Profisee - HIMSS workshop - Mar 2025 - final.pptx

Workshop presentation given at the HIMSS 2025 conference, featuring Martin Boyd from Profisee, Anna Taylor from Multicare, Brigitte Tebow from Azulity, and Camille Whicker from Microsoft

1. Any Why You Should Care CMS-0057-F Overview

2. Brigitte Tebow VP Data Management Services, Azulity Brigitte Tebow is a seasoned healthcare technology executive with over 20 years of experience in data management and analytics. As the VP of Data Management Services at Azulity , she leads strategic initiatives to improve healthcare outcomes through innovative data solutions. Brigitte's expertise spans across data governance, interoperability, and advanced analytics, making her a trusted advisor in the healthcare technology sector. Her passion – Teaching Healthcare Master Data Services to improve patient care outcomes with the goal of making the lives of providers easier! 3

3. Master Data Management by design … CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Content of Provider MDM LLC, Not for copy or distribution 4

4. Compliance Countdown: Are You Ready for These Critical Dates? 5 CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange 2026 2027 Upgrade Patient Access API : Add prior authorization data (requests, decisions, expirations) while maintaining HL7® FHIR® R4 standards and secure access. Automate Payer-to-Payer Data Exchange : Enable secure transfer of patient data between payers using HL7® FHIR® R4 and encrypted transmission. Ensure API Compliance : Test for HL7® FHIR® R4 compliance, validate security, and document implementation for CMS audits and stakeholders. Initiate Patient Access API Metric Reporting: Track API metrics (requests, errors, uptime) and establish secure data pipelines for CMS-compliant reporting. Develop and Deploy Provider Access API: Implement an HL7® FHIR® R4-based API for real-time data exchange with in-network providers, secured with OAuth 2.0. Integrate Prior Authorization API: Automate workflows with an HL7® FHIR® R4 API, enabling real-time status updates and seamless EHR integration. Immediate Action Required Prepare for Advanced Technical Updates

5. Interoperability Standards Ensuring your data follows a defined standard allows for the secure exchange of electronic health information, which can lead to better patient care, lower costs, and increased efficiency CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Ensure compliance with industry standards like HL7, FHIR, and ICD-10 to facilitate data exchange across systems. Resource Profile: USCDI CareTeam Profile The Payer Data Exchange ( PDex ) Implementation Guide (IG) Content of Provider MDM LLC, Not for copy or distribution 6

6. CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Impacted payers must implement an HL7® FHIR® Patient Access API to provide patients with access to their health data, including prior authorization information (excluding drugs). This API must be implemented by January 1, 2027. Impacted payers must implement a Payer-to-Payer API to facilitate data exchange between payers. This API must be implemented by January 1, 2027. Impacted payers must implement and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship. This API must be implemented by January 1, 2027. Impacted payers must implement a Prior Authorization API to streamline the prior authorization process and reduce the burden on providers and patients. Payer-to-Payer API Prior Authorization API Patient Access API Provider Access API 1 2 3 4 The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Content of Provider MDM LLC, Not for copy or distribution 7

7. CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Patient Identity This includes managing patient demographics, medical records, and prior authorization information. Provider Identity Accurate identification of healthcare providers is essential for coordination of care. This includes managing provider credentials, affiliations, and roles within healthcare organizations. Payer Identity Managing the identities of payers, such as insurance companies and government programs, is necessary for efficient data exchange and prior authorization processes. This includes managing payer-specific information and ensuring secure access to patient data. CMS requirements will necessitate MDM solutions that allow for custom models, multiple domains, and high volume record counts CMS 0057 – Where Identities Matters Most Content of Provider MDM LLC, Not for copy or distribution 8

8. CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange As WEDI stated, "lean into what you know and partner for support on what you don’t” Complex and Inconsistent: FHIR IGs can vary widely, making it challenging to achieve seamless system integration. Slow and Uneven Adoption: Healthcare organizations adopt FHIR IGs at different rates, which can create gaps in interoperability. Customization Challenges: Many organizations tailor IGs to their needs, but these customizations can sometimes lead to compatibility issues. Resource Considerations: Implementing FHIR IGs requires time, expertise, and financial investment, which can be more challenging for organizations with limited resources. Content of Provider MDM LLC, Not for copy or distribution 9 FHIR Roadblocks You will Have to Break Through

