EDI (Electronic Data Interchange) and HIE (Health Information Exchange) standards such as X12, 83x, 27x, HL7, and FHIR, written from the perspective of someone with advanced/SME-level experience:
Overview of Responsibilities: EDI / HIE Standards (X12, 83x, 27x, HL7, FHIR)
As a subject matter expert (SME) in EDI and HIE standards, my primary responsibilities have encompassed both strategic oversight and technical leadership across the full lifecycle of interoperability initiatives, ensuring compliance, scalability, and high data fidelity in health and insurance data exchange environments.
🔹 Strategic Responsibilities:
- Governance and Standardization: Led enterprise-wide adoption and implementation of interoperability frameworks, including HIPAA-compliant X12 transactions (especially 837, 835, 270/271, and 276/277) and HL7 (v2.x, CDA) as well as FHIR standards for modern APIs.
- Vendor and Payer Integration: Oversaw integration with EHRs, clearinghouses, insurance payers, and HIEs, ensuring conformance to national standards and maintaining alignment with CMS, ONC, and other regulatory bodies.
🔹 Technical Architecture and Implementation:
- EDI Gateway and Translation Services: Designed and maintained EDI gateways for batch and real-time transactions, including mapping, validation, and translation of X12 messages (e.g., 837P/I/D, 835 ERA, 270/271 eligibility, 278 authorization requests).
- FHIR API Development: Led the development of FHIR-based RESTful APIs for real-time data exchange and patient access use cases (e.g., US Core, Patient Access API, Provider Directory).
- HL7 Messaging Systems: Managed HL7 v2.x ADT, ORU, and ORM message workflows, including message parsing, routing, transformation, and exception handling.
🔹 Data Quality, Monitoring, and Compliance:
- Validation Frameworks: Implemented robust validation pipelines to ensure structural and semantic compliance with EDI/FHIR/HL7 schemas using tools like Edifecs, Mirth Connect, and custom-built validators.
- Audit & Logging: Established auditing systems for message tracking, status monitoring, and dispute resolution, crucial for claims processing and eligibility verification.
- Security and Privacy: Ensured adherence to HIPAA, HITECH, and NIST security standards, implementing secure transport protocols (SFTP, AS2, OAuth2 for FHIR) and end-to-end encryption.
🔹 Collaboration and Stakeholder Engagement:
- Cross-functional Leadership: Acted as the liaison between business teams, developers, QA, and compliance officers to define use cases and data exchange requirements.
- Training and Documentation: Provided SME-level guidance and training to internal teams and external partners on EDI/FHIR onboarding, troubleshooting, and best practices.