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Interoperability: We have tech, data, use case – why the delay?

“Nordstrom knows more about me when I make a purchase than the emergency room knows about me when I show up for care.” 

If you work in healthcare, you have probably heard some variations of the above statement. That’s because healthcare lags far behind other industries when it comes to exchanging an individual’s information across organizational boundaries.

The good news is that the industry is making progress with standards like FHIR and FHIR accelerators such as the HL7 Da Vinci project. Da Vinci’s implementation guides provide a “recipe” for using FHIR standards to address specific industry use cases, like prior authorization.   

The bad news is that even with a compelling use case like prior authorization, adoption of FHIR has been slow. In talking with people across the industry, I think it comes down to three key issues:   

  • Existing processes die hard. Improving processes in healthcare organizations, large and small, requires a willingness to modify systems and change how people do their jobs.
  • Interoperability requires some consistency across payers. Payers maintain their own decision rules for authorizations, but payers must achieve consensus on standards for automating payer-provider communications. From a provider’s point of view, the authorization process will not be interoperable if they are required to submit significantly different information to each payer to receive an initial response regarding whether an authorization is required.
  • Providers and their EHRs must be engaged. Providers do not want to leave their primary workflow to process prior authorizations. Participation from providers and EHR vendors is critical to reducing burden.

Although payer and provider incentives are not completely aligned, the prior authorization use case offers a true “win-win” opportunity regardless of when or whether CMS finalizes its regulations. But addressing these issues and moving FHIR standards forward requires ongoing collaboration.

Availity is helping drive these conversations. We recently held our annual Availity Connects Healthcare Summit, which brought together industry leaders from 25 payer organizations and 14 provider organizations. These attendees overwhelmingly agreed that prior authorization is the biggest industry pain point. There was strong interest in FHIR as an enabling technology, and we expect many more collaborative conversations over the coming months.