How CMS has made progress on healthcare interoperability

Seema Verma is administrator of the Facilities for Medicare and Medicaid Providers.

This text was coauthored with Alexandra Mugge, deputy chief well being informatics officer at CMS, and Shannon Sartin, chief know-how officer on the Facilities for Medicare and Medicaid Innovation.

In 2018, the Facilities for Medicare and Medicaid Providers, the Workplace of the Nationwide Coordinator for Well being IT and the White Home Workplace of American Innovation, publicly introduced our dedication to making sure that sufferers would have entry to their healthcare knowledge wherever and at any time when they want it, and we commenced on a journey to interrupt down the boundaries that maintain important affected person well being data locked in digital silos.

For many years, the trail to healthcare interoperability has been a relay spanning a number of administrations, one through which every administration has handed the baton to the following, transferring the healthcare trade nearer to the objective, however all the time falling wanting seamless interoperability of well being knowledge.

On the end line lies a extra coordinated, seamless system of care through which sufferers have digital entry to their well being data and suppliers are providing aggressive high quality and affected person care, offering extra evidence-based care with much less duplication of testing and errors. We now have taken the race additional by revising previous insurance policies to higher obtain their supposed targets, finalizing new insurance policies to have interaction all stakeholders throughout the healthcare trade and laying a basis for the way forward for interoperability.

Over the previous three years, and as a part of the help beneath the 21st Century Cures Act, our accomplishments have been quite a few. Underpinning a lot of our accomplishments is using utility programming interfaces that enable digital knowledge to stream securely and seamlessly between data methods, and, particularly, using the API commonplace for interoperability generally known as HL7 Quick Healthcare Interoperability Sources, or FHIR. This commonplace allows extra environment friendly collaboration and a contemporary strategy for sharing of knowledge between the completely different digital well being methods important for interoperability.

At CMS, we have now promoted using APIs, each inside CMS and within the broader healthcare trade, to allow the safe trade of knowledge. A few of our externally dealing with APIs embody:

  • In March 2018, we introduced the launch of Medicare’s Blue Button 2.0, a safe means for Medicare beneficiaries to entry and share their private well being knowledge utilizing FHIR requirements. Beneficiaries can select from 74 Blue Button purposes developed by personal sector innovators to assist handle and enhance their well being.
  • In June 2018, we launched a prototype Documentation Requirement Lookup Service, an API-enabled repository of Medicare FFS documentation and prior authorization necessities.
  • In February 2019, we launched the Beneficiary Claims Information API (BCDA), a FHIR-enabled API for Accountable Care Organizations (ACOs) taking part within the Shared Financial savings Program to retrieve Medicare claims knowledge for his or her beneficiaries. In the course of the preliminary section of BCDA, over 50 ACOs signed up for knowledge entry through the API.
  • In July 2019, we introduced the Information on the Level of Care (DPC) pilot, a FHIR-based API that gives Medicare claims knowledge on to suppliers through an interoperable FHIR-standard-based API to advertise higher affected person care.

We now have additionally refined our applications to higher help interoperability and knowledge entry. In 2018, CMS overhauled the Medicare and Medicaid Selling Interoperability Applications (previously generally known as significant use) to prioritize interoperability and affected person entry.

By means of these applications, hospitals and clinicians could obtain diminished Medicare funds if they don’t give sufferers digital entry to their knowledge. On this means, we took a struggling program that was targeted on EHR adoption and remodeled it right into a driver for knowledge trade amongst suppliers to provide sufferers entry to their healthcare knowledge.

As well as, we have now used our regulatory levers to have interaction our stakeholders in knowledge sharing. In September 2019, CMS launched the Discharge Planning Ultimate Rule, which mandates that hospitals guarantee every affected person’s proper to entry their medical data in an digital format, in addition to requiring the seamless trade of affected person data between healthcare settings, and guaranteeing {that a} affected person’s healthcare data follows them after discharge from a hospital or post-acute care supplier. It requires the discharge planning course of to focus on a affected person’s targets and therapy preferences.

In Could 2020, CMS finalized our first rule devoted to interoperability with the CMS Interoperability and Affected person Entry remaining rule.  Based mostly on Medicare’s Blue Button initiative that supplied claims knowledge to sufferers, the ultimate rule targeted on driving interoperability and affected person entry to well being data by liberating claims and scientific knowledge for 85 million sufferers.

By means of our insurance policies, CMS promotes an HHS-wide transfer to FHIR APIs to help interoperability throughout the well being ecosystem. This rule additionally establishes a Situation of Participation, requiring hospitals receiving reimbursement from Medicare and Medicaid to offer affected person occasion notifications at hospital admission, discharge and switch.

These notifications inform sufferers’ medical doctors and suppliers that they’ve been within the hospital and supply related knowledge pertaining to the go to, which facilitates extra coordinated and seamless care. Of essential word is that this notification requirement is simply relevant to mentioned hospitals with digital well being data methods or different digital administrative methods that meet sure technical specs.

