FHIR & The Art of the Possible: Episode 2

Welcome to Episode 2 of “FHIR & The Art of the Possible,” the 1upHealth YouTube series where co-hosts Nolan Kelly, Chief Customer Officer, and Kevin Yamashita, Senior Director of Advisory Services, discuss powerful use cases for FHIR beyond regulatory compliance. 

A new era for health data exchange is here and the CMS Interoperability and Prior Authorization final rule (CMS-0057-F) is the catalyst. Like kids in a candy store (or in the toy aisle of a big box store), Nolan and Kevin could not be more excited for the opportunities that seamless data exchange offers to payers, providers, and patients. 

Watch Nolan and Kevin discuss how FHIR and the recent CMS interoperability regulations are impacting the industry, including: 

  • Changes to the way provider and payer organizations operate

  • Increases in the number and type of data trading partners in the healthcare space

  • Improvements to data quality, timeliness, and completeness (like longitudinal patient records)

To learn more, check out FHIR & The Art of the Possible: Episode 1

Watch the video

Nolan Kelly: Alright, welcome back to the second episode of FHIR and the Art of the Possible. I’m Nolan Kelly, Chief Customer Officer at 1upHealth. 

Kevin Yamashita: And I’m Kevin Yamashita. I lead our Advisory Services organization here at 1up and we’re really excited to be here today. It’s really cool that we’re doing this; there’s so much going on, so much has changed since the last time we talked. 

Nolan Kelly: A lot has changed. We have new regulations that have come out in the industry, a lot of movement in the market, and yeah some pretty exciting stuff. So Kev, as we were preparing for you know this, this time in front of the camera you –

Kevin Yamashita: Preparing, that’s generous.

Nolan Kelly: What are we gonna talk about, you know, how are we gonna play this and we had this very interesting conversation that was like what a moment for us to even be able to do this right and like kind of how cool is this and that brought us back to a video that I shared with you from almost 10 years ago –

Kevin Yamashita: Was it really that long ago? 

Nolan Kelly: It was yeah nine years ago where my oldest son the first time we brought him to a big box retailer we were in Walmart and allowed him to walk around the toy aisle and I videoed this and it was this experience like the wonderment of a the life through the eyes of an innocent three-year-old who couldn’t get over all of the toys and the coolness of it in this like very demonstrative moment, this wonderment, and this amazement and he was walking around and just saying like this is the coolest can you believe it like you know how cool, how cool just the sort of opportunities that were in his eyes were amazing and I just thought that that was  like what a moment uh at that time but we’re at that moment now when we crosswalked that moment that video to kind of today. This is the coolest right, like can you believe it? 

Kevin Yamashita: We made it. Like we’ve made this all these things that we’ve dreamed about, all these things that we thought could happen, all this speculation about what will the government do and how will the industry respond like it’s happening yeah and it might not be happening today and it might not be happening tomorrow, but in you know they say the long arc of history, the pendulum is swinging this direction if we just wait, we’re gonna make it in the end zone. That’s crazy.

Nolan Kelly: Let’s talk for a few minutes like what, what are, you know, this whole concept of can you believe it, this is so cool right like, what are the cool things that are going to happen, that can happen now, as a result of the catalyst of these regulations. 

Kevin Yamashita: Yeah so for those of you that are just tuning in, let’s backtrack a little bit. We now sit in a world where there are, you know, FHIR capabilities on the provider side and not only are those baseline capabilities in place, but now the government is saying you know what, the data that you exposed, we’re going to crank it up a couple levels. You have to share more and more data and there’s a roadmap for how, you know, these subsequent versions of USCDI and this clinical data that we can extract from EMRs via FHIR, you know, that payload gets larger and larger and larger right and that’s really cool. Then on the payer side of things, we have this world where payers have been converting some of their, you know, data to FHIR and now the government’s finally saying well, you know what, all that data that you’ve been converting and storing, now you have to share it. Right, hold on a second, right like we’re actually going to use FHIR to interoperate. That’s, that’s really cool.

Nolan Kelly: Yeah, I think of it as we’ve been in this mode where this has kind of been a tax. A lot of our customers have thought about this investment in FHIR and FHIR APIs as a tax. Now it’s an investment.

Kevin Yamashita: They’ve been running around, you know, the gym, they’ve been running around the field, right, doing laps. Yeah, laps are boring. They’re boring. Now they’re going on a long hike and we’re going to see some things. We’re gonna go some places that we haven’t been before. Yeah, that’s really cool.

