Seema Verma is administrator of the Facilities for Medicare and Medicaid Companies.
This text was co-authored with Alexandra Mugge, deputy chief well being informatics officer at CMS, and Shannon Sartin, chief know-how officer on the Facilities for Medicare & Medicaid Innovation.
In 2018, the Facilities for Medicare and Medicaid Companies, 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 limitations that hold important affected person well being info locked in digital silos.
For many years, the trail to healthcare interoperability has been a relay spanning a number of administrations, one wherein every administration has handed the baton to the subsequent, transferring the healthcare trade nearer to the purpose however at all times falling wanting seamless interoperability of well being knowledge.
On the end line lies a extra coordinated, seamless system of care wherein sufferers have digital entry to their well being info, suppliers are providing aggressive high quality and affected person care, offering extra evidence-based care, with much less duplication of testing and errors. We’ve got taken the race additional by revising outdated insurance policies to higher obtain their meant targets, finalizing new insurance policies to have interaction all stakeholders throughout the healthcare trade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 underneath the twenty first Century Cures Act, our accomplishments have been quite a few. Underpinning lots of our accomplishments is the usage of software programming interfaces that enable digital knowledge to circulate securely and seamlessly between info methods, and particularly, the usage of the API customary for interoperability often called HL7 Quick Healthcare Interoperability Sources, or FHIR. This customary allows extra environment friendly collaboration and a contemporary method for sharing of data between the completely different digital well being methods important for interoperability.
At CMS, we’ve got promoted the usage of APIs each inside CMS and within the broader healthcare trade to allow the safe change 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 method for Medicare beneficiaries to entry and share their private well being knowledge utilizing FHIR requirements. Beneficiaries can select from 74 Blue Button functions 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 Knowledge 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. Through the preliminary section of BCDA, over 50 ACOs signed up for knowledge entry by way of the API.
- In July 2019, we introduced the Knowledge on the Level of Care (DPC) pilot, a FHIR-based API that gives Medicare claims knowledge on to suppliers by way of an interoperable FHIR customary primarily based API to advertise higher affected person care.
We’ve got additionally refined our applications to higher help interoperability and knowledge entry. In 2018, CMS overhauled the Medicare and Medicaid Selling Interoperability Packages (previously often called significant use) to prioritize interoperability and affected person entry.
By way of these applications, hospitals and clinicians might obtain diminished Medicare funds if they don’t give sufferers digital entry to their knowledge. On this method, we took a struggling program that was targeted on EHR adoption, and reworked it right into a driver for knowledge change amongst suppliers to provide sufferers entry to their healthcare knowledge.
As well as, we’ve got used our regulatory levers to have interaction our stakeholders in knowledge sharing. In September 2019, CMS launched the Discharge Planning Closing Rule, which mandates that hospitals guarantee every affected person’s proper to entry their medical information in an digital format, in addition to requiring the seamless change of affected person info between healthcare settings, and guaranteeing {that a} affected person’s healthcare info follows them after discharge from a hospital or post-acute care supplier. It requires the discharge planning course of to give attention to a affected person’s targets and remedy preferences.
In Could 2020, CMS finalized our first rule devoted to interoperability with the CMS Interoperability and Affected person Entry last rule. Primarily based 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 info by liberating claims and medical knowledge for 85 million sufferers.
By way 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 vital word is that this notification requirement is simply relevant to mentioned hospitals with digital well being information methods or different digital administrative methods that meet sure technical specs.
On the identical time, ONC finalized their twenty first Century Cures Act last rule, which is able to help affected person entry to their digital medical information instantly from their suppliers via FHIR standards-based APIs. Collectively, these guidelines addressed each technical and healthcare trade elements that trigger limitations to the safe change of well being info and restrict the power of sufferers to entry important well being info.
By aligning FHIR-based necessities for payers and healthcare suppliers via the CMS Interoperability and Affected person Entry last rule, and well being IT builders, suppliers and well being info networks via the ONC twenty first Century Cures Act last 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 just lately, we launched the CMS Interoperability and Prior Authorization proposed rule. This proposed rule would construct on our efforts round FHIR APIs and would make sure that suppliers and payers have mandatory affected person knowledge. It could 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 change of sure specified knowledge throughout the healthcare ecosystem to sufferers, suppliers and to different payers.
Within the Interoperability and Affected person Entry last rule printed final Could, we required that sure payers change info with each other at sufferers’ request. On this new proposed rule, we’re proposing that this knowledge change be finished 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 virtually as quickly as they enroll, permitting them to know 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 medical 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 info from a payer, they’d have entry to their affected person’s full medical claims knowledge, together with diagnoses, checks, medicines, earlier medical doctors visits, and extra. For suppliers that take full benefit, duplicative checks, pointless procedures, and unsafe interactions between medicines might virtually be a factor of the previous.
In impact, the rule would add one other layer of communication to our earlier last rule that required sure knowledge to be obtainable via APIs, which might make doable for sufferers to instantly entry their knowledge. If for no matter motive 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 probably 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 vital software to coordinate care and decrease prices.
When poorly executed, nonetheless, it may well drain vital time and sources from the very objective of drugs – caring for sufferers and may end up in doctor burnout. When finished effectively, the method can guarantee wanted take care of 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 upfront 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 present workflow, eliminating the necessity for cellphone calls and faxes.
This is able to streamline the documentation course of for your entire system and permit suppliers to ship prior authorization requests and obtain responses instantly from their digital methods.
As we glance ahead, we’re assured that we’ve got laid a stable basis for interoperability on which future administrations can proceed to construct. We proceed to search for methods to develop interoperability by analyzing insurance policies that may each enhance interoperability and scale back burden.
We’ve got been dedicated to transferring in a path of digital high quality measures and FHIR-enabled measure submission methods. CMS is at the moment engaged on rules to undertake requirements for healthcare attachments and digital signatures that can be utilized along side healthcare attachments transactions.
The Heart for Medicare & Medicaid Innovation is constant to drive ahead the usage of customary knowledge assortment in our fashions and offering bulk knowledge via a FHIR APIs to our mannequin contributors. Interoperability and standardized knowledge sharing are important for the way forward for value-based care, and we are going to depart no stone unturned in searching for to ship it to our healthcare system.
Seamless interoperability of well being info comes when standardized knowledge sharing happens with each system, gadget, group and individual having instantaneous entry to the info they want, after 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 corporations 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 illnesses and make it simpler for suppliers to share public well being knowledge.
Know-how is ever evolving and our work will always evolve, however our efforts have laid a basis for future coverage that can allow the safe and interoperable change of healthcare info, drive value-based care in America, and provides sufferers and medical doctors the data they want.