FHIR & The Art of The Possible: Episode 4

Nolan Kelly: Welcome back to another episode of FHIR and The Art of The Possible. I’m Nolan Kelly, Chief Customer Officer at 1upHealth.

Kevin Yamashita: I’m Kevin Yamashita. I lead our Enablement Team here.

Nolan Kelly: Welcome back Kevin.

Kevin Yamashita: Welcome back Nolan. It’s good to see you.

Nolan Kelly: Good to be with you again.

Kevin Yamashita: I mean, to be fair, we’ve been in the office together the past couple days.

Nolan Kelly: We have.

Kevin Yamashita: Hey, it’s been great.

Nolan Kelly: So, we have a topic we want to cover. But we’re going to make this, I think, a relatively quick video. But I want to talk about patient access, the Patient Access APIs that exist in healthcare, a very interesting trend that we are starting to see, and then the implications of that trend. So we can cover a couple of things.

Kevin Yamashita: Love it.

Nolan Kelly: Hopping in there, do you mind maybe just giving a quick recap intro for folks who are watching this and what patient access means?

Kevin Yamashita: Definitely. Definitely. I think it’s interesting because we have some folks that are steeped in this and others that come knock on our door that really don’t understand what it is. So to get everyone up to speed, so this conversation both makes sense and is informative and useful, when we talk about patient access here we’re really focused on a lot of payers, health plans, and specifically those that have Medicare Advantage or Medicaid Lines of Business. Back in 2020, the federal government said that, “Hey, if you have these lines of business, you need to convert your claims and clinical data to FHIR, post that FHIR data in a FHIR server, and make it available so that third-party applications, mobile apps, web applications, whatnot, can access said data.” And that’s a lot of what 1up has been doing in the space since 2020 and now in the past several years, is helping our payer customers get that data converted to FHIR so that it can be made available to individual members when they request access via third-party applications.

Nolan Kelly: Love it. And it’s not a secret, but there hasn’t been tremendous use and adoption of the APIs in the market.

Kevin Yamashita: No, no. And I don’t think that we’re super surprised by that. Even back in 2020 and 2021, I think there was a lot of cynicism with some of the customers we’ve talked about. Is anyone actually going to use this? Will members actually care?

Nolan Kelly: Right.

Kevin Yamashita: And there was a lot of inertia that we had to overcome. And I think that over the past couple of years we’ve seen a couple positive trends. The most positive one is that with CMS-0057, it’s built on patient access. So now all these additional regulations that kick in on 1/1/27, they require patient access, it’s infrastructure, that underlying data, that’s the foundation.

Nolan Kelly: And what are those new regulations for 0057?

Kevin Yamashita: Absolutely. So they’re an extension of the patient access capabilities and at a very basic level what the government is now saying is, “Heck, not only does a payer need to get data and store it and make it available to a patient, but they need to make it available to providers and to other payers.” So now what we’re really seeing is government-mandated, business-to-business, FHIR-based interoperability.

Nolan Kelly: Perfect. So we’ve had regulations dating back to 2020 for implementation in 2021 that were B2C in nature, right? Your health plan exposing claims data to an individual through a restful API, FHIR API, and now building on top of that is the B2B data exchange between payers and providers or payers and other payers. Great.

So that brings us to one of the trends that has shown up in the last few weeks led by a couple of terrific organizations, Flexpa and Defacto Health, and each of these organizations put out reports, Brendan Keeler from Flexpa and Ron and his team from Defacto, that were highlighting the access to these APIs, the data quality of the APIs, and the completeness and timeliness of the APIs, and the results were, broadly speaking across the industry, not amazing.

Kevin Yamashita: Pretty damning, honestly.

Nolan Kelly: Okay. Just a couple metrics here from the Flexpa report. 254 out of the 329 payers scored received 65 or below, scored 65 or below out of 100.

Kevin Yamashita: Out of 100, right?

Nolan Kelly: Out of 100. And 12 of the 28 vendors received a failing mark here, right? And so, on one hand, that’s a very concerning data point. On the other, I actually think it’s pretty cool. We now have organizations that are looking into the use of these APIs and in a B2C world, yes, we want all of this to be perfect, but this is step one on a journey, right? We have a lot of road in front of us and I’d love your just perspective on this moment. We’re now seeing investigation here, not happy with the results, but what do you do?

Kevin Yamashita: You can’t fix what you can’t measure. Right? I think that’s what a lot of this is. I’m excited because for the first time we are seeing these aggregate reports. One of the challenges early on from different spheres in the marketplace was, well, once these APIs exist, how do you find them? How do you aggregate? How do you put them to use? Right? Because one by itself is not super impactful. It’s really when you have a broad swath of API endpoints that represent the whole of the country, that people can do interesting and exciting things. That’s really useful. That’s an incredible place to start from. Beyond that, the fact that we can actually dig a little bit deeper and talk about, well, what is working and what’s not working? Are there issues with the authentication framework? Is the data coming back trivial and not useful? We can actually start to poke and prod on some of these things. And that’s the first step, is just measuring, looking, understanding. That’s huge.

