By Edward Yurcisin

July 30,2019, at the White House

The Centers for Medicare & Medicaid Services (CMS) recently held the second annual Blue Button 2.0 Developer Conference on the 54th anniversary of Medicare. There were several key takeaways from the conference:

  1. CMS launched the Data at the Point of Care Pilot.
  2. The cloud industry reaffirmed their commitments from last year’s Blue Button Developer Conference.
  3. The CARIN Alliance launched a “real-world testing” coalition for Payer Blue Button or the Common Payer Consumer Data Set (CPCDS).
  4. Health Level Seven (HL7) and the Office of the National Coordinator for Health Information Technology (ONC) launched a “real-world testing” coalition for testing and implementing the HL7 Bulk FHIR  specification.
  5. Federal research agencies announced several interoperability initiatives.

Data at the Point of Care

As part of the MyHealthEData initiative, the CMS announced a new pilot program called Data at the Point of Care. This initiative will deliver Medicare’s Blue Button data to clinicians to provide a more complete patient history. Clinicians will be able to access their patients’ information within their clinical workflow, which enables the delivery of high-quality care. This initiative will utilize the Blue Button FHIR APIs and requires that the data be accessed within the existing clinical workflow. Incorporating this data into the clinical workflow requires an EHR integration either through a SMART on FHIR application or through enhancements to the EHR.

This pilot will provide fee-for-service providers FHIR-formatted bulk data files of their active patients. Data is shared for treatment purposes as defined under HIPAA. A healthcare provider will assert to CMS that the provider has a treatment-related purpose for accessing patient information by submitting an attribution roster. CMS is currently piloting the implementation of the Attribution Guide, which is part of the Bulk FHIR specification.

While this pilot initiative is similar to the CMS Beneficiary Claims Data API (BCDA) program, there are some differences. The BCDA provides FHIR-formatted bulk data files to an Accountable Care Organization (ACO) only for all of the beneficiaries assigned to the ACO. The Data at the Point of Care Pilot provides FHIR-formatted bulk data files to fee-for-service providers for their active patients, regardless of the patient’s ACO affiliation.

CMS Manage Your Health is located here.
And information on CMS Blue Button 2.0 is found here.
The CMS announcement on Data at the Point of Care can be found here.
The Google Group for the Data at the Point of Care Pilot is located here.
More information on the Beneficiary Claims Data API program can be found here.

Cloud Interoperability Commitment

Microsoft, Amazon, Google, IBM, Oracle, and Salesforce reaffirmed their commitment to healthcare interoperability. These organizations are contributing and actively participating in FHIR’s standard-development, testing, and use. The open-source tools highlighted include Google’s FHIR protocol buffers and Apigee Health APIx, Microsoft’s FHIR Server for Azure, Cerner’s FHIR integration for Apache Spark, a serverless reference architecture for FHIR APIs on AWS, Salesforce/Mulesoft’s Catalyst Accelerator for Healthcare templates, and IBM’s Apache Spark service. These technology companies are supporting an API-first strategy for healthcare interoperability.

CARIN Alliance

In the 2019 Medicare Call Letter, found here, CMS encouraged plans to “meet or exceed the capabilities of Medicare Blue Button 2.0”, and forewarned of future rulemaking that would make this a requirement. The CARIN Alliance organized a group of health plans, providers, and others to develop the data format needed for commercial payers to meet this obligation. This data format is called the Common Payer Consumer Data Set (CPCDS) or Payer Blue Button.

The CARIN Alliance released the CARIN Blue Button data model and draft the implementation guide, which includes more than 240 claim data elements that have been agreed upon by multiple regional and national health plans. The FHIR Resources of the CARIN Blue Button will assist health plans in meeting the requirements of the CMS Interoperability and Patient Access proposed rule. The CARIN Alliance announcement can be found here.

At the Blue Button Developer Conference, Humana’s Heather Cox announced the organizations that have committed to testing this data format in 2019 so it can move into production in 2020.

The following organizations committed to this testing coalition:

View BBDC 2019 Webinar Recap

  • Anthem, Inc.
  • Apple
  • b.well
  • BlueCross BlueShield of Arkansas
  • BlueCross BlueShield Association
  • BlueCross BlueShield of Louisiana
  • BlueCross BlueShield of North Carolina
  • BlueCross BlueShield of Tennessee
  • Blue Shield of California
  • Cambia Health Solutions / Regence BlueCross BlueShield
  • Florida Blue
  • Google
  • Humana
  • Manifest MedEx
  • Microsoft
  • Marshfield Clinic Health System-Security Health Plan
  • Prominence Health Plan
  • UPMC Health Plan
  • State of North Carolina
  • State of Washington

There will be a track specifically for testing the CARIN Blue Button Implementation Guide at the next FHIR Connectathon held in Atlanta, GA, on September 14th and 15th. Information on the Connectathon can be found here. The Draft Implementation Guide can be found here.

