Post-acute facilities face hurdles in healthcare's interoperability push

Landmark data-sharing regulations from HHS' Office of the National Coordinator for Health Information Technology and CMS seek to tie healthcare providers and patients across the care continuum closer together—but historical disparities in technology adoption between healthcare sectors could pose challenges for providers in post-acute and long-term care settings.

The information-blocking and interoperability rules, provisions of the 21st Century Cures Act, were released last year but implementation was subsequently pushed back to April 2021 due to the COVID-19 pandemic.

Under the information-blocking provisions, providers are barred from blocking patients and other providers from accessing health data unless they meet one of eight specific exceptions.

The ONC's rule uses a definition for healthcare providers from the Public Health Service Act. So it applies not only to acute-care hospitals, but a broad range of providers including post-acute and long-term care facilities like nursing and home health agencies.

It could represent a notable shift for post-acute care providers, who have often struggled to receive data from referral facilities.

Historically, "healthcare has been driven by the hospitals being the keepers of all data," said John Kunysz, CEO of home healthcare provider Intrepid USA Healthcare Services.

The regulations are "long overdue," said Steven Chies, president of North Cities Health Care, a long-term and transitional healthcare provider with sites in Coon Rapids and New Brighton, Minn. He also teaches online courses on health information systems at St. Joseph's College of Maine. "It'll pull us out of the 19th century in terms of technology."

Chies said many senior-care providers exchange data with other providers—such as when receiving a patient from a hospital or when transferring a patient to an emergency department—on paper. In fact, the majority of post-acute care providers—66%—access patient records from referring facilities via fax machines, according to a 2018 report from KLAS Research.

"The post-acute setting is still highly dependent on fax," said Coray Tate, an analyst at KLAS.

Even if a post-acute care provider is on an electronic health records system, they might still be doing patient transfers on paper if their software system doesn't communicate well with the receiving facility's system.

That's why Chies is excited about provisions in ONC's rule related to application programming interfaces—protocols that allow different applications to communicate and share data with one another.

He expects the rule, which sets specific standards for APIs implemented by some healthcare software developers, to make it more likely for acute-care and post-acute care providers to use software that leverages the same data standards. That, hopefully, will allow providers from across the care continuum to more easily share information electronically.

"I've been arguing for 10 years that, without government intervention, there's not going to be a standard for interoperability," Chies said. "A government agency—or anybody—willing to step forward and put forth a standardized protocol for transferring data, is going to be a very good thing, especially for the long-term care segment."

ONC's rule doesn't directly call on providers to use APIs.

The rule has two distinct pieces: the information-blocking provisions, which apply to healthcare providers, health information exchanges and developers of health IT software that have earned approval from ONC's health IT certification program, and an update to the conditions that such software developers are required to meet to be certified.

The API provisions are part of the new certification requirements and force developers to make APIs that meet specific standards available to customers by December 2022.

ONC leaders have suggested that setting up standard APIs under which patients and providers can exchange data will help create a new market of healthcare apps.

But while that vision is enticing, the emerging ecosystem could widen the gap facing the post-acute care sector.

Post-acute providers weren't eligible for the original Medicare and Medicaid EHR Incentive Programs, today known as the Promoting Interoperability Programs. Under those programs, rolled out in 2011, eligible providers have received billions in federal incentives to adopt and use certified EHRs.

The Health Information Technology for Economic and Clinical Health Act of 2009 set the groundwork for CMS' EHR incentive programs. It established EHR adoption and "meaningful use" of such technology as a goal for eligible providers.

"Much of the policy that's come along since the HITECH Act was based on the fact that the acute-care sector (and) ambulatory sector received the financial incentives to purchase and deploy electronic health records," said Cynthia Morton, executive vice president at the National Association for the Support of Long Term Care.

As the information-blocking and interoperability rules take hold, Morton said she's concerned that providers in post-acute care settings will be held to the same requirements as acute-care providers, even though they are further behind in deploying the technology.

"It just doesn't fit our sector so well," Morton said of the regulations.

ONC officials have stressed that the information-blocking and API provisions are separate from one another, and only the former apply to providers.

The information-blocking provisions don't require providers to adopt EHRs, APIs or other technologies, said Mike Lipinski, director of regulatory and policy affairs at ONC. It just requires providers to change practices or policies that inhibit sharing patient data as Congress mandated in the Cures Act.

He added that ONC was "very cognizant of how broad the definition of healthcare provider was."

"It wasn't just talking about those who already participated in the Promoting Interoperability program and had maybe already adopted a lot of advanced technology," he said.

That's where information-blocking exceptions outlined in the rule could come into play.

If a patient requests data in a way a provider is not able to fulfill, the provider could share data through another method, provided they meet criteria under the "content and manner" exception.

Lipinski added that the rule should help smaller providers gain access to data from others more easily.

"While they're covered under the healthcare provider definition, they should see this rule as an opportunity, as well," he said of smaller providers. "This is an opportunity for them to have more access (to information)."

