Enabling Patient Access and Provider Directory APIs using Azure API for FHIR to meet CMS guidelines | VNB Health

Enabling Patient Access and Provider Directory APIs using Azure API for FHIR to meet CMS guidelines

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The final rule of the ONC’s Cures Act Final Rule is aimed for patients and healthcare providers to provide secure, seamless access and exchange of patient’s electronic health information. The rule also implies exceptions to blocking of information when it comes to patients accessing their electronic health record information (EHI). Centers for Medicare & Medicaid Services (CMS) has been working hard on improving the roadmap to improve interoperability and health information access for all stakeholders – patients, providers, and payers. 

One of the key rules released specific to interoperability is the Interoperability and Patient Access final rule (CMS-9115-F). This rule mandates the access and availability of the health information for patients whenever they need it. It also implies that patients must be able to use the information in the best way they can. The inability for seamless data exchange has deteriorated patient care, leading to poor health outcomes and increased medical costs.

The final rule that has been released includes key policies that impact different stakeholders. These policies focus on driving interoperability and delivering access to patient health data for health plans by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). The final rule ensures patients with better access to their health information, improves the interoperability and reduces burden on payers and providers.

Earlier this year, given the ongoing Covid-19 pandemic situation and recognising the challenges faced by payers, CMS exercised enforcement discretion of the Patient Access and Provider Directory API policies for Medicare Advantage (MA), Medicaid, and the Children’s Health Insurance Program (CHIP) for a period of six months. The revised date of enforcement of these policies was set to July 1, 2021.

So, What’s Next post July 1, 2021?

It’s July 2021, and the Patient Access and Provider Directory API requirements from CMS are now effective. The rule requires the regulated payers to enable these new APIs with immediate effect. According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), patients have the right to access their health information. It also requires the information to be exchanged in a way that ensures their privacy and security. The new CMS mandate to deliver Patient Access and Provider Directory API is a major breakthrough in the healthcare industry. This promotes the much needed interoperability of the patient’s medical data between payers and providers.

Patient Access API

According to the Interoperability and Patient Access final rule, all CMS-regulated payers are required to implement and maintain a secure and standards based API (HL7 FHIR API). Through this Health Level 7® (HL7) Fast Healthcare Interoperability Resources (FHIR®) API, patients shall be able to access their claims and encounter information easily. Patients can also choose to receive a subset of their medical information through authorized third-party applications of their choice. This information along with clinical data offer a broader perspective and understanding of the patient’s interaction with the healthcare system. This improves the overall decision making and leads to better health outcomes.

As your trusted partner, VNB Health can help to implement these new CMS requirements and better organize data within your organization. To successfully meet the CMS Patient Access rule for Health plans, we can assist to set-up your fully managed, enterprise-grade FHIR Server on Azure. The offering will be a HIPAA-compliant, platform as a service (PaaS) that can help to convert the clinical data such as claims, encounters and subsets of clinical data into FHIR supported format (FHIR Release 4.0.1 (R4)) using FHIR converters, set up third-party access management (e.g., OAuth 2.0) to ensure safe transmission of the data with the patients.

Azure API for FHIR has new REST API features and capabilities, and offers complete flexibility to businesses on what they can search in the system. The search can be performed using the common search parameters as well as resource-specific parameters and composite search parameters. VNB Health can help in implementing end-to-end solutions using Azure API for FHIR including integrations with specific apps, portals and analytics platforms.

Provider Directory API

The rule finalizes that CMS-regulated payers are regulated to make provider directory information publicly available via a standards-based API. This gives third-party application developers the advantage to access patient information. With this information, they can create services that help patients to find providers for care and treatment. On the other hand, it will also help clinicians find other providers for care coordination purposes. Overall, this aims to improve the quality, accuracy, and timeliness of information.

VNB Health’s experienced team can assist to build information of the providers using the FHIR based API in accordance with the HL7 FHIR 4.0.1 standards. This helps to retrieve provider names, address, phone number, speciality information, pharmacy information from publicly available sources. The API will keep a timely check on these data sources and will keep the data up-to-date. On top the API, our experts will assist in setting up a robust provider directory application. This will enable users to filter providers based on location and/or speciality, search for providers based on their location and office hours, filter specialists and their affiliations with local health practices, and identify a local health practice and their specialities seamlessly onto your application

Payer-to-Payer Data Exchange

The rule requires CMS-regulated payers to exchange patient clinical data (specifically the U.S. Core Data for Interoperability, USCDI, a spec on top of FHIR) on request from the patient. Patients can have this information handy when switching between payers to build a cumulative health record with the current payer. This requirement will take effect from January 2022.

VNB Health can assist your business to enable data exchange between payers. Our experts can easily implement this capability on top of the existing patient access API infrastructure and FHIR APIs. When the patient makes a data request, the payer can make this data available via the FHIR-based API in the form of electronic data and/or the format in which it was originally received.

Get started with FHIR on Microsoft Azure for Health today!

VNB Health has more than 15 years of proven experience working with healthcare organizations using Microsoft’s integration platform. Our experience with HL7 FHIR and Microsoft Azure technology enables us to build the technology to meet the CMS guidelines. As a trusted Microsoft Partner, we’ll work alongside your healthcare transformation journey to deliver improved data accessibility and patient care. Looking for a trusted partner to get started with your interoperability journey? Contact us today to embark on the healthcare transformation journey.

VNB Health Blog CMS FHIR Regulation

Final CMS Interoperability Regulation – Summary

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The Centers for Medicare & Medicaid Services (CMS) released the Interoperability & Patient Access Final Rule (CMS-9115-F) on March 9, 2020. Initially, the rule was expected to be announced during the HIMSS20 conference. The Final CMS Interoperability Regulation builds on top of MyHealthEData Initiative announced during the HIMSS18 conference and the 21st Century Cures Act.

