interoperability: a primer...hl7 health level 7. confidential and proprietary – for blue plan use...
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Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.
Interoperability:
A Primer
Interoperability 101
A Primer on Interoperable Health Data Exchange
Content Developed: January 2020
PRO PRI ETARY AND CO NFI DENTIAL
For Blue Plan Use Only
2CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Agenda
TOPIC SLIDE
Language Level Set (Acronyms) 3
Interoperability Overview 4
Industry Approach to Achieve Interoperability 17
Interoperability Proposed Rules 22
Interoperability and BCBSA 27
BCBSA Tools and Reporting 31
Appendix 35
3CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
The Language of Interoperability
ACRONYM MEANING ACRONYM MEANING
API Application Programming Interface (Apps) IT Information Technology
B2B Business to Business NCPDP National Council for Prescription Drug Programs
B2C Business to Consumer NCVHS National Committee on Vital and Health Statistics
CMS Centers for Medicare and Medicaid Services NPRM Notice of Proposed Rule Making
EHR Electronic Health Records ONCOffice of the National Coordinator of Health
Information Technology
FHIR Fast Healthcare Interoperability Resources RTBC Real Time Benefit Check
HIE Health Information Exchange TEFCATrusted Exchange Framework and Common
Agreement
HIPAAHealth Insurance Portability and Accountability
Act of 1996USCDI U.S. Core Data for Interoperability
HIN Health Information Network WEDI Workgroup on Electronic Data Interchange
HITACHealth Information Technology Advisory
CommitteeXML Extensible Markup Language
HL7 Health Level 7
4CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Interoperability Overview
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Interoperability Defined
Interoperability is the ability for electronic systems to be
able to communicate and exchange data in the same way,
which will make it easier for consumers to access their
healthcare data with security and ease.
6
Interoperability | Ability to electronically share meaningful healthcare
data without special effort
Patients Access to Data Build a Strong Foundation Data Liquidity
Patients own and should have access to
their healthcare data wherever and
whenever they need it.
Standardizing the way we exchange data
is necessary to make health data
accessible, safe and private
Remove barriers preventing flow of data to
allow access in a secure, efficient and cost-
effective way
B C B S I N T E R O P E R A B I L I T Y P R I N C I P L E S
PROBLEM
Information in silos, health data not
connected, no sharing of information
LABS
PRIMARY CARE
HOSPITAL
SPECIALISTHEALTH PLAN
PUBLIC
HEALTH
PHARMACIES
BCBS DESIRED
FUTURE STATE Patients (and their doctors)
have access to their complete health history at
any given point in time
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We are all patients or caregivers…
Why Interoperability
and Why Now
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Lower Cost of Care
Increased Care
Coordination
Greater Consumer
Engagement and
Shared Decision Making
(and we are all
consumers)!
Why Interoperability and Why Now?
Improved Consumer
Experience
Better Patient Outcomes
Improved Quality and
Safety
Greater Operational
Efficiencies
9CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
ENGAGING AND
INFLUENCING
• Associations (e.g., American
Medical Association (AMA),
BCBSA, Leavitt Partners,
etc.)
• Industry Projects:
Commonwell, Sequoia
• Health Level 7 (HL7 Fast
Healthcare Interoperability
Resources (FHIR)
Accelerators (e.g., Da Vinci,
CARIN, etc.)
• Individual Organizations
Major Players in Interoperability
POLICY AND REGULATION
• Centers for Medicare and Medicaid
Services (CMS);
• The Office of The National
Coordinator for Heath Information
Technology (ONC)
• National Centers for Vital Health
Statistics (NCVHS)
• Health IT Advisory Committee
STANDARDS AND
IMPLEMENTATION GUIDANCE
• Standard Development Organizations;
Health Level Seven (HL7), X12, National
Council for Prescription Drug Programs
(NCPDP), etc.)
• Terminology/Code Sets; International
Classification of Diseases (ICD),
Systematized Nomenclature of Medicine
(SNOMED), etc.
