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Blog
Payer Healthcare Interoperability – Are My Vendors Ready?
Understanding vendor capabilities is important in assessing your readiness as a payer
Sep 17, 2020
The adage “You’re only as strong as your weakest link” is true when we look at the implementation of the 21st Century Cures act and interoperability standards as it relates to your systems and vendor partners. As a healthcare payer for Medicare Advantage, Medicaid, CHIP, or Qualified Health Plan issuers on the federally facilitated Exchanges, you will need to ensure that individuals and their authorized caregivers have easy access to their Electronic Health Information (EHI), following industry and federally recognized standards. And this must all be done while promoting patient safety, ensuring data integrity, and adhering to privacy policies.
This presents a level of complexity for payers who run multiple systems, many of which are highly configurable, commercial products. These include core claim systems such as Cognizant’s TriZetto Products (Facets, QNXT, Qic-Link) and HealthEdge’s HealthRules Payor, as well as core care management systems such as Cognizant’s TriZetto CareAdvance, ZeOmega’s Jiva, and Medecision’s Aerial product. In addition to the internal systems, consider all peripheral systems and sources of data. This includes data for outsourced services (e.g., pharmacy benefit management), as well as transactional data submissions (e.g., EDI 837 for claims). The resulting chain of data has its strengths and weaknesses. It is imperative to understand and address the weakest links earlier rather than later. These weak data links may include such problems as missing required data elements or data in non-standard text fields.
Understanding vendor capabilities and readiness is important in assessing your own readiness as a payer. The following activities provide an assessment path, which begins with understanding your own organization.
Understand the regulations
The new standard for healthcare interoperability is outlined in the 21st Century Cures Act (Cures Act), and the set of final rules mandating regulatory compliance for healthcare information exchange was released by the Office of the National Coordinator for Healthcare Information Technology (ONC) on March 9, 2020 and published on May 5, 2020.
Detailed information can be found at https://www.healthit.gov/topic/interoperability. In addition, IQVIA published a white paper that examines the 21st Century Cures Act.
Understand your business
Remember that compliance with the Cures Act is a business requirement. The process flow of your business will inform and drive the assessment of your readiness. A high-level view of your operations might look like the diagram below.
Understand your systems
Using the diagram as your guide, the next step is to identify the systems that support your business. Inventory all applications used to support each business component. This should include details of each app, including vendor, version, and support model. And don’t forget those Excel, Access, and APEX tools. They are often unsupported by IT, and, therefore, are not included in a corporate technology inventory. These systems typically include data that is critical to the business process and will need to be assessed.
As you inventory your systems, be sure to include any underlying technology used to support each system, as well as the technology that supports communications between systems.
Connect with your vendors
Not all vendors are equal when it comes to addressing interoperability standards. Some will be proactive in assessing their own capabilities and will have a plan to address the new regulations. Others will hold off and defer to the requirements as defined by their clients. It is in your best interest to connect early and often with your partner vendors. Participate in their hosted webinars. Be proactive to ensure the needs of your organization are met.
Assess your vendors within the highly integrated technology ecosystem. Automated processes between systems is standard fare for a payer, including third-party vendor software. If there are changes within the core system such as new coding or data transformation, you will need to ensure those changes have no impact on processing within the third-party software. Although your vendors have an arrangement with these software vendors, it is ultimately your responsibility to understand and ensure they are doing what is required to support the interoperability standards.
Connect with your user communities
Most vendors host a forum for their clients to connect with one another. Take advantage of these opportunities. The user group provides a venue for discussing solutions for complex configuration scenarios.
The road to compliance
The road to compliance is a long one and is highly dependent upon vendor readiness. In fact, it’s never- ending, as regulations are continually defined and mandated. Your key to success is building strong vendor relationships, including with third-party vendors, to ensure your voice is heard and your technology needs are met.
The good news is you are not alone. IQVIA, as the industry leader in the use of healthcare data, can assist healthcare organizations facing the challenges of assessing, defining, and implementing the technology needed to support interoperability. Together, we can embrace the vision of the 21st Century Cures Act and improve the care and quality all members and patients deserve.
Cures Act: Getting Ready for the Implementation of TEFCA and Healthcare Interoperability Standards
In this white paper, IQVIA experts walk through the 21st Century Cures Act and the set of final rules mandating regulatory compliance for healthcare information exchange.