Increasing Usable Clinical Data for Payers with FHIR-based Interoperability

Healthcare organizations have long struggled to achieve seamless data exchange between providers and payers, hindering progress in delivering higher quality care. However, innovative partnerships and the adoption of HL7 FHIR (Fast Healthcare Interoperability Resources) are proving that significant advancements in interoperability are achievable today—without the need for massive infrastructure overhauls or waiting for regulatory deadlines.

Vice President of Data Partnerships and Informatics at Providence Michael Westover recently shared his team’s experience implementing an automated FHIR-based Clinical Data Exchange solution based on G10 Electronic Medical Record (EMR) standards (Read full article). Across all value-based contracts, Providence achieved a remarkable 40% increase in the exchange of usable clinical data, leading to substantial improvements in HEDIS quality and risk adjustment scores.

The Challenge: Legacy Systems and Inefficient Processes

Traditionally, sharing clinical quality data involved labor-intensive workflows. For providers, this means combining payer member rosters in non-standard formats with EMR data and reformatting data into proprietary formats for various payers.

This approach is not only costly and time-consuming but also limits the completeness and usability of the exchanged information. Despite these challenges, sharing accurate and timely clinical data is crucial for success in Value-Based Care arrangements and improving patient outcomes.

The Solution: Automating Clinical Data Exchange with FHIR

The adoption of FHIR-based solutions can transform how providers share clinical data with payers. Providence found that pulling data directly in a FHIR-native format from their EMR drastically increased the volume of actionable information that could be shared with payers. This advancement translates to better performance on HEDIS measures, enhancing care delivery without altering clinical workflows.

With Opala's Clinical Data Exchange solution, one of Providence's largest payers was first in the nation to accept data in FHIR format according to the HL7 Da Vinci industry standard, Clinical Data Exchange (CDex) Implementation Guide.

Key Benefits of Enhanced Data Collection

1. Improved HEDIS Scores: More complete data leads to more accurate quality reporting, driving better health outcomes and financial performance.
2. More Accurate Risk Scores: More complete data leads to more accurate risk scores, driving more timely, personalized outreach and better financial performance.
3. Efficiency Gains: Automating data exchange reduces the time and cost associated with manual processes.
4. Scalability: FHIR-based APIs enable bi-directional data sharing at scale, laying the groundwork for future innovation.

A Call to Action for Healthcare Leaders

The success of this collaboration between a provider and payer underscores the critical need for healthcare organizations to prioritize interoperability. To begin reaping the benefits of enhanced data exchange, leaders should consider the following:

• Evaluate High-Impact Data Feeds: Identify which data sources significantly influence patient care and business outcomes.
• Assess Current Workflows: Examine how much time and money are spent on packaging and sharing data.
• Modernize Infrastructure Strategically: Implement scalable APIs and adopt national standards to simplify and standardize data exchange.
• Foster Collaborative Partnerships: Work with technology vendors who share a commitment to interoperability.

Looking Ahead: The FHIR Revolution

The FHIR revolution is reshaping how healthcare organizations share data. By leveraging standards-based solutions and technology partners, such as Opala, providers and payers can break free from the inefficiencies of legacy systems and make meaningful strides toward better patient care and operational performance.

Providence's success demonstrates that improving clinical quality scores is achievable now. Healthcare leaders who embrace these innovations will be well-positioned to navigate future challenges while driving measurable improvements in care delivery.