CMS Payer Interoperability 2022
An Early Look at Purchase Decisions and Vendor Performance in a New Market

KLAS’ CMS Payer Interoperability Vendor Guide

To help health plans learn about vendors that may meet their interoperability needs, KLAS recently published a vendor guide, which provides brief overviews of the vendors in this report and all other vendors known to KLAS as of July 2022 (the guide does not contain any KLAS performance data).

1upHealth, Edifecs, and Smile CDR See Strong Early Traction

Of the vendors in this report, 1upHealth, Edifecs, and Smile CDR are some of the most frequently considered and selected; they have the most customers live on their solutions, and customers are generally satisfied (see next page for performance data). All three are often considered because of their foundational FHIR experience. 1upHealth, a newer vendor in the healthcare industry, has a particular focus on FHIR. Their technology is a strong factor in organization considerations and selections—respondents say it seems advanced and is available for immediate use (as opposed to other vendors’ offerings, which some organizations believe aren’t yet ready for deployment). Edifecs offers various products in the payer market (e.g., enrollment management, risk adjustment, EDI, transaction management), and organizations often select the vendor because of an existing vendor relationship via other products. KLAS has validated that some very large health plans have selected Edifecs. Smile CDR is known for their free, open-source solution, though data in this report focuses on the vendor’s commercial product. Organizations who select Smile CDR highlight the vendor’s leadership. Other reasons for selection include a reasonable pricing structure and the option of having an on-premises solution.

Cognizant and Change Healthcare Already Up for Replacement

Cognizant and Change Healthcare are often considered, with prospective customers pointing to the vendors’ large HIT footprints in the payer market, their breadth of products, and an existing vendor relationship as reasons for consideration. However, KLAS has validated very few recent selections for either vendor’s CMS interoperability product. Some organizations who considered Cognizant ultimately didn’t choose them because of pricing, slow product development, and poor past experiences with the vendor. The one respondent replacing the vendor cites a difficult implementation and the product not functioning as promoted. The organizations that considered but did not select Change Healthcare decided during the sales process that the vendor wouldn’t be able to meet their needs. Two respondents report replacing the vendor; they note that Change Healthcare couldn’t finish the implementation or deliverables on time.

Provider-Sponsored Health Plans Often See InterSystems and Epic as Viable Choices

InterSystems is often, though not exclusively, selected by provider-sponsored health plans (PSHPs), who gravitate to the product’s ability to handle both payer and clinical data. The reasons for selection include the vendor’s prebuilt product and their expertise in interoperability and CMS regulations. Epic’s offering is used only by PSHPs that already have other Epic solutions in place, including Tapestry. Epic respondents choose the offering because, as current customers, they can easily incorporate the functionality into their Epic suite.

Early Performance Insights

1upHealth Customers Highlight CMS Expertise & Smile CDR Customers Satisfied with Technology; Respondents across All Vendors Experience Bumpy Implementations

In this newer market, 1upHealth is seen by most customers as having strong CMS expertise and guidance—all 1upHealth respondents report satisfaction in this area. Customers report 1upHealth can quickly answer questions thanks to their solid experience with the FHIR standard and interoperability requirements. Some respondents mention support challenges—like limited resource bandwidth—due to the vendor’s recent growth. Smile CDR is perceived as easy to work and communicate with. Respondents feel the product’s functionality goes beyond simply meeting the CMS mandate, and they are optimistic about future development. Support is mentioned as an area for improvement; some customers cite delayed responses, insufficient resources, and leadership and expertise that sometimes fall short. Interviewed Edifecs customers are satisfied with the product’s help in meeting CMS requirements.

Across all vendors, customers report more difficulties than expected during the implementation, particularly with data preparation and mapping capabilities. When Smile CDR customers require on-premises support, the vendor works jointly with them to map the data, which some respondents describe as a long learning process. Most Edifecs respondents report implementation issues, often pointing to ineffective communication (e.g., differences in terminology, misunderstandings).

Bottom Lines

Note: See CMS Payer Interoperability Vendor Guide for more details about each vendor.

Rated Vendors

1upHealth | Highly considered vendor in this report. In addition to helping customers meet CMS mandate, the vendor oversees interactions with third-party applications. Customers report experiencing challenges due to vendor’s recent growth (e.g., limited support resources).

