Free Trial Module

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The US health insurance industry is unique and complex with many different kinds of health insurance. How interoperability is now impacting Medicare, Medicaid, other government-sponsored programs as well as commercial health insurance varies. This module covers the different kinds of insurance plans and how interoperability regulation is now impacting each distinctly.

Since 2001, patients can share their health information as they choose. Traditionally, manual and paper-based, benefits have been limited. Yet, a robust understanding of the authorization to release medical information form. and supporting processes is incredibly useful to understand what interoperability is making digital. This module pinpoints key consumer rights in the HIPAA Privacy Rule, how they have been enabled in the past to understand how interoperability will shape the future.

Payers of Medicare, Medicaid, CHIP, and QHP health plans must make their provider directory freely and publicly available via APIs in 2021. This module uncovers what the data of this API is all about including the DaVinci PDEX standard.

Through the Patient Access API, in 2021 more than 80 million Americans will be able to securely get to their insurer's administrative and clinical information through third-party apps. This module explores the capabilities of the Patient Access API including the US Core, DaVinci Consumer PDEX, and CARIN Blue Button® framework.

Payers must HL7® FHIR® for their APIs. Implementation Guides standardize how to do this. These implementation guides identify what data is included in the  APIs, how the data is to be formatted into specific FHIR® profiles, and what standardized vocabularies are to be used. This module walks through US Core, Da Vinci PDex including Plan Net, and the CARIN Implementation Guide for Blue Button®. 

Patients need to be effectively informed regarding the new capabilities of interoperability. They need to understand their rights and risks in order to improve their health and the health of their loved ones while safeguarding their privacy. This module explains the resources available and key scenarios to consider in planning.

Office of the National Coordinator for Health Information Technology of the Department of Health and Human services has offered guidelines and best practices for healthcare app developers. The CARIN Alliance Trust Framework and Code of Conduct offers a framework to healthcare applications that are not covered by HIPAA to exchange, store, and manage personally identifiable health care information. This modules explores best practices to consider for interoperability apps.

While HIPAA protects all types of protected health information, there are highly sensitive types of information that require further special handling. Examples include behavioral health, substance abuse, HIV/AIDS, genetic and more. This module provides an overview of these different kinds of information and what special considerations must be given to them in planning for and enabling of interoperability. Discussion of "data segmentation" and record of disclosures is covered.

Beyond HIPAA, there are other federal laws and regulations that must be considered in regards to interoperability. The 42 CFR Part 2 regulations (Part 2) serve to protect patient records for the treatment of substance use disorders. Further, in the Interoperability and Patient Access Rule, CMS points to the Federal Trade Commission authority to investigate and take action against unfair or deceptive trade practices as well as the FTC Health Breach Notification Rule, which applies to certain types of entities, including vendors of personal health records and third-party service providers, that fall outside of the scope of HIPAA. This module identifies key federal laws and regulation that matter in the world of interoperability.

The Interoperability and Prior Authorization Proposed Rule is the next phase of CMS interoperability rule-making, aimed at improving data exchange while reducing provider and patient burden. This rule will enable certain payers, providers, and patients to have electronic access to pending and active prior authorization decisions. This is expected to cut back on repeated requests for prior authorizations, thereby reducing costs and administrative burden so providers can deliver higher quality care. This module walks-through this rule including its scope and deadlines. The Provider Access API, Documentation Requirements Lookup Service API, ePrior Authorization API, and associated Da Vinci implementation guides are covered.

The USCDI identifies standardized health information terminologies for use in interoperability. Examples include LOINC®, SNOMED CT®, HL7 Standard Code Sets and Value Sets, the CDC National Drug Code (NDC) Directory, The Unified Code of Units for Measure, RxNorm, the Office of Management and Budget (OMB) Directive on Race and Ethnicity, CDC Race and Ethnicity Code Sets, RFC 5646 for identifying languages, HCPCS and CPT-4 for procedures, as well as ICD-10. This module will provide overview of how interoperability standardizes data exchange semantically through these informatics standards.

In working with HL7® FHIR®, the standardized terminologies, APIs, and the specifics of US Core, Da Vinci, and CARIN Alliance Implementation Guides, there are a number of tools and technologies you may want to become aware of. Some of these may accelerate your work and help you meet deadlines and bring ideas to fruition. Some of the tools and technologies are open source while others are commercially available. This module will survey the market to help you understand what's now available to help you out. 

CMS has prescribed specific security technologies for interoperability. SMART on FHIR provides reliable, secure authorization for a variety of app architectures with the OAuth 2.0 standard. OpenID Connect 1.0 is a  identity layer on top of the OAuth 2.0 protocol. It enables clients to verify the identity of the end user. This module walks through these security standards at a high level and provides resources for consideration.

In the Interoperability and Patient Access rule, CMS boldly declares, "we have launched several initiatives related to data sharing and interoperability to empower patients and encourage payer and provider competition." This module explores use cases available for innovation for both industry incumbents and outsiders wanting to increase their value in the healthcare ecosystem.