Medicare Claims Data APIs from the Centers for Medicare ......Provider, payer, vendor collaboration...

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Medicare Claims Data APIs from the Centers for Medicare & Medicaid Services (CMS)Allison Oelschlaeger, CMS Chief Data Officer

MyHealthEData

The MyHealthEData initiative aims to unleash data to give patients control of their healthcare information and allow that information to follow them through their healthcare journey Government-wide initiative led by the White

House Office of American Innovation HHS and CMS are key partners in this initiative

2

A Brief History of Blue Button

3

2010

2018

May 2010: CMS & VA hold innovation event to increase consumer access to data through PHRs

Aug 2010: VA releases Blue Button download

Sept 2010:CMS releases Blue Button download

March 2018:CMS launches Blue Button 2.0 to add developer-friendly, standards-based API to the existing text and PDF downloads

February 2019:CMS releases Interoperability and Patient Access Proposed Rule

2019

Comparison of CMS APIs

Blue Button

Beneficiary Claims Data

• For Medicare beneficiaries

• Single data call

• bluebutton.cms.gov

• For Accountable Care Organizations (ACO)

• Bulk data calls

• bcda.cms.gov

• For Providers

• Bulk data calls

• dpc.cms.gov

Data at the Point of Care

CMS Claims API Projects

BFD

CMS Claims Data

Primary Care Doctor Specialists Care Manager

Patient

ACOs:Beneficiary Claims Data API

Patient- Blue ButtonCaregiver

FFS Providers:Data at the Point of Care

ACO Organization

Supporting Technologies

HL7 Da Vinci Project

Jocelyn KeeganProgram Manager, Da Vinci Project

Senior Consultant, Point-of-Care Partners

Provider, payer, vendor collaboration defining specific implementation guides to support value-based care Supported by over 45 organizations; fund SMEs, provide in kind

staff/resources and commit to implement in production Leverages HL7 FHIR across 14+ use cases; current progress

ranges from proposed (2) to draft standards (12) Use cases span:

Quality Measures Data Exchange Streamlining Prior Authorization Clinical Data Exchange between Providers and Payer Standards to Identify Shared Patients between Partners

2020 Focus - Mature Existing Guides, Artifacts, and Support Implementations

HL7 Da Vinci Project

Project ChallengeTo ensure the success of the industry’s shift to Value Based Care

Pre-Collaboration / Controlled Chaos:

Develop rapid multi-stakeholder process to identify, exercise and

implement initial use cases.

Collaboration:Minimize the development and

deployment of unique solutions. Promote industry wide standards

and adoption.

Success Measures:Use of FHIR®, implementation guides

and pilot projects.

Membership by Primary Industry Role

Vendors

Providers

Partners

For current membership: http://www.hl7.org/about/davinci/members.cfm

Payers

Use Case Focus Areas

Gaps in Care & Information

Coverage Requirements Discovery

Performing Laboratory Reporting

Data Exchange for Quality Measures

Prior-Authorization Support

Risk Based Contract Member Identification

Alerts / NotificationsPatient Cost Transparency

Chronic Illness Documentation for

Risk Adjustment

Patient Data Exchange

Clinical Data Exchange

Payer Data Exchange: Formulary

Quality Improvem

ent

Clinical Data Exchange

Coverage / Burden Reduction

Process Improvement

Member Access

Clinical Data Exchange

In Ballot Reconciliation

Use Case Status

Documentation Templates and Rules

Early February or February 2020 Ballot

In Build

In Discovery

Payer Data Exchange

Payer Data Exchange

Payer Data Exchange: Directory

Payer Coverage Decision Exchange

Join https://confluence.hl7.org/display/DVP/Da+Vinciand sign up for the HL7 Da Vinci Project listserv

Da Vinci Program Manager:Jocelyn Keegan, Point of Care Partners

jocelyn.keegan@pocp.com

Da Vinci Technical Lead:Dr. Viet Nguyen, Stratametrics LLCvietnguyen@stratametrics.com

Get Involved!

Alexandra MuggeDeputy Chief Health Informatics Officer

Centers for Medicare & Medicaid Services

Vision: A Connected, Interoperable Healthcare System

CMS Interoperability and Patient Access Proposed Rule

Ongoing Efforts

• Blue Button 2.0 API• Data at the Point of Care (DPC) API• Prior Authorization

• Documentation Requirement Lookup Service (DRLS) via FHIR-based API• e-Prior Authorization via FHIR-based API

• Quality Data Submission via FHIR-based API• Provider Directory Update