Nolan Kelly: I love your action orientation to it. In a role reversal, I may be a little less optimistic as you are in that one.

Kevin Yamashita: Oh, that’s unusual. Usually I’m the cynic.

Nolan Kelly: I know. But these reports, these metrics, first of all, there are perhaps inherent flaws in all of them, right? They’re done at different times. The measurement piece of it has some question marks. But these APIs, as you said before, these are the foundation. This data is the foundation that goes from your B2C data availability experience to moving data from United to Humana, moving data from Aetna to Mass General Hospital. And this is the data that becomes your Payer-to-Payer, your Payer-Provider APIs.

Kevin Yamashita: At least in theory, right? No customers we’re talking to right now are saying that we’re going to rip and replace our entire patient access infrastructure to rebuild it again. So this seems to be the foundation people are going to use. And that was certainly the intention of the regulations.

Nolan Kelly: It was. Yup, it was. And we’re going to have big decisions being made in the future off of this data exchange, the data portability. And so maybe that’s where I come back to you, right? Understanding the data, using this time to learn the data because in the very near future, this is intended to be the infrastructure that really moves critical data elements between historically competitive organizations.

Kevin Yamashita: 100%. The blast radius and the potential collateral damage of low quality data, incorrect data, the stakes just get higher and higher, and I think we’re only going to continue to see more regulations and more just initiatives in the industry broadly based on these principles, these standards, this type of data. So it’s not even like we’re just going to look at CMS 0057 on 1/1/27 and call it mission accomplished. I mean, this is the second step of a marathon.

Nolan Kelly: Okay, let’s wrap this up. Let’s go, if you were in the market, what’s the one thing to be doing right now based on these types of reports and what we’re seeing with the Patient Access API?

Kevin Yamashita: So I’m actually, I’m going to give you two things. But I think that the basic idea is look at the data, understand the data, and put the data to use, right? So if you have not reviewed these reports, you certainly want to know where you score as an organization, right? I think there’s a lot of faith that different payers put in their technology providers and with good reason, trust but verify. Really thinking through, is this the technology service provider that is solving these problems for me, that has my back, that I want to be partnered with as I’m moving bulk data between organizations?

And then once you’ve established that this is the FHIR foundation you’re going to use, let’s actually try to put patient access to use, right? That’s connecting to third-party applications, that’s marketing them to individual members. We did a case study with one of our customers, and we can share the link in the description, but essentially they saw over a tenfold increase in usage of their Patient Access APIs simply by doing outbound communications and explaining to individuals what they had to do to access the data, what the data would look like once they accessed it.

You have to start there, baby steps.

Nolan Kelly: All right.

Kevin Yamashita: What about yourself?

Nolan Kelly: I think my one, as a sales leader in the market, in these conversations, we see a lot of delay. We see there’s so many priorities that these organizations have within the walls of their organizations and we do see a feeling that January 2027 is far away. That’s a little concerning to me when I look at these types of reports because healthcare is still an industry that operates on proprietary, in terms of data exchange, that operates on proprietary, flat file, batch exchanges over SFTP, looking back 30/60 at best, more like 90/120 days, of moving data between organizations. And I guess my call to action, so to speak, would be now is the time.

The investments that have been made in patient access, the technology infrastructure that’s in play. We at 1upHealth are making significant investments, tens of millions of dollars being poured into our infrastructure, into our backend systems in preparation for moving bulk data between organizations so that the data quality is there, the data governance, the policy management, the auditability and access to understand who’s touching that data, when and why, and the fidelity of that data so that you as an organization can stand behind the API that is in the market, that is delivering a data experience to another organization who’s making an incredibly important decision on someone’s care. We take that very, very seriously.

And so we’re doing a lot of work on that and we’ll share more with the market in the coming months and quarters and are excited to do so. But I think that would be my call to action is really to the market. Lean into this moment because 1/1/27 is close and this foundation is pivotal.

Kevin Yamashita: We’re all in this together and I think in a lot of instances for patient access, originally, a lot of folks look to technology vendors to solve these problems. And, to some extent, we did a great job. In other ways, like these reports indicate, there’s still some work to be done, but for this next rev, we can’t do it alone. We need to work with our customers, we need to work with their frenemies in the marketplace. We’re all in this together and thinking about that new world order and really putting it to work, that has to start today.

Nolan Kelly: Love it. Big “we’re in this together” guy. Alright. Thanks for joining, Kevin. Appreciate the talk today.

Kevin Yamashita: Likewise.

Nolan Kelly: And sharing some of the important points here. And we will be back sharing more about what 1up is doing in preparation for putting this data to use between organizations in the future. Thanks.