert, director of interoperability operations and partnerships at Cotiviti, for this 23-minute episode. They discuss the latest regulatory requirements, what to expect for 2025, challenges, and best practices to implement a robust digital data strategy.

About Katie Devlin
Katie Devlin, DHSc, MS, CPHIMS, vice president, interoperability, Cotiviti, Inc. is responsible for creating an enterprise-wide health data exchange strategy to address clients’ unique business needs while reducing provider abrasion, maintaining regulatory compliance, and optimizing value. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, including the expansion of Cotiviti’s electronic health data networks and strategic partnerships. Drawing on her extensive informatics and health information exchange experience, she is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience.

About Adam Gilbert
Adam Gilbert, director, interoperability operations and partnerships, works collaboratively with payers, providers, and vendors to increase the use of clinical data exchange. With over 20 years of experience in health care operations and consulting, He is committed to enhancing the health care landscape through effective interoperability strategies and operational excellence. Prior to joining Cotiviti, he held senior management roles at Change Healthcare and McKesson. 

About Cotiviti
Cotiviti enables health care organizations to deliver better care at lower cost through advanced technology and data analytics, helping to ensure the quality and sustainability of how health care is delivered in the United States. Cotiviti’s solutions are a critical foundation for health care payers in their mission to lower health care costs and improve quality through higher performing payment accuracy, quality improvement, risk adjustment, consumer engagement, and network performance management programs. The company also supports the retail industry with data management and recovery audit services that improve business outcomes. 

Ilene MacDonald:

Hello and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald, the Editorial Director of RISE. Today is a follow-up to our 2023 episode on interoperability. Last year, Katie Devlin, Vice President of Interoperability at Cotiviti provided insights on the federal requirements and challenges to achieving interoperability and how it supports risk adjustment and quality programs. I'm thrilled that Katie is returning today, along with Adam Gilbert, Director of Interoperability Operations and Partnerships at Cotiviti, we're going to discuss what's changed over the last year since we last talked, and what health plans need to know to fine-tune their digital data strategy. Thank you both for joining me today.

Ilene MacDonald:

Welcome.

Ilene MacDonald:

Last year we discussed interoperability, its importance, the federal regulations that were driving it and the primary challenges for organizations to achieve it. Katie, for our listeners who may not have heard the initial podcast, can you provide a recap on why health care organizations should care about this?

Katie Devlin:

Sure, so really just a level set. We talked about interoperability in the context of payer and provider data exchange and historically, payers have really gotten this information, the clinical data, from providers using different types of retrieval methods. They sort of had to cobble together different approaches to getting the data that they needed, and this included on-site or phone retrieval agents, fax machines, web portals, ROI kind of partners, copy services the list goes on and on, and the process of doing this is just really expensive and it's time consuming. And getting the data in an imaged format like a PDF doesn't really give the payers what they need from a structured data standpoint in order to drive insights for population health management or member intelligence or a number of other use cases. And the financial impact of these inefficient sort of traditional retrieval methods can cost payers millions of dollars annually. So it's just it really isn't a good option, and we talked about that.

Katie Devlin:

There had been an increased emphasis on using EHR vendors, health information exchanges, HIEs and aggregators to support health plan interoperability and sort of get away from those more traditional methods, right, and move the needle in a different way. And up until last year, as we talked about the problem was really that there hadn't been a lot of clarity around the permitted exchange purposes or use cases for sharing clinical data electronically for health care payment and operations, which is where the payers fall right, and that's why it's been so difficult. So, for example, many health information exchanges and national networks have been in support of treatment payment operations data exchange for a long time, but the problem was really on the provider and health system side. They were only required to respond to patient requests or to respond to requests for patient care. And then, more recently, individual health care organizations, right, these large health systems think post COVID, public health reporting, EMR updates. It's really rare to see a health system that's willing to allocate the resources that are necessary to build a connection directly with a payer or even a partner of a payer, right, they don't really want to do that those type of projects beyond what they have to do, right, because they've just so much on their plate and limited resources to do so.

