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articles/healthcare-apis/fhir/carin-implementation-guide-blue-button-tutorial.md

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# CARIN Implementation Guide for Blue Button®
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In this tutorial, we'll walk through setting up the FHIR service in Azure Health Data Services (hereby called the FHIR service) to pass the [Touchstone](https://touchstone.aegis.net/touchstone/) tests for the [CARIN Implementation Guide for Blue Button](https://build.fhir.org/ig/HL7/carin-bb/index.html) (C4BB IG).
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In this tutorial, we'll walk through setting up the FHIR® service in Azure Health Data Services to pass the [Touchstone](https://touchstone.aegis.net/touchstone/) tests for the [CARIN Implementation Guide for Blue Button](https://build.fhir.org/ig/HL7/carin-bb/index.html) (C4BB IG).
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## Touchstone capability statement
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The first test that we'll focus on is testing FHIR service against the [C4BB IG capability statement](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/00-Capability&activeOnly=false&contentEntry=TEST_SCRIPTS). If you run this test against the FHIR service without any updates, the test will fail due to missing search parameters and missing profiles.
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We first focus on testing FHIR service against the [C4BB IG capability statement](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/00-Capability&activeOnly=false&contentEntry=TEST_SCRIPTS). If you run this test against the FHIR service without any updates, the test will fail due to missing search parameters and missing profiles.
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### Define search parameters
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As part of the C4BB IG, you'll need to define three [new search parameters](how-to-do-custom-search.md) for the `ExplanationOfBenefit` resource. Two of these are tested in the capability statement (type and service-date), and one is needed for `_include` searches (insurer).
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As part of the C4BB IG, you'll need to define three [new search parameters](how-to-do-custom-search.md) for the `ExplanationOfBenefit` resource. Two of these (type and service-date) are tested in the capability statement, and one (insurer) is needed for `_include` searches.
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* [type](https://build.fhir.org/ig/HL7/carin-bb/SearchParameter-explanationofbenefit-type.json)
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* [service-date](https://build.fhir.org/ig/HL7/carin-bb/SearchParameter-explanationofbenefit-service-date.json)
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### Sample rest file
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To assist with creation of these search parameters and profiles, we have a [sample http file](https://github.com/microsoft/fhir-server/blob/main/docs/rest/C4BB/C4BB.http) that includes all the steps outlined above in a single file. Once you've uploaded all the necessary profiles and search parameters, you can run the capability statement test in Touchstone.
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To assist with creation of these search parameters and profiles, we have a [sample http file](https://github.com/microsoft/fhir-server/blob/main/docs/rest/C4BB/C4BB.http) that includes all the steps previously outlined in a single file. Once you've uploaded all the necessary profiles and search parameters, you can run the capability statement test in Touchstone.
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:::image type="content" source="media/centers-medicare-services-tutorials/capability-test-script-execution-results.png" alt-text="Capability test script execution results.":::
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## Touchstone read test
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After testing the capabilities statement, we'll test the [read capabilities](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/01-Read&activeOnly=false&contentEntry=TEST_SCRIPTS) of the FHIR service against the C4BB IG. This test is testing conformance against the eight profiles you loaded in the first test. You'll need to have resources loaded that conform to the profiles. The best path would be to test against resources that you already have in your database, but we also have an [http file](https://github.com/microsoft/fhir-server/blob/main/docs/rest/C4BB/C4BB_Sample_Resources.http) available with sample resources pulled from the examples in the IG that you can use to create the resources and test against.
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After testing the capabilities statement, we'll test the [read capabilities](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/01-Read&activeOnly=false&contentEntry=TEST_SCRIPTS) of the FHIR service against the C4BB IG. This tests conformance against the eight profiles you loaded in the first test. You'll need to have resources loaded that conform to the profiles. The best path would be to test against resources that you already have in your database. We also have an [http file](https://github.com/microsoft/fhir-server/blob/main/docs/rest/C4BB/C4BB_Sample_Resources.http) available with sample resources pulled from the examples in the IG that you can use to create the resources to test against.
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:::image type="content" source="media/centers-medicare-services-tutorials/test-execution-results-touchstone.png" alt-text="Touchstone read test execution results.":::
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## Touchstone EOB query test
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The next test we'll review is the [EOB query test](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/02-EOBQuery&activeOnly=false&contentEntry=TEST_SCRIPTS). If you've already completed the read test, you have all the data loaded that you'll need. This test validates that you can search for specific `Patient` and `ExplanationOfBenefit` resources using various parameters.
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The next test we'll review is the [EOB query test](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/02-EOBQuery&activeOnly=false&contentEntry=TEST_SCRIPTS). If you've already completed the read test, you already have all the data that you need loaded. This test validates that you can search for specific `Patient` and `ExplanationOfBenefit` resources using various parameters.
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:::image type="content" source="media/centers-medicare-services-tutorials/test-execution-touchstone-eob-query-test.png" alt-text="Touchstone EOB query execution results.":::
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## Touchstone error handling test
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The final test we'll walk through is testing [error handling](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/99-ErrorHandling&activeOnly=false&contentEntry=TEST_SCRIPTS). The only step you need to do is delete an ExplanationOfBenefit resource from your database and use the ID of the deleted `ExplanationOfBenefit` resource in the test.
