CMS proposes interoperability rules to increase EHR access

Updated 1:45 p.m. ET

CMS on Monday released proposed rules that require many types of insurers to provide electronic health data in a standard format by 2020.

In two long-anticipated rules, the CMS and the Office of the National Coordinator for Health Information Technology proposed requiring healthcare providers and insurers to implement open data-sharing technology to ensure data can move from one plan to another, potentially by way of patient apps.

The CMS and ONC also released two requests for information on how the CMS can promote interoperability and reduce any burden on providers regarding health IT.

In addition, the proposals aim to make public the names of providers who block patient information, in a bid to inspire providers to end the practice. The CMS proposes that only hospitals that now possess an EHR system that can generate such patient notifications will have to meet the requirement, which will go into effect in 2020.

The CMS rule as proposed would require insurers on Medicare Advantage, Medicaid, the Children's Health Insurance Program and Affordable Care Act plans to provide enrollees with immediate access to medical claims and other information by 2020.

The information that must be provided will include data on diagnoses, procedures, tests and providers that a patient has seen, and will provide insights into a "beneficiary's health and healthcare utilization," according to a summary on the CMS proposed rule.

The CMS' proposal also would expand requirements for insurance plans to adopt application program interface technology to make their provider networks available for enrollees and prospective enrollees.

The ONC rule outlines the standardized application format for APIs to expand their use. "We have heard a lot of concerns that interoperability is technically there but because of pricing strategies and shutting down market competition those APIs are not effectively available," said Dr. Don Rucker, the national coordinator for health IT, on a call with reporters on Monday. "This proposed rule would stop that."

The proposed requirement would extend to state Medicaid and CHIP fee-for-service programs, Medicare Advantage, Medicaid managed care and CHIP managed care entities.

"APIs ensure that up to date information for all providers is available for use by developers building tools to support beneficiaries," the CMS said in a statement.

Affordable Care Act plans already have to make provider directory information available in a machine-readable format, so they are exempt from the proposed requirement.

The CMS also proposes that payers in agency programs such as CHIP, Medicare Advantage, Medicaid managed-care and Affordable Care Act plans participate in a trusted exchange network to let them "join any health information network they choose and be able to participate in a nationwide exchange of data. This would enable the information to flow securely and privately between plans and providers throughout the healthcare system," the agency said.

There are key requirements in both proposed rules for hospitals as well. The CMS is proposing requiring psychiatric hospitals, critical-access hospitals and facilities that participate in Medicare to send "electronic notifications when a patient is admitted, discharged or transferred," a summary of the rule said.

Such notifications are a proven tool for improving transitions of care when a patient moves from a hospital to another healthcare setting, the agency said.

If the rule is finalized, the CMS would have the power to name hospitals and practices that "unreasonably limit the availability, disclosure and use of electronic health information."

The ONC proposed rule outlines the exceptions for healthcare providers where information-blocking is acceptable, such as engaging in practices to prevent patient harm and perform maintenance to improve health IT performance.

Interoperability has long been a goal—and a problem—for the health IT industry. With the release of the rule, the ONC could pave the way for greater data exchange. Some have been pushing for that data exchange to happen via patients: Apple, for instance, now lets patients of certain health systems download their health records onto their iPhones, and last spring, the CMS proposed MyHealthEData, an initiative to give patients more control over their health information.

"By ensuring patients have access to their information and that information follows them on their healthcare journey, we can reduce burden, eliminate redundant procedures and testing, and give back valuable clinician time to focus on improving care coordination," the summary said.

Some industry groups were pleased that the ONC and CMS acknowledged exceptions to information-blocking such as privacy and security of electronic health information, according to a statement from the American Health Information Management Association, a credentials and standards-setting group for health information management.

"We are pleased that CMS' proposed rule includes a request for information on leveraging CMS' authority to improve patient identification," the group added.

A coalition of vendors, and patient, provider and employer groups called Health IT Now also praised the rule's attempt to target information-blocking. "Congress doled out nearly $40 billion to ensure patient information could be shared and used to improve care," Health IT Now Executive Director Joel White said in a statement. "Yet we never ensured bad actors weren't blocking information."