1upHealth recently hosted a webinar entitled, “Rethinking Payer Data: The Need for Computable Clinical Data.” Moderated by Miriam Paramore, a healthcare and health IT industry veteran, the webinar featured panelists Alison Aluli-Imberman, Vice President of Operations for Health First Health Plans, and Dr. Don Rucker, Chief Strategy Officer at 1upHealth and former Director of the Office of the National Coordinator for Health Information Technology (ONC).
If you weren’t able to attend the webinar, here are 5 key insights you missed:
#1 Health First Health Plans’ approach to data and interoperability
As the operations leader for the organization, Alison sees the opportunity around data and interoperability for Health First Health Plans having three distinct phases. Phase 1 is about creating a foundation. This isn’t one and done. It’s a constant evolution in the organization’s approach to data acquisition and utilization. Phase 2 is focused on increasing data literacy across the business. The goal is for operational leaders, and the broader organization, to be able to access and utilize the data for the betterment of the member. Finally, Phase 3 is about infusing interoperability into operations so data can be shared across the full continuum of care in order to better care for the patient.
#2 The role of FHIR® data in driving improved patient outcomes at a lower cost
For payers, there has historically been a backing into decisions around the clinical care of a patient based on highly disparate data. Not having clinical data on members is still a major challenge for payers. That’s where Fast Healthcare Interoperability Resources (FHIR) comes in. It allows us to start to see multi-dimensional care from a different perspective. FHIR data needs to reside in data stores that are accessible to not only those who are passionate about data, but also the general population that needs the information. Patients need to be able to access their own health information to take a little more control over their own care. Providers need the data to be able to care for that patient. And payers need the data to be able to make care decisions that are efficient from a financial perspective.
#3 The power of clinical and claims data integration
Overall, healthcare needs to be more efficient, affordable, and reasonable. Increasingly, especially as it relates to economic efficiency, the focus is on the integration of clinical and claims data. Don shared that’s a big focus at the ONC: How do we merge these data streams to do the type of purchasing of healthcare that we would like. A very large part of this is APIs. You need to minimally be able to exchange information. But that’s really only the beginning of what you can do. Forward-thinking organizations are using integrated clinical and claims data as the baseline for recording, decision-making, reimbursement, clinical care, and more. Beyond Patient Access, leaders should be asking, how do we strategically operationalize the investment in FHIR data.
1upHealth is already starting to see customers tackling more impactful financial use cases with integrated clinical and claims FHIR data, including prior authorization and quality measurement. Don also predicts we’ll start to see more use cases around consumer convenience, like appointment scheduling and getting data into consumer/member-facing apps.
#4 Getting ready for Prior Authorization and the other regulations coming in 2026
While the industry as a whole still needs to mature data acquisition and accessibility in order to appropriately utilize and leverage FHIR for the future, Health First Health Plans has partnered with 1upHealth to gain the necessary maturity within its organization. The health plan is taking advantage of the runway leading up to the new regulations coming in 2026, including Prior Authorization, which Alison sees as a key way to improve the cost of healthcare. Prior Authorization brings all of the data into a single stream and provides a full view of the member and the care they’re receiving. Health First Health Plans is focused on improving data literacy across the organization and infusing the regulations into their operations ahead of the deadline.
#5 What’s the best next step that payers can take towards computable clinical data
Don put it this way. If you’re a payer, you’re going to have to get enough computable clinical data to make reasonable clinical judgments about the allocation of care. You’ll need a repository – or a platform – to store and compute on all the new clinical information that’s coming in. From there, you’ll have to get into all of the highly mundane things like: How do I do member matching? What tools do I have? What analytics? And beyond that, you’ll need an entire business strategy. Who’s looking at the data? How are they looking at the data? For payers, it’s a very daunting task and not something that’s easily built from scratch. That’s where the 1up FHIR Platform comes in.
Ready to hear more?
To hear more of what our experts had to say on these and other subjects, watch the full webinar.