Benefits for the Payer Community

RCE - Benefits for the Payer Community

Together with the Office of the National Coordinator for Health Information Technology (ONC), we are developing the Trusted Exchange Framework and Common Agreement (TEFCA) as required by the 21st Century Cures Act. Once operational, the network-of-networks based on the Common Agreement will facilitate exchange of health information on a nationwide scale, simplify connectivity among networks, and create efficiency by establishing a standardized approach to exchange policies and technical frameworks. Together with ONC, we announced in July 2021 that we plan to publish the Common Agreement V1 in Q1 of 2022.

The network based on the Common Agreement will offer a nationwide approach for the exchange of health information to support a range of exchange purposes, enabling a multitude of use cases. 

The Common Agreement’s single set of rules will simplify connectivity to a health information network (HIN) for the benefit of patients and health plans. Consistent policies and technical approaches will increase the overall exchange of health information.

The ultimate goal of the network based on the Common Agreement is to establish a floor of universal interoperability across the country. This will enhance provider, payer and consumer access to health information that supports better clinical decision-making, improved outcomes, and lower costs.

The Benefits of the Network Based on the Common Agreement for the Payer Community

The network based on the Common Agreement will provide an efficient vehicle to send, receive and query for standardized electronic health information from a broad array of participants across a national scope. Specifically, this can help health plans and payers:
Improve care coordination and case management. Efficient information sharing allows health plans to have a more complete picture of the care an enrollee has received and determine which individuals would benefit from case management services, such as ensuring people receive the right care after being discharged from the hospital or arranging for the support people need to manage a chronic illness. Giving providers access to test results and diagnostics performed in the recent past may limit the need for repeat and redundant services, saving costs and reducing inconvenience for patients.
Provide individuals with access to their information. Today, patients’ access to their electronic health information relies on the use of different portals tied to each of their health care providers or health plan. The network based on the Common Agreement can facilitate expanded access to an individual’s health information across all settings of care as well as from their health plan(s)—in one stop—without having to remember multiple passwords.Today, patients’ access to their electronic health information relies on the use of different portals tied to each of their health care providers or health plan. The network based on the Common Agreement can facilitate expanded access to an individual’s health information across all settings of care as well as from their health plan(s)—in one stop—without having to remember multiple passwords.
Access information needed to close care gaps. Efficient information sharing allows health plans to have a more complete picture of the care an enrollee has received and helps to close care gaps (such as missing immunizations or diagnostic tests).
Support information gathering of quality improvement data that health plans use to track their own performance or to report to federal and state government programs or plan sponsors.
Support value-based care and population health. The network based on the Common Agreement will enable payers to share member data with providers and receive information about the care their members receive. Increased sharing of relevant information supports efficiency and success under value-based payment models. Having broader access to demographic and other health data will also enable analytics regarding trends in chronic disease and disparities across population groups.
Better integrate administrative and clinical data. Easier access to clinical information will support patients, providers, and health plans in gathering the data needed for prior authorization or other administrative activities that help ensure that planned care is appropriate and safe.
Facilitate bi-directional exchange with public health. To manage future pandemics or other public health challenges, it is important for public health agencies to be able to share and receive information from health plans, such as immunization records and guidance on best practices for treating new conditions.

The Basics of the Network Based on the Common Agreement

ONC has awarded a cooperative agreement to The Sequoia Project as the TEFCA Recognized Coordinating Entity (RCE) responsible for developing, updating, implementing, and maintaining the Common Agreement. The RCE will also play a central role in operational activities for the network based on the Common Agreement, including ensuring ongoing performance and creating a participatory and trustworthy governance process.

The Common Agreement will provide a single set of rules that address permitted data uses, privacy and security policies that must be followed, breach notification requirements, and other policies that must be in place before data can flow. It is important to note that Common Agreement will not supersede or override state or local laws, such as those governing privacy or public health reporting.

The technical standards underlying this network-of-networks approach will connect Qualified Health Information Networks (QHINs) to serve as the high-capacity infrastructure to share electronic health information across the entire nation—with the needed privacy and security protections. QHINs will be the central connection points within the network based on the Common Agreement, responsible for routing queries, responses, and messages among participating entities and individuals. Members of participating HINs will be able to request and receive electronic health information from QHINs in the network based on the Common Agreement starting with query and message delivery.

The Common Agreement will be signed by the RCE and each QHIN. Some provisions of the Common Agreement will flow down to other entities, such as QHIN Participants and providers. The QHIN Technical Framework (QTF) describes the technical and functional requirements for electronic health information exchange between QHINs and will be incorporated into the Common Agreement. The QTF requirements include, among others, privacy and security steps, approaches for identifying and authenticating exchange participants, how to conduct patient discovery and identity resolution, as well as support for required exchange protocols. The QTF will include a standards-based approach to directory services—an aspect of exchange that has been challenging to date. Exchange within a given QHIN will generally be covered by the QHIN’s participant agreements and technical requirements. Implementation timelines will take into account the need to modify existing agreements.

On the Radar

As we continue to develop the Common Agreement, the RCE is committed to informing the community about key developments through informational calls and updates. Activities underway include:

  • Development of a participatory governance structure to ensure a transparent and fair process that includes representation of stakeholders.
  • Development of transparent and efficient application and onboarding processes for QHINs.
  • Development of the Common Agreement and QTF that will outline the technical requirements for exchange. The Elements of the Common Agreement and QTF Draft 2 are now available for review and stakeholder input.

We encourage the payer community and other stakeholders to engage with us as the community works together to realize nationwide health information exchange.

To prepare, health plans should consider how nationwide exchange could support their operations and ask the health information networks they currently participate in whether they are planning to participate in the network based on the Common Agreement.

We encourage you to connect with us and learn more at: https://rce.sequoiaproject.org/participate/.

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