Interoperability Is Catching FHIR

Interoperability Is Catching FHIR

By Emad Rizk, MD

COVID-19 exposed the risks that exist when providers cannot access trusted and complete data at the point of care. Physicians and researchers lost valuable time uncovering which chronic conditions raised patients’ risk for serious illness and which treatments worked best—and for whom. Clinicians struggled to pinpoint the social determinants of health (SDOH) that worsen outcomes, delaying efforts to help the most vulnerable populations.

As new interoperability rules set the standards for data sharing between payers, providers, and patients, health plans must now consider how they will put actionable insights into the hands of clinicians and consumers when the data come from disparate sources and in multiple forms.

This challenge will require heightened collaboration among payers, providers, and industry experts—and access to tools that turn data into clinical intelligence.

The Road to April 2021 Integration

The federal government delayed the compliance dates for information blocking and other health information technology requirements of the 21st Century Cures Act until April 2021 due to COVID-19. However, payers and providers are not confident the extra time was sufficient for them to be fully prepared—and not just due to the pandemic.

While most national and large insurers are ready for compliance, smaller plans could face greater challenges in this journey due to the tight deadlines.

A 2020 survey by KLAS Research and the College of Healthcare Information Management Executives (CHIME) found that progress toward interoperability is advancing, with 67 percent of providers saying they “often” or “nearly always” have electronic access to the records needed.

However, high costs and lack of technical readiness by electronic health record (EHR) vendors still stand in the way, respondents said. They are also almost evenly split over whether they could count on EHR vendors for the support needed to be successful.

Health plans also struggle to develop a cohesive enterprise data strategy and infrastructure that can harmonize disparate data from multiple sources and departments, such as risk management and care management. This makes it challenging to develop a single source of truth, which is critical to providing the right care and guidance at the right time. Most plans also don’t have the analytic capabilities to draw insight from the data collected. Put simply, the ability for data to “talk” to each other has limited value without the analytic support to gain meaningful insight.

Then there is the advent of application programming interfaces (APIs) such as Fast Healthcare Interoperability Resources (FHIR), which are a central component of the new interoperability rules.

For consumers, APIs will help ensure that all their healthcare data—from clinical data to financial (claims) data to encounter-specific details—can be accessed at the touch of a smartphone.

For the industry as a whole, APIs hold strong potential to strengthen patient engagement, enhance collaboration and deliver a more seamless, tightly integrated patient experience. But plans face challenges using the new API standards not just for external data sharing, but also to power internal workflows.

Today, many health plans have cracked the code for compliance relevant to patient access, provider master, and payer-to-payer APIs, but they have yet to determine how to make compliance beneficial for their business.

Getting There from Here

Improving health outcomes for individuals and entire communities depends on access to timely, comprehensive data that can be delivered in an easily digestible format when minutes count. It also necessitates a longitudinal view of patients’ health and health risks that takes into account not just data from clinical charts and claims, but also SDOH, medication adherence history, and trends in laboratory results.

On the road to Cures Act compliance, payers can strengthen their ability to securely share and leverage health data in the following ways.

Break down internal data silos. Even within health plans, Medicare Advantage, Medicaid, and commercial lines of business often operate independently from one another. When silos exist between pharmacy and medical benefits management, health plans struggle to develop a comprehensive view that could deepen their understanding of members’ health behaviors and needs. Without the ability to connect the dots among the data, they miss vital opportunities to deploy interventions that could reduce health risks, enhance outcomes, and reduce costs of care.

One way to break down data-sharing barriers across departments and divisions is to offer tangible incentives for developing strong internal partnerships. For example, by tying incentive payments to team members’ ability to transform care for specific populations, health plans can encourage creative solutions to complex scenarios while fostering an environment of innovation and collaboration.

