CMS has issued new prior authorization interoperability rules, as well as requirements for payers to exchange data electronically using modern application programming interfaces (APIs). The eHealth Exchange is at the center of an ambitious digital health pilot project in Utah to implement a statewide FHIR-based ecosystem. Its president and executive director, Jay Nakashima, recently spoke with Healthcare Innovation about how the Utah project can serve as a model for other states. 

Healthcare Innovation: How did eHealth Exchange get involved in this Utah interoperability pilot project?

Nakashima: There’s a payer called Cambia out on the West Coast, and they operate some commercial plans, including Regence Blue Cross Blue Shield. They were struggling with payer-to-provider exchange as well as payer-to-payer exchange. They developed a super slick prior authorization application using SMART-on-FHIR technology. They piloted it at some health systems who happen to be eHealth Exchange participants. 

MultiCare and other health systems loaded this app. It appears as a single tab in the EHR. Providers and Cambia really liked this application but the providers told us they can’t have all these tabs in their EHR, one for United, one for Cigna, one for Cambia, one for Humana. Cambia said the same thing. They cannot be calling 6,000 U.S. hospitals and asking to negotiate a trust agreement and asking to create a technical connection.

They all told us they need a centralized solution, and we said we could create a hub-and-spoke model. No. 1, we already have a trust agreement. We just need the payers to join us. No. 2, we’ve got technical connections with 75% of U.S. hospitals. 

Then, as I understand it, the governor in Utah said, “Hey, we need to get all the healthcare organizations in Utah — public health agencies, providers, payers, and social networks connected, and instead of doing it the old-school way, via CCDAs, let's do it using more modern HL7 Da Vinci APIs.”

HCI: What’s the timeline of this project and is it ongoing? 

Nakashima: Ryan Howells of Leavitt Partners is managing this. It started about two years ago. There is no end date. It’s forming a model for state-based connectivity in 12 other states, Washington being No. 2. 

HCI: Are you seeing other states starting to form committees to begin these pilots themselves?

Nakashima: Yes, there are 11 other states that are in various stages of trying to copy what Utah and then Washington are doing.

HCI: One of the Utah goals is testing prior authorization APIs. CMS-0057 regulations require three prior authorization APIs, which provide payers, providers, and patients real-time information on the status of prior authorization, with the goal of reducing burden and patient wait times. Are there some lessons learned in that process?

Nakashima: That's been under way for a couple of years. My first lesson was that initially I didn't think much of the the API that asks: is this procedure or service even covered for this patient?  But to my surprise, that is the hallmark of the success. That is where something like 80% of the determinations are made. 

Another of the big takeaways is that the payers and providers have learned that they really need this hub-and-spoke model. For instance, a health system like Intermountain Health’s first inclination might be to say we know who we exchange with. We're going to spend nine to 10 months negotiating a trust contract with them and then spend nine months negotiating how we're going to do this technically, and how we're going to interpret HL7 Da Vinci.They learned quickly that that's going to get them nowhere fast. 

So they've connected to our hub-and-spoke model, and it really accelerated that process. Intermountain already has the technical connection. They've already got the trust contract. All they have to do is electronically trust or consume an eHealth Exchange SMART-on-FHIR app that they can load that into their EHR —just like you trust loading a new app on your phone, right? 

HCI: In Utah, there are a couple of other elements I saw described that seem even more ambitious and aligned with what folks at CMS are saying now about single sign-on framework and a federated digital identity ecosystem. Is that work that's they've already made some progress on, or is that kind of future-looking?

Nakashima: Individuals patients have had the right for the past year and a half to electronically retrieve their rich clinical histories. But it hasn't been plug and play. It's been tough. This new CMS Aligned Network idea is proposing to really streamline individual or patient identification. This involves a technology called IAL2 — think about how when you go to the airport and and you use CLEAR, or how you use ID.me. The concept is really trying to to give these technologies and processes more clout and reliability. CMS really kind of surprised the interoperability segment with their engagement a couple weeks ago. So I'm not clear yet when the next steps will kick in.

HCI: What are you working on these days in your role as a QHIN under TEFCA? I know you have many HIE organizations using eHealth Exchange as their connection to TEFCA.

Nakashima: We’re always here to support the federal agencies. So far, the Indian Health Service chose eHealth Exchange for that. We do not yet have the other federal agencies, so the Veterans Administration, DOD, FDA, SSA, etc.

HCI: And that's a lot of data.

Nakashima: That's a tremendous amount of data. We’r working to get them ready for TEFCA. We're working with public health agencies in all 50 states trying to get them onboarded to TEFCA. They have been victims over the decades of these Frankenstein architectures, with systems that don't talk to each other. We're really working hard to modernize public health exchange, ideally over TEFCA. 

And then there is payer exchange. My God, that is so ripe for for automation. We move over 25 billion transactions annually across the U.S., and 98% or 99% of those move for treatment purposes. What that means, though, is that the remaining 1% or 2% of our transactions moved are moving to help public health or to help payers or to help individuals, so we're trying to rapidly expand that non-treatment exchange of data.

HCI: Well, does that require more work at the RCE-level on agreements or has that already been established for other use cases?

Nakashima: Really it's not a technology issue. It's a trust policy issue. It's about convincing the providers that it's safe and responsible to release information for non-treatment purposes in an automated fashion. They're accustomed to doing it via phone and fax, and we need to move that to more modern solutions.

HCI:  Was there a question when the administration changed about whether this new administration was going to be gung-ho about TEFCA or not? It seemed like there was a pause in the RCE meetings. Were people trying to read tea leaves about whether this is the way they want to go or were they going to propose something else?

Nakashima: Yes, we spent a good five months asking that same question, but it has become clear over the past six weeks that this current administration is gung-ho on TEFCA.