Why the CMS Interoperability Final Rule Will Change Everything for Healthcare

"The Interoperability and Patient Access final rule (CMS-9115-F) delivers on the Administration’s promise to put patients first, giving them access to their health information when they need it most and in a way they can best use it."

With those 37 words, the Centers for Medicaid and Medicare Services changed the face of healthcare. This rule has the opportunity to change the way the entire healthcare industry does business. Historically, the healthcare IT standards focused on standardizing communication between insurance companies and providers with information like enrollment, payments, and claim status. This rule "allows patients to easily access their claims and encounter information, including cost, as well as a defined sub-set of their clinical information through third-party applications of their choice."

This is not news for many IT people in the health insurance industry--this rule has been talked about for a long time and there are dozens of boutique IT firms popping up to provide "FHIR servers." Nevertheless, it is still relatively unknown to many in the business community. And there is a lot of confusion about the terminology and the implementation. This is an attempt to "demystify" exactly what it is and to give the average person a working knowledge of this rule. Why? Because once this is implemented, any IT organization that meets the security and privacy requirements will be able to use these APIs and provide differentiating experiences to people. Imagine building an app that enables people to help them with their budget, marrying together their bank account and the projected spend from the claims their doctor submitted. Or imagine, as an employer, putting together an intranet application which enables your employees to choose a doctor close to your workplace (or their home) without forcing them to log into the provider's portal. Imagine putting together a app which allows people to see the closest pharmacy while on the phone with their doctor in the app of their own choosing. These will all be possible once the mandate is fully implemented.

What is the Core of the CMS Mandate?

The CMS mandate is aimed at standardizing the way healthcare companies talk to each other and providing their solutions so that non-healthcare IT organizations can also take advantage of the standardization. It's easy to get lost in all the terminology (and I'll define three key terms in the next section), but at its core, the CMS Mandate, if implemented as envisioned, will do for healthcare what the ACH specification has done for banking: it will make information sharing easier, and enable faster and more accurate information to anyone authorized to see it. Just like ACH, within 20 years, we'll likely see a commercial just like this one:

Key Terminology

Let's talk about four terms: FHIR, SMART on FHIR, "Resource", and "FHIR Server".

FHIR: "Fast Interoperability Health Resources." This is the industry “technical” term for a specification owned by an industry organization (HL7) that describes the full that enable interoperability. It's not specifically a "language"--it's a specification that can be implemented several ways. Think of FHIR as a skeleton--it's a "framework" that everything else goes on top of.

SMART on FHIR: "Substitutable Medical Applications and Reusable Technology": SMART was developed in 2010, pre-dating FHIR; however, was updated in 2014. It describes the key agreements that all participating apps need (like how to authorize someone to access, how to show it to end users, etc.). Think of SMART on FHIR as the muscular system. It needs the skeleton of FHIR, but also supports the overall goal for interoperability.

Resource: A "resource", in FHIR terms, is a logical collection of data which helps both systems and people make sense of the complexity of medical information. Some good examples of resources include "patient", "appointment", "medication" and other information.

FHIR Server: Software that implements the FHIR specification in a way that developers can interact with it.

Isn't FHIR just a set of APIs?

No. While the core FHIR specification does have a set of APIs, it's much broader. It also contains a collection of "information models that define the data elements, constraints and relationships for the “business objects” most relevant to healthcare." 

FHIR has been gaining traction since 2014 and it has accelerated. Several open source frameworks have emerged that implement the FHIR standard (see HL7.org for a list of known implementations on Java, .Net, Python, Ruby, Swift and others). Recently, Google, Microsoft , and IBM have also implemented their own FHIR servers and AWS supports all of the implementations on their Cloud offerings. In addition, some of the major health IT vendors like Cognizant (Trizetto) and Edifecs have also implemented value-add services using the base technologies above

Where Can I Learn More?

Feel free to send me a message and I can give a one hour overview of FHIR. Or, if you have time, the best place to start is at the source: https://www.hl7.org/fhir/