AMIA Recommends 'Phased Approach' to Payer API Requirements

Tuesday, June 4, 2019

Informatics experts call for new Innovation Center funding models to foster the growth of advanced clinical informatics professionals and Board-certified Clinical Informaticians

BETHESDA, MD – In comments submitted today to the Centers for Medicare & Medicaid Services (CMS), the nation’s informatics professionals recommended a phased approach for making payer and insurance plan data available through open application programming interfaces (APIs) to beneficiaries. The American Medical Informatics Association (AMIA) also called on the CMS Innovation Center (CMMI) to develop new models to provide structural funding for the training of ACGME-accredited Clinical Informatics fellowships.

In a notice of proposed rulemaking (NPRM) issued in April, CMS proposed several policies important to the informatics community. First, CMS proposed requirements that would make Medicare Advantage (MA) organizations, State Medicaid or CHIP agencies, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plans (QHP) in Federally Facilitated Exchanges implement and maintain open APIs that permit third-party applications to retrieve data through the use of common technologies. Such access would be with the approval and at the direction of the individual beneficiary. These APIs would need to be in place by January 2020 for MA and QHP plans, and July 2021 for Medicaid and CHIP agencies.

AMIA supported these API proposals, but noted that the government’s timelines were too aggressive, given the state of standards development and adoption. For instance, CMS would have required the adoption of new data standards proposed by the Office of the National Coordinator for Health IT (ONC) as part of the U.S. Core Data for Interoperability by January 2020. ONC is not expected to require certified health IT to generate such data until January 2021 at the earliest. Further, AMIA noted that there is inconsistent adoption and use of standards beyond those included as part of the USCDI, especially for laboratory results, drug benefit data, pharmacy directory information and formulary data.

To address these issues, AMIA recommended CMS establish a phased approach, beginning July 2020, to require payer data be made available to beneficiaries via open API. The first phase would include claims and encounter data; the second phase would include clinical data and lab results; and the third phase would include drug benefit, pharmacy directory, and formulary data. AMIA noted that CMS may want to consider the use of ONC’s Certification Program to align standards and implementation decisions across stakeholders who generate and use these datatypes.

“We applaud CMS for their proposals to improve beneficiary access to health plan data,” said Peter J. Embi, MD, MS, FACP, FACMI, FAMIA, AMIA Board Chair, and President and CEO, Regenstrief Institute, Inc. “But we must install deliberate processes and sensible timelines to ensure these data are useful for beneficiaries.”

The NPRM also included several Requests for Information (RFIs) seeking input on a range of issues from how to improve adoption and interoperability of Long-term, Post-Acute Care settings to ways that the CMS Innovation Center can leverage its authority to advance interoperability. In response to the CMS Innovation Center RFI, AMIA recommended that CMMI develop models that preference applications that promote interoperability and advance health IT. One approach could be to enhance model application requirements for all CMMI models to optimize the use of informatics and improve interoperability. Another recommendation AMIA made was to fund ACGME-accredited Clinical Informatics fellowships through new funding models.

“Structural and specified funding mechanisms for the training of Clinical Informatics fellows is necessary for CMS to attain stated goals for improved interoperability and use of data for patient care,” the comments stated. “AMIA calls on policymakers and federal funders to create direct support for Clinical Informatics fellowships through new funding models at CMMI.”

Finally, the NPRM proposed changes to Medicare Conditions of Participation for hospitals. CMS proposed a new “Electronic Notifications” standard that would require hospitals to send electronic patient event notifications of a patient’s admission, discharge, and/or transfer to another health care facility, or to another community provider.

In comments submitted to CMS in June 2018 as part of the IPPS NPRM, AMIA recommend that CMS garner experience and insights under the Information Blocking rule, once finalized, before deciding to modify COP/CfC/RfPs. AMIA also recommended that, “Should CMS endeavor in this direction, we recommend considering Admission, Discharge, Transfer (ADT) feeds as potential candidates for incorporation into CoPs/CFCs/RFPs updates.”

In response to this NPRM, AMIA recommended CMS proceed with limited scope on eNotification Medicare Conditions of Participation requirements, and compile stakeholder feedback over the next payment year to better understand which standards and technical approaches are preferred by industry.

Click here for AMIA’s full comments.
 

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AMIA, the leading professional association for informatics professionals, is the center of action for 5,600 informatics professionals from more than 65 countries. As the voice of the nation’s top biomedical and health informatics professionals, AMIA and its members play a leading role in assessing the effect of health innovations on health policy, and advancing the field of informatics. AMIA actively supports five domains in informatics: translational bioinformatics, clinical research informatics, clinical informatics, consumer health informatics, and public health informatics.