• Appointed coordination and oversight
organizations; Council for Affordable
Quality Healthcare & CAQH Core, WEDI
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The Ideal State is the Learning Health System
https://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf
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Value-Based Care Drives Focus on Patient Outcomes
Enable providers to see
the right data at right time for
specific patient coverage,
benefits and care coordination
INTEROPERABLE
DATA
Patient Outcomes
Regulatory Impact
Cost Constraints
VALUE
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The EHR Incentive Program introduced as part of ARRA in 2009 incented health care providers and hospitals to adopt and “meaningfully use” certified EHRs
Interoperability: A look back
Meaningful Use was first implemented to encourage the use of electronic health
records, however it created “walled gardens” with limited interoperability
13CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Current Barriers and Concerns
• Patient Identifier
• Limited Defined Standards
• Data Blocking
• HIPAA Minimum Necessary
• Data stored between disparate systems
• Directory Services
• Identity
• Security
• Testing, Conformance,
& Certification
• Versioning
• Scaling
PROCESS & REGULATORYTECHNICAL
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Interoperability Drivers
Consumer Demand
• Ease of Access
• Clear understanding of benefit
and coverage
• Ability to see cost/quality data
• Patients Manage own data
• Ensure privacy and security
Shift to Value-Based Care
• Focus on outcomes
• Innovation in business models
and use of technology
• Shared Upside/Downside
between payers/providers
Regulatory Requirements
• Data Blocking
• Coverage Portability
• Price Transparency
• Ensure privacy and security
Quality and Safety
• Improve information and attestation in
workflow
• Follow agreed upon best practices
• Unlock payer data to care givers
INTEROPERABILITY
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Manual Exchange
Interoperability Enablers – TODAY
CUSTOM INTEGRATION
EXCEL FILES
FAXES
PROVIDER 1
PROVIDER 2
PROVIDER 3
PROVIDER 4
PAYER 1
PAYER 2
PAYER 3
PAYER 4
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Interoperability Enablers – on FHIR
Emerging
Standards
Agreed Upon
Ways to Use
Standard
Shift to Real
Time
Information
from Batch
Process
Improved Tools
to Build
Applications
INTEGRATORS INTEGRATORS
PROVIDER 1
PROVIDER 2
PROVIDER 3
PROVIDER 4
PAYER 1
PAYER 2
PAYER 3
PAYER 4
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Industry Approach to
Achieve Interoperability
18CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Policy and Regulation
ROLE
The Government passes legislation, sets national policy, regulates
industry and funds innovation in health IT and standards development.
WHERE THEY GET INVOLVED
The Government address health IT policy as directed by the Executive
or Legislative branches of government.
HOW THEY WORK
Federal programs promote the adoption and use of health IT by
incorporating requirements to federal health care programs such
Medicare and Medicaid; regulating health IT developers, requiring,
testing and certifying the use of health IT standards, and funding
research and innovation in heath IT.
EXAMPLES ORGANIZATIONS
Centers for Medicaid and Medicare Services (CMS); The Office of
The National Coordinator for Heath Information Technology (ONC);
The National Institute of Standards and Technology (NIST); The Food
and Drug Administration( FDA); Congressional Committees (e.g., House
Energy and Commerce, Senate Health, Education, Labor and Pension,
Senate Finance).
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Standards and Implementation Guidance
• Set standards to move clinical
data intra and inter organization
(i.e., Medical Devices to EHR)
• ADT and Lab results
• Fast Healthcare Interoperability
Resources (FHIR) Extensible
Markup Language (XML-based)
Application Point Interfaces (API)
standard – Exchange of
healthcare information between
stakeholders through use of
“resources” and specifications for
exchange of resources
• Convenes industry
stakeholders to collaborate on
best practices, identify solutions
and deliver educational
resources for health information
technology
• Administrative Data
• Named standards by HIPAA
to be the only way Covered
Entities transact with other
Covered Entities
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• Designed to assist implementers across the
health care spectrum in the creation and
adoption of FHIR Implementation Guides.
• Accelerator Overview
– CARIN Alliance: Focused on consumer-facing
exchange of data (Blue-Button and Consumer
facing RTPBC)
– Da Vinci: Focused on B2B exchange of data for
Value-based Care
– Argonaut Project: Focused on exchange of data
for EHRs and other HIT vendors (CDS Hooks)
– Gravity Project: Focused on data exchange of
socioeconomic risk factor data
– CodeX: Focused on creation of national platform
for interoperable cancer data modeling
HL7® FHIR® Accelerator Program
21CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Engaging and Influencing
ROLE
Associations and Alliances exist to provide a collective voice to protect
or advance the shared interests of their collective members.
WHERE THEY GET INVOLVED
HOW THEY WORK
Associations tend to form around specific industries or professions.
Alliances tend to form around a specific set of issues.
Associations and Alliances efforts tend focus on using their members or
employed staff to promote an issue that their members would be
ineffective at ding or are barred from doing individually. Their methods
include but are not limited to advocacy, funding or
fundraising, research, education, representation, convening,
collaboration, outreach and developing and disseminating key
messaging. They typically, but not necessarily hold not-for-profit status
and receive funding through membership fees, fundraising, grants
and/or provision of services.
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Interoperability Proposed
Rules
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Proposed federal rules on data interoperability were released in 2019 and focused on further enabling interoperability and removing information blocking; this will disrupt the electronic data sharing landscape for all healthcare stakeholders.