Develop data partnerships with payers, providers, and other stakeholders. During COVID-19, unique partnerships emerged between payers and providers and between providers and public health organizations to share meaningful data that could help key stakeholders better understand the populations most at risk of serious illness. For example, one health plan equipped community health workers with data to connect at-risk individuals with local resources to address vital needs. Support included not just assistance in accessing physical and behavioral health services, but also overcoming food insecurity, transportation challenges, and language barriers.

In 2021 and beyond, data-fueled partnership will be key to closing gaps in care that threaten members’ long-term health. It will also support sharing of real-world evidence—in real time—that is critical to understanding how a disease progresses and the treatments that are most effective in certain scenarios. By expanding providers’ data view beyond statistics specific to their own organization during a crisis, these partnerships bolster the nation’s health response. One example: Florida Blue, which donated $100,000 to the University of South Florida and paired data analysts with university researchers to help track the coronavirus and forecast the impact by county.

Invest in tools that turn data into actionable intelligence in near real time. Data is only as good as it is actionable and timely. Achieving the true promise of interoperability requires that data is clean, accurate, comprehensive, and consistent—and can be easily shared across the continuum of care. It also demands that data be available for dissemination soon after it is captured so that physicians, clinicians, and researchers have the most recent information on which to base their decisions.

Consider how our understanding of COVID-19 has evolved. For example, during the first months of the pandemic in the spring, seniors as well as patients with diabetes, heart disease, high blood pressure, and obesity who contracted the coronavirus were linked to higher rates of hospitalization.

However, by summer 2020, new data showed a shift in the age groups affected by the virus, with patients aged 20 to 29 comprising more than 20 percent of infections from June through August. Suddenly, those with comorbid conditions were less likely to be hospitalized after contracting the virus, and seniors no longer made up the majority of COVID-19 hospitalizations. Instead, the analysis showed that younger generations—those ages 20 to 39—and those without underlying conditions were responsible for more COVID-19 cases. A Boise State University survey showed those under 40 were less likely than those over 40 to comply with public health measures designed to contain the virus.

This example points to the need to examine up-to-date data from multiple sources in making care decisions, assessing the impact of disease on specific populations, and more. It also underscores the need for tools such as predictive analytics, machine learning, and other forms of artificial intelligence in uncovering actionable insight from volumes of data. During the pandemic, leading organizations are using machine learning to predict COVID-19 health risks. They also are sharing data widely to improve public health and health outcomes.

Shore up capabilities for detecting fraud, waste, and abuse. One of the concerns that America’s Health Insurance Plans, the American Hospital Association, and other healthcare groups have had regarding the new interoperability rules is that they put patient privacy at risk. These are serious concerns and should be addressed, but they should not be a roadblock to innovation. Instead, payers should seek ways to leverage data analytics to spot anomalies in data that could point to instances of fraud, waste, or abuse, positioning payers to proactively respond.

For example, government payers typically are a target for those seeking to game the system. Because Medicaid patients comprise a small percentage of each provider’s panel, health plans often lack sufficient data to identify patterns of fraud, waste, and abuse among claims for this population. Even when patterns are identified, payment recovery is a long, arduous, and costly process.

However, when health plans supplement their existing fraud, waste, and abuse recovery solutions with partnerships that leverage Medicaid insights across multiple payers, they strengthen their ability to catch fraudulent activity before claims are paid. Over time, the more data the health plan has at its disposal, the better able the plan becomes at flagging claims for internal review by health plan nurses or coders, reducing risk over the long term. Given that 25 percent of healthcare spending could be attributed to waste, expanded access to data through the new interoperability rules could make a deep impact in payers’ ability to detect and eliminate wasteful spending.

Preparing for the New Normal of Interoperability

Efforts to achieve interoperability present pain points for payers and providers alike, but they could also pave the way for stronger relationships and deeper levels of trust. By exploring ways to partner with providers, health plans, and other key stakeholders in attaining Cures Act compliance, payers can more effectively realize the benefits of interoperability, establishing a basis for more value-driven care.


Emad Rizk is president and CEO, Cotiviti.