9. Your Common Data Platform Microsoft & Profisee

10. Safeguard your people, health data, and infrastructure Help protect and govern your health data across clouds, apps and devices Empower your healthcare workforce Unlock value from clinical and operational data Accelerate research, discovery, and development Stay focused with AI tools that enhance productivity and automate workflows Realize savings and drive better outcomes through unified data insights. Innovate with data and AI at scale to transform healthcare Enhance patient and member experiences Deliver personalized and connected experiences to improve care management Microsoft Cloud for Healthcare

11. Microsoft Cloud for Healthcare Global Partner Ecosystem Healthcare-relevant IP Clinical applications Modern work Business applications Digital and app innovation Infrastructure Data and AI Security Our unique approach empowers healthcare customers and partners to innovate with AI responsibly at every layer of the cloud.

12. An end-to-end analytics platform that brings together the data and analytics tools that healthcare organizations need to go from the data lake to the business user All your data in one location Data Factory Synapse Power BI Data Activator Synapse Synapse Data Integration Data Engineering Data Warehouse Synapse Data Science Real Time Analytics Business Intelligence Observability Unified data foundation Onelake UNIFIED SaaS product experience Security and governance Compute and storage Business model Microsoft Fabric Healthcare data solutions Healthcare data models Healthcare clinical data pipelines Healthcare analytical solutions Healthcare data solutions

13. Healthcare Data Solutions in Microsoft Fabric Healthcare Data Model – Harmonize healthcare data into a comprehensive model A data model that is both comprehensive and familiar. It can handle the many business domains found in healthcare, such as clinical, administrative, financial, and social. The healthcare data model supports analyzing FHIR clinical data leveraging traditional SQL based tooling, by providing FHIR data in a relational form. Clinical Records Data (Relational FHIR) Imaging Data (FHIR Imaging Study) Social Determinants of Health Data DAX Copilot Data Claims Data  Public Preview GA Patient engagement

14. Some Data Products Core to the HDM Healthcare Data Model – Harmonize healthcare data into a comprehensive model A data model that is both comprehensive and familiar. It can handle the many business domains found in healthcare, such as clinical, administrative, financial, and social. The healthcare data model supports analyzing FHIR clinical data leveraging traditional SQL based tooling, by providing FHIR data in a relational form. Clinical Records Data (Relational FHIR) Imaging Data (FHIR Imaging Study) Social Determinants of Health Data DAX Copilot Data Claims Data  Public Preview GA Patient engagement Patient 360 Provider 360 Reference Data Payer 360

15. Building the Healthcare Data Model Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model Microsoft Fabric Databricks Snowflake

16. Building the Healthcare Data Model Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model ERPs CRMs Legacy Apps Data from many siloed sources – inconsistent and incomplete Regional systems Data Feeds Etc. ? Many Data Sources Dynamics 365 Kyruus Health Symplr EPIC Systems Legacy App Cloud App Custom App Microsoft Fabric Databricks Snowflake

17. Building the Healthcare Data Model ERPs CRMs Legacy Apps Data from many siloed sources – inconsistent and incomplete Regional systems Data Feeds Etc. ? Many Data Sources Dynamics 365 Kyruus Health Symplr EPIC Systems Legacy App Cloud App Custom App Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model Microsoft Fabric Databricks Snowflake

18. Modern Data Estate – MDM before Analytics Platform Microsoft Purview Scan and classify sources Define data standards Profisee MDM Enforce data standards Match/merge Standardize Validate Remediate ERPs CRMs Legacy Apps Data from many siloed sources – inconsistent and incomplete Regional systems Data Feeds Etc. Many Data Sources Dynamics 365 Kyruus Health Symplr EPIC Systems Legacy App Cloud App Custom App Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model Microsoft Fabric Databricks Snowflake

19. Building the Healthcare Data Model Data Stewardship Master Data Match/ Merge Workflow Profisee MDM Microsoft Purview Data Catalog Master Data Assets and Processes Governance Standards and Policies Data Quality ERPs CRMs Legacy Apps Data from many siloed sources – inconsistent and incomplete Regional systems Data Feeds Etc. Many Data Sources Dynamics 365 Kyruus Health Symplr EPIC Systems Legacy App Cloud App Custom App Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model Microsoft Fabric Databricks Snowflake

