COVID-19 pandemic

In the coming months, 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 January 2021, after being postponed for several months due to the onset of the current COVID-19 pandemic.

“The main challenge facing the healthcare system for many years, both in the United States and Puerto Rico, is the fact that existing technology platforms used to handle patient information do not communicate,” said Dolmarie Méndez, CEO and co-founder of Abartys Health, a tech startup. “The current state of fragmented communication among insurers, providers and patients dramatically increases costs and stops patients from receiving the best health services.”

The idea, she noted, is to give patients the power to access, contribute to and integrate information from their own health records using apps, portals and other software tools, enabling them to set and meet personal health goals.

“For example, Abartys is giving patients a centralized data delivery system that functions as a one-stop-shop for personal healthcare records, insurance documents and physician history. For insurers, our patientLynk platform facilitates access to long-term lab results to offer a comprehensive vision of patient health. For labs, the platform increases laboratory diagnostic testing capacity, surveillance system, and routine reporting.

“Moreover, the need for universal patient identification and faster lab test response times has been dramatically underscored amidst the current pandemic,” she added.

The Centers for Medicare & Medicaid Services (CMS) published in March new guidelines for providers and insurers that require the latter to make available electronically and in a standardized way patient health information as well as medical provider directories. Providers are also required to comply with new electronic notification requirements. The guidelines aim to provide patients 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.

Méndez underscored the need for the industry to take urgent steps to prepare adequately for the 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 the Children’s Health Insurance Program, meaning that the vast majority of insured beneficiaries would be covered.

Insurance Companies React

Iraelia Pernas, executive director of the Insurance Companies Association (Acodese by its Spanish acronym), told THE WEEKLY JOURNAL that the members of the private organization are already working towards complying with the new provisions.

“The health insurance members of Acodese are working to faithfully comply with the CMS interoperability requirements that come into effect on Jan. 1, 2021. Many guidelines are already being met and, in other cases, we are currently working in coordination with our providers to be able to comply,” Pernas said in a statement.

Meanwhile, Triple-S, the largest health insurance company in Puerto Rico, explained that it has provided its beneficiaries with centralized access to their providers and health information through the ‘Mi Triple-S’ platform since 2017. 

“Mi Triple-S is an important tool for physicians, as it shares information about healthcare and health events in the recent past and helps them to have a clearer picture of their patients when treating them. This platform was extended this year to Triple-S policyholders in commercial plans and we will soon be taking it to Vital beneficiaries under Triple-S,” said Pedro Aponte Gil de Lamadrid, Chief Information Officer of Triple-S.

In a statement to THE WEEKLY JOURNAL, the insurance company’s CIO explained that the tool has allowed Triple-S to work in advance on interoperability issues. “At this moment, we are developing the specific format (Application Programming Interfaces) required by the CMS regulation and thus be ready for July 1, 2021, the date on which it comes into force,” he added.

Moreover, Pernas and Aponte Gil de Lamadrid concurred that the new federal regulations are a step toward improving health services. “In terms of the requirements and the compliance with those requirements, we believe that it will promote a benefit for the patient,” Pernas stated.

“The CMS interoperability rule is a positive step that will allow greater access and exchange of health information; this should result in truly coordinated care and better health outcomes for people,” Aponte Gil de Lamadrid affirmed.

Important for Patients With Low Incomes

Héctor García, director of the Puerto Rico Primary Care Association Network, who also works with the Puerto Rico Primary Health Association (ASSPR by its Spanish acronym), said the initiative is particularly important for patients from lower income groups.

For example, he noted that the ASPPR, “as part of its role and support to the 330 Primary Health and Prevention Network, has developed a collaboration with nonprofits whereby it has invested resources to implement platforms with use and access to ‘Telesalud’ (telemedicine). This is to improve the provider’s and patient’s experience at the Primary Health Centers.”

Since 2016, the entity has been working on developing user-friendly technologies that streamline information exchange between providers under the Health System, while also enhancing patients’ access to their providers, particularly during the COVID-19 emergency.

García also stressed the relevance of the new requirements in the scope of the pandemic. “The final rule of the CARES Act… has facilitated the process to advance interoperability between medical plans and their networks of health providers; the use and access of [telemedicine] for the provider and patient; reducing the burden and fatigue of the provider in medical care; improving the quality of health services; promoting data analysis and statistics processes for decision-making, empowerment and commitment of the patient towards their health and medical care; promoting the exchange of health information; [and] avoiding the blocking of information between electronic medical-record systems between providers and patients.”

Improve Efficiencies, Save Money

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,” explained Méndez of Abartys. “It has also accelerated the need for the universal identification of patients and the rapid transmission of clinical lab results.”

For example, she noted that patientLynk is a tool that works with lab information systems to offer access to data and clinical information results via an online patient portal. Lab results and historical information are hosted on each patient profile, which can then be accessed via smartphone, laptop and SMS, or short message service. The solution allows patients to track, trend and better understand their personal health regardless of the fragmented systems that were involved in creating their health data. Better yet, some receive cheaper insurance premiums for simply using the platform.

“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 infectious disease outbreaks, such as the one caused by the SARS-CoV-2 virus,” Méndez said.

- Correction: The 'Mi Triple-S' service is offered through an online platform, not an app.  

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