On the similar time, ONC finalized their 21st Century Cures Act remaining rule, which is able to help affected person entry to their digital medical data straight from their suppliers via FHIR-standards-based APIs. Collectively, these guidelines addressed each technical and healthcare trade components that trigger boundaries to the safe trade of well being data and restrict the power of sufferers to entry important well being data.

By aligning FHIR-based necessities for payers and healthcare suppliers via the CMS Interoperability and Affected person Entry remaining rule, and well being IT builders, suppliers and well being data networks via the ONC 21st Century Cures Act remaining rule, we’re driving an interoperable well being IT infrastructure throughout methods and guaranteeing suppliers and sufferers have entry to well being knowledge when and the place it’s wanted.

Most lately, we launched the CMS Interoperability and Prior Authorization proposed rule. This proposed rule would construct on our efforts round FHIR APIs and would be certain that suppliers and payers have mandatory affected person knowledge. It might require Medicaid and CHIP fee-for-service and managed care payers, in addition to insurers providing particular person market certified well being plans on the Federal Exchanges, to facilitate trade of sure specified knowledge throughout the healthcare ecosystem to sufferers, suppliers and to different payers.

Within the Interoperability and Affected person Entry remaining rule printed final Could, we required that sure payers trade data with each other at sufferers’ request. On this new proposed rule, we’re proposing that this knowledge trade be carried out utilizing a FHIR API when a affected person modifications from one payer to a different, or has a couple of payer.

As a result of the rule would require a FHIR-based API permitting completely different payers’ methods to speak with one another, new plans would have entry to a sufferers’ claims knowledge nearly as quickly as they enroll, permitting them to grasp their affected person’s earlier care and medical wants.

As well as, this rule would require payers to construct APIs enabling the sending of affected person claims, encounter knowledge and scientific knowledge on to suppliers’ EHRs, once more permitting for suppliers to have their sufferers’ full medical historical past.

As quickly as a supplier requests this data from a payer, they might have entry to their affected person’s full medical claims knowledge, together with diagnoses, assessments, medicines, earlier medical doctors’ visits and extra. For suppliers that take full benefit, duplicative assessments, pointless procedures and dangerous interactions between medicines might nearly be a factor of the previous.

In impact, the rule would add one other layer of communication to our earlier remaining rule that required sure knowledge to be obtainable via APIs, which might make doable for sufferers to straight entry their knowledge. If for no matter cause a affected person didn’t have their knowledge at a selected go to, their suppliers ought to be capable to pull it up as an alternative utilizing the API.

Lastly, the proposed rule would deal with one of many foremost challenges for suppliers, payers and sufferers alike: efficient prior authorization. Prior authorization is an administrative course of for suppliers to request affirmation from payers that the suppliers will likely be paid for a medical service, prescription or provide.

This course of takes place earlier than a service is rendered and is a part of suppliers’ negotiated settlement to take part in a payer’s community. Prior authorization is a crucial software to coordinate care and decrease prices.

When poorly executed, nonetheless, it may possibly drain important time and sources from the very goal of drugs – caring for sufferers – and may end up in doctor burnout. When carried out nicely, the method can guarantee wanted look after sufferers and assist them keep away from unnecessarily paying out of pocket.

The proposed rule once more would construct on our efforts to advertise FHIR and APIs to require sure payers to construct a brand new FHIR-based API that might enable suppliers to know prematurely what documentation is required for every completely different medical insurance payer topic to the rule. We proposed that one other API be constructed to permit suppliers to ship prior authorization requests and obtain responses electronically and inside their current workflow, eliminating the necessity for cellphone calls and faxes.

This could streamline the documentation course of for your entire system and permit suppliers to ship prior authorization requests and obtain responses straight from their digital methods.

As we glance ahead, we’re assured that we have now laid a stable basis for interoperability on which future administrations can proceed to construct. We proceed to search for methods to increase interoperability by analyzing insurance policies that may each enhance interoperability and scale back burden.

We now have been dedicated to transferring in a course of digital high quality measures and FHIR-enabled measure submission methods. CMS is at the moment working on rules to undertake requirements for healthcare attachments and digital signatures that can be utilized along with healthcare attachments transactions.

The Middle for Medicare and Medicaid Innovation is constant to drive ahead using commonplace knowledge assortment in our fashions and offering bulk knowledge via FHIR APIs to our mannequin contributors. Interoperability and standardized data-sharing are important for the way forward for value-based care, and we’ll depart no stone unturned in looking for to ship it to our healthcare system.

Seamless interoperability of well being data comes when standardized knowledge sharing happens with each system, machine, group and individual having instantaneous entry to the information they want, once they want it. This future consists of requiring interoperability of all medical units, guaranteeing that a part of the approval course of means producers and know-how firms have recognized how they may guarantee units are related to sufferers and suppliers.

Within the period of the COVID-19 pandemic, the necessity for knowledge to maneuver seamlessly is important for public well being surveillance, each now and sooner or later. A very interoperable system will enable us to quickly detect rising infectious ailments and make it simpler for suppliers to share public well being knowledge.

Know-how is ever evolving, and our work will continuously evolve, however our efforts have laid a basis for future coverage that may allow the safe and interoperable trade of healthcare data, drive value-based care in America, and provides sufferers and medical doctors the data they want.


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