20. Building the Healthcare Data Model Patient 360 Provider 360 Payer 360 Reference Data Consumable Data Products Consolidated, certified, documented Trusted and ready to use Healthcare Data Model Microsoft Fabric Databricks Snowflake Regulatory compliance CMS-0057-F Cures Act Trusted data to share With other organizations With your internal customers Analytic and Operational improvements Prior authorization process Patient engagement Population health foundation Claims analysis Outcome analysis Provider Directory Provider scheduling Asset utilization …

21. Benefits of a Common Data Platform Multicare

22. Purchaser Value Criteria Range of Services: Adequacy to serve members/ beneficiaries Affordability Outcomes of Care Effectiveness of Care Proactive quality & equity of health Addressing Health Equity and Social Determinants of Health Utilization Management Digitally Interoperability Coordinated Care Team of Teams

23. Strategic Alignment Operational Engine Enterprise Business Case (Requirements) Drivers Federal Rulings & Compliance Economic Access to Technology Diminishing Reimbursement Rates Internal tipping points driving the transition from historical methods of interoperability to an advanced standardized solution Signals for Semantic Interoperability

24. Let’s solve for the problem together : Regence Let’s try something new : reporting quality measures using open standard APIs Let drive results :

25. Prior Authorization Time Study December 2023 Time Study completed by MultiCare Pre-Service centralized Auth Team Completed for all real-time authorization tools as well as payer portals (manual) Grouped by specialty Bot Technology EMR Solution FHIR App Payer Portals Lower is better Types of Auths Average Minutes to Complete Prior Auth Went from 3-5 Auth per hour to 10-12 per hour

26. What we learned : Identity as a foundation of APIs Grouping for CMS 0057 – Linking Plans No Universal Plan Codes No Universal Payor Codes How FHIR APIs are presented (Semantics, our EHR utilizes all active coverages in the coverage API Creating internal linking keys and identities between Payor and Provider

27. Decrease in Patient Matching Error Rates Burden reduction from processing matching errors 5-10 min Per Error 60% Decrease in Error Rate Measuring the Value – Risked Based Membership (ATR) 29 67.5% Time saved per FTE Efficiency gains to be redirected to other activities

28. Have a Voice - Join Us in the Work HL7® Da Vinci FHIR Accelerator: https://www.hl7.org/about/davinci/ CMS Claims-Based FHIR APIs: BCDA, Blue Button 2.0, AB2D CMS Office of Healthcare Experience and Interoperability: https://www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability NCQA Digital Implementors Community: https://www.ncqa.org/digital-quality-implementers-community/ Bulk FHIR Quality Coalition: https://www.ncqa.org/bulk-fhir-api-quality-coalition/ 30

29. DA VINCI PROJECT: PROJECT CHALLENGE To ensure the success of the industry’s shift to Value Based Care Transform out of Controlled Chaos Develop rapid multi-stakeholder process to identify, exercise and implement initial use cases Collaboration Minimize the development and deployment of unique solutions. Promote industry wide standards and adoption Success Measures Use of FHIR ® , implementation guides and pilot projects

30. USE CASE & IG READINESS Implementation Guide Dashboard: https://confluence.hl7.org/display/DVP/Da+Vinci+Implementation+Guide+Dashboard * Referenced in or supports Federal Regulation Aligned with expected Federal Regulation Guide Paused and Core Functionality moved to PDex Dial denotes progress in current STU Phase Overall Maturity: Most Mature Active Growth Least Mature Coverage, Transparency & Burden Reduction Clinical Data Exchange Clinical Data Exchange ( CDex ) t Payer Data Exchange (PDex) * Notifications * Coverage Requirements Discovery (CRD) * Documentation Templates and Rules (DTR) * Prior-Authorization Support (PAS) * Formulary * Plan Net/Directory * Patient Cost Transparency (PCT) * Foundational Assets Member Attribution List t Health Record Exchange (HRex) Payer Coverage Decision Exchange + Quality & Risk Data Exchange for Quality Measures/Gaps In Care (DEQM/GIC) t Risk Adjustment (RA) Value Based Performance Reporting (VBPR) Postable Remittance