Chrissy Farr from CNBC wrote a fascinating article for CNBC on the CARIN Alliance announcement. It can be found here.

HL7 / ONC Bulk FHIR Testing Coalition

ONC and HL7 announced a collaborative to test the Argonaut Project’s Bulk FHIR Implementation Guide. Working with the EHR vendors, these organizations will conduct early real-world testing of the Bulk FHIR specification. This is a critical upgrade to the interoperability ecosystem because it reduces the cost burden to acquire and ingest clinical and claims data by enabling population-level data exchange. At the Blue Button Developer Conference, the CMS Administrator stated that “bulk is one of the most important keys to interoperability, allowing us to share data on groups of patients instead of just individuals.” Seema Verma’s full remarks can be found here.

Organizations with a contractual right to data will be able to utilize Bulk FHIR to extract data from electronic medical records for the patient population. The announcement from HL7 and the ONC can be found here.

These are the early adopter organizations that have committed to testing the specification:

  • Anthem, Inc.
  • BlueCross BlueShield of North Carolina
  • BlueCross BlueShield of South Carolina
  • BlueCross BlueShield of Tennessee
  • Boston Children’s Hospital/SMART
  • Cambia Health Solutions
  • CVSHealth (Aetna)
  • Florida Blue
  • Humana
  • Intermountain Healthcare
  • Jefferson Health
  • Manifest Medex
  • Marshfield Clinic Health System and Security Health Plan
  • Medical University of South Carolina & Health Sciences South Carolina
  • Medigold
  • Mount Sinai Health System (NY)
  • MultiCare Health System and Physicians of Southwest Washington
  • OCHIN
  • OrthoVirginia
  • Oscar Health
  • Rush University System for Health
  • Trinity Health
  • U.S. Department of Veterans Affairs

The Bulk FHIR coalition will kick off with a conference call on Tuesday, August 27th at 11 am. If you are interested in joining the kick off call please email either [email protected] or [email protected].
The Bulk FHIR Implementation Guide can be found here.

Bulk FHIR utilizes group attribution to identify a patient population. Information on Bulk FHIR Attribution from the SMART-on-FHIR team can be found here.

Federal Research Agencies Interoperability Initiatives

The National Institutes of Health (NIH) announced a Guide Notice, found here, on FHIR the encourages NIH-funded research to utilize the FHIR standard. With this notice, the NIH is promoting interoperability and the use of FHIR in its funded clinical research. Additionally, the NIH posted a Notice of Special Interest also encouraging the use of FHIR in the development of health IT applications. This notice for Small Business Innovation and Research can be found here.

Additionally, the Agency for Healthcare Research and Quality (AHRQ) announced that their Chronic Pain Management application is available for use. This application was tested by OCHIN in an Epic EHR using FHIR resources for data access. This application has the potential to integrate with state PDMPs. In July 2015, CMS released guidance stating that through Section 1115 Waivers, states could request federal funding for nonelderly adults primarily receiving substance use disorder services in institutions for mental disease (IMDs).

On November 1, 2017, CMS issued revised guidance that continues to allow states to seek Section 1115 waivers to pay for services provided in IMDs, including substance use disorder services. The AHRQ Chronic Pain Application would likely qualify, and the federal funds could be used to enhance any necessary infrastructure. More information on the AHRQ application can be found here.

There is another NIH interoperability project from the National Library of Medicine (NLM). The NLM has released a SMART-on-FHIR application Questionnaire application for Social Determinants of Health. More information on this application can be found here. An FHIR R4 version of the application is found here. The application uses the Questionnaire and QuestionnaireResponse FHIR resources and is designed to be launched from an EHR using SMART-on-FHIR to connect to the EHR’s FHIR server.


There were several other items of interest discussed during the webinar.

“Blue Bar” to Align Data Access to Application Strategy
First, the concept of the “Blue Bar for Interoperability” was introduced. This is important for any organization that is publishing or consuming data with others. The purpose of the Blue Bar is to manage the three categories of applications that will need approval to obtain access to data. The three types of applications are:

  1. Consumer Access applications
  2. Bulk Access applications
  3. Network Access applications

Consumer Access applications are applications like Apple Health. Developers will need to register applications to pull data for one patient at a time.

Bulk Access applications are applications that operate under a contract. Applications that are accessing data for a health plan or an ACO require this second type of authorization.

Network access applications require a third type of authorization. For example, an application could request that a health system provide notification whenever a patient in the network is admitted or discharged from a hospital.

Coordinating these three types of applications necessitates a “Blue Bar” to align the access policy to strategy.

Ciitizen Scorecards
Also discussed on the Recap Webinar was that Ciitizen has released scorecards on how medical record providers comply with the HIPAA right of access on patient requests. The scorecards can be found here.