# Infosys Whitepaper 
Title: The right approach to testing interoperability of healthcare APIs under FHIR 
Author: Infosys Limited 
Format: PDF 1.7 

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 VIEW POINT THE RIGHT APPROACH TO TESTING  INTEROPERABILITY OF HEALTHCARE  APIs UNDER FHIR 

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 External Document © 2020 Infosys Limited External Document © 2020 Infosys Limited Abstract Historically, the lack of mutual data  exchange on patient health between  entities in the healthcare industry has  impaired the quality of patient care. This  has led to poor health outcomes and  increased costs for patients. The Trump  administration’s MyHealthEData initiative  has the stated objective of placing the  patient at the center of the US healthcare  system. The initiative aims to promote  interoperability of patient health data  between entities using latest technologies  such as cloud and APIs.<|endoftext|>This paper outlines the test approach  to ensure compliance with the CMS  (Centers for Medicare and Medicaid  Services) payor policies mandate effective  July 2021. The paper explains 3 simple  steps for interoperability of cloud/on- premises healthcare APIs between payors  and providers as per Fast Healthcare  Interoperability Resources (FHIR)  guidelines using the Infosys FHIR testing  solution. This solution has been built on  the proven Infosys Interoperability Test  Automation Framework that leverages  open-source tools, cloud components, and  test servers.<|endoftext|>

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 External Document © 2020 Infosys Limited External Document © 2020 Infosys Limited Introduction All healthcare payors, providers, and  stakeholders need to ensure that their  systems are truly interoperable based on  Fast Healthcare Interoperability Resources  (FHIR) guidelines. Organizations are seeking  to minimize the manual effort involved  in ensuring data integrity and real-world  testing as per these guidelines. The need  of the hour is test accelerators that can  seamlessly integrate with FHIR cloud/ on-premises servers to run automated  conformance and data validation tests.<|endoftext|>Fragmented data consolidation Currently, organizations have non-standard  data consolidation architecture due to  the nature of their source systems. To be  CMS (Centers for Medicare and Medicaid  Services) certified, organizations must  implement FHIR-compliant microservices- based architecture for API enablement  including authentication and security  policies. This adds additional complexities  for testers to validate data accuracy and  performance at the FHIR layer (cloud/ on premise) in addition to specification  conformance validation.<|endoftext|>Any test strategy to achieve FHIR  compliance must be carefully structured  to mitigate all known challenges. To begin  with, organizations must finalize their  API end-to-end operating model, cloud/ on-premises implementation strategy,  consent management, and intermediate  data aggregation strategy so that we  understand the various stages that need  FHIR testing.  Key challenges Adoption and interpretation  of FHIR standards FHIR standards have base rules,  constraints, and other metadata that  make them complex to interpret and  derive conformance scenarios. FHIR  regulated payors and providers will be  required to implement FHIR compatible  cloud/on-premises based healthcare APIs  considering different market segments  like Medicare, Medicaid, and any other  state-specific inclusions. They also need  to enable various FHIR resources such as  diagnostics, medication, care provision,  billing, payments, and coverage to  be accurate and accessible as per the  standard SLAs for patient and provider.<|endoftext|>Real world testing This is a gray area at this initial stage  because of the lack of a SMART application  (a user-facing application that connects  to payors or providers for a patient’s  health records). This limits the process of  simulating and validating complete end- to-end testing for FHIR conformance. A  payor or provider must qualify themselves  as FHIR compliant both internally and  externally through acceptance from  consumers. To achieve acceptance, a  payor needs to conduct multiple tests to  cover data integrity, conformance, and  consumer registration and consent as per  FHIR guidelines. Tests need to be conducted  between peer-to-peer servers, client to  server, and from a standalone server to a  proven FHIR-compatible test framework.<|endoftext|>Infosys 3-step process for  interoperability testing Infosys recommends these 3 simple steps  to achieve interoperability of cloud/on- premises healthcare APIs between payors  and providers as per FHIR guidelines Step 1 – Functional/non- functional testing  The primary focus areas of functional  testing are: • Conformance (structure and behavior)  validation based on FHIR specifications • Data validation of cloud/on premise- based healthcare APIs through the  original source or from intermediate  data aggregation or virtualization. If  an organization considers any data  aggregation before FHIR mapping, then  additional testing around data quality  should be done to ensure source data is  aggregated correctly at the FHIR layer  Non-functional testing such as  performance and security testing are  equally important given that APIs are  exposed externally using OAuth2.0 or  OpenID connect protocols.<|endoftext|>

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 External Document © 2020 Infosys Limited External Document © 2020 Infosys Limited Step 2 – Regulatory  compliance testing This validation should ensure payor or  provider complies with the guidelines  defined by CMS and FHIR. The primary  focus of regulatory compliance testing  is on features mandated by HealthIT  standards which includes self- discoverability, capability statement,  authentication/authorization, FHIR  conformance and so on. Every payor must  undergo this testing so that they can pass  the CMS certification within the given  deadline.<|endoftext|>

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 External Document © 2020 Infosys Limited Step 3 – End-user beta testing There are several third-party healthcare  applications (cloud/on-premises) that are  under development by Apple, Amazon,  Google, and other payor/vendors that are  registered in their respective developer  portals. Our strategy involves partnering  External Document © 2020 Infosys Limited with these vendors and using their beta  applications to integrate with payor FHIR  servers. This will provide payors early  confidence in terms of usability and  conformance with regulation.<|endoftext|>Figure 1 below depicts an end-to-end  automated test-driven development flow  of Infosys Interoperability Test Automation  Framework covering the 3-step testing  procedure. The framework leverages  Infosys FHIR Testing Solution, open-source  tools, cloud components, and test servers  to achieve FHIR compliance seamlessly  across various healthcare entities within a  short time to market.<|endoftext|>Figure 1: Infosys Interoperability Test Automation Framework 

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 External Document © 2020 Infosys Limited External Document © 2020 Infosys Limited The road ahead Today, organizations are focused on  getting their FHIR-compliant cloud/on- premises based patient access API and  provider directory API up and running.  However, organizations must also think  of other policies specified in the CMS final  rules. These include payor to payor data  sharing, improving user experience for  the beneficiary, and admission/discharge/ transfer event notifications. With such  requirements in mind, payors and vendors  need to think about developing a scalable  test automation framework that not only  works between payors and consumers but  also across payors.  Infosys is enhancing the capabilities of its  FHIR testing solution so that it is future  ready.<|endoftext|>

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 External Document © 2020 Infosys Limited Conclusion  Establishing end-to-end testing for FHIR  guidelines compliance across healthcare  payors and third-party vendors comes with  its own challenges and complexities. The  only way forward is based on the final CMS  interoperability rule.  A solution that ensures fast and effective  delivery of FHIR rules to consumers should  focus on two key aspects: • Building configurable FHIR accelerators  with the ability to support cloud/on- premises FHIR servers • Identifying FHIR-compliant consumers for  continuous testing practices The end goal is to build a test approach  that can be scaled rapidly based on the  rate of increase in FHIR adoption by payors,  providers and consumers.<|endoftext|>External Document © 2020 Infosys Limited 

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 © 2020 Infosys Limited, Bengaluru, India. All Rights Reserved. Infosys believes the information in this document is accurate as of its publication date; such information is subject to change without notice. Infosys  acknowledges the proprietary rights of other companies to the trademarks, product names and such other intellectual property rights mentioned in this document. Except as expressly permitted, neither this  documentation nor any part of it may be reproduced, stored in a retrieval system,