Key Aspects of the Interoperability & Patient Access Final Rule

The Final CMS Interoperability Regulation focuses on a “Patient First” objective. The rule puts a stress on making patient health information easily accessible when in need. The rule also aims to drive more interoperability and data exchange across the entire healthcare ecosystem.

With this new Final CMS Interoperability Regulation, patients can get better access to their health information. They can always be informed of better care and better outcomes. The improved levels of interoperability between payers, providers and patients; and the data being readily available; the CMS aims to achieve better care, improved health outcomes and reduced costs of treatment.

The Final CMS Interoperability Regulation proposes 7 policies that will take the healthcare system forward to achieve higher levels of interoperability. These policies have certain levels of impact on payers and providers with strict timelines.

CMS Payer Policies

There are 4 new policies for both Medicare and Medicaid payer organizations; along with some implications for the providers.

Policy Policy Details Additional Information Compliance Date
Patient Access Through APIs CMS regulated Payers should make Claims and Encounter Data readily available to patients through the use of a secure, standards based (HL7 FHIR Release 4.0.1) API. This API should meet the HHS standards that are established by ONC 21st Century Cures Act final rule. The API should make available the following details –Adjudicated claims, remittances, cost share, encounter details along with clinical data, lab results, preferred drug list, and so on. Patients can access this information through any third-party application and integrate it to their EHR January 1, 2021. According to the latest update (on April 21, 2020), CMS will not enforce this requirement until July 1, 2021.
API access to published provider directory data CMS regulated Payers should make provider directory information publicly available through a FHIR-based Provider Directory API. The API should provide the following details – names of providers, addresses, phone numbers and specialty. January 1, 2021. According to the latest update (on April 21, 2020), CMS will not enforce this requirement until July 1, 2021.
Payer-to-Payer Data Exchange CMS regulated Payers should exchange patient’s clinical data upon the patient’s request as they move from payer to payer to help create a cumulative health record with their current payer. At a minimum, the data elements specified in United States Core Data for Interoperability (USCDI) v1 should be made available to the patients. Moreover, patients now have a cover of 5 years after the end of their coverage term to submit a request to a payer to share their information. January 1, 2022 (no changes to this date)
Increased Frequency of federal-state data exchanges for dual eligible members All the states should submit the Medicare and Medicaid enrollment information to CMS daily. Previously, it used to be weekly / monthly.   April 1, 2022 (no changes to this date)

CMS Provider Policies

There are 3 new provider policies that apply to hospitals and physicians.

Policy Policy Details Additional Information Compliance Date
Public Reporting and Information Blocking CMS will put up a public list of providers and clinicians who act as information blockers based on their attestation to CMS Promoting Interoperability (PI) Program or the MIPS program. CMS will also put up an additional list of providers based on their performance in a way to promote the interoperability under the Merit-based Incentive Payment System (MIPS). Late 2020
Digital Contact Information CMS will publish a list of names and National Provider Identifier (NPI) of the providers who do not have digital contact information. The providers need to have the digital contact information included in the National Plan and Provider Enumeration System (NPPES) Second Half of 2020
Admission, Discharge and Transfer (ADT) Event Notifications CMS is making modifications to Conditions of Participation (CoP) which requires hospitals to send electronic patient event notifications of the patient’s admission, discharge and transfer to another facility/provider/practitioner. This event messaging system will help deliver improved care coordination and better patient outcome. Fall 2020; Changed to Spring 2021. This rule is effective 12 months after the final rule is published in the Federal Register, which will be May 1, 2020.

COVID-19 Challenge Brings Relief for Payers and Providers

The COVID-19 crisis has crippled the world economy to something that has never been witnessed before. The US Healthcare domain is no different! Healthcare providers and payers are facing an uncertain future in this pandemic situation.

CMS has acknowledged the seriousness of this situation, especially for hospitals (CAHs), and decided to extend the implementation of Admission, Discharge and Transfer (ADT) Event Notifications by 6 months (from Fall 2020 to Spring 2021).

ONC Final Rule

The Office of the National Coordinator for Health IT (ONC) also finalized technical, content and vocabulary standards in the 21st Century Cures Act Final Rule. The rule focuses on advancing interoperability by supporting the access, exchange, and use of electronic health information (EHI) and information blocking.

The ONC final rule identifies 8 exceptions when a healthcare actor will not be considered as an information blocker. These exceptions are divided into two categories –

Exceptions that involve not fulfilling requests to access, exchange, or use EHI

  1. Preventing Harm Exception
  2. Privacy Exception
  3. Security Exception
  4. Infeasibility Exception
  5. Health IT Performance Exception

Exceptions that involve procedures for fulfilling requests to access, exchange, or use EHI

  1. Content and Manner Exception
  2. Fees Exception
  3. Licensing Exception

ONC has finalized the transition from Common Clinical Data Set (CCDS) to the United States Core Data for Interoperability (USCDI). USCDI allows for a broader sharing of electronic health information to support patient care.

How VNB Health Can Help?

VNB Health can help payers and providers with best-in-class and easy-to-use interoperability solution. Our solution takes advantage of FHIR API in order to meet the CMS interoperability final rule requirements. As a HL7 Gold Member, VNB Health has been working on HL7 FHIR since its inception. We’ve built a variety of services by leveraging the power of Microsoft Cloud Platform and FHIR resources. Take advantage of our continuous innovation mindset to connect existing health data sources to new devices; and, generate actionable insights across all your health data.

Want to build your interoperability solution to meet the rules and regulations? Contact us to find out how we can help you with your interoperability needs.