The main challenge facing the healthcare system for many years, both in the continental United States and Puerto Rico, is the reality that existing technology platforms used to handle patient information do not communicate with each other.
They hold information hostage with proprietary programming interfaces to the detriment of patients and the overall healthcare system. The current state of fragmented communication among insurers, providers and patients dramatically increases costs and stops patients from receiving the best health services.
In the coming months, however, patients could gain unprecedented access to their healthcare data, giving them more control over the management of their conditions as new federal interoperability regulations push insurers and health providers to adopt new technologies and standards.
The new guidelines are set to take effect starting on January 2021, after being postponed for several months due to the onset of the current COVID-19 pandemic.
Insurers will be required to make available patient health information electronically and in a standardized way, as well as medical provider directories. Providers are also required to comply with new electronic notification requirements. The guidelines aim to provide patients with better access to their health data.
Moreover, states and territories will now be required to improve the coordination of medical care for eligible beneficiaries under Medicare and Medicaid through the daily exchange of data with CMS.
The industry needs to take urgent steps to prepare adequately for these technological changes and secure compliance with the new guidelines. In Puerto Rico, the new rule applies to medical plans under Medicare Advantage, Medicaid (known as “Plan Vital”), and CHIP federal programs, meaning that the vast majority of insured beneficiaries would be covered.
A 2019 review of published peer-reviewed studies published on JAMA Network last October found that the U.S. healthcare industry loses almost $1 trillion in waste each year, including up to $265.6 billion lost due to administrative complexity, $165.7 billion due to failure of care delivery, and $78.2 billion from failure of care coordination.
Study authors expect that the new efforts by the federal government to foster data interoperability will help eliminate inefficiencies as patient “information flows more freely, and billing and authorization processes become more automated.”
Beyond the issuance of the new guidelines, the coronavirus pandemic has contributed to push the industry to adopt new technological solutions. It has also accelerated the need for the universal identification of patients and the rapid transmission of clinical lab results.
Compliance with the new CMS guidelines will give us the opportunity to transform healthcare, as we establish the basis for a robust and secure digital infrastructure that allows for better care management and delivery as well as handling of infectious disease outbreaks such as the one caused by the SARS-CoV-2 virus.