CMS Interoperability: A Payer’s Solution for Compliance

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.

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 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.

The adoption and application of ​​standards—common methods, guides and measures—in an industry creates the foundation for how large-scale problems are solved in the real world. For example, when ISO (International Standards Organization) came into existence in 1947, several nations adopted common standards in an effort to rebuild infrastructure after the war. The standardization of processes, materials and components, along with management and quality guidelines, enabled specialization of skill, efficient utilization of resources (time, funds and labor) and provided the ability to drive progress across industries, including healthcare. Today organizations such as HL7 (Health Level Seven International) create open interoperable standards—like HAPI FHIR—to create new foundations for global health IT infrastructure.

Smile’s solution suite is a commercially viable, enterprise-level solution that integrates these foundations with clinical logic (CQL) into a robust architecture, which no other vendor in the marketplace currently offers. The solution architecture allows for more advanced capabilities like Multi-threaded Processing—the ability to have multiple concurrent users of a program without duplicating it. This is an essential requirement to ensure organizations have high-performance solutions that are robust, secure, scalable and supported by technology experts.  

Even with well-established CPGs, the lack of standardization and interoperability results in inconsistent application. Adherence to CPGs for colorectal surgery can be as low as 29%, which creates gaps in care. Smile’s solution suite can be leveraged for predictive assessment of care gaps and clinical recommendations to close the gaps before they ever occur. By choosing Smile as a vendor for digital transformation and innovation for any one part of the CQI lifecycle, the technology implementation will solutionize the entire cycle—be it CPG, CDS, CQM or dQM.

Historically, CDS and Clinical Quality Measures (CQM) were developed in silos and were not interoperable; even though they are both a part of the Quality Improvement cycle. A meaningful and continuously evolving CQI (Clinical Quality Improvement) cycle requires harmony and exchange between these two specifications, so that improvements can be assessed, implemented and measured. Integrating FHIR and CQL brings needed technological revolution to harmonize the entire lifecycle of CQI, including but not limited to CDS, CQMs and dQMs (digital quality measures).

The work to unify the quality lifecycle solution has taken almost a decade. The standards and cutting edge technology—FHIR, CPG and CQL based solutions—now exist. The next steps are to capitalize on this work and invest in the innovative Clinical Quality solution suite within the Smile Health Data Platform (HDP) to generate sustainable improvements in revenue, operations, patient care and care quality.