Proposed Federal Interoperability Rules and Frameworks
CMS
Technical Standards Related
to Interoperability
Provide information via standardized,
open APIs (ex. claims, encounter
data, provider directory data,
clinical data, drug benefit data, )
API standards
Trusted Exchange Networks
Information blocking rules and
seven exceptions
Updates to the 2015 Edition
Certification Criteria (USCDI,
e-prescribing, clinical quality
measures, APIs, privacy/security)
Conditions and Maintenance
of the Certification
Policy and technical approach to
enable nationwide exchange of
electronic health information across
disparate networks.
Provide a single on-ramp to nationwide
connectivity for secure electronic
information exchange.
TEFCA will give patients, health care
providers, payers, HINs, health IT
developers, and others access to
data to support patient care.
ONC TEFCA
SUMMARY OF RULES
Senate HELP - Lower Health Care Costs ActSection 501 would extend CMS/ONC interoperability proposals to the commercial market.
24CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Target Areas for Proposed Rules
Covered Entities and BAA
Regulated Under HIPAA – B2BConsumer Directed - No HIPAA – B2C
FTC Jurisdiction
ONC CMS
EHRs EHRs Payer Payer
SMART App Consumer App Portal Provider
25CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
CMS NPRM Mapped to Industry Standards Efforts
Claims Clinical Data
Pharmacy
Real Time
Benefit Tool
Coverage
Decisions
Formulary
Coverage
Directory -
Pharmacy &
Payer
Consumer Consumer
FHIR for
Consumer
NCPDP for
Provider
- - -
Provider –
Source for
Inferred
Clinical
Data
Provider &
Payer-
Payer to
Payer for
Continuity of
Coverage for
Consumer
Basics for
Consumer
Shopping,
not dispense
or price
Basics for
Consumer
Network
Coverage
NOTE: Proposed Rules are targeting Qualified Health Plans, Medicare Advantage and related lines of business
Payer To:
26CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Targeted Industry Landscape
Industry Engagement Opportunities
Industry Initiative AudiencePharmacy
vs. Medical
Public/
PrivateKey Objectives Action
HL7 FHIR Community All Both Public Standards Immediate
HL7 Da Vinci Project Provider Payer Both Private Value-Based Care workflows Immediate
CARIN Alliance Consumer Both PrivateRTPBC and patient access to
own dataImmediate
ONC – FHIR at Scale
Taskforce (FAST)All Medical Public
FHIR infrastructure/ scaling,
macro level obstacles across
technology stack
Immediate
eHI Members Medical PrivateReduce, remove or automate
Medical PAWatch
Sequoia/ Carequality Provider Provider Medical Private Clinical record exchange Watch
Argonaut Consumer Medical PrivateClinical data to providers and
patientsLeverage
CommonWell Provider Provider Medical PrivateProvider to provider clinical data
exchangeWatch
Innovation Taskforce Provider Provider Medical Public mPA, 275 attachments Future
27CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Interoperability and BCBSA
28PROPRIETARY AND CONFIDENTIAL – For Blue Plan Use Only
BCBS Interoperability Vision
• Consumers can easily retrieve all of their clinical
health data and share that information securely with their
providers and others whom they choose
• Patients can, without difficulty, use their data with third-
party applications that allow them to understand,
analyze, track and manage their healthcare needs
• All participants in the healthcare ecosystem can easily
access and use all necessary healthcare information,
with consumer approval and appropriate privacy
and security safeguards
The Data Board approved an aggressive plan for the BCBS System (BCBS) to become a
recognized leader in accelerating health data interoperability
29PROPRIETARY AND CONFIDENTIAL – For Blue Plan Use Only
Data Board-approved Strategic Priorities | Demonstrate leadership, empower consumers and accelerate industry adoption
BCBS Desired
Future State
Patients (and their
doctors) have
access to their
complete health
history at any
given point in time
Business Operations
Policy
• Blue Button 2.0®*
• Patient Matching
Demonstration
• Coalitions
• CMS & ONC NPRM
Comment Letters
Thought Leadership
• Consumer Testing
• Communications Toolkit
Standards
• Da Vinci Project
• BCBS Implementation Guides
*Blue Button, the slogan, 'Download My Data,' the Blue Button Logo, and the Blue Button combined logo are registered service marks owned by the U.S. Department of Health and
Human Services. Participation does not imply endorsement by HHS or the U.S. government.
