Photo: Al David Sacks/Getty Images

Interoperability in healthcare, it would seem, is at an important inflection point.

Rules around data exchange have been around for years and regulate what patient information gets shared between payers, providers and the patients themselves. There are also standards around how that information is shared and the forms it can take. But the transition to value-based care has caused a shift in terms of the standards that apply to the data exchange, and new rules and technology mean there’s less chance for redundancy, administrative waste and roadblocks to patient access.

Joerg Schwarz, head of healthcare interoperability strategy at cloud software company Infor, said the 21st Century Cures Act, first passed in 2016, was instrumental in bringing interoperability into the modern era. The 21st Century Cures Act is a huge piece of legislation with varying pieces enacted on different timelines, including key components enacted this year.

Before that law passed, data exchange was regulated largely by HIPAA, which stipulated that payers and providers were allowed to share information with one another. That data sharing was not a requirement, however. So oftentimes payers and providers would decide it was not in their best interest to do so.

What the 21st Century Cures Act did was require payers and providers to exchange data. That, along with the emergence of value-based care, was perhaps the biggest leap forward for interoperability since the concept first emerged.

“I think the reason for that is we have learned over the last 10 years, with the transition toward value-based care, that it is essential for payers and providers to get access to clinical data and utilize that clinical data to improve the way they provide care,” said Schwarz.

The Affordable Care Act was another important cog in the machinery, as it mandated that providers create electronic health records that would allow them to share lab data in a standardized format. The American Recovery and Reinvestment Act required healthcare providers to adopt and demonstrate “meaningful use” of electronic medical records by January 1, 2014.

The ACA mandated improvements in the way laboratory test results are exchanged and transmitted to electronic health records, including a process to get laboratory data back to the point of care for use by clinicians to make more informed and meaningful decisions for their patients.

This standardized data has become critically important for interoperability in a value-based care framework, both in the commercial world and in the government world, with more and more Accountable Care Organizations popping up, and Medicare and Medicaid having shared savings plans in which they contract with provider groups.

“These provider groups have an incentive to actively manage the health of the population they’re responsible for,” said Schwarz. “They can only do that if they have good data.”


Under the older data standards from 2009, clinical document architecture (CDA) was mandated by the feds and stipulated there be an Extensible Markup Language (XML) document that contains much of the data exchanged between payers and providers.

That sounded good in theory, but in reality, the document would typically contain a lot of redundant information. If Provider A generated an XML document, Provider B added its own document and then exported it, the final document would contain information from both providers; and if there were five or six providers involved, most of the information would be the same.

The new standard, said Schwarz, is based on modern web standards and application programming interfaces, or APIs.

“You can be much more precise in what you need,” he said. “So, if you are creating an application that manages the dosing for an infusion pump, for example, and you say, ‘I need to know how to prepare the right dosage for the patient. I want to know the bio of the patient and the gender of the patient,’ you can ping an API and request exactly that information. You get exactly what you need from the data source, not a bunch of information where 99% of it is stuff you’re not interested in in this instance.”

The other advantage of the API world is that providers can orchestrate modern workflows. They do it by taking data from one API and putting it into another – which is how they can, for instance, use applications in a digital front door. The patient can interact with a chatbot and present some symptoms, and the chatbot may ask relevant questions based on the assessment of the API, and then recommend where the patient should go, whether it be the emergency room or urgent care. Another app might use the information to make an appointment.

“So, the patient experience is in an integrated world,” said Schwarz. “I don’t have to re-enter data multiple times. I have a seamless environment behind the scenes.” This benefits patients, but payers and providers as well, because it reduces administrative workload.

APIs can also orchestrate a dialogue between payers and providers for pre-authorization, said Schwarz.

“Today, that’s state of the art,” he said. “If the patient is seen for a complex procedure, they often need prior authorization. The provider asks the payer, ‘Under which terms will you cover the costs of this procedure?’ Sometimes that requires a dialogue with faxes or emails, and it can take days or weeks for this prior authorization to happen. 

“That should be automated, so when the provider sees the patient and says, ‘You need this surgery,’ they can request prior authorization from the payer through the API that collects data on the prior authorization. The payer receives the info in their API. They check the information and respond back and say, ‘I want this information, and this information on top.’ The responding API can reach into the EMR and prompt them to get additional info.”


One limitation of the 21st Century Cures Act is that the Centers for Medicare and Medicaid Services can only mandate data exchange for providers and payers that are government-funded – Medicare and Medicaid-related claims, for instance. But that’s still a large portion of the economy. Nearly all commercial payers have Medicare Advantage plans or work as management companies with state Medicaid plans.

“This will have a broad impact because everyone has to comply with the rules,” said Schwarz. “The workflow will become prevalent, which means all the EHR vendors have to prepare for it.”

Companies such as Infor have turned this into a sales opportunity. They have been working with payers and vendors to put translation layers on top of their existing systems to allow for smoother data flow and exchange. In this way, payers can use technology to consolidate all of the data they have about a patient.

The next step is payer-to-payer data exchange, said Schwarz, which will allow payers to keep track of patient information if, for example, someone switches their insurance during one of the open enrollment periods.

One of the big questions moving forward is what the patients themselves will do with all of this data. Companies are now forming that will allow a patient to house this data, providing an environment in which someone can use the data as they see fit.

“For example, if they’re interested in participating in a clinical trial, they can say, ‘Here’s my data. Tell me if there’s a clinical trial I would qualify for,'” said Schwarz. “Another use case is if you want life insurance. When you apply for life insurance, they literally send nurses to the house to take blood and put you on a scale and assess your health information.

“These companies are very interested in clinical data when they can get it. But a life insurance company would say, ‘Hey patient. You have access to your health information. If you give us access, we’ll give you a code for life insurance in hours instead of weeks, and you can go shopping for the best life insurance rate with the best underwriting.”

Ultimately, the goal of interoperability is that all of the providers and payers a patient interacts with will have access to all of their data, said Schwarz.

“On the payer side, the goal is for payers to have a good comprehensive picture about a patient,” he said. “With value-based care, they’re interested in keeping the patient healthy, so they’re developing tools to identify gaps in care and being really proactive about this.”


The Centers for Medicare and Medicaid Services released the Interoperability and Patient Access final rule in May 2020 but said it would delay enforcement action due to the COVID-19 pandemic.

CMS exercised enforcement discretion for the Patient Access API and Provider Directory API policies for Medicare Advantage, Medicaid, CHIP and qualified health plan issuers from January 1, 2021, through July 1, 2021. On July 1, 2021, CMS began enforcing these requirements.

In September 2021, CMS said it would delay enforcement action on the payer-to-payer data exchange provision in the May 2020 rule.

During HIMSS22 in March, CMS Administrator Chiquita Brooks-LaSure said CMS would soon release additional rulemaking for payer-to-payer data exchange, including the inclusion of APIs using the HL7 FHIR standard. 

Twitter: @JELagasse
Email the writer: [email protected]

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