“What really swung us toward 1upHealth was their show-and-tell. They had information available on the website. They let us access and play with their tool. We could sign up for a development account and work through the process of what they did. Most people would go with big, stable vendors, but we could touch the 1upHealth platform, and that wasn’t hypothetical or a slide show, and that was a big deal. We followed 1upHealth’s directions, and the system worked. They might have growing pains because they are young, but they would partner with us. Overwhelmingly, they felt further with their technology than others because we could touch and use it. 1upHealth was super excited and supportive of the way we wanted to work with them. Everything about them said that they were a true group of people that wholeheartedly believed in their mission.” —VP (organization who selected)

“We had a lot of issues with our implementation due to staff turnover on 1upHealth’s side. 1upHealth had a real problem with retaining employees. At the time of our implementation, a lot of people were having that same problem because of COVID-19. That problem hurt the vendor quite a bit and slowed down our implementation. We still got everything implemented in time, but things were slow.” —Director (current customer)

Edifecs | Both customer respondents and organizations who consider Edifecs express appreciation for the vendor’s expertise with CMS regulations. Some customer respondents report miscommunication during implementation.

“Out of every vendor I spoke to, Edifecs had the most knowledge. They understood their product and what the goal of the product was. Other vendors could say the buzzwords, but they couldn’t answer the questions I asked during the RFP. Nobody knew the full scope, and that was critical with the complexity of this requirement. Edifecs offered a mapping suite that was extremely attractive, gave options for the plan, would save time, and reduced cost overall.” —Director (current customer)

“Our future satisfaction depends on the way Edifecs implements changes. I think they need to get better at their upgrades and at knowing the impacts that occur with the upgrades so they can make testing easier. Edifecs needs to get better at regression testing and being able to copy over data without loss. The vendor should stay on top of changes in the industry and have more communication on how they are moving forward with their road map.” —Manager (current customer)

InterSystems | PSHPs often choose vendor because of platform’s ability to handle both payer and clinical data. Customers view vendor as a partner who stays on top of regulation requirements. Training seen as an area needing improvement.

“InterSystems has some really good businesspeople that are plugged in to the Sequoia Project, HL7, and the Da Vinci Project. So InterSystems is very close to what is happening from a legislative perspective and in the industry. There were some payer-to-payer issues that were a little difficult to deal with or at least get a straight answer on just because they were so ambiguous, so we had to interpret things a lot. But InterSystems was a great partner when it came to telling us what we would need to anticipate for upcoming changes with interoperability in general, specifically patient access and provider APIs.” —Manager (current customer)

“InterSystems could improve their training by understanding the client’s needs and current skill set more and then, based on that, making a suggestion for a training approach. The vendor needs to listen to the client and work with what we have. InterSystems tends to be a little forceful at times. The vendor should ensure the customer is comfortable and up to speed on one product before they start contacting everybody in our organization that has three initials to sell other products.” —Manager (current customer)

SmileCDR | Known for their free, open-source platform, which is incorporated into some other vendors’ products. Commercially available product is often considered by organizations and seen as reasonably priced. Customers report low satisfaction with data preparation and mapping.

“Smile CDR is aligned in the industry as the open source for HL7. I needed a commercialized product, and when Smile CDR walked in and presented their cost, I wrote the vendor a check. That was the easiest executive decision I have made in years. I like Smile CDR because they are built on purpose. Every vendor is saying they have FHIR, but that doesn’t mean we have to make the vendor the king in our connectivity strategy. That is the way Smile CDR set up their company. How the vendor sells things has enabled me. We can also use the vendor for infrastructure and bigger things and do all that as well, but the product is much cleaner for how I have set things up. At the price point, we felt like it was an insurance policy.” —Director (current customer)

“There is a lack of scenario-based training documentation. There are a lot of ways to do things, but the documentation is just very vague. When we were going live, it was really hard to find information on what we needed to do with the modules. We still have the same struggle. I would like to see Smile CDR put together configuration documentation, not just instructions, but actual real scenarios. I just don’t see any of that.” —Manager (current customer)

Other Validated Vendors

AaNeel | One organization selected the vendor, citing a prior relationship via case management and their perception of the product as an economical choice. The organization says the vendor helped them meet the CMS requirement.

“AaNeel said they could do interoperability, and they just stood it up. The choice to go with AaNeel was pretty easy from a business perspective. The system didn’t cost me much, and I didn’t look any further than AaNeel. They met all the requirements. They built and tested the system, and it made sense for me to go with them. The way CMS defines and requires interoperability was a new take on what AaNeel already does. Their platform is essentially software as a service and is mostly API based. We are just fine-tuning a couple of interfaces to meet the CMS requirements.” —CEO (organization that selected)

Change Healthcare | Often considered by organizations because of their breadth of HIT offerings and large presence in the payer market. Though sample size is currently insufficient for performance data to be shared, KLAS has validated two customers replacing the vendor due to missed implementation and delivery deadlines.

