CARIN Alliance Moves Forward on Tools for Consumer-Directed Exchange

May 18, 2020
FHIR accelerator developing blueprint for health plans to share their adjudicated claims information with members

The final interoperability rules ONC and CMS published in March will require payers and providers to share data with patients’ third-party apps via standard application programming interfaces (APIs). That development has accelerated the work of the CARIN Alliance, an HL7 FHIR accelerator project working on consumer-directed exchange.

During a recent online presentation, CARIN Alliance team leaders gave an update on their progress. Leavitt Partners’ Ryan Howells, CARIN Alliance’s program manager, led off by describing the impact of the new regulations from ONC and CMS.

 “This is the first time that providers and payers have been required to send this information outside the HIPAA regulatory environment to the Federal Trade Commission-regulated space, and it is happening at scale across the industry,” he said. “Our focus at CARIN Alliance is on removing barriers to getting consumers digital access to their health information, and allow them to aggregate both the health plan information and clinical information they need to make better decisions and increase the ability for shared decision-making between patients and providers.” He added that the industry is trying to get beyond just providing access to data, but moving to an era where the question is what you can do with the data to make it actionable.

Howells noted that the FTC basically regulates by following the privacy terms of service of the app developer. Whatever the vendors promise consumers is what the FTC enforces. “In healthcare, that doesn’t work well when we are dealing with protected health information,” he said. “We are establishing a common set of policies built on informed consumer consent that companies can attest to.” It is a volunteer code of conduct that the FTC and third-party certification bodies can check to make sure companies are following.

 CARIN Alliance has developed a draft “questionnaire” that would allow consumers to configure their own privacy preferences using the principles in the CARIN code of conduct. It also is using the concept of a “nutrition label” taken from food packaging to make it easier for consumers to understand the privacy and consent policies of app developers.

 A new website called MyHealth Application allows consumers a transparent way to select apps that attest to the CARIN code of conduct, view an app's terms of service, screen shots, and the app's affiliations or connections, such as to CMS Blue Button, the Veteran’s Health Administration or Apple Health.

 Another focus of the CARIN Alliance is digital identity, Howells said. One goal is to move from a system where our digital identities are tied to organizations to one that is person-centric to be used across multiple organizations. They are working with other organizations on promoting NIST standards for identity, working on multifactor authentication as well as trust and federation. Working with other organizations, CARIN has started drafting an open federated digital trust agreement that would allow a person to create an ID-proofed, person-centric, digital identity credential and voluntarily use that single credential across multiple systems.

This year the CARIN Alliance has successfully balloted two HL7 FHIR API implementation guides for consumer-directed payer data exchange ( known as CARIN Blue Button) and consumer-facing real-time pharmacy benefit checks.

 Amol Vyas of Cambia Health, technical lead for the CARIN Blue Button, said the framework provides a blueprint for health plans to share their adjudicated claims information with members through an app of their choice. CARIN is leveraging the HL7 Argonaut Project as a best practice industry-led approach.

 “Just like Argonaut’s common clinical data set, we have created a Common Payer Consumer Data Set (CPCDS) that basically becomes the starting point for the exposure of adjudicated claims data,” Vyas explained. “We map this to FHIR profiles that are the physical representation of the logical/canonical model. This allows for the mapping of their internal claims systems of record to the CPCDS. It becomes a cross-walk to the ultimate FHIR profiles. We want to make it easier for them to stand up consumer-directed FHIR APIs, where their members can access their own data. We have created the FHIR data query profiles as a starting point for payer development teams to begin this process of standing up consumer-directed APIs.”

 Vyas said the ancestor of the CPCDS is the CMS Blue Button 2.0 API content model. “We took the Medicare content model from CMS Blue Button 2.0 API and expanded it to accommodate non-Medicare health plans.”

 The CARIN Blue Button Implementation Guide  is undergoing HL7 ballot reconciliation, and the team recently participated in an HL7 Virtual Connectathon May 13-15, and will appear at the MiHIN Virtual Interopathon on May 28-29.

 Pooja Babbrah with consultancy Point of Care Partners is project manager for the real-time pharmacy benefit check project. She noted that besides patients accessing their records, the consumer-focused approach also targets price transparency with real-time benefit tools. “There are market drivers as it relates to patients understanding what it is going to cost them to pick up their medication. This includes a big push from government,” she said. There is a CMS drug pricing final rule that states that as of January 2021, all Medicare Advantage plans must offer a real-time benefit tool to providers. There is a proposed rule that CMS put out in February that would require real-time pharmacy benefit tools for Medicare beneficiaries to look up price information for their medication.

 CARIN Alliance is developing an implementation guide for the development of APIs for real-time pharmacy benefit checks for consumers that will enable them to access their out-of-pocket costs, therapeutic alternatives, benefit and formulary information, and what their price would be if they paid cash.

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