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Why FHIR will disrupt the healthcare payer landscape in 2021 and beyond

Shyamsree Nandi
September 9, 2020

Everyone is talking about FHIR interoperability in healthcare. FHIR is like the “ninja of care coordination” and holds promise in terms of driving healthcare transparency and better patient access. FHIR is an extremely open standard that is a potent framework to drive common information models across the care continuum. The candidate resource lists have expanded over time as FHIR evolved and V4 has the most comprehensive set of resources that can appropriately exchange information at a basic granularity of what is required across clinical, financial, and administrative data. The extension framework of FHIR is also extremely amenable to fluid extensions of almost every FHIR resource in order to address bespoke data elements or those that uniquely fit individual payers or providers.

While this flexibility is great and is also a best practice for any interoperability standard, it makes it slightly open to interpretation and hence a candidate for extensive business debate in terms of what fields a payer wants to populate beyond the mandatory cardinality requirements. Explanation of benefits, for instance, has important information related to benefits and pricing. This could even be sensitive competitive intelligence that payers may want to carefully evaluate before engineering the FHIR resources. From a consumer angle though, it is expected to drive a lot of innovation in healthcare product design. The question in front of payers is “how much is enough?”

FHIR is not just a standard that will sit at the endpoints. It is expected to change the way we exchange data internally within a payer landscape. The patient access APIs can only be as real time as the slowest-moving data element internally. We all know that claims systems and data warehouses have organically evolved in payer organizations and hence improving timeliness of data would require overhauling several hitherto batch processes. It would also mean rapid data consolidation and harmonization. None of the FHIR JSONs can be generated easily unless payers take up the time-consuming projects of creating single sources of truth and consistent information models that help map the critical FHIR elements.

Timeliness and standardization are the two biggest pieces of the FHIR puzzle, at least for the CMS 2021 mandate. Payer data exchange will also have several other connotations in the longer run. The wonderful aspect about these two dimensions is that they can foster TCO reduction through consolidation efforts and accelerate a payer’s data modernization initiative. More often than not, a bid to embrace cloud modernization is gaining foothold on the back of FHIR compliance implementation.

At Capgemini, our focus for FHIR has been not just to address FHIR as a mandate or address this as an API integration program, but to look at it through the lens of improving member intimacy. For the core compliance we are leveraging our FHIR accelerators, parsers, and testing frameworks which can accelerate the compliance journey by as much as 45% and sometimes more. Beyond compliance we are leveraging FHIR to better understand risks and develop “Tree of member’s life.” We feel that security does continue to be one of the most critical considerations on this journey but the openness to digital transformation and heightened focus on member centricity are becoming defining moments in the healthcare payer industry today. In my next blog, I will write about how FHIR is fundamental to improving member experience and addressing a long unmet need of developing member 360.