30PROPRIETARY AND CONFIDENTIAL – For Blue Plan Use Only
31CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
BCBSA Tools and Reporting
32CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Initiatives Program Dashboard
LEGEND:
Type: EXT: External = Work between Plans &/or BCBSA and external organizations INT: Internal = BCBS Plans and/or BCBSA
Project Status: R = Not on track Y = At risk G = On Track (as related to schedule, budget, scope, or other factors)
Plan Engagement = High, significant adoption by xx # of Plans, Med = Moderate adoption by xx # of Plans, Low = Little or no adoption by xx# of Plans
Driver: Corporate Goal= BCBSA Goal; Data Board = Data Board Initiative; Regulatory= required by regulation or law
BCBSA Engagement: Monitor (watching for updates/changes), Build (creating artifacts, pilots, etc.), Educate – Sharing knowledge, On Hold, Complete, Ongoing
Timing: N/A or Quarter/Year for targeted project completion or other deliverable noted as “Build” in BCBSA Engagement column
Levers: POLICY = OPERATIONS = THOUGHT LEADERSHIP = STANDARDS =
Project Name Type Project Status Plan Engagement Driver BCBSA Engagement Timing Levers
Blue Button 2.X BCBS INT G Data Board Initiative Q42019
HL7 EXT R Q12020
HL7 Da Vinci Project EXT G Data Board Initiative Q12020
HL7 Gravity Project EXT G Data Board Initiative Q22020
CARIN Alliance EXT G Data Board Initiative Q12020
Data Vendor Strategy INT G Corporate Goal Q42019
The Sequoia Project EXT G Corporate Goal Ongoing Q42019
Patient Matching Demo EXT G Data Board Initiative Complete Q42019
Rules Readiness INT Y Regulatory Educate Q22020
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
XX XX XX
HIGH MED LOW
33CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Patient Matching Demonstration
Program General UpdateSTATUS: TIMING: 2019-2020
Engagement Level:
Applicable to: BCBSA BCBS Companies BCBS System
SUMMARY
A patient matching demonstration project with a national Health Information Exchange and in partnership with BCBS MI, was completed in
November, 2019. The results of this demonstration project confirmed the ability of the BCBSA Member Matching Identifier (MMI) solution to be
used outside of the payer community to accurately identify unique patients in a dataset. Ultimately, this will allow for effective linking of unique
individual’s healthcare experience over time to create a longitudinal view of care.
INDUSTRY DRIVERS & IMPACT GOALS
Notice of proposed rulemaking (NPRM) by CMS (and anticipated for
approval in late 2019) require Plans with a government market
program (i.e., Medicare Advantage, QHP, etc.) to provide claims data
to other payers.
1. Contribute to ability to increase visibility and leadership on clinical
data interoperability.
2. Demonstrate BCBSA MMI solution is useful outside of a payer
community and can be replicated in other environments
ASSOCIATION IMPACT PLAN IMPACT
Ability to aggregate unique individual’s patient care experiences over
time and separate Plans allows for greater data analysis and support
of value-based care initiatives.
MMI solution and aggregation of a unique patient over time and
separate Plans provides ability to respond to requests and receive
data from other payers as required under current NPRM.
ACTION NEEDED: No action needed
N/A for this project
34CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Patient Matching Demonstration Project
Program Milestone Progress
ROADMAP/APPROACH FOR 2020
Continuation of demonstration project to extend to other national
partners. The goal is to demonstrate the Services phase of the MMI
solution which allows for a longitudinal view of the care experience of a
unique patient over time and separate Plans. This will inform value based
care decisions such identification and management of care gaps to
improve care outcomes.
COMPLETED MILESTONES SUCCESS MEASUREMENTS
Q4 2019: Completed patient matching demonstration project
Q3 2019: Identification of national partner for demonstration project
Q2 2019: N/A
Q1 2019: N/A
2019 Goals: Data analysis results yielded a 99.9% match rate which
was higher than our HIE partner’s ability to match 98% of the unique
members within the dataset used for this experiment.
2020 Goals: TBD
KNOWN RISKS/MITIGATION 2020 COMPANIES COMMITTED BY USE CASE
Rule Drop with potential 2021 Deadlines N/A for this project
BLUE ENGAGEMENT & EARLY ADOPTERS
This project relied on data already available from Plans in the National
Data Warehouse. Additional support was provided by one Plan (BCBS
MI) to serve as an intermediary with the HIE partner to conduct the
demonstration experiment. No early adoption or other Blue
Engagement required.
35CONFIDENTIAL AND PROPRIETARY – For Blue Plan Use Only
Resources/Contact
• For more information on interoperability initiatives visit
the Health Information Technology BlueWeb page
• HIT Team Contacts
– Matt Schuller, Director, HIT | 312.297.6859 | [email protected]
– Gwenn Darlinger, Manager, Health Data Interoperability | 312.297.6026 |
– Lenel James, Business Lead, HIE & Innovation | 312.297.5962 | [email protected]
– Desla Mancilla, Business Lead, HIT Program Implementation | 312.297.6530 |
– Farrah Khan, Sr. Consultant, HIT | 312.297.6889 | [email protected]