By Katie Devlin
Traditionally, payers have struggled to obtain clinical data in a structured format, which is crucial for determining appropriateness of treatment, utilization, and member engagement, and for capturing digital quality measures.
The 21st Century Cures Act established an ambitious vision for healthcare interoperability — the ability of two or more systems to exchange and use health information — but it wasn’t until recently that health plans had a clear path forward to achieve it, and to ultimately obtain the clinical data needed to support their strategic goals.
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Now, the clock is ticking for payers to become compliant with the CMS Interoperability and Prior Authorization Final Rule. As payers prepare to meet these new requirements, which leverage industry best practices, they must create powerful partnerships and build an infrastructure to support interoperability at scale.
Forward-thinking health plans must ask themselves several critical questions as the state of healthcare interoperability continues to evolve.
Is your plan leaving data on the table?
Payers rely on healthcare providers and other data sources to supply structured clinical information that they use for a range of applications, from Healthcare Effectiveness Data and Information Set (HEDIS®) reporting to population health management strategies. However, these partners aren’t all on a level playing field when it comes to interoperability — specifically regarding the use of FHIR.
The HL7® FHIR® (Fast Healthcare Interoperability Resources) standard has defined how electronic health records (EHRs) can be exchanged between payers and providers using application programming interfaces (APIs). When fully implemented, FHIR resources allow payers to share data more easily with downstream applications used for quality reporting, analytics and other aims.
At this time, FHIR is not frequently utilized for data sharing between payers and providers. Many providers prefer to send data via web-based portals or more traditional methods such as Integrating the Healthcare Enterprise (IHE) integration profiles. With this in mind, it’s important that payers remain agile and accommodate data partners where they are from a technical standpoint by offering FHIR APIs, IHE or web-based portals as connectivity options.