Katie Devlin:

So we met last year. We talked about new regulatory changes that were sort of expected to expand payer access to clinical data. We talked about the Cures Act and how it created sort of this universal floor for national data exchange using standard protocols called FHIR, fast Healthcare Interoperability Resources, and it also expanded and standardized the minimum data elements for data exchange via the US Core Data for Interoperability or USCDI Core Data Set for Interoperability, and the plan for this is to come to fruition through the trust exchange framework and common agreement, TEFCA. So lots of alphabet soup here, but if you think about the Cures Act as sort of the what TEFCA is, the how it's going to get done, right, and TEFCA really promises to provide this single on-ramp for stakeholders to participate in national data exchange through another acronym for you, Qualified Health Information Networks or QHNs, and the idea here is really to leverage existing networks and health care organizations to create this sort of brokered approach to clinical data exchange where they connect to each other, the QHINs connect to each other and they can query each other easily and have confidence in the quality of data being returned. What was at the time and what is still exciting about T EFCA is that it requires participants to respond to queries for data that fall under treatment, payment and operations, as well as public health, individual access, government benefits, determination and a couple others.

Katie Devlin:

And at the time that we last recorded, the first version of the common agreement had been published and it focused initially on treatment and individual access, which wasn't surprising.

Katie Devlin:

Those are sort of the core use cases for interoperability if we think about patient care and getting access as a patient, getting access to your records. So we were really waiting with anticipation, right or at least I was, I guess to see which organizations were going to qualify for QHIN status and then when on earth are we going to actually see the health care payment operations piece of this come to life? I think we also talked about the regulations around information blocking too. Last year, Office of the Inspector General published its final Information Blocking rule, so that essentially imposed a million dollar penalty each time a health IT developer or HIE interfered with the access of clinical data, and that was great and much needed.

Katie Devlin:

But it didn't really apply to providers and health systems, which was the biggest problem. Right, and towards the end of last year and I think it was around the time we were recording we saw a proposed legislation aimed at providers and health systems. That was very similar and for them, information blocking could potentially reduce reimbursement or negatively impact their MIPS score. So there's a real incentive there to share this data electronically now. So I'd say, with all that said, sort of to wrap up this question right, the message from our last podcast was really that organizations, especially payers, who need to access this data electronically, should be really keeping tabs on these regulations and thinking about how they can sort of tap into the data as it becomes available.

Ilene MacDonald:

Thank you. That's a good recap. And, Katie, what if organizations haven't done that? What if they fail to do it? Where do they stand now?

Katie Devlin:

Yeah, I mean, I think it's kind of simple right, they're going to miss out, they're going to have FOMO. Right, they're going to miss out on these opportunities to get the data that they might need to support their risk adjustment, payment integrity and quality improvement programs. And you know, especially on the quality side, this is going to become, you know, really impactful.

Ilene MacDonald:

And can you talk a little bit, and maybe, Adam, you can also join in on this, what's the impact of interoperability on risk adjustment and quality improvement programs?

Adam Gilbert:

Sure yeah. Interoperability significantly enhances risk adjustment by allowing health care organizations to optimize data acquisition, ensure more accurate risk scoring via data standardization. And third, it enables a more holistic or 360 degree view of the patient's health status for better informed decision- making. And I'll review each of these in more detail, in no particular order. But first, interoperability optimizes data acquisition. It helps payers maximize the number of records retrieved while also reducing provider abrasion and administrative effort. As time progresses, the industry will be less reliant upon manual processes like copying, faxing, mailing, uploading records to portals and utilizing copy services. This will reduce manual effort and errors within each of these processes as well. Second, interoperability ensures more accurate risk scoring due to data standardization.

Adam Gilbert:

Today, records are retrieved in various formats, such as PDFs and CCDs, but also various data sources like EHRs, lab results and claims data, just to name a few.

Adam Gilbert:

Interoperability facilitates the seamless exchange of health data between providers, payers and other health care stakeholders for consistent data formats that are needed for accurate analysis and comparison. The structured data also allows entities the ability to utilize machine learning and analytics to drive further insights and efficiencies. And third this is really a positive outcome of my first two points, which were data standardization and data acquisition is that interoperability allows payers and providers the ability to obtain a holistic or 360-degree view of the patient. Entities will be able to access real-time data to health care organizations based upon the latest clinical information, and this should reduce inconsistencies in data reporting and decrease medical errors during care as well. And by pulling data from these various sources, like EHRs, labs and pharmacies, health care organizations can gain a complete view of the patient's health status, allowing for more precise risk assessments and appropriate care planning for high-risk individuals. So interoperability really ensures a complete picture of the patient's health and therefore, most importantly, improving patient care as well.

