What You Need to Know about FHIR Implementation Guides for CDex and PDex

We’ve reached a tipping point in healthcare where the allocation of care has moved from providers to payers. Nowhere is this more apparent than in Medicare. And, as more and more people make the move to Medicare Advantage (MA), the shift – and the consequences of the shift – becomes even more pronounced. 

Data and Data Liquidity are Extremely Important

It’s in this current state of play – where the goals of improving care quality while decreasing care cost are paramount – that data has become the currency of care. To be successful, we need to be able to exchange clinical data and payer data, combine it, and compute on it. We must continue to move away from manual, analog processes and digitally transform, just as almost all other industries have. 

To-date, most digital transformation efforts in US healthcare have been driven by the Centers for Medicare & Medicaid Services (CMS) through administrative efforts. And, fortunately for all of us, the drive to transform how data is handled in healthcare has been a largely bipartisan effort, moving forward across party lines and administrations.

Since its inception, there has been lots of progress pushing FHIR® as the de facto standard in health data exchange, including decades-long investments and regulations at both the federal and state levels. Base capabilities to handle FHIR have been built into EHRs. And the building blocks of Bulk FHIR, SMART, and CDS Hooks are all in place.

In addition, the market is ready for FHIR. Both providers and payers – especially those in value-based agreements – have a high need for standardized clinical and claims data. And it’s clear where standardized FHIR data can have the greatest impact, including clinical data exchange to manage quality, risk, and care, and to automate prior authorization. 

Enter HL7 FHIR Accelerator Programs

Founded in 1987, Health Level Seven International (HL7®) is a not-for-profit standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of health data. 

HL7 is a great example of the public and private sectors coming together – including CMS, ONC and over 500 corporate members representing providers, payers, vendors, and consulting firms – to set standards and accelerate transformation. 

As part of its efforts, HL7 fosters Accelerator Programs to assist implementers and developers across the healthcare and research spectrum in the creation of HL7 and Da Vinci FHIR Implementation Guides. 

But what exactly is an implementation guide? An implementation guide is a set of rules about how FHIR resources are used (or should be used) to solve a particular problem, with associated documentation to support and clarify the usage. At its core, an implementation guide is, at a given point in time, in a workflow with a specific set of rules and actors, surfacing what data is available so that developers can build APIs that are fit-for-purpose and extend them. They are reusable, use case specific, built with workflows in mind, open source, content-rich tools. With them, implementers can build initial patterns for specific business challenges and then reuse them, saving time and money. 

Clinical Data Exchange (CDex) and Payer Data Exchange (PDex) 

Two key areas of focus for the HL7 Accelerator Program are in the areas of Clinical Data Exchange (CDex) and Payer Data Exchange (PDex). CDex and PDex are essentially payloads for the three CMS Access APIs and Prior Authorization API. Together, CDex and PDex help answer the questions: Who’s getting what care, where, and at what price? 

CDex focuses on how to get data out of EHRs and into the hands of other people who need it – like patients, payers, and other providers. It can be used for Payer-to-Payer APIs and Prior Authorization APIs. CDex use cases include:

• Requesting documentation to support claim submission and Prior Authorization
• Exchanging clinical data between referring providers
• Sending supporting documentation for claims and Prior Authorization

PDex, on the other hand, is clinical and non-financial data that a payer can share with providers (Payer-to-Provider) and the subsequent payer (Payer-to-Payer Bulk Data Exchange). It’s focused on reducing the burden on patients and providers, enabling authorized persons to self-service the information they need.

Implementation Guides Aren’t Just for Technical People

At first glance, implementation guides can seem very dense. But, they can be very helpful to leverage as cheat sheets – providing a list of things to think about – even for non-technical people. Some examples of who might use implementation guides and for what include:

• Industry best thoughts on data fields available and collected, and how to use the data available
• Product developers can infer and learn from what’s in the guides
• Product teams can get guidance during the design phase

FHIR Implementation Guides for the Win

Real progress has been made as a result of these implementation guides. Some payer-provider partnerships are already doing clinical data exchange for real-time attestation around quality measures and HEDIS scores for payment, and Bulk FHIR has advanced significantly. 

In the end, implementation guides illustrate the power of people working together to solve common technical challenges. Saving time. Saving money. Driving to better solutions. Creating repeatability. All to fix healthcare – a very lofty goal indeed. 

To learn more about the important work of HL7 and Da Vinci, and CDex and PDex Implementation Guides, watch this presentation entitled “CDex, PDex, and All that Jazz” from the 2024 WEDI Spring Conference, led by Dr. Don Rucker, Chief Strategy Officer of 1upHealth, and Jocelyn Keegan, Program Manager for the HL7 Da Vinci Project and Payer Practice Lead for Point-of-Care Partners.