The healthcare ecosystem is moving forward, with a refreshing consumer centric approach, helping members take informed care decisions. CMS has recently published a set of proposal rules that would extend requirements defined in the Interoperability and Patient Access Final Rule. The proposed rules aim to standardize exchange of healthcare data, streamline prior-authorization process, and even improve collaboration among payers, providers, and patients.
Proposed Engagement
Regulation Mandates/Requirements for Health Plans
Compliance with the regulations require the alignment of the following APIs and metrics.
Objective
Enhance to implement a process for third-party application developers to attest to certain privacy policy provisions
IGs
- CARIN IG for Blue Button®
- HL7 FHIR Da Vinci PDex
- HL7 US Core
- HL7 FHIR Da Vinci - PDex US Drug Formulary
Objective
Flat FHIR-based API to share claims, encounter data, as defined in the USCDI version 1, and prior authorization decisions
IGs
- HL7 FHIR Bulk Data Access (Flat FHIR) Specification
- HL7 FHIR Da Vinci Payer Coverage Decision Exchange
- CARIN IG for Blue Button®
- HL7 FHIR Da Vinci PDex, US Core
- HL7 FHIR Da Vinci - PDex US Drug Formulary
Objective
Disclose active and updated provider directory by payers
IGs
- HL7 FHIR Da Vinci PDex Plan Net
Objective
An API for payer-to-provider data sharing of claims, encounter data, pending and active prior authorization decisions
IGs
- CARIN IG for Blue Button®
- HL7 FHIR Da Vinci PDex
- HL7 US Core
- HL7 FHIR Da Vinci - PDex US Drug Formulary
Objective
Build and maintain a FHIR-enabled DRLS API, complaint with specified IGs, that could be integrated with a provider’s (EHR)
IGs
- HL7 FHIR Da Vinci Coverage Requirements Discovery (CRD): Version STU 1.0.044
- HL7 FHIR Da Vinci Documentation Templates and Rules (DTR): Version STU 1.0.045
Objective
Implement and maintain a FHIR-enabled PAS API to send prior authorization requests and receive responses electronically
IGs
- HL7 FHIR Da Vinci - PAS
Objective
Report utilization metrics
Metrics
- The total number of unique patients whose data are transferred via the Patient Access API to a patient designated third-party app.
- The number of unique patients whose data are transferred via the Patient Access API to a patient designated third-party app more than one.
Objective
Requesting information on how providers and patients can control data sharing with stakeholders
IGs
- Substance Abuse and Mental Health Services Administration’s (SAMSHA) Consent2Share
- HL7 Data Segmentation for Privacy (DS4P)
How Can You Achieve It?
Here are a few items to add to your to-do list, to ensure compliance. Hurry up, before the deadlines are knocking on your doors.
USCDI V1, FHIR V4
Enterprise Application Integration
Application attestation and registration
Policy authorization and administration framework
Authentication and authorization
Data Management
Audit
Error Handling
Content and Vocabulary Mappings
What are the Challenges that Await?
Even though the idea is to reduce burden, these are a few hurdles you might come across along the way to compliance
- Transformation of existing data to align with Implementation Guides
- Comprehending the IGs for timely implementation of requirements
- Adherence to interoperability standards (FHIR, USCDI) and corresponding challenges
We Can Help You Out
We have been integrating and updating systems with interoperability standards, such as FHIR/USCDI, and overcoming implementation challenges on the way. We can help you with the same.
Assessment
Analyze and identify processes for alignment
Roadmap Planning
Effective and efficient plan with milestones
Implementation
Mold technology to make roadmap reality
Go-Live and Support
Continuous improvement and support