Still, Morton questions why on the developer side the rule only impacts those with ONC-certified products, but applies to all providers, regardless of what software they have in place. A different timeline for providers not using certified software could have proved helpful, she said, for example, if the information-blocking regulations had started with providers who received money from the Promoting Interoperability Programs and later phasing in others.

She said many post-acute care providers have implemented EHRs, but not necessarily ones certified by ONC.

In 2017, 78% of home health agencies and 66% of skilled-nursing facilities had adopted some form of an EHR, according to a data brief published by ONC in 2018, the most recent data the federal agency has published on the post-acute and long-term care sector. Those figures are likely higher today, experts said.

If the federal government wants to encourage more post-acute care providers to adopt certified EHRs, it should look at new incentives, experts said. After all, EHRs are an expensive purchase.

"Change often does not come without incentives or disincentives," said Dr. Shaun Grannis, vice president of data and analytics at the Regenstrief Institute.

That could involve providing incentives to providers who meet certain data-sharing metrics or giving providers points on quality score cards if they're using an appropriate EHR system, experts said. Or payers, such as CMS or state Medicaid agencies, could offer grants or even roll out policies similar to what was done in the acute-care and ambulatory sectors.

That said, it doesn't necessarily make sense for all post-acute care providers to implement software certified by ONC, since functionality needed for certification traditionally has focused on acute-care and ambulatory needs, said Alan Swenson, who joined interoperability framework Carequality as executive director last week. He spoke with Modern Healthcare while at his previous roles, vice chair of NASL's IT committee and vice president of interoperability at healthcare interoperability company Kno2.

Swenson suggested ONC broaden its certification program, so that software developers that aren't otherwise certified could seek some acknowledgment of their data-sharing capabilities.

While the government can encourage adoption with incentives, there are signals from the private sector that could push providers and software developers toward standard APIs, too.

WellSky, the developer behind Intrepid USA's EHR system, has added standard APIs to a handful of its products, so that patients can download their health data to a personal app.

Software platforms that have received ONC certification have such APIs, as well as some—but not all—of the company's platforms that aren't certified. The company's hospice and palliative-care software is certified; it sought certification since some palliative-care clinicians get bonus points toward quality scores in CMS' Merit-based Incentive Payment System if they use certified software, according to Amy Shellhart, senior vice president of solutions management at WellSky.

WellSky is continuing to build on its API strategy and plans to have additional capabilities in the next 18 months.

To date, the company's API strategy has focused more on connecting to other providers, rather than for patient access.

"Historically, the demand for those patient-managed health apps tend to be in the younger population," Shellhart said, rather than the patients in the post-acute care setting. She noted that demand could change as millennials and Gen Zers age into the senior population.

Dr. Donald Rucker, who led ONC as national coordinator for health IT when the draft and final rules were released in 2019 and 2020, respectively, acknowledged acute care has historically been able to invest more in advanced technology. But he suggested APIs will proliferate outside of the ONC's certification program.

Already, Amazon, Google and Microsoft Corp. have released API tools that use the same standards outlined in the rule on their respective cloud platforms, despite not being required to.

And Apple has released a tool that lets patients download their health data from providers onto the iPhone's Health app, using APIs that link a provider's EHR to the app. Since Apple launched the health records feature in 2018, well before ONC's rule, more than 500 organizations—including hospitals, clinics and laboratories—have signed on to make patient health records available through the service.

"These standardized APIs will be everywhere," Rucker said. Not only because of patient access, but also "for reasons that have a lot to do with how providers provide care."

Rucker has previously suggested standard APIs could underpin new apps that help providers report quality measures, among other uses.

"The modern world in every sector of the economy is using these types of tools," Rucker said. "It seems reasonable to think that healthcare service folks will use them."

Even if post-acute care providers don't need certified EHRs for specific programs, they may decide they need to move to EHR systems that are interoperable with software at acute-care facilities—or else lose their referral sources.

MatrixCare, another developer of EHR software for the post-acute sector, also has added standard APIs to some products, including its home health and hospice applications. It's part of an effort to make it easier for those facilities to exchange data with referral sources.

MatrixCare doesn't have applications certified by ONC. But it's planning to continue developing capabilities for the APIs, such as patient-facing use cases. The company declined to share an expected timeline for such additions.

"I really think the drive for connected care is going to cause broad adoption of support for those API sets, regardless of whether or not a given product is certified," said Nick Knowlton, vice president of strategic initiatives at ResMed, the company that acquired MatrixCare in 2018. He's also board chair of the CommonWell Health Alliance.

Roughly three-quarters of acute-care providers indicated they would switch to a post-acute care provider that has electronic data-sharing capabilities, such as the ability to accept electronic referrals, according to a recent survey of providers conducted by market research firm Porter Research and MatrixCare.

"That's a big driver," said Chies from North Cities. "Whatever your admission source is telling you, you're going to try to accommodate them as best as possible."