Leveraging FHIR for Payers
The implementation of the CMS Interoperability rule (9115-F) required payers to use HL7® FHIR® as a way to share clinical, claims and pharmacy data with their members via third-party apps. It also required them to share provider directory data so that other organizations can make use of that data.
This transformation process involved significant time and resources, but once completed, it presents an opportunity for payers to leverage their investment in FHIR infrastructure and aggregated data beyond just regulatory compliance. By exploring FHIR’s capabilities, payers can:
- Enhance member engagement using third-party apps connecting to the FHIR repository.
- Leverage the assets of the
HL7 Da Vinci project to strengthen provider relationships through enhanced data sharing and improve value-based care processes. For example, reducing the burden of data capture for quality measures and automating the thorny problem of prior authorization.
- Improve operational efficiencies by using aggregated data to serve other internal applications such as ongoing performance measurement and reporting.
- Use the data aggregated through FHIR APIs to enable innovation such as improved risk adjustment or infrastructure modernization.
The collaborative Da Vinci project continues to develop, test, and deploy FHIR-based solutions to solve for some of the most pressing use cases for the move to value-based care. For example, Data Exchange for Quality Measures (DEQM) provides a FHIR-based mechanism for exchanging data for quality measures and to identify gaps in care.
Gartner’s recent report Clinical Data Integration Capabilities and Sourcing Recommendations for U.S. Healthcare Payers, states that CIOs need to, “Futureproof your clinical data integration (CDI) strategy by incorporating Fast Healthcare Interoperability Resources (FHIR) API adoption and proliferation scenarios”¹. Furthermore, through new rulemaking like the CMS-0057P Advancing Interoperability and Improving Prior Authorization Processes, CMS has made it clear that FHIR will continue to be part of the regulatory roadmap.
Business Transformation Manager
Not every organization that implemented and complied with 9115-F, will benefit fully from the new infrastructure they built. There were three types of organizational approaches to the rule:
- Those that did the bare minimum to “check the box” by the deadline. Many of these chose a short-term partner to expedite their immediate need.
- Those who saw the strategic opportunity, and made incremental investments with a long-term partner. This group recognized the need for future expansion, but chose not to create a detailed plan.
- Those who built out comprehensive shared data and FHIR infrastructure with a long-term partner and plan, for example, organizations like
MVP Health Care.
When MVP Health Care was looking for a vendor to help them implement the CMS-9115 regulations, they wanted a partner that would help them achieve their larger goals – to improve their HEDIS scores and enhance their member experience. No one can navigate the journey toward interoperability and actionable insights alone. When MVP resolved to invest in building a data-driven, member-centric organization, Dominick Bizzarro, Chief Growth Officer, knew his next move. “We’re all in,” he recalls. “Let’s work with a partner that recognized we’re going to be in a relationship — a long-term relationship.”
If you’re not sure, consider working with a partner that sees this as a journey. One that can expand existing capabilities to support your future business requirements, your clinical data strategy and future use cases and is committed to the new regulatory requirements. Consider InterSystems.
InterSystems can help you craft and realize your future strategy for innovating with better data and better workflow. Here’s why:
- We have been members of the HL7 Da Vinci Project for the past 4 years and have experience with the implementation guides.
- We have years of experience with healthcare standards and have supported FHIR since its earliest versions.
- As experts in interoperability, we know how to aggregate and normalize data into a unified member view.
- We put our customers success first. InterSystems customers rated our support with 100% satisfaction over the past year.
To learn how InterSystems can help you leverage FHIR to streamline measurement, improve operational efficiencies, and enhance quality and member engagement, visit InterSystems.com/Payers
1 - Gartner “Clinical Data Integration Capabilities and Sourcing Recommendations for
US Healthcare Payers”, Mandi Bishop, April 26, 2021, refreshed September 12, 2022
2- Eight Drivers for Payer Interoperability Implementation, Now!, IDC #US46539920, Jeff Rivkin, June 2020