Strategies for Adjusting With Health Care Interoperability

Katie Devlin, DHSc, MS, CPHIMS, VP, Interoperability, Cotiviti

Please share your name, title, and a brief overview of your professional history. 

My name is Katie Devlin and I am the VP of Interoperability at Cotiviti. I’m passionate about driving digital health transformation and have dedicated more than 15 years to health care informatics and clinical data exchange. Prior to joining Cotiviti, I oversaw network expansion and integrations for MedVirginia Health Information Exchange, where my team and I developed innovative strategies to acquire and ingest electronic health data. I also led the digital health strategy for a Fortune 100 insurance company and managed a technology innovation center for a large teaching hospital in Massachusetts. Earlier in my career, I implemented and supported various electronic health record systems and oversaw complex integration projects for the Pioneer Valley Information Exchange.

I hold a Doctor of Health Science in Health Informatics Management, a Master of Science in Organizational Leadership, and a Bachelor of Science in Business Administration. I’m also a Certified Professional in Healthcare and Information Management Systems through HIMSS (Healthcare Information and Management Systems Society).

How do you anticipate health plans will be affected by major shifts such as the Trusted Exchange Framework and Common Agreement (TEFCA) and the CMS Interoperability, Prior Authorization Final Rule, and the onboarding of QHINs? 

Payers are up against tight timelines to meet the CMS Interoperability Rule. Despite compliance being in 2027, payers will have to implement 3 key APIs and integrate them meaningfully into their existing workflows. The challenge is that many payers will have to deal with legacy infrastructure or, in some cases, overly complex processes before implementing these APIs. At a high level, payers will have to communicate the approval or denial of a prior authorization request, or the request for more information, and include this information in the data that is available to members via the Patient Access API. In addition, health plans will need the ability to exchange claims and encounter data with other payers, as well as in-network providers, for better care coordination. Despite having approximately 2.5 years to prepare, this work can be challenging if a health plan needs to deprecate technology, select new vendor partners, or hire talent to become compliant with these regulations.

When it comes to TEFCA, I think we’re finally starting to see the right things happening to improve data availability. Until TEFCA, there was no clear path for acquiring clinical data for healthcare payment and operations exchange purposes. However, the latest version of the Common Agreement allows payers and their delegates to participate in QHIN data exchange for health care operations purposes like quality reporting and patient stratification.

What are the most important areas within the current state of health care interoperability that health plans should focus on as they adapt to new data regulations and standards? How can payers best position their organizations for success? 

As health plans adapt to new data regulations and standards, they should consider joining a QHIN. In doing so, they can dramatically increase the amount of available data through a single connection. Even if they plan to acquire data through a delegate, payers need to make sure that they’re listed in the directory. Given the complexities of QHIN onboarding and testing, payers should consider using a delegate partner that is already a QHIN participant to handle connectivity and the rigorous testing that’s involved. With this approach, payers can immediately begin querying the QHINs through their delegate once the payer is listed in the directory.

What industry changes do you anticipate regarding interoperability requirements and regulations over the next few years? 

Currently, TEFCA authorizes 6 exchange purposes, including treatment, individual access, healthcare operations, payment, government benefits determination, and public health. However, responses are only required for treatment and individual access. I believe we will see all 6 of these exchange purposes become required soon and, with that, more QHIN adoption. As more data becomes available, I think payers can significantly reduce their reliance on copy services and traditional retrieval methods that are more abrasive and costly.

Is there any final message you’d like to share with our audience on this topic? 

It’s important to remember that this is a marathon, not a sprint. We won’t see a ton of data become available overnight, as the QHINs are just now onboarding their participants and sub-participants. However, within the next 12 to18 months I believe there will be a significant uptick in the information available to health plans, and this will continue to increase over time. There are now 7 organizations that have earned the QHIN designation, and payers can choose the one with the support and business model that best suits their needs.