Nolan Kelly: So what are we gonna see right because you’re, we’re moving, from a world where data was transformed and could leave an environment one member at a time for health plans right out to the third-party applications to an environment where you actually have to consume data from other health plans, bring that data into your environment, mix that data alongside the data you’re creating through claims and clinical events that are happening with your members, create data classifications, expose that data to other payers to providers hopefully to vendors right, and to actually start to create this data liquidity, if you will right, but it has to be usable.

Kevin Yamashita: Yeah what are we gonna see? We’re gonna see a couple things. Let me give you a couple of my thoughts and… 

Nolan Kelly: Is your head cold?

Kevin Yamashita:  My head’s going to explode, right, with all the possibility. I’m worried I’m going to lose track, you know. I think we’re going to see a couple things. Like first and foremost right, this changes the way that organizations operate right because the beauty of, you know, the payer regulations is that, while we put this infrastructure into place, you can use this infrastructure for other purposes, which means as you have, you know, different TPO arrangements with data distribution partners, you can use all this tech that you’re putting in place. 

So we’re not talking just about “oh I can share data with other payers” and “I can share data with other providers,” but there’s this whole other world of data trading partners, digital health companies, and application companies, and, you know, other parts of technology within the enterprise. The idea that now we can leverage this investment and start to move data to some of those applications. Data that is potentially higher quality, data that’s more timely, data that’s more comprehensive because it’s joined. 

That’s really interesting to me. We’re finally going to start to see perhaps a real longitudinal personal health record, right. When we think about the ability to aggregate different touches over different payers over the life of an individual, that’s really interesting,  you know. And finally, I think the last piece of this that kind of pulls at me is this idea that we’re starting to see payers right now lean into this idea that if we’re going to have to do this for our CMS-backed lives, let’s do it for commercial too. Yeah, that’s a game changer. 

Nolan Kelly: Yeah absolutely agree. It’s funny, we have this conversation a lot with our customers.  The people who work on these projects with us don’t even get to benefit from it because a lot of the health plans are only using it for the CMS lives, but that is starting to change and it’s starting to change, we talked about this on a recent webinar we hosted about the regulations. It’s a competitive Advantage, right like enabling data to be made available to members can be viewed as a competitive advantage.  And then, beyond that, operating through bulk data transactions opening up real-time access to the data trading partners that you talked about, that is an operational advantage, right. And so now you can think at a macro level, about how are you using this infrastructure to truly change the data transactions, data acquisition, data management, right, and data distribution.

Kevin Yamashita: And what I think is so interesting about this moment in time is we have a better view of where the industry is going and where some of the, you know, market forces are pushing us. 

Nolan Kelly: Yeah – 

Kevin Yamashita: If we go back to the Patient Access days, you know circa 2020, 2021, well of course we’re also distracted by Covid, that was a such an interesting time to be putting all that together, but secondarily we didn’t really know how these pieces were going to fit together. We had a sense of the shape and the outline, but it was really hard to say this is how this dataset will land and this is how we’ll use the outcomes. We have that view now, and because we have that view and because we have this, you know, remarkably decently long runway, right, there’s opportunity for, you know, those forward thinkers, those fast movers, to make their investments now and to reap some of the compound interest.

Nolan Kelly: Yeah.

Kevin Yamashita: You don’t need to wait for January 1, 2027 to put these things in place. You could be live in a year and a half and you can get a year and a half of, you know, advanced work put in to modify your processes and be more responsive to your customer needs and provide nudges to, you know, individuals receiving care. Actually you do all these things to differentiate yourself as an organization, as a health plan. Yeah, that’s kind of interesting.

Nolan Kelly: I don’t know if we will have spliced the video in, but I’m gonna take you back to that kind of big box for a second. You know you’re this three-year-old. You’re looking around, “can you believe it, this is so cool, this is so cool.” If you’re that kid, what are you going to take off the shelf first? Like what’s the first toy you’re going to take down and why is that so cool?

Kevin Yamashita: Oh, that’s a hard question. There’s so many things. One of the really easy ones that comes to mind is just being able to do better modeling of what we think is going to happen with patient cohorts, right, you know. With health insurance, so many times folks come on and off the plans every year, every two years, every four years, right, so you really never have this view of who this person is. But suddenly with payer-to-payer, the idea that when someone joined your plan you could know what maintenance drugs are they on, right, what, you know, ER visits have they had, what major inpatient stays have occurred in the past two years. If you’re an organization trying to plan your financial future in this economic climate, that’s really important information for you to have and to be thinking about. So I think there’s one level of really just like forward-looking analytics you can start to lean into, but on the flip side of things, one of the things that gets me really excited is just the ability to actually impact patient care in a meaningful way. Sounds so silly doesn’t it, that’s what this is all about.

