Welcome to “FHIR & The Art of the Possible,” a new 1upHealth YouTube Series hosted by Nolan Kelly, our Chief Customer Officer, and Kevin Yamashita, our Customer Enablement team leader.
Fast Healthcare Interoperability Resources (FHIR®) is widely recognized as the key to modern data exchange in healthcare, with the potential to enable a value-based system in the US. Business leaders are championing FHIR investments, viewing interoperability not as a series of technology projects, but as an overall digital transformation program that fundamentally alters and uplevels their business operations. Fueled, in part, by current and upcoming government regulations (including the CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule) we’re seeing more and more saavy business leaders raising the bar and looking for ways to translate “compliance cost” into an “efficiency engine.”
In this YouTube Series, Nolan and Kevin explore what’s possible with FHIR, including real-world scenarios from across our base of 80+ enterprise organizations looking to improve quality measurement, member experience, and risk adjustment and to power a multitude of internal analytics use cases.
In this first episode, Nolan and Kevin:
- Introduce the 1upHealth Customer Enablement team and their focus on helping our customers derive business value from their technology investment.
- Define computable interoperability and the accuracy, completeness, and timeliness of FHIR “data on demand”.
- Discuss the evolving compliance landscape and the “forcing function” of this next wave of CMS regulations as an opportunity to innovate and leapfrog competition.
- Share examples of strategic thinking and data-driven decision making, including a midsize health plan’s focus on ACO relationships and value-based care, as well as a state Medicaid agency’s approach to enhancing care delivery for a significant portion of their population.
Watch the video
Nolan Kelly: Alright. Hello, I’m Nolan Kelly, Chief Customer Officer at 1upHealth, and I’m excited to be joined today by Kevin Yamashita, our Senior Director of Customer Enablement.
Kevin Yamashita: Yeah, really pleased to be here.
Nolan Kelly: Thanks for joining us, Kev. So Kev, let’s start with this title you’re carrying here, this Customer Enablement. It’s sort of a non-traditional title. What are you doing?
Kevin Yamashita: Yeah, I’m doing all sorts of really cool things here at the organization. Customer enablement as a function is really a confluence of a couple of different things. At a very basic level, we’re helping our customers to derive business value from their 1upHealth FHIR platform. On some days, we’re talking about business strategy and trying to define business values for decision-makers in the C-suite. On other days, we’re doing art of the possible demonstrations and proof of concept development to really find where the rubber meets the road.
But at the end of the day, a lot of customers here at 1upHealth came to us to solve a compliance problem, and we’re trying to help them understand that with that existing investment they made, there’s actually a lot of opportunity to revolutionize their business and really find new value, new potential, new opportunity in their technology investment.
Nolan Kelly: Terrific. Yeah, I love it. And in Q2 of this year, Gartner actually released a study that said the interoperability investment decisions were being driven by the C-suite, so that’s good news. And that those investments were really well aligned to the enterprise priorities. So I think about risk adjustment, network design, value-based care programs, things like that. But at the same time, only 16% of health plans were seeing an ROI from their investment in these interoperability initiatives, and that strikes me as a real problem. So this customer enablement approach, kind of designed to go right into that challenge that the industry’s facing?
Kevin Yamashita: Yeah, absolutely. Let’s be honest, I think in a lot of situations people like to talk about interoperability and they like to champion it, but at the end of the day, a lot of folks are not willing to make the investments to actually solve the hard problems. And for better or for worse, the government stepped in and really forced some folks’ hands. So we have a lot of infrastructure now that didn’t exist three, four or five years ago, but one of the problems we see is a lot of organizations that went through a lot of these different machinations, they never really thought about how they would put these different pieces in place to solve higher order problems. It’s kind of the same way that when your parents tell you to go exercise, you do, but you don’t like it and it’s not until much later you realize that you’re actually doing this for a purpose. And we’re just trying to help people understand the joy of exercise, the joy of having this infrastructure in place to solve these novel problems that have plagued the industry for decades.
Nolan Kelly: It’s an uphill battle, the joy of exercise. Thanks for-
Kevin Yamashita: Yeah, yeah, yeah. I think we both know.
Nolan Kelly: We do. We both know, for sure.