Adam Gilbert:

Katie Devlin: Yeah, I can weigh in on the quality side too, a little bit more right. And you know, NCQA has set a goal of transitioning over to all digital measures by 2030 for HEDIS reporting, and the digital measures will leverage the FHIR standard. So it's great because it's building off of what TEFCA is doing and what the CURES Act has mandated. So it shouldn't really be a surprise to us, but it really is going to be more efficient for HEDIS reporting because there's less need for manual and duplicative work. The digital measures that shift towards digital measures, excuse me also means that there's less room for human error and that payers are going to get more recent and updated data to support their year-round digital strategies, as Adam alluded to. So you know, really this means they can create earlier interventions, for example. And you know 2030 really isn't that far away when we think about it, at least Cotivity for Cotiviti, as we think about all the payers that we support and when we need to be ready, we're, you know we're thinking. You know we've got to be ready, more so in the 2027 timeframe. So we're actively working on preparing for this and for many payers they've got decisions to make about choosing a quality partner or, you know, maybe they're looking, you know, to make some serious technology investments within their organization to support getting the data digitally as well, as you know, not just doing that, but also normalizing and mapping it to FHIR, because, as Adam mentioned, getting the data in a structured digital format is great, but even that format varies.

Adam Gilbert:

Some organizations are using FHIR, some are still using the CCDA standard. Many, most actually, are still sending data in the CCDA version 2.1 standard. So you do, then, at least on the quality side, have to map it to FHIR. And you know, even if everybody's using FHIR, it really is standard with a small s right it's. You know different organizations are using different FHIR resources. You know, for example, one might use the FHIR document resource document reference resource to pull a CCDA. One might use, you know a example, one might use the FHIR document resource document reference resource to pull a CCDA. One might use, you know, a bundle of resources to go get the information that they need. So you still need to have that mapping component and you know I think it's probably overwhelming for a lot of payers is that, as they figure out, you know how, how to execute on

Ilene MacDonald:

And is there any changes that the federal government has made to sort of push them to move faster on this in the last year?

Katie Devlin:

Yeah, so in the interoperability space in general not particularly for quality, but for just broadly right. Since we've last met, I think there's quite a few things that have happened. So we saw in the past year there's now seven qualified health information networks QHINs under TEFCA. These include eHealthExchange, KONZA, EPIC, HealthGorilla, Commonwealth, Kno2, and MedAllies. And I just recently saw that Oracle Cerner is applying for QHIN status as well. So we'll see how that pans out. We also saw the second version of the common agreement come out. So this is particularly exciting because it focused on health care operations exchange purposes, and what's great about this version is that it also provides a carve out for delegates or business associates of payers, like Cotiviti, to participate in TEFCA and obtain the data on behalf of the health plans that they work with. So now that that's happened, we at Cotiviti are really focused on onboarding to a QHIN. We are already regular participants of two of the QHINs that are out there. So we're kind of in the process of evaluating what else we need to do to onboard under TEFCA, because there are sort of separate requirements there.

Katie Devlin:

We also saw on the regulatory side, the CMS interoperability and prior auth final rule, which basically says payers will be required to implement FHIR-based APIs to improve data exchange but then also expedite the prior authorization process, and this is not unlike what payers had to do for individual access. It's another FHIR API. They should sort of look at it through that lens, use the same team members to do this if they're going to be implementing this themselves. And the three specific APIs that are called out in this rule include payer-to-payer access right. So if, for example, one of the use cases would be if a member changes insurance companies health plans right and they there is a need to share that information for them.

Katie Devlin:

It's also the API for provider access to share claims and encounter data back with in network providers. And then the prior auth API, of course, which is basically communicating whether the payer approves, denies or needs more information regarding a prior auth request. And this data also has to be made available to members via that patient individual access API that I mentioned they should have already implemented, which came as a result of the CMS patient access rule. So all of the above sort of have a deadline of January 1, 2027. And we actually did a blog post. Cotiviti actually did a blog post on this topic. That goes into a little bit more detail, if any of the listeners are particularly interested in diving into that topic.

Ilene MacDonald:

Thank you, Adam, can you talk about how these regulations influenced organizational strategy for the past year?

Adam Gilbert:

i Yes, these regulations have had a significant influence on our strategy. I'll discuss four or five. To start, as Katie mentioned, we onboarded as a regular participants of two of the seven QHINs now possibly eight, as she stated with the announcement from Oracle recently, and we're in the process of figuring out what we need to do differently as a QHIN participant versus a regular network participant. We're also identifying strategic HIEs or health information exchanges that best complement Cotiviti's current provider connections.

