The Fast Healthcare Interoperability Resource (FHIR) data-exchange standard has generated headlines in health information technology circles for the last several years, but its inclusion in recently finalized federal patient access and interoperability rules has led to a surge in interest across the broader healthcare industry – and it’s now mandatory for payers.
The primary purpose of the interoperability rules, issued in March by the U.S. Department of Health and Human Services (HHS), was to enable patients to have convenient, safe and secure access to their own health data to help them make better healthcare decisions. As envisioned by HHS officials, smartphone apps will be among the primary vehicles through which healthcare organizations such as payers and health systems facilitate patient access to this data.
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John D'Amore John D’Amore is the president and co-founder of Diameter Health, a clinical data optimization company focused on improving the quality and quantity of actionable health data.
That’s where FHIR enters the picture. A key provision of the rules is the requirement that developers use FHIR version 4 as the technical standard underpinning the application program interfaces (APIs) that healthcare apps use to exchange data with other apps and information systems.
Before going any further, it must be acknowledged that FHIR is not a silver bullet that will solve all of the healthcare industry’s long-standing interoperability problems – but it will lead to improvements. For payers and other health organizations, FHIR offers several advantages over other healthcare data standards.
While other standards without a doubt include important health data, that data is not necessarily easy for apps to use. FHIR, in contrast, is a more modern technical standard that enables apps to plug directly into electronic health records systems or claims databases to obtain patient health data. Additionally, when contrasted with other standards, FHIR allows for the sharing of small, discrete, specific bits of data, as opposed to reams of information in a Continuity of Care Document.
Challenges payers will face with FHIR
For payers, implementing these new standards presents several challenges. The first is simply how quickly the date of enforcement is arriving – July 1, 2021. As of that date, payers must have gone live with two different APIs, one providing members with access to their own clinical and claims data and the other delivering public-facing directory services for provider networks and drug formularies.
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The second major challenge revolves around the quality of the clinical data that payers present to members. Health plans must use the FHIR standard to make these five types of data available: 1) adjudicated claims; 2) encounters with capitated providers; 3) provider remittances; 4) enrollee cost-sharing; and 5) clinical data, including laboratory results.
Some payers have previously implemented systems to process the first four types of data, which can be mapped to three parts of FHIR, specifically: explanation of benefits; patient; and coverage resources. The fifth type, clinical data, is generally the most valuable data for patients but also represents the most significant potential roadblock for payers, particularly those that are not yet leveraging clinical data.
The reason is that the success of FHIR as an exchange format is dependent on data being well-structured. Because clinical data is often incomplete, redundant, or inconsistently coded, its value for patient access via FHIR can be limited. Information that is poorly formed in the source electronic health record will render incomplete as an FHIR resource.
In some respects, the state of clinical data – whether structured or unstructured — is healthcare’s dirty little secret. In many cases, clinical data is not structured or codified, appearing as little more than an ugly blob of text in patient records. For example, critical measures such as blood pressure or a diabetic’s HbA1c levels sometimes are recorded in the unstructured “notes” field of EHRs. Further, even when data appears in structured fields, it often lacks the detail required to achieve true semantic interoperability.
Regardless of its state, clinical data exists in many different forms and will need to be mapped to a large directory of FHIR resources. Specifically, the regulations call out the usage of the U.S. Core Data for Interoperability, which contains standardized health data classes and data elements and uses over a dozen different parts of the FHIR standard.
Although the deadline for compliance with the FHIR patient access rules is fast approaching, most payers are not prepared, according to a June report from Gartner. Mapping data from existing formats to FHIR resources is likely to represent payers’ greatest challenge in the process. While payers’ struggle to attain “clean” clinical data that can be effectively used in FHIR APIs is likely to be substantial, data quality progress will yield significant rewards in higher member satisfaction, improved HEDIS scores, stronger population health analytics and more-accurate risk adjustment.
Photo: JamesBrey, Getty Images
John D’Amore is the president and co-founder of Diameter Health, a clinical data optimization company focused on improving the quality and quantity of actionable health data.
