Edifecs E

Matt Spielman

Posted on January 31, 2025 | 5 min read

The Digital Health Transformation: (Re)Defining Interoperability

Categories:

Healthcare Data

Operational Excellence

Regulatory Compliance

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The Digital Health Transformation- Redefining Interoperability

Achieving comprehensive and meaningful data exchange to support better patient experiences has long been a priority for the healthcare industry. But despite industry leaders’ best efforts and regulatory nudges in the form of CMS interoperability rules 9115-F and 0057-F, that goal feels almost as far out of reach today as it did five years ago.

We have everything we need to make holistic interoperability a reality, but something is holding us back. It’s not the technology, the data standards, or the regulatory requirements; it’s how healthcare executives approach investing in interoperability. There is a right way and a wrong way to think about interoperability—and industry leaders need to embrace a new mindset.

The Wrong Way

Although the piecemeal rollout of regulatory mandates has been less than ideal, true interoperability is essential to the future of healthcare. The industry is struggling with rising administrative costs, unsustainable workloads, inefficient workflows, and an overall lack of trust and collaboration between payers, providers, and patients. We have the data we need to support a healthcare system that works for health plans, providers, and patients, but thus far, we haven’t been using that data as effectively as possible. It’s a collective problem that demands a collective solution.

Too often, industry leaders think of interoperability as a feature or a standard that has to be met to satisfy regulatory requirements: as long as they implement some sort of FHIR-based API and use the right X12 codes, they’ll avoid any compliance risk. The flurry of new interoperability regulations that have cropped up in recent years is at least partly to blame. Each new mandate requires further investments into interoperability, even if their last investment still hasn’t paid off.

Many executives try to soften the financial blow of these investments by building their own minimum viable product or by purchasing a third-party solution designed solely to meet the narrowest requirements of the latest mandate. This approach follows the letter of the law rather than the true spirit of interoperability—and while it may mitigate short-term costs, it’s almost always more expensive in the long run.

When regulations and their interpretations inevitably evolve, healthcare organizations become locked in a cycle of updating their solutions, inflating the cost of what is, at its core, a bare-bones solution that offers no value beyond achieving compliance. Not only does this approach fail to eliminate data silos or streamline workflows, it often achieves the opposite effect: new silos are created, and workflows become even more complex.

By approaching interoperability this way, healthcare leaders are missing an opportunity to meet a key business imperative within their own organizations. And the industry as a whole is missing a crucial opportunity to evolve and meet the challenges of the moment.

The Right Way

A compliance-first (or compliance-only) approach to interoperability will never be enough to meet evolving patient or member demands, ease provider abrasion, address inefficient workflows, or ultimately enable the kind of transformation healthcare desperately needs. Healthcare leaders need to embrace what we call “strategic interoperability,” where interoperability is not just a means to achieve compliance but an enterprise capability that can play a foundational role in their long-term operations.

Operationally speaking, strategic interoperability is the ability to seamlessly exchange and manage data in any format, including EDI, FHIR, NCPDP, HL7v2, or any other proprietary format. From a big-picture standpoint, strategic interoperability is less about the format itself and more about building a platform that can adapt and evolve to support past, present, or future use cases—no matter how things change.

Strategic interoperability investments help improve organizational agility and reduce total cost of ownership of the organization’s tech infrastructure. This enables organizations to improve business processes and efficiency to ensure better reliability, service, and partner/customer experiences, giving them a crucial competitive advantage in the marketplace—all while ensuring compliance with current and future regulatory mandates.

Here’s how to get started.

Achieving Strategic Interoperability

Step 1: Establish your goals, needs, and strategy

To function as a foundational part of your operations, your interoperability capabilities must align with your broader organizational goals. Ask yourself:

  • What are the organization’s strategic imperatives over the next three, five, or 10 years?
  • How will these imperatives impact business success and member/patient outcomes?
  • How can interoperability investments support your organizational goals and help you achieve the quadruple aim?
  • What can we learn from our past investments in interoperability?

Step 2: Take stock of the current environment

Understanding the current landscape can help you better prepare for what lies ahead—not just for your organization, but for your key stakeholders as well. Ask yourself:

  • What systems does each key business function use? How interoperable is each today?
  • What options exist to make these systems durably interoperable?
  • Can this be achieved with minimal disruption to (or replacement of) existing systems?
  • Are there limiting beliefs or practices towards interoperability within our operation that need to be addressed?

Step 3: Consult and partner with internal and external stakeholders

Too often, healthcare leaders grade their organizations’ interoperability based on how easily and efficiently data can be shared, integrated, and orchestrated internally. But remember, this is a collective problem: if your investments don’t take into account the needs of your external partners, what you’re building is not interoperable—it’s intraoperable. Ask yourself:

  • Where is the data used to facilitate business decisions or engage with external parties located?
  • How consistently defined and well-formed is that data? How well do we manage changes to this structure?
  • Can we leverage existing integration, orchestration, and data management infrastructure to facilitate more effective data exchange with external partners?
  • What short- and mid-term business objectives could be advanced through a more interoperable enterprise and ecosystem?
  • Do we have the processes and resources necessary to maintain alignment over time?

Step 4: Define your interoperability strategy

With a clearer idea of how your data can be put to most effective use, it’s time to define your interoperability strategy. Your strategy should be organized around three key pillars:

  1. Orchestration (including access control)
  2. Integration (both internal and external)
  3. Data management (all formats and standards)

From there, consider:

  • How will you apply your interoperability strategy to all your current systems and data sources? How will you extend it to future systems and sources?
  • Who are the technology vendors you can partner with on the design and procurement of the solutions you’ll need?
  • Are there solutions that can fulfill more than one requirement for faster implementation and streamlined procurement?

Step 5: Execute

Once you’ve laid the groundwork for your long-term interoperability investments, it’s time to execute on your strategy. To streamline things, start with the areas in which your organization’s existing capabilities are strongest. An enterprise-level roadmap will help you prioritize the deployment and enhancement of your systems.

Interoperability is not a fixed state: regulations and mandates will change, technologies will evolve, consumer expectations and behaviors will fluctuate, and data standards will shift. A strategic approach to interoperability will make you better-equipped to weather those changes, address rising costs through earlier intervention, work more effectively with partners and stakeholders—and, above all, be a leader in driving transformation.


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