Nolan Kelly: Yeah, sounds important.

Kevin Yamashita: Um, you know, but I think about some of these basic things we have, you know, provider directory and formularies and you know EOBs and encounter information. How can we help our customers, you know, individuals find the right care at the right providers at the right time and the right places. We actually now have all this information coming together. We have the provider directory information up to date, we know the formulary list so when we see things happening in real time, we can make a nudge and say “oh you really should be getting this drug,” “oh you should be really seeing this physician who’s closer with better quality scores.” We just didn’t have the timely data before this to these things, right, and what’s so magical about this point in time is this now no longer all incumbent on the health plan they count on their partners to do this work using the infrastructure they put in place. That’s the real game changer in my mind.

Nolan Kelly: Yeah. What about, what do you think about moving towards, you know, nonproprietary data, getting off of X12 right, and allowing well I’ll just refer to a much broader skill set right, of the, you know, employees in the industry who can come in and actually develop on and touch and interact with this data?  That in and of itself really should be changing the game in terms of who can come in and who wants to come into the healthcare industry. Who wants to work with healthcare data. Before it was such a niche and like unique cumbersome clunky experience. This really should open up into a new world, of a new way of thinking.

Kevin Yamashita: Yeah, absolutely. I mean we use these buzzwords democratization of data so much, but that’s really what we’re seeing. It’s like the ability for folks that have a certain skill set, a much more common skill set, to actually engage with this stuff, right. This is no longer a special item that sits on the shelf that only one person can read and understand. This is now in common English that everyone can absorb and think about and respond to.  That’s really interesting, you know. Not only are we able to get, you know, different minds starting to look at these things, we’re able to use tools that already existed. 

Like now we can use common commercial capabilities to solve healthcare problems. Like all these Cloud services that have existed, all these, you know, point solutions and you know application libraries and tool sets have existed that have built the internet now we can apply to healthcare.

I mean the economies of scale there are incredible right, and that’s even before we start to talk about getting these things in front of business users that can actually solve problems because their data is more accessible, it’s more understandable, there’s better semantic labeling, and, you know, a better data dictionary, and it’s more consistent and observable, and all these other things like we share the data more and it’s more usable. I’m so excited.

Nolan Kelly: I love it. Well I’m excited as well and, you know, I’ll just share with you the conversations we’ve had in the market with customers and with prospects over just the last couple weeks have really elevated.  They feel like they’re much more sophisticated. We’re looking further out into the future, having conversations around “alright, now that we know where we where we’re going to be able to acquire data from,where we have to exchange data to, how we’re going to we need to think about the evolution and the advancement of our data operations,” the conversations are more fun. They, you start to innovate and start to think creatively and that’s what has me excited about looking at, you know, sort of all the toys on the shelf now.

Kevin Yamashita: You hit the nail on the head right like if we fast forward five, six, seven years into the future and imagine a world where the regs are in place and the infrastructure exists and now all these things that we wanted to do that we weren’t able to do because the whataboutism and the naysayers and the technology problems and all that friction. Imagine where that friction is gone and we can actually have these fun conversations about “I have these APIs, I know the data is there, I know it’s timely, I know it’s a decent quality, I know I have the security restrictions figured out and the data use rights in order. Now I can just go.”

Nolan Kelly: Yeah, absolutely. So we’re gonna wrap this up, I’m gonna, I want to tease the next episode, which we haven’t even really talked about, what we’re going to do at that point, but you know this is such a moment of excitement and energy right around the Art of the Possible as we’ve named this when but there’s also a lot of issues that are happening out in the market. You know you can pick up some headlines and understand the Q4 performance and the Q4 headwinds of our Medicare Advantage plans that are out in the market. There’s just a tremendous amount of noise in this industry around how healthcare is operating and the challenges and cost and payment reform and all of the above and so we’ll get into some headlines, but I want our next conversation to be less about the Art of the Possible and more on the Art of the Necessary, which is okay,let’s now come back to planet Earth. What needs to change now to help this industry be sustainable because right now we’re on a tough track.

Kevin Yamashita: I think that’s a hugely important thing for us to unpack. Okay you know if organizations are not careful, there may not be a five, six, seven years down the road to wait for all this to come to fruition. There’s a lot of stuff we need to talk about now that really solidifies folks’ places like in this utopian future.

Nolan Kelly: Yeah, for sure. The competitive dynamics are changing quickly. So alright. Well hey thanks for sitting down today, thanks for tuning in, and we look forward to catching up again in the future.

Kevin Yamashita: Cheers.

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