Joseph
Sima Verma is the Director of Centers for Medicare and Medicaid Services.
This article was co-authored by Alexandra Moggi, CMS Deputy Chief Health Informatics Officer, and Shannon Sartin, Chief Technology Officer for Medicaid and Medicaid Innovation.
In 2018, the Centers for Medicare and Medicare Services, the Office of the National Coordinator for Health Information Technology and the White House Office of American Innovation publicly declared our commitment to ensuring patients have access to their healthcare data wherever and whenever they need it. And we embarked on a journey to break down barriers that lock up critical patient health information in digital silos.
For decades, the path to healthcare interoperability has been a succession that stretches across multiple departments, with each department passing the stick to the other, bringing the healthcare industry closer to the target, but always falling short of seamless interoperability of health data.
At the finish line, there is a more streamlined and coordinated care system in which patients can electronically access their health information, service providers provide competitive quality and patient care, and provide more evidence-based care while reducing duplication of testing and errors. We have taken the race even further by reviewing old policies to better achieve their intended goals, finalizing new policies to engage all stakeholders across the healthcare industry and laying the foundation for the future of interoperability.
Over the past three years, as part of the support provided under the Twenty-First Century Cure Act, we have been numerous. Many of our achievements are underpinned by the use of APIs that allow electronic data to flow securely and seamlessly between information systems, and specifically, the use of an API standard for interoperability known as HL7 Fast Healthcare Interoperability Resources or FHIR. This standard enables more efficient collaboration and a modern approach to information sharing between the various e-health systems essential for interoperability.
At CMS, we have leveraged the use of APIs, within the CMS and in the wider healthcare industry, to enable the secure exchange of data. Some of the APIs that we encounter externally include:
- In March 2018, we announced the launch of Medicare’s Blue Button 2.0, a safe way for Medicare beneficiaries to access and share their personal health data using FHIR standards. Beneficiaries can choose from 74 blue button apps developed by private innovators to help manage and improve their health.
- In June 2018, we released a prototype of the Documentation Requirements Find service, which is an API-enabled repository for Medicare FFS documentation and pre-authorization requirements.
- In February 2019, we launched the Beneficiary Claims Data API (BCDA), an FHIR-enabled API for Responsible Care Organizations (ACOs) participating in the Shared Savings Program to retrieve Medicare claims data for beneficiaries from them. During the initial phase of BCDA, more than 50 ACOs signed up to access data via the API.
- In July 2019, we announced Data in Pilot Point of Care (DPC), an FHIR-based API that delivers Medicare claims data directly to service providers via an interoperable FHIR-based API to promote better patient care.
We have also improved our software to better support interoperability and data access. In 2018, CMS overhauled the enhanced Medicare and Medicaid interoperability programs (formerly known as targeted use) to prioritize interoperability and patient access.
Through these programs, hospitals and physicians may receive reduced Medicare payments if they do not give patients electronic access to their data. In this way, we took a challenging program that focused on EHR accreditation and turned it into a data exchange engine between service providers to give patients access to their healthcare data.
Additionally, we used our organizational tools to engage our stakeholders in sharing data. In September 2019, CMS released the Final Discharge Planning Rule, which obligates hospitals to ensure every patient has the right to access their medical records in electronic format, as well as to require the seamless exchange of patient information between healthcare settings, and the patient’s health care assurance. Information tracks them after they are discharged from the hospital or a post-acute care provider. The exit planning process requires focusing on the patient’s goals and treatment preferences.
In May 2020, CMS completed our first rule dedicated to interoperability with the final rule for CMS interoperability and patient access. Building on Medicare’s Blue Button initiative that provided claims data to patients, Final Rule focused on driving interoperability and patient access to health information by editing claims and clinical data for 85 million patients.
Through our policies, the CMS promotes a migration at the HHS level to FHIR APIs to support interoperability across the health ecosystem. This rule also specifies the participation requirement, requiring hospitals to receive Medicare and Medicaid reimbursements to provide notifications of patient events upon hospital admission, discharge, and transportation.
These notifications inform patients’ doctors and service providers that they have been in the hospital and provide relevant data related to the visit, facilitating more coordinated and seamless care. It should be noted that this notification requirement applies only to the aforementioned hospitals that have electronic health records systems or other electronic management systems that meet certain technical specifications.
