US Government Lights FHIR Under Payers

Author:  Clement Ng

In order to achieve the goals of the 21st Century Cures Act, Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) proposed companion interoperability rules in February 2019. These proposed rules mandate US health plans adopt the HL7 FHIR standard to provide secure exchange and access of electronic health information for authorized users and eliminate interference in the exchange and use of this information.

The implementation of these proposed rules shifts much of the focus and burden of interoperability to US Health Insurers to provide patients with their data, as health plans have data sets that follow patients across the healthcare system over time.  In order to meet these Value-Based Healthcare rules, Payers must capture and make available not just claims data but also a wealth of clinical information covering the previous five years. 

US health plans must work towards an interoperability strategy that unifies a rich and diverse set of Provider and Payer data into a FHIR-accessible architecture.  Most health plans will need to create a new data strategy in order to meet the requirements of the proposed rules. 

When formulating an appropriate FHIR strategy, Payers will need to select a FHIR server in order to enable FHIR endpoints for data exchange with others. The good news is that the robust and standardized FHIR model provides the flexibility of standardized delivery of data from diverse sources. However, FHIR servers offer a wide range of capabilities from simple API gateways to a fully functional clinical data repository (CDR), and varying capabilities within those categories. Payers should, therefore, assess FHIR servers based on their needs to ingest, protect, cleanse, store and deliver data through FHIR.  

A FHIR-based CDR provides a strong foundation not only for using FHIR APIs to enable a flexible and adaptable IT interoperability platform for Payers, but also for realizing huge value in other areas such as analytics, leveraging Smart on FHIR applications for better Member and Provider interactions, etc.

Smile Digital Health is a complete, purpose-built clinical data repository designed around the HL7 FHIR standard that is used for storing and exchanging health data.  Smile provides the full range of capabilities of a FHIR Server with multiple persistence models.

The FHIR standard (APIs and data model) provides a proven and flexible base for healthcare data exchange, and 2020 will be the year Payers re-orient their IT infrastructure around FHIR. 

Stay tuned for our next blog where we’ll dive deeper into various FHIR deployment strategies to share actionable insights on what Payers should look for when evaluating potential solutions.