CMS Interoperability: A Payer’s Solution for Compliance

Executive Summary

The CMS announcement of the Interoperability rule in March 2020 has created enormous opportunities for the healthcare system. Recently, a leading American health insurance company (Company) contacted Smile Digital Health searching for a cloud solution that could deliver:

• CMS Interoperability Rule (Patient Access APIs, Provider APIs and Payer-to-Payer exchange) 

• FHIR Platform

• Manage Existing Standard and Non-Standard Data Exchange 

• Managing Trading Partners 

After a thorough procurement process, Smile deployed on Microsoft Azure was selected.

Successfully Meeting CMS Patient Access Rule

Determined to meet the newly launched Centers for Medicare & Medicaid Services (CMS) Interoperability rule requiring the implementation of the Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) data standard, a leading American health insurance company (Company) reached out to Smile, a recognized expert in FHIR standards for assistance. 

With a purpose-built clinical data repository, Smile Digital Health is a leader in health data exchange, currently serving over 100 clients globally who utilize Smile to revolutionize and modernize their health ecosystem. Smile’s data fabric unifies and creates a single data access plane for interoperability to accelerate and simplify the ability to share clinical information across the care continuum for patients, providers, payers, researchers and governments.

Smile has been a leader in FHIR since the company’s inception in 2016. Prior to this, Smile’s founders, Duncan Weatherston and James Agnew, worked together on developing the open source HAPI FHIR, a complete implementation of the HL7 FHIR standard for healthcare interoperability in Java, which is now a product of Smile.

Challenges

The Patient Access Rule mandate is an industry disruptive event that many payers had to quickly maneuver and address in order to maintain compliance. Some of the challenges that The Company faced were:

• Managing competing priorities in addition to the CMS Interop project;

• Accelerating their cloud strategy;

• Learning and adopting the new FHIR standard and transforming their data to FHIR.

Managing Priorities

At the start of the project, The Company was already embarking on a data consolidation project to create a data lake from their source systems. With the addition of the CMS Interop project, the challenge was to create a solution that could leverage and complement this activity, while limiting the impact to the existing data lake project.  

To minimize the impact on the existing project, the Smile team successfully deployed Smile on Microsoft Azure, leveraging the same environments that the data lake project utilizes. This reduced architecture complexity while maximizing the value received from Microsoft Azure.

Accelerating Cloud Strategy

The CMS Patient Access mandate was an impetus for The Company to accelerate their strategy and adoption to the cloud. After executing the first Patient Access API mandate on July 1, 2021, the Smile team also successfully implemented the second mandate—the Payer-to-Payer exchange on January 1, 2022. As a result of these accomplishments on Microsoft Azure, The Company is now embarking on a new initiative that will utilize Smile as its data fabric platform for interoperability across the enterprise. These new initiatives would not have been possible before. However, with Smile, The Company now has access to its data in a unified and normalized format via the FHIR open standard.

Learning and Adopting FHIR

Another challenge was general knowledge regarding FHIR and how it could benefit The Company strategically and operationally. At the time the project was started, there was very little understanding of FHIR in the industry and how it could be leveraged. This was a government mandate that had to be met and The Company needed to adapt and build their understanding of FHIR. By selecting Smile, with their long-established expertise in the area, it gave an opportunity for The Company to leverage their know-how while unifying its data into FHIR resources. This opened up new opportunities and strategies that were limiting factors before because normalizing and standardizing source data had been a challenge. With the completion of the first mandate on July 1, 2021, which resulted in the ingestion of clinical data into Smile from January 1, 2016, The Company now has a better understanding of FHIR and how the data can be utilized more effectively and efficiently for members, thus improving the care cost curve.

Future Endeavors

With Smile deployed in production on Microsoft Azure, this now opens up future opportunities like healthcare third-party applications to access clinical data through FHIR APIs.  Applications that adhere to SMART on FHIR can follow this universal API for accessing clinical data, by following a secure authorization and authentication process to make access requests to FHIR resources in the form of OAuth 2.0-compliant authorization and OpenID connect for authentication.

Furthermore, Risk Adjustments and Prior Authorization are also opportunities that The Company is now in a position to accomplish with Smile. With data stored as FHIR resources inside Smile, applications specialized in risk adjustments and prior authorization can access this data and provide the business value in a more efficient manner.  

Lastly, The Company is also now in a position to improve their HEDIS score and STAR rating. With data readily available as FHIR, The Company can now determine how members receive their care and use this information to report to CMS more accurately.

Smile Digital Health and Azure

Smile is working with Microsoft Azure in other innovative and transformative projects in healthcare. Recently, Smile was declared as the technology standard for Ontario Health and will be the platform of choice for the future EHR. In addition, Smile is also the technology of choice for several of the top 10 US healthcare delivery networks and will also be deployed on Microsoft Azure. Together with Microsoft, Smile can deliver a cloud-based solution to meet many healthcare challenges.