Your medical history in the palm of your hand via smartphone — anytime you want it. That is the vision of the 21st Century Cures Act Patient Access and Interoperability Final Rule.
To get there, CMS and ONC (Office of the National Coordinator for Health Information Technology) directed the industry to build standardized, common application programming interfaces (APIs) using standard data resources and a common security and application architecture. By defining the interface and available data access, CMS let the industry innovate on how to access, collect, translate and transform the available data into those data resources and APIs with the goal to put patients first, giving them access to their health information when they need it most and in a way they can best use it.
Additionally, in 2015, CMS required each state Medicaid agency to submit a set of data to CMS monthly to support standardized reporting and research. The standard data, called T-MSIS (Transformed – Medicaid Statistical Information System), includes claims, provider, member, managed care and third-party liability information. Gainwell embraces the CMS goals of leverage and reuse and integrates the T-MSIS data files as a primary source of our Patient Access and Interoperability (PAI) solution. PAI is a platform-as-a-service offering with common cloud-based infrastructure. In this way we dramatically reduce the customization necessary while allowing state Medicaid agencies to meet the needs and goals of this important federal initiative within the required time frame.
Common Platform, Uncommon Results
Leveraging and reusing national data sets and making them the primary source for medical and provider data shared with Medicaid beneficiaries makes good sense. And it emphasizes their value as a key source of policy and program data for this population.
Our modular approach to the Patient Access Final Rule allows State Medicaid Agencies to choose the solution components that provide the desired value:
Level 1 – Patient (member or beneficiary) has access to their health data, which Gainwell populates from T-MSIS files, through a mobile or web app via a secure API gateway
Level 2 – Includes the integration of clinical data held by the state or accessed directly from the provider or HIE systems; supports care coordination, analytics and value-based payment models
Level 3 – Supports patient-centered care through member control of the transfer of their data between organizations; patient can request their current Medicaid patient record be sent to entities of their choice (payers, providers), which can incorporate that data into their operations
At Level 2 and Level 3, our solution provides additional modules that offer state Medicaid agencies the opportunity to use the data for other purposes, such as population health and medical management, performance measures and value-based pricing or for care coordination across payers, providers and other entities of the patient’s choosing.
True data interoperability will fundamentally change healthcare delivery. It starts by giving patients full electronic access to their health information. But we gain the real value when clinical data is combined with the administrative and claims data of a payment system.
Having a simpler way to share and aggregate this data across systems will accomplish three key goals: allow for enhanced population health management; support value-based payment; and validate quality measures and incentives. It all adds up to achieving better health outcomes by having more complete data input. The real benefit to healthcare is in the final rule’s name: Patient Access and Interoperability. It will be an interesting journey — one that Gainwell wants to take with you.
About the Author
Jeff Strand is a business solution architect with more than 30 years of healthcare industry experience. He is a member of the MITA Governance Board and is a co-chair of National Medicaid EDI HIPAA (NMEH) sub-workgroup on MITA. At Gainwell he helps define modular healthcare solutions to align to the CMS Medicaid Information Technology Architecture and evolving State and Federal requirements.
Jeff can be reached at: firstname.lastname@example.org