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The Opportunity In Interoperability

I know regulations can seem overwhelming, but if you look beyond checking the boxes to ensure compliance, there is so much opportunity. I always try to remind the health plans I work with that regulations result from constituents going to their legislator with a problem that needs to be fixed, eventually resulting in a mandate. Beyond compliance, addressing these mandates can have positive results for the health plans and its members.

Think of interoperability, for example. It may seem overwhelming, but the concept of serving tailored, customized information to an individual is not far-fetched. If someone turns on their TV or opens a streaming service, the consumer sees a menu of options and suggested programming or channels of interest based on previous activity. With interoperability, individuals can apply that same concept to healthcare.

Traditionally, members have had to collect data from various sources—member portals, lab results, claims statements, and more— and try to figure out what it all means, and what to do next! Interoperability will pull that information together and make recommendations based on that information.

The driver behind interoperability is that patients, or members, want to know more about their own health. Interoperability provides information and analytics that could help individuals connect the dots and take away guessing when it comes to their healthcare. Interoperability empowers individuals to address their concerns, ask questions, identify additional steps, and lifestyle changes they can take to improve their well-being and have the full picture of their health.

For members, interoperability is about getting access to the right information. For health plans, interoperability is about collecting and sharing that information.

To make interoperability successful, health plans need the right technology and, almost more importantly, sound business processes, resulting in good data. Anyone can learn how to do FHIR-enabled APIs. But understanding how a claim should come in, how it should process in the system, and how it produces the information needed to be consumed by the APIs is very important. Payers should focus on the claims administration system and ensure they’re collecting the right data consistently so that they can provide the right message to the patient, other payers, and providers.