So you mentioned the regulation sort of compliance, and oftentimes we hear from our customers and the market that this concept of interoperability for compliance. And that’s just a very small piece of the puzzle, sort of why this has all started, why there are such universal investments in FHIR and APIs right now and that type of infrastructure. But at the same time, there should be this recognition that, for the first time in the history of this industry, really, we have modern tech stacks that exist at the provider and exist at the payer with a universal data model and RESTful APIs. That should be transformative as we think about where this industry has been historically and needs to go in the future.
Kevin Yamashita: It’s incredible, right? For an industry that has been mired in the past, held back by legacy technology and bespoke custom processes and a lot of black boxes, for the first time, we’re really seeing all of these other commercial technologies, all these other things that have powered the rest of the technology space. I mean, FHIR is nothing more than JSON and REST APIs. These are technologies that fueled the internet revolution of the past 20 years, and just now we’re seeing them injected into the healthcare arena.
So the ability to take some of these tried and true digital transformation catalysts and really start to apply them to the healthcare problem, one of the most intractable problems of our age, that’s really exciting. But it really requires a different way about thinking, of thinking about what problems you’re going to solve and how you’re going to solve them. And I think that’s where a lot of people struggle. They don’t see that, this is not a one-off project. This is a long-term program of evolving businesses, evolving industries, and that’s hard and that’s scary. But we’re here to really help our customers figure out how you take that first step because that’s all it is. It’s the first step and then another and then another. And then before you know it, you’re running a marathon.
Nolan Kelly: Nice. Yeah. We talk about placing some strategic bets in the future and in this transformation that is enabled right now.
There is a bit of a sentiment that the initial compliance push that health plans underwent was a bit of a tax on their businesses. There wasn’t a tremendous amount of value realized from those dollars spent in those projects that they went through. But we’re also now looking at a next wave of regulations that are coming soon.
And my sense is, I’m curious if you see the same way, my sense is that we’re kind of beginning the shift from this mindset of a tax on the health plan to an investment now and how that investment can realize value for that health plan. As we start to think about what historically for the last couple of years has been converting legacy systems to FHIR R4 and making that data available to leave the organization, we’re moving to a world now where we’re starting to talk about bringing external data into the system and into the organization and putting that data to work for you.
Does that resonate? Are you guys seeing the same thing?
Kevin Yamashita: I think so though I would push back. I think the idea that Compliance 1.0, if you will, is it a tax? Yes and no, right? On one level, certainly it was some effort that all these organizations had to exert. And as you mentioned, as Gartner mentioned, the gains were mediocre at best for a lot of organizations.
But I think what’s really interesting about that is not necessarily that everyone was taxed in a certain way, but that everyone was forced to really think about what is the infrastructure for the future. And what I find really interesting, and some of our forward-looking customers find really interesting, is you now have kind of a level playing field. Everyone now has these base capabilities.
So in some ways it’s a forcing function. It’s an opportunity to say, “Okay, we’re all here. How do we remain competitive? How do we think about this differently? How do we do things that our neighbors are not doing so that we can be unique?” And then to your point, as we think about this next wave of regulation, that’s really a matter of, “Okay, let’s put these things to work. Let’s not just serve this data up, but let’s transfer it. Let’s move it. Let’s actually try to solve some problems. Let’s actually interoperate.”
And let’s be clear, when we talk about interoperability, it’s really two parts. It’s the sharing of data, I think that’s what a lot of people think about. But it’s also the usage of that shared data. And I think now that’s what we’re seeing. Step one was to get the data. Step two was to send and use the data. And if there’s a little bit of a tax we have to pay to actually be able to change the way the fabric of this industry works, I think we owe it to ourselves and all of our other human beings in this country to do that.
Nolan Kelly: Well said. It’s a noble cause. We talk at 1up about helping to enable a societal change in healthcare and, really, the data portability is at the center of that happening to help bring healthcare to where the other industries have gone through a lot of the change of this modern internet economy.
Kevin Yamashita: Yeah, absolutely. I think that what we’re all seeing in the 21st century is that data really fuels revolution in so many ways, the literal ways, the metaphorical ways. But when we talk about healthcare, certainly we’ve never really been able to say, “Here’s what I pay and here’s the quality of what I’m getting.” And there are different things we put in place to try to weave around the edges of that, but to really cut to the core of that is what we’re talking about right now, and that’s really exciting.