At the same time, ONC ended the final rule of 21st Century Cures, which will support patients’ access to their electronic medical records directly from their providers through FHIR standards-based APIs. Together, these rules addressed technical and healthcare industry factors that create barriers to the safe exchange of health information and limit patients’ ability to access essential health information.
By aligning FHIR-based requirements of payers and health care providers through the ultimate base for CMS interoperability and patient access, health IT developers and providers and health information networks through the final rule of ONC 21st Century Cures, we are driving an interoperable health information technology infrastructure Ensure that service providers and patients have access to health data when and where it is needed.
Recently, we released the proposed rule for CMS interoperability and pre-authorization. This proposed rule will build on our efforts around FHIR APIs and will ensure that service providers and payers have the necessary patient data. Medicaid and CHIP fees for managed care will be required, as well as insurers offering eligible health plans for the single market on federal exchanges, to facilitate the exchange of some specific data across the healthcare system for patients, service providers, and other payers.
In the Final Rule of Interoperability and Patient Access published last May, we asked specific payers to share information with each other at the request of patients. In this new proposed rule, we propose that this data exchange take place using the FHIR API when a patient changes from one drive to another, or when he has more than one stimulus.
Since the rule requires an FHIR-based API that allows different payer systems to communicate with each other, new plans will have access to patient claims data once they are registered, allowing them to understand patient care and their prior medical needs.
Additionally, this rule requires fee payers to create APIs that enable patient claims, coincidence and clinical data to be sent directly to service providers’ electronic health records, again allowing service providers to obtain the complete medical history of their patients.
Once a provider requests this information from a payer, they will have access to their patient’s full medical claims data, including diagnoses, tests, medications, previous doctors’ visits and more. For providers who are taking full advantage, repeated tests, unnecessary procedures, and dangerous drug interactions may be almost a thing of the past.
In fact, the base will add another layer of connectivity to our previous final rule requiring certain data to be available through APIs, giving patients direct access to their data. If a patient does not have their data on a particular visit for any reason, their service providers should be able to pull it off instead using the API.
Finally, the proposed rule will address one of the most important challenges facing providers, payers, and patients alike: effective pre-licensing. Pre-authorization is an administrative process for service providers to require confirmation from fee-payers that service providers will be paid for a medical service, prescription or supply.
This process takes place before the service is provided and is part of a negotiated agreement for service providers to participate in a payer network. Advance authorization is an important tool for coordinating care and reducing costs.
However, when performed poorly, it can drain a lot of time and resources from the primary purpose of medicine – caring for patients – and can tire the doctor. When done well, the process can ensure needed care for patients and help them avoid unnecessary pushing from Their pockets.
The proposed rule will build again on our efforts to promote FHIR and APIs to require specific payers to build a new FHIR-based API that would allow service providers to know the pre-requisite documents for each different health insurance payer subject to the rule. We suggested creating another API to allow providers to send pre-authorization requests and receive responses electronically and within the current workflow, eliminating the need for phone calls and faxes.
This will simplify the documentation process for the entire system and allow service providers to send pre-authorization requests and receive responses directly from their electronic systems.
As we look forward, we are confident that we have laid a solid foundation for interoperability that future administrations can continue to build on. We continue to look for ways to expand interoperability by examining policies that can increase interoperability and reduce burden.
We have committed to moving in the direction of digital quality standards and measurement delivery systems that support FHIR. CMS is currently working on regulations to approve standards for healthcare attachments and electronic signatures that can be used in conjunction with healthcare facility transactions.
The Medicare Innovation Center and Medicaid continue to push for the use of standard data collection in our forms and to provide aggregate data through FHIR APIs to our form participants. Interoperability and standardized data sharing is essential to the future of value-based care, and we will spare no effort in striving to bring it to our healthcare system.
Seamless interoperability of health information comes when a unified sharing of data occurs with every system, device, organization and person who has immediate access to the data they need, when they need it. This future includes interoperability for all medical devices, and making sure that part of the approval process means manufacturers and technology companies determine how to ensure devices are connected to patients and service providers.
In the era of the COVID-19 pandemic, the need to seamlessly transfer data is critical to monitoring public health, now and in the future. The truly interoperable system will allow us to quickly detect emerging infectious diseases and make it easy for service providers to share public health data.
Technology is constantly evolving, and our work will continually evolve, but our efforts have laid the foundation for a future policy that will enable the safe and interoperable exchange of healthcare information, enhance value-based care in America, and give patients and doctors the information they need. need to.
