interoperability: a primer...hl7 health level 7. confidential and proprietary – for blue plan use...

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


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


Interoperability Overview


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


We are all patients or caregivers…

Why Interoperability

and Why Now


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


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


The Ideal State is the Learning Health System

https://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf

https://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf


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


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


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


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


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


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


Industry Approach to

Achieve Interoperability


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).


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


• 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

http://argonautwiki.hl7.org/

http://www.hl7.org/carin/

http://www.hl7.org/codex/

http://www.hl7.org/about/davinci/

http://www.hl7.org/gravity/


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.



Interoperability Proposed

Rules


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.


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


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:


http://www.hl7.org/about/davinci/


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


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


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.


BCBSA Tools and Reporting


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


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


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.


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 |

[email protected]

– Lenel James, Business Lead, HIE & Innovation | 312.297.5962 | [email protected]

– Desla Mancilla, Business Lead, HIT Program Implementation | 312.297.6530 |

[email protected]

– Farrah Khan, Sr. Consultant, HIT | 312.297.6889 | [email protected]

http://bluewebportal.bcbs.com/article?id=5383620

mailto:[email protected]





interoperability: a primer...hl7 health level 7. confidential and proprietary – for blue plan use...

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