Nolan Kelly: Nice. All right, well let’s pivot there. Let’s cut to the core. There are some cool things that I know our customers are doing. I know your team plays a big role in this value realization of the investments that some of these customers have made. So why don’t we start with… I know there’s a, call it, midsize regional health plan that is leaning into use cases well far and above and beyond what they’re doing for compliance.
Kevin Yamashita: Yeah.
Nolan Kelly: Do you want to help us set the context of what they’re up to?
Kevin Yamashita: Yeah, absolutely. So yeah, one of the customers I have in mind, they are a midsize health plan in the New England area. And what I think is really interesting is because they’re midsize in New England, they’re really trying to punch above the weight class. There’s a lot of big dogs in this arena.
So this is a customer that does not have excess resources to spend frivolously. They have to make their bets. They have to be really thoughtful and double down where they think they can actually get some returns, but they can’t be wishy-washy. And whenever we talk about placing bets and doubling down, if you’re not using data to inform those decisions, I don’t know what you’re doing. That’s just a gamble.
So what we start to think about here is, “Well, how do I get the data to make better decisions? How do I start to ask better questions?” Because it becomes a feedback loop. As you get more data, you know where to look. As you start to look in those places, you get better data. You make better decisions, you ask better questions, you iterate on top of that.
And I think that’s one of the things that’s really exciting about this midsize payer market as they understand where they can push and where they’re better and where they can be more agile, frankly, than a lot of their larger competitors. And we’re really starting to see, like I said before, people saying, “Well, if everyone has these capabilities, how do I make them special for me? What do I know about my organization? Why are we unique? Where do we like to push?”
And in particular, what we’re seeing a lot is folks really thinking about ACO relationships and value-based contracting. This is obviously the next push to try to realize higher quality care at lower cost.
But I think one of the challenges that a lot of 1up customers face is that as they get into these ACO relationships and they write these value-based contracts, it’s really hard to know, “Well, what are the outcomes going to be? What is the performance of this arrangement? When it comes time to recontract and to negotiate, what do we do? What do we say? How do we make it defensible?” The data doesn’t exist. And when the data does exist, the payers and the providers can’t agree on what that data is or what it says. Different formats, different timeframes.
So the idea that now we can reach in and have FHIR consistently across different continuums of care in all these different environments that we can all point to and say, “This is real. This is true. We can agree on this.” You have to start from that kernel of truth, that shared understanding. Otherwise, the whole thing falls apart.
Nolan Kelly: Yeah, no, I love that you went right to the ACO relationship.
CMS had said they want 100% of Medicare beneficiaries in a value-based care contract by 2030. And that’s not that far away, right?
Kevin Yamashita: No.
Nolan Kelly: Which is a little scary. But the only way that that will be successful is if you do have this ability to get out of how things have worked historically, proprietary data models, flat file exchange over SFTP, and start to really light up data on demand in this sort of computable manner. Is it-
Kevin Yamashita: Yeah, Data on demand. You hit the nail on the head right there. The issue is not that the data doesn’t exist. The data does exist and we can argue about different formats and different transfer mechanisms and all those things. And don’t get me wrong, that’s a drain on IT departments across the country.
But one of the things I really want to zero in on is data on demand, because I think the timeliness of FHIR data, that’s a game changer. Think about the traditional way that payers and providers work together. A payer is just kind of sitting there waiting, and maybe they find out about something that happened 30 days ago, 45 days ago, 90 days ago. Well, after 90 days, it’s too late to really be thinking about transitions of care. It’s too late to be thinking about steerage and referrals and network leakage. But gosh, the fact that we can get this data in real-time as these encounters close with an unbelievable amount of richness and accessibility and computability, it’s a game changer.
Nolan Kelly: Yeah, for sure. Let’s stay on this mid-market health plan. I was on the phone yesterday with an employee of a very large health plan, and I’ll paraphrase, but one of the lines he said was that our stability is one of the most limiting aspects of our organization right now. And so I took from that that we like to talk about change, but we don’t necessarily need to change. We’re a very stable organization.