31. Recommendations and Resources 33

32. Readily available via MDM Accepting new patients PCP and specialty classification types (as defined by ACOs, payors services) Referral Frequency and Classifications Attribution Analytics (Admitting, Attending, Consulting) Ages of Patients Seen Population Seen Specific Privileges Performed (not purchased reference data for common scope-of-practice) Degree Groupings Specialty Groupings Data Elements not typically managed through a centralized channel: CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Content of Provider MDM LLC, Not for copy or distribution 34

33. Strategic Roadmap & Milestones 35 Milestones CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange 1 2 3 Reference Architecture and Data Flow Tactical Planning – 2025, 2026, 2027 Before the FHIR - Disaster Preparedness Planning

34. Before the FHIR 36 Understand Implementation Guide(s) (IGs) Per Requirement Define Governance Process to approve IG use Code Sets vs. Value Sets vs. Extensions When to Customize the IGs Internally defined Reference Data (Groupers, Hierarchies, Code Sets, Ontologies) Additional Data Elements for local, regional, federal, etc. Identify Expertise Required – Internally vs. Externally Define areas of responsibility and critical milestones Milestone 1- Disaster Preparedness Planning CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange 1

35. Interoperability - Governance FHIR Insurance CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Provider Patient Member Coverage Organizations Facilities Locations Sites Departments Geospatial Models  Taxonomies Hierarchies Ontologies Value Sets (Code Sets) Cross-walks Identifiers Historical Data  Laboratory Pharma Recruitment Employment International Classification of Diseases Current Procedural Terminologies Diagnostic Related Groups Relative Value Unit Codes National Uniform Claims Codes Phone Types Email Types Communication Preference Types Degree Codes Specialty Codes Fee Schedule Patient Status Code Gender Codes Coverage Code Types Claim Transaction Status Postal Address Type Mapping Cost Share Type Mapping Employment Status Type Zip to County Content of Provider MDM LLC, Not for copy or distribution 37

36. Before the FHIR 38 Understand Required Capabilities before tool selection process Known existing Internal tools/capabilities (Application Inventory) Collaborate on Infrastructure Needs within the Industry Internal Peers Networking Across Industry Advisory Services Understand the Data Flow – End-to-End Architecture Milestone 2- Reference Architecture and Data Flow CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange 2

37. Before the FHIR 39 Identify Critical Domains and Development Order Obtain backing/support from Clinical Stakeholders and Application/Source Owners – to clear roadblocks Build the Bench Program Resources Project Resources Define the Work breakdown Structure and Critical Dates Milestone 3- Tactical Planning CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange 3

38. Consistent Provider Data CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Degree Status Specialties (Privileges) ARNP Active with privileges Anesthesia A.R.N.P Member with privileges Anes ANP-R Hospital based EP2 AP-RN Office based Anesthesiology APRN Allied health independent AN   Promotes consistency Creates common terms for use throughout the organization Allows subject matter experts to understand information more readily Data Sources Collect Consolidate Cleanse Distribute Users MDM PLATFORM Centralize and standardize provider information (NPI,  credentials, specialties) across different systems to ensure uniform attribution. Content of Provider MDM LLC, Not for copy or distribution 40

39. Master Data is used to provide a single point of reference for critical data utilized across the enterprise. The key objective is to provide the organization an authoritative Source-of-Truth for a given information area (e.g. patient, provider, member, location, reference) The basic process consists of ingesting data from multiple sources into an MDM engine which then matches and/or merges records and applies logic to provide consumers with data that is standardized into a single “master” or “golden” record that has the agreed upon best (highest trusted source information) and finally, providing it to consumers in the manner they prefer. CMS Interoperability and Prior Authorization Final Rule: Transforming Healthcare Data Exchange Client Use Case Master Data Management Data Flow Content of Provider MDM LLC, Not for copy or distribution 41

40. Resources LISTEN & SUBSCRIBE https://profisee.com/podcast Hear from Data Leaders CATCH THE REPLAY https://profisee.com/data-hero-summit CMS-0057 and Related QR Code linking to resources landing page

41. Thanks for your Time!