TIBCO & Smile Digital Health Whitepaper: Payer Interoperability Rules and Your Digital Transformation

Author:  Clement Ng

The release of the CMS and ONC interoperability and patient access final rules in March has quickly been recognized as a profound transformation in the way payers will collect, store and distribute patient information. 

This transformation is driven by the move of US healthcare away from the traditional fee-for-service model towards a value-based care model whereby providers are rewarded for positive patient outcomes as opposed to compensated based on the volume of patients who receive treatment. To support the value-based care model, CMS and ONC are mandating providers to share patient clinical data with payers, to unlock health data too often trapped in information silos and make it accessible and usable to patients via consumer apps of their choice. This forces the healthcare industry to leverage developments in the consumer digital economy, especially APIs and apps, and be open to opportunities in innovation.

The end goal: a competitive marketplace filled with interchangeable health apps fuelled by interoperable patient data that balances free-flowing information with strong protections for patient privacy. And as the final rules make clear, payers have a key role to play in making that a reality. That means standing up significant new infrastructure that can handle clinical data, including patient access APIs that can enable 3rd party applications to retrieve data from payer systems using FHIR. This will be a challenging endeavor for payers of all sizes. 

The industry has now had a few months to digest the rules and consider their implications. Moving forward with needs assessments, vendor selection and implementation are undoubtedly top-of-mind, given that the first milestones for compliance come due in 2021. 

What’s clear is that payers need a new flexible IT platform that can quickly provide customer-centric applications for patients and new digital capabilities that can deliver strategic value in the coming age of increased transparency and value-based care reimbursement models. Apart from infrastructure and tooling, payers should be on the lookout for vendors with experience working with other health plans performing enterprise-class FHIR implementations.  

Are you looking to implement a FHIR data platform? Get in touch and let’s explore how we can help.