If you’re in that mid-market segment, are you the change agent of the industry? Is that where we’re going to see change driven?
Kevin Yamashita: I think you have to be. I think you have to be. And there’s a couple different reasons for that. One, like we talked about before is if you are not a big dog, then you have to be agile. You have to find that opportunity around the edges, just because of the way that the market dynamics work.
But another thing that I think is really interesting is if you are not as large and not as stable, that means you really need to be more thoughtful about your book of business. That’s who you are insuring, it is the premiums that you’re charging. And historically, it has been really difficult to model future expenditures, understanding, “Do I have a large population of individuals that are going to experience heart disease or diabetes in the next 5, 10, 15 years? Do I have a large influx of folks that are going to be aging into Medicare plans that maybe have not been in? How do I think about what that population looks like?”
The ability to actually model those things, especially for a mid-market plan, is really, really important as you think about your financials. You just don’t have, generally speaking, that much buffer. But with FHIR and the richness of this data, we’re starting to see the ability for folks to actually look at different data elements, clinical data elements, lab values, social determinants of health. Those are all really important things if we’re trying to predict future cost.
Nolan Kelly: Yeah. Last question just on this particular customer that you’re thinking of. In order for an organization, especially one in the segment to make investments on whether it’s process redesign or a new way of acquiring and exchanging data elements, it has to be tied to some tangible business value. I mean, you have to get from that 84% who aren’t realizing value to the 16% who are. And I’m just curious, where are they focused? What are they looking at as they think about the opportunity in front of them?
Kevin Yamashita: I think that’s a great question. It’s funny because here at 1upHealth, we’re a technology company which means that we have developers and we use terms agile and fail fast and all of these things.
And I think in some ways, the same way that FHIR is allowing us to take the best technologies of the rest of the tech space and apply them to healthcare, we need to be taking the best thinking from outside healthcare and applying it to healthcare. And what I mean by that is really looking for those quick, easy wins, that low-hanging fruit. In the agile methodology, we always talk about finding ways to deliver business value. We should be doing things that actually show value, even if marginal and incremental.
And that’s what we’re really seeing in the space with our payer customers is trying to say, “Okay, well, I know there are 700 things I want to change. I know we have all these pain points. But what are two things that I can change in the next month that move the needle 0.05%?” Because again, it’s that first step. If you haven’t done 100 pushups before, you don’t start by doing 100 pushups. You start by doing one. And listen, that first one, it might suck. But then the next day, you do two. It’s the same thing. It’s trying to find areas in your business process where you can make incremental change.
But the last thing I think I want to leave you with, because this is really important and this is what our most forward-thinking customers really recognize: this is not a technology problem. The technology is easy, and it’s not. It takes time and effort and all these things. But at the end of the day, this is a people problem. It’s a business process problem.
And I think if we look inside ourselves, we understand, again, in this 21st century age that we live in, the tech is there to solve so many things, but it’s how I use it. It’s what problems I solve. It’s what I choose to win. It’s how I convince other people to come on this journey with me. That’s the hardest thing.
So we’re always pushing our customers, “Think about change management, think about identifying that business value, finding other folks that are advocates, evangelists, really building camaraderie and excitement, energy.” It’s all those intangible things. The human psyche gets in the way of so much.
Nolan Kelly: It does. I’d go even a step further, not just a people problem, it’s a political problem. You could question, “Do health plans and providers really want to share data with each other?”
Kevin Yamashita: I question every day.
Nolan Kelly: I know! We see the momentum of it. And so that’s why it’s so interesting that you went to the ACO and value-based care because there you have contracts that are designed to be, not to say they always are, but designed to be aligned on an incentive model. And in order to perform the right way, measure success and understand how you’re performing against those contracts, you need to have an aligned data set.
Kevin Yamashita: Yeah, I think so. I think about this a lot because there’s so much negativity sometimes towards payers and providers, and I think that’s misplaced. I think we’re all genuinely good people that work in this industry because we want to make a real difference and make the world a better place. And sometimes, you just get so caught up in the details. I would push everyone to really think about, again, “How do I make this 2% better? Why am I doing what I do? And how do I get other people to not lose sight of that?” Because as soon as you find that nugget of excitement, it’s infectious.
