Author: James Agnew, CTO
Healthcare depends on the timely sharing of information between patients, payers and providers. This communication involves information flow patterns about millions of people over a vast geographic area. And yet, healthcare remains one of the largest markets for pens, papers and fax machines, generating billions of healthcare documents. Healthcare resistance to keeping up with other industries in adopting new technologies has been one of the major blocks of modernizing it.
“Healthcare is the quintessential information-based industry, yet has singularly failed to harness these forces,” write Tim Benson and Graham Grieve in their book Principles of Health Interoperability: SNOMED CT, HL7 and FHIR. In 2012, spurred on by healthcare’ interoperability woes, a small group (which I joined early on) began building HL7® FHIR® to meet current healthcare data and interoperability needs. Our goal was to liberate healthcare data, and make it function more like information on the internet, meaning to be traceable, searchable and usable.
Today, HL7® FHIR® defines how healthcare information is exchanged between different computer systems, regardless of how it is stored in those systems. It offers interoperability, integration and innovation. It allows clinical and administrative data to be available securely to those who have the right to access it—including patients themselves.
Much like the early years of the internet, FHIR's true potential will not be realized until it's embraced by all stakeholders, allowing for streamlined information sharing to benefit patients, payers, and providers. FHIR will open the way to an “Internet of Health”, unleashing enormous potential and benefits, and ushering in a new era of innovation in a space that has traditionally been hard to innovate in. For HL7® FHIR® to reach its full potential and enable true interoperability, it needs to be more widely adopted—and soon. Fortunately, recent legislation around healthcare data exchange is expediting HL7® FHIR® adoption.
The time for widespread adoption is now.
HL7® FHIR® is rapidly gaining maturity, recognized and backed by a big community. Since 2014, it has been a Draft Standard for Trial Use. It is an evolving standard—parts remain non-normative—but a large portion has matured into validation and finalization. FHIR has already gained widespread acceptance and there is rapidly growing adoption globally by governments, businesses and healthcare delivery organizations.
Amongst the earliest adopters of HL7® FHIR® were electronic medical records (EMR) and electronic health records (EHR) companies. They used the data model to provide APIs for patient-facing data. For several years, healthcare software giants EPIC and Cerner have offered patient portals to access their healthcare records—all built on HL7® FHIR®. Meanwhile, Apple Health allows patients to download data from EPIC and Cerner, easily extract data from wearables, and share health data with others. All of these capabilities are built on the HL7® FHIR® standard. However, these efforts only represent the tip of the iceberg of what’s possible.
Legislation is quickly pushing FHIR front and center. Interoperability has gone from a best practice to a mandate with increasing regulations surrounding healthcare data collection, use, and interoperability.
The CMS Payer-to-Payer Data Exchange Rules
On March 9, 2020, the Centers for Medicare & Medicaid Services (CMS) released the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), designed to give patients, providers and payers better access to healthcare data. While well intended, the rule fell short on the specifics of data exchange format: FHIR was merely encouraged rather than mandated. Ultimately, data could be sent in any format. (For example, a member’s record could be sent as an eFax or a PDF.)
In December 2020, CMS announced the CMS Interoperability and Prior Authorization Proposed Rule (2023). The Proposed Rule was intended to address the interoperability flaws of the initial, Final Rule. It expands on the types of data exchanged and standardizes the methods by which that data is to be exchanged. It strongly encourages data exchange using a FHIR-based Payer-to-Payer API.
These rules are a critical early step towards creating a full-scale FHIR-based data exchange network. Importantly, they also serve as a clear signal from CMS and the ONC that end-to-end data interoperability is considered a priority of the utmost importance within the healthcare sector.
The CURES Act
The 21st Century CURES Act came into effect on April 5, 2021. It is a revolutionary US law stating that patients should have access to all their health data. Patients who are unable to access their personal health information or are not provided with this information “without delay” from their clinicians or health systems are now able to submit a report of “information blocking” through the US Department Health & Human Services website. Similar ideas are under consideration in Germany, Australia, the UK, and the Netherlands.
The CURES Act indicates how personal health records (PHR) are the way of the future. When these are built on HL7® FHIR®, patients cannot only view their data but also decide who they want to share with and for how long.
The UK’s National Health Service (NHS) makes extensive use of FHIR, using it as a standard for RESTful APIs, documents and messages. At the same time, there is increasing support from federal agencies such as the Centers for Disease Control and Prevention (CDC) and the Office of the National Coordinator for Health IT (ONC). In November 2021, they announced their joint support for the Helios effort to streamline data sharing across all levels of public health using the HL7-FHIR® standard.
Ultimately, these data exchange rules and the supporting policies aim to achieve a comprehensive, longitudinal record for each patient. This record offers care providers all the information they need to make informed clinical decisions leading to improved patient outcomes. The record will also make the health history available to patients themselves.
The benefits for Payers and Providers
There are substantial potential benefits for Payers with this data exchange that they may not even realize. Since data is the new oil, more data is good for business.
The payer-to-payer data exchange means that payers will share information of their outgoing members and receive historical health data for incoming members in return. This increased data will give them visibility into members’ clinical history that payers can use for:
- Clinical risk analysis and mitigation
- Analysis for statistical and administrative purposes, etc.
- Participation in the broader economy of health data
A common data standard completely circumvents the need for faxes, duplicate labs or imaging, and many other forms of waste and inefficiency. Also, it empowers patients by making their health data accessible by their care providers. By getting rid of fragmented health records resulting from switching payers, providers can make informed clinical decisions, thereby importing patients’ overall care and reducing potential gaps in care.
Providing departing members with a comprehensive record of their health history fosters member satisfaction and general organizational goodwill, and therefore is beneficial to payers. For the most part, members leave a payer for reasons they cannot control (e.g., job change, residence, or economic changes). By sending a member’s data with them when they move to a new payer, the former payer acquires competitive information, such as where the member went and why. In this new structure, payers will be motivated to send health data to providers, reducing risk and ensuring that their members are being cared for most cost-effectively.
The most compelling reason for payers to invest in this data sharing is that the payer-to-payer data exchange will inevitably be followed by the exchange of data between payers and providers. The systems payers put in place now will prepare what comes next.
Building the future together
There is so much innovation and legislation around HL7® FHIR®—and so much more to come. Currently, we are in the growing pains phase as organizations gradually adopt this data model. Admittedly, adopting any new standard is a time-consuming, labor-intensive process. However, as more organizations adopt this data model, an ever-increasing number of organizations can both send and receive data seamlessly. The ONC recently reported that ten health IT developers, including Allscripts, Epic, Cerner, GE, eClinicalWorks, Meditech, and others, are already using FHIR. As this number grows, the interoperability effects snowball.
Today’s system may be handling data, but tomorrow’s systems will need to exchange data. The benefits of joined-up healthcare depend on safe, secure, and reliable interoperability to provide the correct information when and where required. HL7® FHIR® is a mature standard for global health data interoperability that’s ready to meet the increasing demand.
Participants in the new healthcare economy will depend on the right tools for adaptability and survival. Realistically, Payers should be preparing for the future by developing an HL7® FHIR®-based solution to facilitate the ingestion and management of this data.
Do you have a strategy in place for upcoming rules from CMS and ONC? Reach out to the friendly team at Smile CDR for implementation support from an expert in this domain.
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