Advancing true healthcare interoperability and data fluidity is dependent upon collaboration, and collaboration requires participation. Recently, the Centers for Medicare and Medicaid (CMS) sent out three separate Requests for Information (RFI) to help shape the development of these major initiatives: Advanced Explanation of Benefits and Good Faith Estimates, a National Healthcare Directory, and Promoting Efficiency and Equity within CMS programs. The purpose of the RFIs is to gather ideas, feedback, and concerns from a diverse range of healthcare stakeholders, including but not limited to patients, providers, payers, and health IT developers to aid in planning and developing the new policies and implementation requirements or modifying existing.

Point-of-Care Partners (POCP) frequently participates when regulators issue an RFI, dedicating time and resources to share the unique perspective of our subject matter experts who have extensive experience building, coordinating, and collaborating on real world interoperability efforts. POCP consultants gain valuable insights through the leadership roles at the program and use case level of Health Level 7 (HL7) Accelerators like Da Vinci Project, FHIR at Scale Taskforce (FAST) and CodeX. These accelerators are progressing the industry towards true interoperability through their work across the ecosystem whether focused on improving payer/provider data exchange, FHIR infrastructure, or improving clinical workflows through FHIR. Below are some highlights from our recent RFI responses:

Advanced Explanation of Benefits (AEOBs) and Good Faith Estimates (GFEs)

The premise of this RFI is that AEOBs and GFEs will help patients make informed choices about the care they need. While we agree with the premise, we believe the level of effort required to create and share this information cannot be achieved without a greater culture of aligned priorities and incentives.

To advance AEOB and GFE needs for patients, we recommended that CMS should incentivize the use of FHIR-based Application Programing Interfaces (APIs) and the ONC should update Health IT Certification requirements to require certified HIT vendors to advance to the latest USCDI version. This would help prioritize infrastructure improvements related to data exchange and support alignment between providers and payers. While some healthcare stakeholders will not be able to implement FHIR-based information exchange without substantial investments and well-defined standards in which to do so, FHIR is emerging as the native language of Patient Applications. Patient Access APIs can be utilized for patients to receive and view their AEOB and GFE information with ease, seeing costs and options within their patient portal and through apps on their phones. While patient demand for this access will lead some payers to invest in infrastructure improvements, others will wait until required to do so, potentially via certification requirements.

The Da Vinci Patient Cost Transparency Implementation Guide (PCT IG) outlines the standards needed to implement necessary changes to meet the transparency in billing requirements. The PCT IG provides a standard API for data exchange of GFEs from provider to payer and for the payer to provide the AEOB for the patient, and optionally for the submitting provider.

In our RFI response, we also suggested a phased schedule of mandated use. This would allow for planning and more thorough testing of the business processes and standards provided in the PCT IG. By allowing two or three phases before AEOBs and GFEs are necessary for all services and products consolidated across providers, the industry time will be given the time needed to evolve business processes and implement necessary technology without overburdening their resources. CMS should continue evaluation of the work happening at Da Vinci to develop an open-source solution that aligns with claim submission standards and balances minimum data known at the time of scheduling with a rich data set for accurate estimation. You can read our complete response here.

National Directory of Healthcare Providers and Services

POCP also responded to the CMS RFI regarding the development of a National Directory of Healthcare Providers and Services (NDH) that would serve as a centralized data hub for healthcare provider, facility, and entity directory information nationwide. We support the creation of a NDH as it is a critical piece in creating an interoperable healthcare ecosystem; however, we believe the inclusion of all healthcare entities, 24/7 accessibility, and confidence in the quality of data will be critical for adoption.

We urged CMS to pursue a standards-based platform for the NHD that uses FHIR and provides options to access the directory via APIs or other FHIR-enabled systems or applications. This will allow patients to view the directory within their patient portal or via phone-based apps. Accurate, validated, readily accessible provider information is utilized and needed to facilitate a plethora of healthcare activity and transactions. The HL7 FAST National Healthcare Directory Implementation Guide (NHD IG)* describes the architectural considerations for attesting to, validating, and exchanging data from a central source of validated provider data as well as a RESTful FHIR API for accessing data from a validated healthcare directory.

To help establish industry confidence in data quality, we suggested the directory should be pre-populated with provider demographics, relationships between individual providers and provider organizations, payers, and their FHIR endpoints using the provider data that exists todays in the CMS Provider Enrollment, Chain, and Ownership System (PECOS), the National Plan and Provider Enumeration System (NPPES), and other directories. We also recommended referencing the “Attestation” and “Verification” sections of the NHD IG for requirements to populate a directory with validated, attested, and verified data.

Use of the HL7 NHD IG would establish a standard means for EHRs, practice management systems and payers and others to implement technical requirements to support real-time updates to the CMS NDH, and methods to use automation to pull information from the CMS NDH. You can read our complete response here.

POCP did not respond to the CMS RFI Make Your Voice Heard: Promoting Efficiency and Equity Within CMS Programs; however, we will be reading the responses once published to look for ways to support this important endeavor.

We are experts in healthcare IT, interoperability, and federal and state healthcare policy. Reach out to me at kim.boyd@pocp.com you have questions about upcoming CMS requirements or want to discuss information sharing solutions.