Nolan Kelly: Awesome. Let’s pivot. So went from the sort of mid-size payer. Who else are you working with? What’s another example of something that our customers are doing in the market that you think is changing a little bit of the game?
Kevin Yamashita: Yeah, so another customer I’m thinking about is a state Medicaid agency that we work with. Medicaid organizations also have FHIR compliance requirements, sitting on the other side of some of the commercial players. And I think Medicaid is a really interesting space. We see a lot of variety in the way that Medicaid is administered across the country. We see a lot of variability in the different states.
The one customer that I’m thinking about comes from a state where more than 25% of the population is on Medicaid. It’s a relatively large state. So there’s a lot of complexity in delivering care, and that makes it really difficult for a government agency to provide the best care possible. We’re dealing with limited resources, both financially and in terms of just provider capabilities. We’re dealing with very complicated sets of medical problems. In many cases, it’s not just medical problems, it’s that concept of social determinants of health we talked about.
And I’m really excited this keeps coming up again because at the end of the day, the same way that this is a people problem, not a technology problem, I think sometimes the medical details, they’re actually kind of figured out. We know that people need to get screened for cancer. We know that if you are at risk for heart disease, there are certain things that we can do. But gosh, why are people not making those simple choices? A lot of really legitimate factors not related to healthcare, but related to what? Social determinants of health.
Nolan Kelly: Yeah. We have a tremendous partnership here with a company called Gainwell Technologies, and it’s allowed us, 1upHealth, to be the FHIR data platform for, today, 20 state Medicaid agencies. And that’s, I think to your point, just a really critical piece of the market. It’s a really important piece of our business. And as we think about going back to enabling societal change, the Medicaid market, the Medicaid population is primed to benefit the most from this type of transformation of the data space.
Kevin Yamashita: Truly, truly. And again, I go back to this idea that why do we do this? It’s to make the world better. It’s to help people that need help. It’s to take care of our brothers and our sisters. And I think that in these ways, this is another example where we can really use technology to try to help people do the right thing. And by people, I’m talking about all the people involved in the continuum of care: transitions of care, gaps in care. Some of these really basic things come to mind.
Disease management, I think, is another really good example. We know there are populations of people that have chronic disease. We know that those with chronic disease are a disproportionate amount of the healthcare expenditure in the country. What do we do about that? And how do we think about this not just in terms of an economic problem, but really a societal and equity problem?
And that’s really interesting because data can change the way that we solve these problems. It means we can apply our resources in a more thoughtful way. It means we can be more responsive. It means we can make data-driven decisions. We can have better contracts, not just between payers and providers, but maybe third-party organizations that help us to provide some of this care. We can hold people accountable. We can ask better questions. All of these are things that we could not do before. And again, because we’re using technology that has tried, true, tested, commercial, off-the-shelf, it means that these state agencies that have limited resources, really lean IT departments, they can do a lot more with a lot less.
Nolan Kelly: Yeah. And to your point before, it’s not about new data, per se. The data is accessible. The problem is, it’s accessible through manual processes or through paper trails or faxes or flat files that are made accessible once every 30, 45, 60 days. And that really is what drags the industry on the inefficiency there and the lost opportunity by not having data on demand through automated processes.
Kevin Yamashita: Truly.
Nolan Kelly: That’s the opportunity.
Kevin Yamashita: Truly, truly. I mean, so many of these systems are brittle, and I mean both the IT systems and the company and people process systems.
And one of the problems is that as soon as you have these brittle systems, if you see a failure in one or two points, you lose confidence in the system. And again, it’s human psychology. As soon as you lose confidence in the system, you don’t buy in as much. And if you don’t buy in as much, your partners don’t buy in as much because the system starts to fail, and it just crumbles.
So this is about not only trying to fix some of these problems, but trying to fix them in sustainable, scalable ways where we can build faith that if people commit, if they stack their hands and we’re all in this together, we can actually make a difference. Because nobody wants to stack their hands by themselves. But I think this is an opportunity for us to come together, from all different parts of the healthcare continuum, to really solve these problems in novel, interesting, and sustainable ways.