“Change Healthcare seems knowledgeable about the regulation.” —Manager (organization reporting perception of Change Healthcare)

“We started with Change Healthcare’s product, but our go-live date kept getting moved back. The vendor missed timeline after timeline, and it seemed obvious that they didn’t have the technical abilities to support us. They couldn’t hit our marks, and they didn’t understand our business. We finally decided that we needed a new vendor.” —VP/other executive (customer who replaced the vendor)

Cognizant | Widely recognized vendor, often considered because of large presence in the payer market; KLAS has validated few selections. Though sample size is currently insufficient for performance data to be shared, KLAS has validated one customer replacing due to bumpy implementation and product not working as promoted.

“We used Cognizant’s system in another area of business, so we decided to look at Cognizant, and they had a very compelling solution.” —Director (organization who considered but did not select)

“We had a complex implementation because of other things going on in our organization. We struggled with having Cognizant understand some of those things. The final nail in the coffin for Cognizant was that they told us the product would work fine without a certain component, but we ended up needing that component. They missed a huge gap and didn’t communicate to us about it. The product didn’t hold up to the quality our organization was known for, and our experience with interoperability made us step back from Cognizant in other areas.” —Manager (customer who replaced the vendor)

Epic | Used exclusively by PSHPs that already have Epic HIT solutions in place, including Tapestry. Epic respondents select the functionality in Tapestry for the easy, prepackaged interoperability capabilities.

“We chose Epic because the interoperability was there and packaged as part of their offering. For us, the decision was really just a financial decision. There was zero additional cost, and other vendors’ systems would have come at a high cost. Epic didn’t provide the provider API portion, so we had to go to another vendor for that, but Epic was the cheapest option for us overall.” —Director (current Tapestry customer who selected CMS interoperability functionality)

“When we make a decision, we start with Epic because they have a number of customers. When we talked to Epic, they made things happen. For the required CMS guidelines, we are looking at whether Epic can help us meet the regulation. Epic is coming back to us with what they can and cannot do. For the things they can’t do, we will look elsewhere for someone else to accomplish those.” —CIO (current Tapestry customer who selected CMS interoperability functionality)

Health Catalyst | One PSHP chose the vendor, citing their existing use of the vendor in other areas and their view of the vendor as knowledgeable about FHIR. The organization reports that with the vendor’s functionality, they met the CMS mandate on time.

“Having an existing relationship with Health Catalyst has definitely helped. We had several calls with other vendors and tried to scope out who we felt was confident and could help us meet the mandate. Health Catalyst came to the forefront based on their knowledge.” —Manager (organization who selected)

HealthLX | Two health plans chose HealthLX because of their technical expertise. Another organization considered HealthLX because they used the vendor previously for advisory services.

“One thing that made HealthLX stand out was that they were part of the Da Vinci Project way in the beginning and worked with CMS way in advance regarding the interoperability requirements that were anticipated to come. To me, that gave the vendor advanced knowledge. They had a leg up on what had happened to get us to this point as well as what was coming down the pike. Everything was proactive. I felt that HealthLX was ahead of the game with their platform and what they had.” —Manager (organization who selected)

Onyx | Organizations select vendor because of their knowledge and expertise in CMS regulations. Specifically, one organization decided to purchase because of NewWave’s (Onyx’s parent company) collaboration with CMS in building Blue Button 2.0 API.

“Onyx was far ahead in their knowledge of the CMS requirements, including showing us the solution that was a fit for us. Onyx had one of the best solutions we had seen. Onyx had some great people, including someone who had worked for CMS in the past and who had a high level of knowledge and understanding of the CMS requirements. Onyx performed very well in our proof of technology that we did with them.” —Director (organization who selected)

“Onyx Technology was definitely a contender when we were making our choice. At the time, Onyx Technology was well funded, and they were a brand-new company. Corporations sometimes find it difficult to invest in companies that may or may not exist in a few years, even if their products are good. We decided on another vendor instead.” —Manager (organization who considered but did not select)

ZeOmega | One organization selected the vendor because of a past relationship where the organization used other ZeOmega products. The organization says they leveraged the functionality to meet the CMS mandate on time.

“Using HealthUnity was a logical decision for us because of our relationship with the vendor. ZeOmega had a FHIR API solution in place, so we didn’t bother to look at other vendors. They stepped up to help us meet a certain timeline, and they were able to deploy their solution quickly so that we could stay in compliance.” —Director (organization who selected)

About This Report

The data in this report comes from two sources: (1) KLAS Decision Insights data and (2) KLAS performance data.

To expand upon the data gathered with the standard evaluation, KLAS also asked supplemental questions specific to the CMS payer interoperability market. Respondents were asked to rate their vendor’s (1) expertise and guidance for CMS interoperability and compliance, (2) data preparation and mapping capabilities, and (3) FHIR repository and APIs.