The Digital Health Transformation: Going Beyond CMS Mandates 

To reduce administrative workloads and overhead, minimize provider abrasion, meet evolving patient/member demands, and support compliance with regulatory mandates, healthcare leaders need to rethink their approach to interoperability.

A strategic approach to interoperability can help leaders go beyond satisfying regulatory requirements. As we discussed last time, FHIR® plays a big role in that strategy—but as we’ll explain today, there’s a lot more to it than that.

The individual provisions in CMS final rules 9115-F and 0057-F each serve a valuable purpose, but in our view, these mandates also serve a larger purpose. Since the easiest way for organizations to fulfill these provisions is by adopting FHIR standards, it seems the true goal of both mandates was to promote FHIR as the industry standard for data interoperability. If that was indeed CMS’s objective, it worked: 79% of EHR vendors adopted FHIR in 2024 (up from 63% in 2023), and FHIR adoption is expected to increase in the coming years.

If your aim is simply to meet CMS mandates, then incorporating FHIR into your existing infrastructure is enough to get there. FHIR is the popular standard for interoperability today, but it’s not the only one—and its place in the hierarchy could change at any time. Your strategy needs to be flexible enough to accommodate new modalities of data exchange, whether that’s FHIR or whatever comes next.

By taking a compliance-first approach to interoperability, healthcare leaders are locking their organizations into an ongoing series of sprints. Whenever a new mandate is handed down, the organization scrambles to fulfill the technical requirements—without stopping to consider how those new standards will impact their existing infrastructure.

Going Beyond Compliance

If you’re just sprinting from point A to point B, it’s possible to drag your existing infrastructure along for the ride. But strategic interoperability isn’t a sprint; it’s a long journey across often treacherous terrain that requires the right equipment and a strategy for how you’ll utilize it. Hauling your current infrastructure along for the journey may not be feasible for the same reason it’s not a great idea to bring your refrigerator on a hike.

Thinking strategically about interoperability ensures that no matter how the regulatory landscape evolves in the future, you’ll have the right foundation to adapt to those changes. More importantly, strategic interoperability enables you to maximize the utility of—and return on—your interoperability investments by applying them to novel use cases, including:

Clinical Data Retrieval for Risk Adjustment

The Trusted Exchange Framework and Common Agreement (TEFCA) was created to establish a single nationwide framework for data sharing between healthcare organizations. Naturally, FHIR plays a big role in that, which is why FHIR-based APIs were recently introduced into the TEFCA exchange. But even if your organization doesn’t follow TEFCA standards, FHIR can be used for two very valuable use cases: risk adjustment and quality measure implementation. FHIR streamlines the process of exchanging coding gaps between payers and providers faster and more efficiently, which helps ensure complete and accurate documentation and coding.

Social Determinants of Health

To thrive in a data-driven model like value-based care, payers and providers need a complete picture of the patient or member’s health—one that goes deeper than just their current care needs. The variety of non-medical factors that can impact patient health, outcomes, and costs are known as social determinants of health (SDOH), and understanding those factors is vital.

Gathering SDOH data is easy enough. However, because that information is not standardized, it often isn’t properly incorporated into the patient record, making it difficult for organizations to share and utilize the data. With FHIR, it’s now easier for organizations to collect SDOH data, standardize it, and exchange it across the healthcare continuum for better-informed and more consistent patient care.

Patient/Member Consent Management

Patient/member consent management is a key pillar of CMS-0057-F, and there’s increasing pressure on HIPAA covered entities to ensure that consent preferences are accurately captured and able to move with the individual. Unfortunately, when patients cross organizational or geographical boundaries, their data hasn’t always traveled with them—but FHIR is helping fix that.

New FHIR APIs are designed to facilitate greater portability of consent policies and preferences by enabling seamless exchange of patient consent between organizations. Not only does this help ensure compliance with CMS-0057-F, it also supports a better patient/member experience by eliminating the need to reaffirm consent preferences while ensuring those preferences are honored wherever the member goes.

Improve Care Quality & Outcomes

Your organization’s goal is to deliver the best possible care and outcomes for your patients or members. To achieve that, your organization needs to be able to exchange data quickly and seamlessly with anyone—and FHIR is the most robust standard yet for doing so. FHIR enables real-time event-based notifications for changes in patient/member status to support earlier intervention and more effective care planning.

Quality measures are another essential component of improving care outcomes, but creating and sharing quality measures between organizations can be difficult and time-consuming. FHIR’s Clinical Reasoning Module and Clinical Quality Language (CQL) helps create a standard for measuring quality that enables easier identification and transmission of quality improvement data across multiple organizations and systems. By doing so, you can ensure that you and your partner organizations are all relying on a consistent and cohesive set of quality measures and reporting that ultimately support better care and outcomes.

The Big Picture

There are plenty of valuable use cases for FHIR, but remember: it’s not just about how to leverage FHIR standards. It’s about remaining flexible enough that your organization can incorporate any new standard and identify relevant use cases that will help you maximize the return on your investment.

There’s no doubt that CMS mandates can be onerous, especially when it feels like your organization is constantly scrambling to comply with each new rule. Like it or not, interoperability is the future, and organizations that refuse to recognize that reality will be stuck playing catch-up.

By taking a strategic approach to interoperability, you can help ensure your organization is prepared when new mandates are inevitably handed down—and capture significant value in the meantime. That sounds like a smart strategy to us.