Nolan Kelly: So if that example is of a Medicaid agency making their data accessible to their business partners, another play on that is where you’re the vendor. And we have many customers across many different segments. I’m thinking of one who’s in the clinical research space, and their entire business relies on the acquisition of clinical records, of charts, from the various providers who provide the important clinical services to their patients. And that model has always been a very manual, labor-intensive model. There’s challenges of authorization.
And now for the first time, thanks to a lot of the regulations from ONC of making FHIR R4 APIs and bulk APIs a requirement for your ONC-certified EMRs, these types of organizations can rethink how they acquire data and then when that data comes in, what they do with IT, at the resource level, their ability to run inclusion/exclusion criteria, power their own products and their own analytics. Not saying that every system is now on a completely level playing field, but moving to REST APIs and having the FHIR data format really has enabled that organization to change how they acquire data and operate on that data.
Kevin Yamashita: Yeah, I think about this a lot. It’s funny, one of the first part-time jobs I had was working at a doctor’s office, and I did this just for one summer. But they were trying to digitize, which means that I sat in a closet and I took paper charts and fed them into a scanner. And I remember sitting there thinking to myself, “Well, gosh, this is silly because no one is ever going to actually look at these scan documents.” Of course, they were doing it to preserve the records and to make sure that they were in compliance with all the different policies for data retention.
But what really struck me was the idea that for a long time, if you wanted to do any research on clinical data, what did you do? You sent 10 temp workers to a closet and you opened up every chart one by one, and you scanned through to try to find the thing you were looking for. So if you’re looking for particular procedures or diagnoses, what a slow, laborious process.
And of course, one turn to the crank is now we have these electronic medical records. So now what do we do? Well, 10 years ago, five years ago, we sent someone to the hospital and they sat in the closet and they logged onto the computer and did the same dang thing.
And just now, just now we’re starting to see the ability to actually reach in, pull all this information out in a structured, consistent way where we can, like you said, do advanced inclusion and exclusion logic.
And one of the problems is, I think in the past, because it was so much work to find some data, we missed a lot of the other data. Because, again, it comes back to equity, making sure that we have everybody’s record. But in many cases, the folks whose records are available are not always consistent based on the providers they see, the types of providers they see, urgent care, ER, PCPs, how many people are going to see specialists for issues versus their PCP because they can’t go to a specialist.
We’re suddenly seeing the ability to actually pull all this together in a much more centralized way. So not only is it easier to get the data, but it’s a better data set, and it’s simpler to leverage for the advanced, big data capabilities that everybody wants to lean into.
Nolan Kelly: Okay. You nailed it. We should close on this because that is the perfect summary of the opportunity.
Kevin Yamashita: Absolutely.
Nolan Kelly: I think how we should all be thinking about the opportunity. This is this first wave of regulations where health plans were required to transform to FHIR and make the data accessible. I stand on my soapbox, you know this, that says CMS did not necessarily do that… my words, my viewpoint, did not necessarily do that thinking that everyone would run and go retrieve their claims history and bring it onto their smartphone. They did it to push the foundation and the rails across every health plan in the country so that the infrastructure was in place that maps to the EMRs and now allows this richness of data to flow on demand.
Kevin Yamashita: Absolutely.
Nolan Kelly: Process redesign.
Kevin Yamashita: I’m glad that you said rails, because the analogy I always like to make is that the government said that we had to lay this rail across the country connecting payers and providers, and they only mandated that folks be able to put one tiny little hand-cranked car running between Chicago and St. Louis. But that wasn’t the point. The point was that the most entrepreneurial, the most forward-thinking could load up huge, long trains of freight and send those between all these different cities. That’s really the game. That’s what this rail is for. That’s what this infrastructure’s for. So now it’s just a matter of which plans, which providers are going to do that, and how they’re going to change the world.
Nolan Kelly: Love it, love it, love it. There’s a reason you’re doing this customer enablement stuff. You ooze the desire to help push change across the industry.
Kevin Yamashita: Well, it’s exciting. We’ve lived with this mediocrity for so long. If we don’t do this, then who will?
Nolan Kelly: Alright. Thanks, Kev. Appreciate it.
Kevin Yamashita: Nolan, it’s always a pleasure.