Health Plan Interoperability

The public comment period for the proposed CMS rule concerning interoperability and prior authorization processes recently closed in mid-March. Now is the perfect time for players in the health care delivery space to assess where they stand against goals and how they can move forward in advancing EHI interoperability. From the bird’s eye view perspective, it’s clear that many health plans are experiencing a performance gap between goal setting and goal achievement.

Many of the barriers to enhancing health data information exchange are known and include: myriad supporting software systems with varying data and nomenclature standards; antiquated legacy systems, and making the data available to analysts and decision makers. Although some of these challenges may seem daunting, they may be overcome. Two actions health plans should consider in advancing achievement of their interoperability goals include:

  • Partner with clinical data integration experts. Unfortunately, some health plans have hindered their success by supporting the false economies of an “in-house” approach to a very complex problem. Characteristics of a successful solution provider operating in this space include: understanding the best methods to ingest, standardize and curate information from multiple sources; how to truly make the curated data available to the client at scale in their environment; and how to deploy the data access and analysis tools to internal and external users.

  • Use Fast Healthcare Interoperability Resources (FHIR) API tools as a foundational technology. Effectively deployed, FHIR APIs will enable health plans to exchange health data with patients, providers and other care delivery partners. According to Gartner®, Inc., “the ROI of FHIR can be achieved through digital capabilities that serve several business and clinical use cases. Benefits include operational efficiencies through workflow improvements, revenue generation through higher reimbursements and risk reductions through enhanced patient safety.”

Gartner®, Quick Answer: What is the ROI of FHIR?, March 29, 2023


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