CMS launching pilot program to give providers direct access to claims data

The Centers for Medicare & Medicaid Services is launching a pilot program to put claims data directly into the hands of healthcare providers and clinicians through application programming interfaces via the Medicare Blue Button program.

The pilot program will start in September, CMS officials said

CMS Administrator Seema Verma announced the pilot at the White House Blue Button Developers Conference on Tuesday afternoon and said it builds on the agency's MyHealtheData initiative and Blue Button 2.0, two programs that CMS launched last year.

The Data at the Point of Care pilot will enable providers to have the information they need to deliver high-quality care to Medicare beneficiaries, Verma said during an embargoed call with reporters on Monday to discuss the new program.

"By connecting claims data directly to providers at the point of care, providers will spend less time chasing down information or working with an incomplete picture of patients' medical history," Verma said.

The DPC pilot program will use Medicare’s Blue Button to provide access to claims data to fill in the data gaps for providers by giving them access to information like previous diagnoses, past procedures and medication lists, CMS officials said.

The pilot will launch today on the program website,, where providers can request access to the pilot. CMS will start deploying to the first few providers with test data in August and plans to start testing with production data in September and October, CMS officials said.

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CMS plans to slowly roll out to more providers and continue testing and enhancing the workflow as the pilot program grows. CMS plans to eventually make the Data at the Point of Care API available to all fee-for-service providers but CMS officials would not provide a timeline.

Without access to claims data, doctors are left offering treatment solutions with incomplete patient histories, putting patients at risk and potentially duplicating tests and treatments that can be costly or unnecessary, CMS officials said.

Providers participating in the DPC pilot program will, once their health IT is properly configured, be allowed to request a Medicare beneficiary’s Medicare claims data from CMS. This will be done through a developer-friendly, industry-standard API using Health Level 7’s Fast Healthcare Interoperability Resource (FHIR) standard.

By participating in the DPC pilot, providers will have access to patient information directly within their electronic health record workflow, without needing to log into another application, Verma said.

“Technology, coupled with open data sharing, is how we will improve value, control costs and keep patients healthy while ensuring a solvent Medicare program for generations to come," Verma said.

Medicare beneficiaries will automatically be opted-in to data sharing as part of the MyHealtheData initiative and will need to call 1-800-Medicare to opt-out, CMS officials said. The pilot builds on MyHealthEData and Blue Button 2.0 initiatives, both announced by CMS at the 2018 Healthcare Information and Management Sytems Society's (HIMSS) annual conference and exhibition in Las Vegas.

MyHealtheData, led by the White House Office of American Innovation, focuses on giving patients more control over their health data. Blue Button 2.0 uses an FHIR-based API to give Medicare beneficiaries access to their claims data.

There are now more than 2,000 developers using synthetic data in the Blue Button 2.0 sandbox to develop apps and 28 organizations have applications in production, CMS officials said.

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The pilot comes six months after CMS issued its proposed rule on interoperability and patient access that will require Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and Qualified Health Plans to make patient data available through an API to connect with third-party software applications. Many industry groups and federal lawmakers have called on CMS to delay implementing that rule and take a more phased-in approach to lessen the burden on payers and providers.

Jared Kushner, senior advisor to President Donald Trump who has been involved with the White House Office of American Innovation, told reporters on the call Monday that administration officials conducted a national listening tour in 14 different markets and heard firsthand from healthcare innovators about what steps the administration should take to advance interoperability in healthcare.

"Earlier this year, CMS and ONC issued new interoperability rules to ensure the APIs for data access are the new normal and data blocking is a thing of the past. We have widespread adoption of the FHIR standards. The VA and HHS are lined up in support of the FHIR standard. We're very close to the tipping point, or maybe at the tipping point, where monumental innovation in healthcare can have wide adoption and achieve true data interoperability," Kushner said.

The healthcare industry is close to achieving major breakthroughs in interoperability and data sharing, he said.