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The final test we'll cover is testing [error handling](https://touchstone.aegis.net/touchstone/testdefinitions?selectedTestGrp=/FHIRSandbox/CARIN/CARIN-4-BlueButton/99-ErrorHandling&activeOnly=false&contentEntry=TEST_SCRIPTS). The only step is to delete an ExplanationOfBenefit resource from your database using the ID of the deleted `ExplanationOfBenefit` resource in the test.
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:::image type="content" source="media/centers-medicare-services-tutorials/test-execution-touchstone-error-handling.png" alt-text="Touchstone EOB error handling results.":::
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>[!div class="nextstepaction"]
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>[DaVinci Drug Formulary](davinci-drug-formulary-tutorial.md)
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FHIR® is a registered trademark of [HL7](https://hl7.org/fhir/) and is used with the permission of HL7.
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[!INCLUDE [FHIR trademark statement](../includes/healthcare-apis-fhir-trademark.md)]
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articles/healthcare-apis/fhir/centers-for-medicare-tutorial-introduction.md

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# Introduction: Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule
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In this series of tutorials, we'll cover a high-level summary of the Center for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule, and the technical requirements outlined in this rule. We'll walk through the various implementation guides referenced for this rule. We'll also provide details on how to configure FHIR service in Azure Health Data Services (hereby called FHIR service) to support these implementation guides.
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This series of tutorials covers a high-level summary of the Center for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule, and the technical requirements outlined in this rule. We'll walk through various implementation guides referenced for this rule. We'll also provide details on how to configure FHIR® service in Azure Health Data Services to support these implementation guides.
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## Rule overview
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The CMS released the [Interoperability and Patient Access rule](https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index) on May 1, 2020. This rule requires free and secure data flow between all parties involved in patient care (patients, providers, and payers) to allow patients to access their health information when they need it. Interoperability has plagued the healthcare industry for decades, resulting in siloed data that causes negative health outcomes with higher and unpredictable costs for care. CMS is using their authority to regulate Medicare Advantage (MA), Medicaid, Children's Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) to enforce this rule.
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The CMS released the [Interoperability and Patient Access rule](https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index) on May 1, 2020. This rule requires free and secure data flow between all parties involved in patient care (patients, providers, and payers) to allow patients to access their health information. Interoperability has plagued the healthcare industry for decades, resulting in siloed data that causes negative health outcomes with higher and unpredictable costs for care. CMS is using their authority to regulate Medicare Advantage (MA), Medicaid, Children's Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) to enforce this rule.
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In August 2020, CMS detailed how organizations can meet the mandate. To ensure that data can be exchanged securely and in a standardized manner, CMS identified FHIR version release 4 (R4) as the foundational standard required for the data exchange.
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There are three main pieces to the Interoperability and Patient Access ruling:
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* **Patient Access API (Required July 1, 2021)** – CMS-regulated payers (as defined above) are required to implement and maintain a secure, standards-based API that allows patients to easily access their claims and encounter information, including cost, as well as a defined subset of their clinical information through third-party applications of their choice.
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* **Patient Access API (Required July 1, 2021)** – CMS-regulated payers (as previously defined) are required to implement and maintain a secure, standards-based API that allows patients to easily access their claims and encounter information, including cost, as well as a defined subset of their clinical information through third-party applications of their choice.
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* **Provider Directory API (Required July 1, 2021)** – CMS-regulated payers are required by this portion of the rule to make provider directory information publicly available via a standards-based API. Through making this information available, third-party application developers will be able to create services that help patients find providers for specific care needs and clinicians find other providers for care coordination.
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* **Provider Directory API (Required July 1, 2021)** – CMS-regulated payers are required by this portion of the rule to make provider directory information publicly available via a standards-based API. Through making this information available, third-party application developers will be able to create services that help patients find providers for specific care needs, and clinicians find other providers for care coordination.
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* **Payer-to-Payer Data Exchange (Originally required Jan 1, 2022 - [Currently Delayed](https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index))** – CMS-regulated payers are required to exchange certain patient clinical data at the patient’s request with other payers. While there's no requirement to follow any kind of standard, applying FHIR to exchange this data is encouraged.
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* **Payer-to-Payer Data Exchange (Originally required Jan 1, 2022 - [Currently Delayed](https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index))** – CMS-regulated payers are, at the patient’s request, required to exchange certain patient clinical data with other payers. While there's no requirement to follow any kind of standard, applying FHIR to exchange this data is encouraged.
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## Key FHIR concepts
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As mentioned above, FHIR R4 is required to meet this mandate. In addition, there have been several implementation guides developed that provide guidance for the rule. [Implementation guides](https://www.hl7.org/fhir/implementationguide.html) provide extra context on top of the base FHIR specification. This includes defining additional search parameters, profiles, extensions, operations, value sets, and code systems.
