These APIs must be implemented by January 1, 2027, requiring payers to move quickly and make the necessary infrastructure investments.

What other changes can payers expect?
Other industry developments affecting providers could deliver benefits for health plans. Specifically, recent changes targeting information blocking could help ease payer requests for medical records from providers.
In July 2023, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) released its final rule, which included a penalty that can reach up to $1 million for health IT developers and health information exchanges (HIEs) that unfairly restrict patient access to health information. However, this rule was limited in scope because it didn’t apply to provider organizations. According to the American Medical Association, providers that interfere with payers seeking electronic health information to confirm a clinical value are at high risk for information blocking.

To address this, a new rule has been proposed by HHS that would reduce reimbursement and impose other penalties on providers that block patient access to information.

Rapid progress toward interoperability
In the past, the healthcare industry had been somewhat reluctant to embrace opportunities to promote better data sharing. For example, when the Meaningful Use Program was first introduced back in 2009 to promote EHR adoption, the initiative took several years to gain traction. Now that the benefits for interoperability are clear, payers and other healthcare organizations will act quickly to join QHINs. Over the next 12 to 18 months, payers can expect to see more seamless data exchange between payers, health systems, HIEs and other organizations come to fruition.

How can payers get started?
Health plans looking to improve their interoperability strategy should first assess their infrastructure for scalability and compliance with interoperability standards. Furthermore, payers must collaborate with their legal, compliance, and subject matter experts to critically evaluate each potential data partner for compatibility with their market, infrastructure and use cases. Questions to ask include:

• Where does the partner have clinical data available for my use cases?
• What is the average patient match and document return rate for the partner?
• Do I need a Data Use Agreement?
• Where are my gaps from an infrastructure perspective? Do I have the ability to ingest data, standardize and normalize/enrich the information for downstream use cases, such as HEDIS reporting and year-round member engagement?

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