The secure exchange of sensitive patient data has become a top priority for healthcare organisations, especially with increasing requirements for interoperability and recent high-profile data breaches. Expanding data sharing, such as granting payers direct access to electronic health records (EHRs), offers operational benefits but also introduces privacy, financial and compliance risks. As healthcare leaders evaluate these strategies, implementing appropriate safeguards is essential to ensure patient information remains protected while enabling efficient healthcare delivery.
Potential Benefits of Granting Direct EHR Access
Granting direct EHR access to payers can streamline operational processes across revenue cycle management and health information management departments. When properly managed, this access can reduce administrative burdens, particularly in use cases like prior authorisation, risk adjustment and payment integrity audits. Direct data extraction by payers eliminates the need for manual record transactions, potentially speeding up claims adjudication and reducing friction in payer-provider relationships.
Such collaboration can lead to more efficient communication between payers and providers, improving negotiation dynamics for reimbursement and contract terms. Additionally, organisations might experience cost reductions as administrative overhead declines. Direct access also supports real-time data exchange, which can help health systems meet regulatory requirements more effectively. However, these benefits hinge on robust data-sharing agreements and effective oversight to ensure access is limited to authorised purposes only.
Privacy, Security and Financial Risks
Despite the advantages, expanded data sharing introduces significant privacy, security and financial concerns. Allowing payers direct EHR access increases the risk of data breaches, particularly under the Health Insurance Portability and Accountability Act (HIPAA). Third parties may gain unintended access to protected health information (PHI), exposing organisations to regulatory penalties and reputational damage.
Additionally, security vulnerabilities can arise if organisations do not implement stringent controls for monitoring and auditing payer activity. Cybersecurity incidents involving unauthorised data access can severely impact patient trust and organisational integrity.
Financially, the expectation of reduced administrative costs through direct access has not always been realised. Many organisations still report high volumes of manual interventions due to patient matching errors, with up to 30% of payer requests requiring manual follow-up. This continued administrative demand can erode the anticipated cost savings. Furthermore, some payers may overreach, accessing more patient data than intended, potentially leading to broader audits or increased claim denials.
Some healthcare organisations have raised concerns about payers using direct access for purposes beyond those originally agreed upon, such as “fishing” for additional claims to deny or reviewing unrelated patient encounters. This practice not only risks violating data-sharing agreements but can also create financial strain for healthcare providers through increased audit activities and potential revenue loss.
Establishing Effective Safeguards and Oversight
To mitigate the risks associated with expanded data sharing, healthcare organisations must establish robust guardrails and oversight mechanisms. A critical first step involves reviewing and negotiating data-sharing agreements with payers to ensure mutual benefit. Contracts should specifically address issues such as denial rates, data access limitations and compliance with HIPAA regulations.
Additionally, organisations should evaluate the trade-offs between operational efficiency and potential revenue loss. While direct access can accelerate claims processing, it should not come at the expense of lost reimbursement revenue or heightened compliance risks.
Effective monitoring strategies include defining strict access templates within EHR systems. Each template should specify the exact data elements accessible for each use case, limiting exposure to only necessary information. Ongoing audits should track which encounters and patients are accessed, how frequently payer staff view records and whether duplicate requests occur. These measures can help organisations detect improper data use and maintain compliance.
Further, training staff on data protection policies and maintaining an incident response plan are crucial steps in preparing for potential security breaches. Clear communication with payers about expectations and limitations can prevent misunderstandings and unauthorised data use.
Looking Ahead: Preparing for Future Data Sharing Requirements
With regulatory changes continuing to evolve, such as the CURES Act and the Trusted Exchange Framework and Common Agreement (TEFCA), healthcare organisations must stay prepared for increasing demands for data sharing. Payers are being pushed to process prior authorisation requests within 72 hours using streamlined data exchange processes. While these initiatives aim to enhance efficiency and interoperability, they must be balanced with strict data privacy protections.
Healthcare leaders must take a proactive stance by staying informed about policy developments and regularly updating their data governance frameworks. By aligning their practices with emerging standards, they can ensure both operational efficiency and patient safety.
As the healthcare industry moves towards increased data sharing to meet interoperability regulations, healthcare organisations must balance operational efficiency with privacy protection. Granting payers direct access to EHR systems can deliver significant administrative benefits but also introduces considerable security and financial risks. By establishing clear safeguards, regularly monitoring data access and negotiating comprehensive agreements, organisations can ensure compliance while protecting patient data. Ultimately, careful oversight and strategic planning will be essential in navigating the evolving landscape of healthcare data exchange while safeguarding the integrity of patient information.
Source: Chief Healthcare Executive
Image Credit: iStock
