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HL7 FHIR-enabled APIs to Help Payers Meet CMS Requirements for Data Sharing

[fa icon="calendar"] Aug 7, 2020 9:01:07 AM / by Fred Bazzoli

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Recap of the June Session of the HL7 Da Vinci Community Roundtable

The HL7 Da Vinci Community Roundtable held June 24, showcased work that is continuing on applications that can seamlessly deliver healthcare data to consumers using application programming interfaces (APIs) to pull data from payers’ information systems.

The pressure is on to deliver the functionality, and soon. Final rules from the Centers for Medicare & Medicaid Services (CMS) will require payers to make claims payment data and other patient or member clinical information available to consumers with no obstacles, ideally through simple apps that query for, gather and organize the data in meaningful ways that create value for the user.

HHS rules require HL7’s Fast Healthcare Interoperability Resources (FHIR®) standard to be used to support this process, and application vendors have already deployed products that are being used by consumers. Three such app developers demonstrated how their applications work using payer-based data and described the underlying technology at the community roundtable.

CMS Final Rule & Da Vinci Implementation Guides

The final rules call for payers to provide healthcare data to members through the use of FHIR-based APIs, as well as using a similar methodology to make provider directories available to patients. The CMS rules require that CMS-regulated payers allow patients to easily access their claims and encounter information, including cost, as well as a defined subset of their clinical information through third-party app developers of their choice, as long as that data is being maintained by the payer organization.  The CMS implementation resources for pending rules mentions a number of implementation guides developed by the Da Vinci Project to meet the regulations: Payer Data Exchange: Provider Directory (Plan-Net) to share details on available providers and pharmacies for a particular plan design, Payer Data Exchange for payers to share clinical data, and access to clear formulary information to support patient choice capabilities regarding prescription drugs and potential purchasing alternatives through Payer Data Exchange: Formulary.

The rules set January 1, 2021 as the date for payers to implement capabilities enabling the Patient Access API and Provider Directory API, but actual enforcement won't begin until July 1, 2021.

The use of FHIR can help standardize approaches for achieving the requirements, noted John Kelly, principal business advisor at Edifecs, a technology vendor working on developing and testing the implementation guides that detail how to use the standardized FHIR standards.

The final implementation guides represent the maturing of adoption of FHIR by the industry – developing these standardized approaches increases the transparency of patient data exchange, and reduces the burden on industry players that otherwise would develop their own solutions, which would create barriers to interoperability. The Da Vinci initiative accelerates the consolidation of industry approaches to common problems, thus eliminating wasted time and expense associated with the development of one-off solutions. The use of standards among all industry participants is the most efficient way to achieve interoperability.

“This adherence to standards, we have to be bullish about it,” Kelly said. “You see out in the marketplace that some people say, ‘I’m not going to use that implementation guide; I’m going to publish my own implementation guide.’ Well, how does that play out in the market? By agreeing to use the standards, it’s a big lift.” However, today’s demos show how effortlessly compliance can be achieved and consumers can get understandable and actionable health information.

Payers traditionally have accumulated information about members’ health and treatments as they handle the claims coming from providers, noted Amit Shah, director of shared applications and services at GuideWell, the parent company that manages a health insurer with 27 million covered lives. “With the new CMS rule, the idea is for all payers to make available that information back to members,” he said. The demonstrations during the roundtable “showcased how that interaction would work and how the application is able to access information for a particular user.”

The intent behind the CMS initiative is to improve the ability of members “to access their claims, payment information and clinical data so they can become more involved in their own care planning,” Kelly said.

FHIR can facilitate this by enabling easy access to members’ information stored on payers’ FHIR servers, which can receive structured queries from application developers. Security is ensured because of existing user authentication protocols – like OAuth – which allow access delegation. “The biggest challenge we have is ensuring that the record is being shared for the correct member or patient or user in the most secure fashion,” Shah said.

Challenges still exist in normalizing the data, Shah noted. “A payer gets information from multiple sources; it could be from claims information or clinical information. As a payer, we have to ensure we provide concise and clear information back through the API.” Partnering with a company like Edifecs facilitates the process leveraging their FHIR-based API platform, he added.

“It’s important that whoever the payer is working with is filling the critical role of mediating between all the back end complexity – finding out where data is, what form it’s in, how to get it into FHIR format, and then making it available as APIs in a standards-based way,” Kelly said. “Managing the complexity of adhering to a standard is a role for the technology partner.”

Once data is normalized and available on a FHIR-standard server, that’s when consumer-facing applications can make queries for that data, on behalf of the consumer, access the consumer’s information on the payer’s FHIR server and then present it back to the consumer in an understandable visual way on the consumer’s smartphone.

For example, the MaxMD app aims to give patients more access to their explanation of benefits, said Keith Finlay, the company’s product manager, who gave a demonstration of the product’s capabilities. Beyond that, it enables patients to access clinical data from payers’ and providers’ FHIR servers, returned to them and rendered for viewing.

Another application that uses FHIR to enable data access from payers is 1UpHealth, a company that offers a platform for patients, providers, payers and app developers to aggregate and share medical data. It connects to FHIR endpoints at more than 10,000 hospitals, health centers and other provider organizations to provide a longitudinal view of patient information from multiple sources, said Doug Williams, the company’s chief product officer.

The final presentation was from b.well Connected Health, a company that is aiming to enable the digital transformation in healthcare that consumers are demanding through a simple, on-demand digital experience, said Philips Johnson, its chief technology officer. In addition to enabling the aggregation of medical records, its app offers formulary transparency for consumers as well, another emerging requirement of CMS regulations.

The app developers’ applications rely on the use of FHIR implementation guides, which enable the easy use of standardized coding to support data interchange, Kelly concluded. “These vendors’ goals are to create a user experience for a target audience. Yes, this is hard to accomplish, but it’s important” for patients, and for the industry to get behind the initiative.

Watch the Recording

The recording of this Da Vinci Project Community Roundtable is now available for viewing by clicking here.

About the Community Roundtable

The goal of the Da Vinci Project’s community roundtables is to increase public awareness among payers, providers and vendors of the resources and progress coming out of Da Vinci’s efforts. These 90-minute virtual sessions are open to Da Vinci members and the public and highlight how members leverage the Da Vinci use cases and implementation guides (IGs) in action in workflow.

Typically, two or three organizations showcase their work and answer audience questions, allowing for a vibrant discussion and fostering industry understanding of the Da Vinci work products and resulting market solutions. Sessions are recorded and available online after the event.

Join the Community

To learn more and join the community, visit

Topics: FHIR, HL7 community, interoperability, Payers, CMS, Da Vinci, value based care, implementation guide, payer data exchange

Fred Bazzoli

Written by Fred Bazzoli

Fred Bazzoli is a writer specializing in healthcare IT topics. He's a former editor for several healthcare IT publications and past communications director for both CHIME and HIMSS.

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