Unlocking the Future of Healthcare Technology: Interoperability, Transparency, and AI

At a recent executive roundtable, HealthEdge® brought together health plan leaders from across the U.S. to share their experiences and see how other organizations are addressing key challenges. One recurring barrier? How to eliminate internal data siloes and leverage actionable insights.

In this article, we highlight key insights from a panel of payer executives who shared how their organizations are currently leveraging the HealthEdge ecosystem to improve data accuracy, transparency, and efficiency.

Why should payers focus on interoperability and data transparency?

Interoperability has been a major disruptor for the healthcare industry, forcing payers to address legacy technologies, siloed processes, and outdated systems. This shift has highlighted the undeniable need for digital innovation and vendor partnership.

By focusing on making data accessible and understandable, payers can streamline processes and move toward a more integrated, forward-thinking system that supports the future of interoperability.

“As we evaluated our operations, we recognized the need to take a data-centric approach to drive meaningful change,” said one panelist, the Enterprise Platform Strategy Leader at a regional health plan. “We applied the RACI model to our data, not just for identifying users and authors, but also focusing on data transformers, a critical yet often overlooked piece. Data is transformed through processes, and by understanding this, we could better align and optimize our operations to meet interoperability requirements.”

What are the practical advantages of leveraging a cloud-first, modern architecture to break down data silos?

Focusing on data as a corporate asset was key. For digital solutions like the HealthEdge ecosystem, the cloud isn’t just a storage site—it’s a foundation for everything from interoperability to analytics. For example, using the FHIR data standard in the cloud isn’t just for compliance. By making this information available in a universal format, health plans can easily repurpose it in areas like provider workflows, integrating data where it adds the most value and meeting requirements beyond regulatory mandates.

“We’ve been cloud-first for 10 of the 11 years I’ve been with the company,” said the Chief Information Officer at a New York-based health plan. “We’re as well-positioned as we could be. Because we organize our data according to FHIR, we’ve been able to use it to create endpoints that we’ve been able to integrate into provider workflows that has delivered value.”

How do health plans address the separation of “business” and “IT” to drive cross-functional collaboration?

“Separating business and IT is a false dichotomy,” said the Vice President of IT at a nationwide health plan. “In our role, we have a unique vantage point to see the silos and inefficiencies that exist across operational areas. It’s not enough to simply point these out; we need to understand the business deeply enough to propose and build meaningful use cases that deliver real value.”

Take “care-related” transactions as an example. Sometimes, the only way a provider knows a member has been discharged is through personal phone calls—a process that’s far too slow. By following the member’s journey and connecting all the data touchpoints, we can provide timely, actionable insights. For instance, tracking discharge data and delivering it to providers immediately can help prevent re-admissions and ensure better care. Our role is to connect the dots, drive accountability, and create solutions that enable business value and improve outcomes.

How can payers ensure new technologies improve efficiency instead of adding more complexity?

The process begins by evaluating what the legacy system actually does. Usually, the system is attempting to serve every need but failing to address core priorities effectively. Payer leaders must identify when a workflow faces bottlenecks, or when a cluttered system is more overwhelming than supportive.

“We really had to understand what our legacy platform did,” said the Enterprise Platform Strategy Leader. “Because we built it, it became all things to all people. But it can’t be everything to everyone, otherwise it’s nothing to nobody. Our legacy platform had more than 500 letters for member communications. By simplifying the logic and adopting a more efficient data model with HealthEdge GuidingCare®, we were able to reduce that to 17.”

With tools like GuidingCare Letters, member communications can be generated in real-time without manual effort, significantly cutting overhead and allowing care managers to focus on improving member outcomes.

With so much data available, how can payers determine what is actionable for improving care management?

Having a lot of data means nothing if you can’t trust it or act on it. The first step is to build a culture that trusts and validates available information so it can guide organizational action. It’s common for health plans to get different answers to the same question depending on where and when the data is pulled.

“I don’t think our core KPIs change, it’s the speed at which we understand the data in order to get those KPI changes materializing,” said the Vice President of IT.

Solutions like HealthEdge® Provider Data Management can automate data ingestion and validation to give payers a single source of truth, reducing workflow complexity and improving the member experience.

What are the most promising AI strategies you’re seeing in healthcare right now?

Artificial Intelligence (AI) is a hot topic, with use cases ranging from streamlining care management to enhancing customer experiences. Innovative uses include agentic AI for tasks like syncing provider data across platforms or performing ambient call center analytics.

“Trust is the fuel that goes in the rocket of AI,” said the Vice President of IT. “We’re exploring how to use AI to identify the right data, confirm its cleanliness, understand its governance and history, and then apply it effectively. The problem often isn’t the absence of data, but rather knowing which data is clean, what it means, and how to use it. By using AI to establish that foundation of trusted data, we can unlock its full potential.”

AI-driven tools can unlock new possibilities, but the costs often emerge before the economic benefits, requiring health plans to maintain careful oversight and budget management. The key to success is keeping humans in control—defining, containing, and curating the knowledge an AI agent can access while validating its outputs.

“I think it’s really important that humans have to stay in control,” said the Chief Information Officer, “We’re spending a lot more time investing in managing knowledge and making sure we’re in control of the knowledge we give AI access to.”

What are the key technology challenges and priorities for health plan executives?

A persistent roadblock for many payers is that demand for new projects consistently exceeds the available supply of resources. It’s easy to initiate technology adoption, but far more challenging to demonstrate tangible value and complete them. Promoting a culture of rapid iteration and testing is essential.

“A cultural thing we struggle with is embracing failing often enough, because we’re trying something so new—and embracing that at the engineer level is key,” said the Vice President of IT. “We’re seeing such an accelerated pace of change in technology that if we spend too much time trying to make one solution work that multiple competitive capabilities can come out in the meantime. It’s important to be able to fail, fail fast, be okay with it, and move on to new things.”

Another significant challenge is driving adoption and establishing trust among teams who may be skeptical of new technologies. It is common for users to demand explainable, compliant AI solutions before they are willing to fully integrate them into their workflows. Consequently, effective change management and complete transparency regarding the capabilities and limitations of these tools are essential for successful implementation.

Achieve Greater Value from your Digital Solutions

This panel discussion revealed that breaking down data silos is not just a technical challenge, but a strategic priority for healthcare organizations. By aligning technology with business objectives and implementing AI responsibly, health plans can leverage verified data to streamline operations and deliver superior member experiences.

Learn more about how your health plan can leverage technology to deliver an integrated and impactful member experience in the eBook, “Disjointed to Dynamic: How Nascentia Health Modernized Care with HealthEdge GuidingCare.”