FHIR for CMS Interoperability

In 2020, the Centers for Medicare & Medicaid Services (CMS) published rules primarily designed to make healthcare information accessible, via an API, to individuals covered by a government healthcare program. The CMS Interoperability and Patient Access final rule requires CMS-regulated payers to effectuate and maintain secure, standards-based APIs using Health Level 7® (HL7) Fast Healthcare Interoperability Resources® (FHIR). These APIs enable 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. The rule also requires MA organizations, Medicaid FFS programs, CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities to make provider directory information publicly available via a FHIR-based Provider Directory API.

The CMS Interoperability and Patient Access final rule governs how FHIR APIs are required to work. The Rule provides a standard for electronic systems to use to exchange health data and it enables patients/members to access their health information through third-party applications.

The FHIR standard was created by HL7 International. FHIR builds on previous HL7 data format standards like HL7 version 2.x and HL7 version 3.x, but is easier to implement since it uses a modern web-based suite of API technology, including an HTTP-based RESTful protocol. It also provides a choice of JSON, XML, or RDF for data representation.

The Opala APIs support FHIR, Da Vinci (PDex) , and CARIN for Blue Button^® . The APIs provide programmatic access to electronic medical record (EMR) data for payers, patients, and the organizations that serve them. The Opala APIs follow the SMART App Launch Framework for the HL7 FHIR Release 4 specification , and the United States Core Data for Interoperability (USCDI) .