Data production is rapidly increasing in the healthcare industry, opening up new opportunities to improve patient care and enhance operational efficiency. However, it also presents a substantial challenge: safely and efficiently accessing health data across teams in the care continuum to glean actionable insights for advanced patient care.
The HL7 Fast Healthcare Interoperability Resources (FHIR) standard addresses this obstacle by defining how healthcare information (both clinical and administrative) should be shared. Additionally, the recent CMS 0057 mandate puts new emphasis on enhancing health record access through improved prior authorization processes.
As the adoption of these standards accelerates, the ability to leverage data is becoming more standardized and efficient. This article focuses on the increasing importance of FHIR in data-driven healthcare and the implementation considerations to keep in mind.
Benefits of FHIR in data-driven healthcare
As data has become a nonnegotiable factor in patient care delivery, FHIR offers significant benefits for analyzing data and making data-driven decisions:
Improves access to clinical data
Seamless data exchange across disparate systems is the key to patient engagement, scalable insights, and collaboration among health systems. A primary example of this can be seen in electronic health records (EHR), for which Arcadia recommends using an interoperable system that aggregates data from payers, patient histories, and population health insights.
FHIR improves data exchange by ensuring that clinical data can be accessed quickly, easily, and securely. As a result, healthcare payers can access a comprehensive view of patients’ medical histories to make informed coverage decisions.
Enhances data management
By structuring healthcare information into standardized resources, FHIR ensures consistency in data retrieval and recording. Especially when paired with the advice of a healthcare technology consultant, these standards guide health professionals to effectively manage their data for a unified patient view and streamlined workflows.
This way, payers and providers alike can harness the full potential of health data for analytics and data-driven decision-making.
Optimizes care costs
Accurate and timely data exchange allows providers to access all the information needed for early interventions and informed clinical decisions. This not only improves patient outcomes but also helps to reduce the need for unnecessary healthcare expenditures.
Familiar technology patterns
Unlike much of the healthcare industry, which uses uncommon and aging approaches, FHIR implements the modern pattern HTTP and JSON. This makes it easier for developers without healthcare backgrounds to meet the changing needs of their employers and work on FHIR-related projects.
In this way, FHIR supports the shift toward value-based care by facilitating access to the data needed to measure outcomes and performance. This allows payers to align payments with quality care delivery.
Additionally, access to comprehensive data on a patient’s health status is vital to risk adjustment analytics, as an understanding of risk requires insight into care utilization and cost. This ensures beneficiaries likely to incur higher costs can still maintain coverage and access to care.
Implications of the CMS 0057 mandate
The CMS 0057 mandate drives the widespread adoption of FHIR by requiring healthcare providers and payers to adopt FHIR-based application programming interfaces (APIs) for data exchange. There are several key provisions outlined in this new rule, some of which include:
- Standardized Reasons for Denial: Impacted payers must provide a specific, standardized reason for denying prior authorization requests. This provision ensures clarity and consistency in denial communication, which helps providers understand the reasoning behind a denial and potentially resubmit requests with necessary adjustments.
- Patient Access to Prior Authorization Information: Prior authorization requests and decision data must be included within the Patient Access API. This way, patients can directly view their prior authorization history, unlocking greater access to their own health information.
- Provider Access API: CMS-0057 establishes an API focused on reducing manual data entry and enhancing care coordination. While not yet implemented, the Provider Access API will improve access to member data from payers, allowing providers to retrieve necessary data and collaborate with one another.
J2 Interactive’s VP of Technology, Steve Heard notes, “Some of healthcare’s biggest leaps in modernization have been through government initiatives and CMS 0057 will be no different. Previously, the HITECH Act kickstarted the shift to electronic health records and the 21st Century Cures Act gave patients better access to their own health data.” By embracing these provisions, payers can contribute to increased collaboration, streamlined workflows, and even reduced costs across health systems.
Implementation challenges and considerations
While the benefits of FHIR and the new CMS 0057 rule are clear, putting these standards into practice comes with its own challenges, including:
- Technical complexity: Implementing FHIR requires secure solutions that support data collection, organization, analysis, and exchange. Leverage an analytics solution purpose-built for payers to gain valuable insights about members and make informed adjustments to health plans and services.
- Integration with existing systems: Every team across the care continuum has varying needs when it comes to the right tools for care delivery, which makes it challenging to ensure interoperability without disrupting existing MA workflows. For seamless implementation, payers should evaluate their current prior authorization processes to maximize operational efficiency.
- Compliance timelines: Payers must adhere to the compliance deadlines outlined in the recent CMS 0057 mandate. Some rules become effective as early as January 1, 2026, meaning impacted payers must begin implementing the practices and systems needed to comply.
- Connecting to legacy systems: There are deeply entrenched and nuanced methodologies in healthcare’s data systems, and expertise in traditional approaches remains essential – even when implementing HL7’s user-friendly FHIR – to successfully bridge the gap as these complex infrastructures evolve.
Given these considerations, payers must foster open communication about adopting these standards both internally and externally. Internal teams, such as utilization management and claims processing, must be educated on any new requirements and the implications for their workflows. Additionally, payers should communicate with providers about accessing member prior authorization data and preparing for the adoption of Provider Access API.
To effectively implement FHIR standards and align with government regulations, payers can consult a specialist in solutions for health systems, such as J2 Interactive, with expertise in interoperability. Guidance from a knowledgeable industry expert ensures that payers not only implement these standards properly but also realize the benefits of adopting them.
As the healthcare industry evolves toward a more data-driven future, the adoption of FHIR is vital to support better patient outcomes and drive operational efficiency. As interoperability becomes established as a standard practice across the industry, providers and payers alike can contribute to a connected and efficient healthcare system.