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As mentioned previously, FHIR R4 is required to meet this mandate. In addition, there are several implementation guides developed that provide guidance for the rule. [Implementation guides](https://www.hl7.org/fhir/implementationguide.html) provide extra context on top of the base FHIR specification. This includes defining additional search parameters, profiles, extensions, operations, value sets, and code systems.
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The FHIR service has the following capabilities to help you configure your database for the various implementation guides:
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The FHIR service has the following capabilities to help you configure your database for the various implementation guides.
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* [Support for RESTful interactions](fhir-features-supported.md)
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* [Storing and validating profiles](validation-against-profiles.md)
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The Patient Access API describes adherence to four FHIR implementation guides:
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* [CARIN IG for Blue Button®](http://hl7.org/fhir/us/carin-bb/STU1/index.html): Payers are required to make patients' claims and encounters data available according to the CARIN IG for Blue Button Implementation Guide (C4BB IG). The C4BB IG provides a set of resources that payers can display to consumers via a FHIR API and includes the details required for claims data in the Interoperability and Patient Access API. This implementation guide uses the ExplanationOfBenefit (EOB) Resource as the main resource, pulling in other resources as they're referenced.
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* [HL7 FHIR Da Vinci PDex IG](http://hl7.org/fhir/us/davinci-pdex/STU1/index.html): The Payer Data Exchange Implementation Guide (PDex IG) is focused on ensuring that payers provide all relevant patient clinical data to meet the requirements for the Patient Access API. This uses the US Core profiles on R4 Resources and includes (at a minimum) encounters, providers, organizations, locations, dates of service, diagnoses, procedures, and observations. While this data may be available in FHIR format, it may also come from other systems in the format of claims data, HL7 V2 messages, and C-CDA documents.
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* [HL7 US Core IG](https://www.hl7.org/fhir/us/core/toc.html): The HL7 US Core Implementation Guide (US Core IG) is the backbone for the PDex IG described above. While the PDex IG limits some resources even further than the US Core IG, many resources just follow the standards in the US Core IG.
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* [HL7 FHIR Da Vinci - PDex US Drug Formulary IG](http://hl7.org/fhir/us/Davinci-drug-formulary/index.html): Part D Medicare Advantage plans have to make formulary information available via the Patient API. They do this using the PDex US Drug Formulary Implementation Guide (USDF IG). The USDF IG defines a FHIR interface to a health insurer’s drug formulary information, which is a list of brand-name and generic prescription drugs that a health insurer agrees to pay for. The main use case of this is so that patients can understand if there are alternative drug available to one that has been prescribed to them and to compare drug costs.
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* [HL7 FHIR Da Vinci PDex IG](http://hl7.org/fhir/us/davinci-pdex/STU1/index.html): The Payer Data Exchange Implementation Guide (PDex IG) is focused on ensuring that payers provide all relevant patient clinical data to meet the requirements for the Patient Access API. This uses the US Core profiles on R4 Resources, and includes (at a minimum) encounters, providers, organizations, locations, dates of service, diagnoses, procedures, and observations. While this data may be available in FHIR format, it may also come from other systems in the format of claims data, HL7 V2 messages, and C-CDA documents.
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* [HL7 US Core IG](https://www.hl7.org/fhir/us/core/toc.html): The HL7 US Core Implementation Guide (US Core IG) is the backbone for the PDex IG previously described. While the PDex IG limits some resources even further than the US Core IG, many resources just follow the standards in the US Core IG.
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* [HL7 FHIR Da Vinci - PDex US Drug Formulary IG](http://hl7.org/fhir/us/Davinci-drug-formulary/index.html): Part D Medicare Advantage plans have to make formulary information available via the Patient API. They do this using the PDex US Drug Formulary Implementation Guide (USDF IG). The USDF IG defines a FHIR interface to a health insurer’s drug formulary information, which is a list of brand-name and generic prescription drugs that a health insurer agrees to pay for. The main use case is so patients can determine if there is a drug available alternative to one that has been prescribed to them, and to compare drug costs.
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## Provider Directory API Implementation Guide
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## Touchstone
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To test adherence to the various implementation guides, [Touchstone](https://touchstone.aegis.net/touchstone/) is a great resource. Throughout the upcoming tutorials, we'll focus on ensuring that the FHIR service is configured to successfully pass various Touchstone tests. The Touchstone site has a lot of great documentation to help you get up and running.
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[Touchstone](https://touchstone.aegis.net/touchstone/) is a great resource for testing adherence to the various implementation guides. Throughout the upcoming tutorials, we'll focus on ensuring that the FHIR service is configured to successfully pass various Touchstone tests. The Touchstone site has a lot of great documentation to help you get up and running.
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## Next steps
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>[!div class="nextstepaction"]
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>[CARIN Implementation Guide for Blue Button](carin-implementation-guide-blue-button-tutorial.md)
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FHIR® is a registered trademark of [HL7](https://hl7.org/fhir/) and is used with the permission of HL7.
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[!INCLUDE [FHIR trademark statement](../includes/healthcare-apis-fhir-trademark.md)]

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