Adam Gilbert:

We developed a scalable Cotiviti FHIR app for specific health care operations purposes. In addition, we published an EPIC Cotiviti FHIR app. Also, we're working with other health care organizations on FHIR connectivity. Next, we're collaboratively speaking with health plans to identify strategic provider connections. And as we talk to some of the largest providers in the country, we regularly hear about privacy concerns, provider abrasion and the effort needed to retrieve and submit records, and really our Cotiviti FHIR App helps providers solve all of these issues . And finally, we're reevaluating existing partnerships with EHRs and aggregators by conducting regular data quality audits to identify additional opportunities as well.

Ilene MacDonald:

And Adam, do you have any best practices that you'd suggest health care organizations use to fine-tune their digital data strategies?

Adam Gilbert:

Yes, we are seeing a trend with payers and providers that they don't have the resources to execute on a digital data or interoperability strategy. Okay, they're really looking for a high-quality partner to help them navigate this new environment. You know, first, I'd recommend that the organization become familiar with TEFCA, as Katie mentioned earlier that's the Trusted Exchange Framework and Common Agreement and also possibly join a QHIN. To execute on TEFCA, you'll likely need to create an internal task force to lead and understand interoperability standards and protocols. Also, engage IT staff and legal leaders or stakeholders in the organization.

Adam Gilbert:

I'd also suggest utilizing a regional or state HIE to broaden data exchange capabilities and the sharing of patient information across multiple health care settings. It's also important to use accepted industry standards like HL7 and FHIR. Cotiviti is able to connect to various vendors, providers and EHRs to retrieve data in standardized formats that I discussed in a previous question. Next, I'd implement a data quality management strategy to ensure accuracy of the records or data that's received from your various partners. And, lastly, you really want to have a scalable infrastructure that includes the API technology that's needed to send and retrieve data via FHIR resources. So it's had a pretty big impact.

Ilene MacDonald:

Definitely. Is there anything that we haven't discussed yet that you think is important for our listeners to know?

Katie Devlin:

Yeah, I mean I can really take this one.

Katie Devlin:

I think it's important for payers that, as exciting as TEFCA is and as promising as it is right, there's still no silver bullet for interoperability.

Katie Devlin:

In fact, Adam and I were just at the Civitas Health Alliance Conference two weeks ago in Detroit and that was sort of the theme and these are, you know, large QHINs and health information exchanges and you know the best of the best from the ONC and almost everybody there in their sessions were saying there is no silver bullet.

Katie Devlin:

And again TEFCA is really exciting but participation is not mandatory in it. So payers have to think about how they can create that multifaceted approach not just to retrieving the digital information but about ingesting, mapping it and normalizing it for their downstream use cases, whether that's risk adjustment, payment integrity, quality reporting, et cetera. For some of the larger national payers they might have the resources and expertise to build that task force that Adam was talking about and take this on themselves, but others we're finding really want to look at a partner like Cotiviti who has these capabilities already in place and is keeping tabs on the regulations and is making sure that we're you know compliant and can do that for them on their behalf and sort of take that piece of it off their shoulders.

Ilene MacDonald:

Finally, and maybe each of you can take this on, what would you say to our listeners, their most important takeaway?

Katie Devlin:

But\ Bu Just to reiterate there is no silver bullet. I think you want to make sure that you are paying close attention to the regulations and how they impact you as a payer depending on what markets you do business in, whether you focus more on quality on risk adjustment, you have to look at particular use cases for the data and see how they may be affected. Consider

Katie Devlin:

joining different work groups or task forces, for example Cotiviti is part of the NCQA’s Quality Bulk FHIR coalition. So, we are part of testing these FHIR implementation guides for digital measures. hink

Katie Devlin:

about what makes the most sense for you and your organization and then think about where you're going to need to invest to meet these timelines right, whether it's the 2027 one for the interoperability prior authorization final rule, whether it's 2030 or a little bit before that for the digital measures. You know you guys, you know all these payers kind of really need to take that inventory and figure out how they can get there right, create that roadmap.

Katie Devlin:

Adam GilYeah, and I think there's a common theme, and that is payers and providers need timely and high-quality patient data. But how do we more quickly and accurately retrieve medical records while also reducing provider abrasion? How do you implement a digital data strategy? How do you manage all these new regulations and improve patient care? At the end of the day, integrating all these diverse health care systems and technologies is technically challenging. However, the benefits of interoperability will not only improve risk adjustment and quality programs, but really drive significantly better patient outcomes as well, and I can tell you here at Cotivit, we are extremely excited about these opportunities to improve the healthcare ecosystem via interoperability.

Ilene MacDonald:

Well, thank you both. This was really informative. Maybe we'll have to check in next year to see where we stand, or at least in 2027. Thank you both.