Providence is using FHIR standards to streamline payer-provider data exchange, enhancing quality reporting and reimbursement while reducing administrative burdens.

By Hannah Nelson, Assistant Editor

Payer-provider data exchange is critical for reimbursement, but legacy data sharing processes can be burdensome. Implementing data standards like Fast Healthcare Interoperability Resources (FHIR) can help streamline the reimbursement process, alleviate administrative burdens and improve clinical workflows.

At a session during the 2024 WEDI Spring Conference, Providence’s director of informatics, Semira Singh, discussed how the health system is advancing health data exchange for quality measures through FHIR.

Challenges to payer data exchange

Singh explained that while provider claims include billing data, payers often need supplemental clinical data to verify medical necessity, appropriateness, and accuracy of the services billed. Clinical data might include patient diagnoses, treatment plans, medical histories, lab results and other relevant health information.

“Billing data is wonderful, and there are so many things that it’s important for, but it does not always close quality gaps, especially when it comes to quality measures,” Singh said.

For instance, provider organizations must submit supplemental data for the HEDIS Glycemic Status Assessment for Patients With Diabetes measure because the claims do not include information on patient A1C values.

Singh noted that submitting supplemental data can be burdensome. Provider organizations often must extract the necessary data from the EHR, compile it in a spreadsheet, and send the document to the payer or manually enter information into a payer portal.

“The way that this process currently works is not very scalable,” Singh said.

CDex implementation

Providence partnered with Premara Blue Cross to implement FHIR to streamline quality reporting data exchange.

The organizations used standards created by the HL7 Da Vinci Project, a private sector consortium that aims to improve interoperability standards to support value-based care and reduce administrative burden.

In particular, Providence and Premara tapped the Clinical Data Exchange (CDex) and Member Attribution (ATR) standards to create a data-as-a-service (DaaS) product for quality reporting.

“We looked at those value sets with Premera for a year and a half, going data element by data element to make sure that the data we give to our payer partners is data that they can use,” Singh explained.

“We were so thankful and excited to partner with Premera on this and build something that, hopefully, other payers and providers will be able to use,” she added. “The goal here is to come together and build something that’s going to help everyone, whether it’s in value-based care or in whatever data exchange contract is supported between the involved parties for patient care.”

Benefits of FHIR integration for payer data exchange

Provider organizations can improve reimbursement rates by automating the exchange of comprehensive clinical data, which more effectively captures outcomes for quality reporting.

This will free up your clinical teams, clinic teams, referral coordinators, etc., to focus on care and not on data exchange and submitting information for the fifth time because we’re not speaking the same language.

For instance, Singh said that Providence was able to generate an additional $2 million from a Medicaid contract after implementing supplemental clinical data exchange.

“There’s a lot of money tied to value-based care, and a lot of that is tied to not just what you do, but how you’re able to prove that you did that, how you’re able to ensure that you and your payer partner are of the same understanding of what was done,” Singh said.

Additionally, automating quality reporting helps reduce administrative burden.

“This will free up your clinical teams, clinic teams, referral coordinators, etc., to focus on care and not on data exchange and submitting information for the fifth time because we’re not speaking the same language,” Singh said.

The importance of data provenance

Singh emphasized that setting data exchange parameters is critical whenever a health system establishes a partnership with a payer to ensure trust.

“We go through a formal process involving our HIM team to make sure that the payers can see we are not mapping the data, and we’re not saying something happened that didn’t happen,” she said. “We are reflecting true clinical data out of our EMR, so we share that proactively to make sure that they have trust in the process.”

Data provenance is critical in payer data exchange, as most provider organizations work with outside labs and other organizations to deliver care, Singh added.

“We have to have a way to showcase where that information comes from,” she said. “That is always front and center when we’re sharing our data.”

Future expansion

Singh mentioned that Providence plans to add additional data to the FHIR integration to expand quality reporting capabilities.

“The data set that we picked initially was more of a slim set targeted toward the quality measures, but we know that quality measures expand over time,” Singh said.

“We hear from our payer partners and industry partners that more data should be added, so one of our goals as we expand to new measures is to expand to additional data,” she continued. “We know that over time, more data needs to be exchanged if our goal is to be true partners and to ensure that we have exactly what we need to provide the best care to our members.”

As the industry continues its shift toward value-based care, Providence’s use of FHIR highlights the critical role of payer-provider interoperability in achieving the shared goals of better patient outcomes and more efficient care delivery.

• Nelson has been covering news related to health information technology and health data interoperability since 2020.