June 4, 2019 -- BETHESDA, MD – In comments submitted today to the Centers for Medicare & Medicaid Services (CMS), the nation's informatics professionals recommended a phased approach for making payer and insurance plan data available through open application programming interfaces (APIs) to beneficiaries. The American Medical Informatics Association (AMIA) also called on the CMS Innovation Center (CMMI) to develop new models to provide structural funding for the training of ACGME-accredited Clinical Informatics fellowships.

In a notice of proposed rulemaking (NPRM) issued in April, CMS proposed several policies important to the informatics community. First, CMS proposed requirements that would make Medicare Advantage (MA) organizations, State Medicaid or CHIP agencies, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plans (QHP) in Federally Facilitated Exchanges implement and maintain open APIs that permit third-party applications to retrieve data through the use of common technologies. Such access would be with the approval and at the direction of the individual beneficiary. These APIs would need to be in place by January 2020 for MA and QHP plans, and July 2021 for Medicaid and CHIP agencies.

AMIA supported these API proposals, but noted that the government's timelines were too aggressive, given the state of standards development and adoption. For instance, CMS would have required the adoption of new data standards proposed by the Office of the National Coordinator for Health IT (ONC) as part of the U.S. Core Data for Interoperability by January 2020. ONC is not expected to require certified health IT to generate such data until January 2021 at the earliest. Further, AMIA noted that there is inconsistent adoption and use of standards beyond those included as part of the USCDI, especially for laboratory results, drug benefit data, pharmacy directory information and formulary data.


To address these issues, AMIA recommended CMS establish a phased approach, beginning July 2020, to require payer data be made available to beneficiaries via open API. The first phase would include claims and encounter data; the second phase would include clinical data and lab results; and the third phase would include drug benefit, pharmacy directory, and formulary data. AMIA noted that CMS may want to consider the use of ONC's Certification Program to align standards and implementation decisions across stakeholders who generate and use these datatypes.

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