A report from the HL7 Da Vinci Project describes how two pioneering organizations demonstrated the real-world practicality and value of applying standard application program interfaces (APIs) to streamline the prior authorization process.
Regence, a payer based in the Pacific Northwest, and MultiCare Health System, a provider based in Washington state, spent about a year testing and fine-tuning processes that leverage HL7’s Fast Healthcare Interoperability Resources (FHIR®) standard for APIs.
In addition, dozens of other organizations have tested FHIR APIs at more than 15 Connectathon testing events.
The report, posted on the Da Vinci Project’s website and later to be in the Federal Register, describes how the two organizations dramatically improved efficiency by using FHIR APIs for prior authorization data exchange and request processing. Using the APIs enabled the organizations to achieve an improvement of 140% or more in the time it took to complete individual point-to-point transactions, says Anna Taylor, MultiCare’s associate vice president of population health.
“Our project has proven that the efficiency gains from using this [FHIR] workflow are above anything else available in the marketplace today,” Taylor says.
Easing System Integration
Integrating technologies is typically a time-consuming task, she points out. Using FHIR APIs is like downloading an app from the app store; you can start using them right away, Taylor explains. That means technology implementation takes about a week, rather than many months.
Until now under HIPAA, organizations have been required to use ASC X12 standards for prior authorizations and many other transactions, explains Kirk Anderson, CTO at Regence. But these standards are oriented for document-based data exchange.
In 2021, the U.S. Department of Health and Human Services granted a HIPAA exception, as requested by the Da Vinci Project, that allowed organizations to test an alternative approach using FHIR APIs instead of the X12 standards for prior authorization transactions. After those tests, HHS earlier this year issued the final rule requiring many payers to move to FHIR APIs for prior authorizations and certain other transactions by January 2027.
‘Tremendous Benefits’
The tests by Regence and MultiCare proved “that not only is it possible to do prior authorization transactions with APIs, but there are tremendous benefits in being able to process these transactions in real time,” Anderson says.
The two organizations have gone beyond tests to implement FHIR APIs for prior authorization in full production. And Regence is using the APIs for point-to-point connectivity to several other providers as well.
A More Modern Approach
The report describes the many benefits of moving to FHIR APIs. “This shift is going to help us reduce our administrative overhead and complete transactions in a much more modern way,” Anderson says.
The report, however, is not a playbook, Taylor notes. The best source of guidance on how to implement FHIR APIs are HL7’s Implementation Guides, she points out.
For its initial tests, MultiCare and Regence focused on the use of HL7 FHIR for point-to-point data exchange.
In Da Vinci’s Trebuchet project, the two organizations, and many others, are testing using FHIR APIs to exchange data via a QHIN, or Qualified Health Information Network, as called for in the Trusted Exchange Framework and Common Agreement, or TEFCA.
National interconnectivity fueled by FHIR APIs would significantly reduce the burden associated with health data exchange, Anderson and Taylor stress.
The HIPAA exception report illustrates the impact FHIR APIs can have on burden reduction for point-to-point data exchange. Meanwhile, the ongoing Trebuchet project ultimately could demonstrate that the QHIN model for FHIR-based data exchange also works well.
Learn More
To learn more and view the report, visit: Da Vinci HIPAA Exception - Da Vinci - Confluence (hl7.org)
