6 capabilities that can help U.S. healthcare payers make progress toward interoperability

Strategy development, data curation and consent management are among the core capabilities that can help health plans transform into the organizations that help take the friction out of healthcare.

By | 3 minute read | May 20, 2020

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Interoperability has been a long journey for healthcare, and many would agree that we have miles to go. In March 2020, the U.S. Department of Health and Human Services (HHS) finalized two rules designed to help improve patients’ access to their data, prevent information blocking and increase secure healthcare data exchange.1

While interoperability efforts have traditionally focused on electronic health records (EHRs) and healthcare providers, these final rules include new requirements for health plans, such as provisions to support standard Application Programming Interfaces (APIs) to enable better access for members to their own claims, clinical and cost data, an open provider directory and payer-to-payer data exchange.2 FHIR is the standard that can help bridge the existing communication gap between the payer and provider domains. In my opinion, FHIR has the potential to help automate manual workflows, which could result in improved processes, lower costs, and improved patient and provider satisfaction.

Given the upheaval caused by the COVID-19 pandemic, and the January 1, 2021 compliance deadline, the government has exercised a six-month enforcement discretion for the member access and provider directory requirements.3 For many health plans, interoperability remains top of mind.

For healthcare payers to be able to pivot to achieve interoperability that meets requirements and supports business transformation, we recommend they take a holistic approach – combining the right technology with a strong set of core capabilities. In my opinion, there are six core capabilities that can help health plans meet these new requirements and get good return from these investments, including:

1) Strategy development – Define a short- and long-term vision for interoperability. Health plans should prioritize the use cases that are most important to their mission and develop a solid execution plan. Fully engaged and aligned organizations are more likely to have this capability.

2) Data curation – Integrate data from disparate systems, including claims, clinical, pharmacy and other data sources. Patient and facility matching, FHIR validation, as well as logs and audits, are critical components of data management capabilities. This can be especially difficult for healthcare payers that have older, customized administrative systems, and those with disparate systems as a result of mergers and acquisitions. Being able to link, standardize and conform data from disparate health systems into FHIR formats, is required for interoperability and can help create a common view across the enterprise.

3) Consent management – Maintain privacy and security of the data they are sharing with members, including assessing vulnerabilities of third-party applications. Healthcare payers should be able to audit, track and report all aspects of consent and dispute resolution with trust and transparency. Most importantly, they should be able to track and use fine-grained patient consent to manage data sharing with respect to the legal rights and consent choices of patients. We believe blockchain technology is well-suited for providing an immutable single source of truth across distributed systems. It will be critical to have a strategy around how to educate and support members through this process.

4) API management – Develop and manage standards-based APIs, including app registration, authorization and authentication. Health plans should help ensure end-point security of these solutions. They should ensure their API development platform includes healthcare API starter sets to speed innovation. Again, for healthcare payers with older, customized or disparate administrative systems, this can be a difficult step.

5) Implementation and support – Solutions should match the most recent requirements and guidance. Healthcare payers must integrate solutions and monitor for updates.

6) Responsiveness – Automate and manage inquiries from members, providers and other health plans. They should be able to leverage conversational AI in the form of a digital assistant to support members and other stakeholders using these new capabilities.

This is a time for healthcare payers to re-imagine their business, and not just as a compliance initiative. With these core capabilities, they have an opportunity take mandated, required interoperability requirements and use them to transform themselves and their value proposition. In my opinion, health plans can be the organizations that take the friction out of healthcare and deliver insights that help improve member experience, coordinate care, manage outcomes and lower costs.

At IBM, we believe that interoperability across stakeholders is essential to help achieve the quadruple aim. With over 40 years of experience supporting health plans with regulatory reporting and compliance, IBM is here to help organizations meet their interoperability requirements and help them create an environment where stakeholders across the healthcare ecosystem can benefit.

Learn more about IBM Watson Health payer solutions



  1. https://www.hhs.gov/about
  2. Ibid.
  3. https://www.hhs.gov
  4. IDC Market Spotlight: Foundational Data Platforms Improve Payer Interoperability, sponsored by IBM® Watson Health®