The exchange of digital data in health care offers significant opportunities for payers to reduce inefficiencies, minimize waste, and enhance the timeliness and quality of information used in care decisions. By promoting interoperability among health care stakeholders, organizations can unlock the potential of structured data, driving informed decisions and enhancing organizational intelligence. This foundation leads to improved risk adjustment and quality outcomes. However, achieving interoperability comes with challenges that include making substantial investments, finding specialized expertise, and dedicating resources.
Regulatory updates and emerging opportunities
Recent regulatory changes have aimed to improve interoperability by broadening access to structured clinical data and prioritizing seamless data exchange. The Trusted Exchange Framework and Common Agreement (TEFCA) has become a key initiative for efficient, nationwide data exchange. The release of TEFCA version 2.0 in 2024 expanded its scope to include FHIR-based exchanges and broader exchange purposes, including health care operations like quality reporting and patient stratification.
The CMS Interoperability and Prior Authorization Final Rule mandates federally funded payers to implement FHIR-based APIs to enhance interoperability and streamline prior authorization by January 1, 2027. In addition, the National Committee for Quality Assurance (NCQA) aims to transition to all-digital measures for HEDIS® reporting by 2030, utilizing the FHIR standard to reduce manual errors. NCQA has also launched a Bulk FHIR API Quality Coalition to test clinical data content from FHIR APIs, assessing the accuracy of the data received
Business impact
Interoperability primarily benefits health care payers by improving data acquisition, data standardization, and care delivery. Clinical data is currently retrieved from various disparate sources such as health systems, provider offices, and health information exchanges, among others. In addition, the formatting of this data can vary. Interoperability enhances data acquisition by reducing retrieval time, maximizing the volume of records obtained, minimizing provider abrasion, and streamlining administrative processes. This seamless exchange and consistent formatting reduce manual errors and inconsistencies.
Standardized data allows payers to use uniform formats across channels and sources, fostering improved collaboration among stakeholders and supporting the implementation of advanced analytics and AI-driven programs. Access to real-time, comprehensive data empowers health plans to elevate risk adjustment and quality program outcomes. It also provides a holistic view of members, enabling more effective population health strategies. With more accurate risk assessments and tailored care plans for high-risk members, health care organizations can improve member care while optimizing risk adjustment programs.
Key recommendations
Payers should consider the following best practices to build a scalable interoperability program in 2025 and beyond:
• Set up an internal taskforce: Involve leaders from IT, legal, and clinical areas to determine interoperability requirements and their impact on current operations. Monitor regulatory trends and identify their impact on specific use cases. Engage external partners with dedicated expertise to accelerate innovation and support plans to meet deadlines and goals.
• Join external working groups: Participate in initiatives like the HL7 Da Vinci Project to test and learn new digital requirements. The Da Vinci Trebuchet Pilot, for example, involves payers, providers, and technology vendors testing scenarios such as prior authorization and TEFCA exchange.
• Implement scalable technology infrastructure: Establish diverse connections and network options such as Qualified Health Information Networks (QHINs), health information exchanges, and health systems, and implement FHIR-based APIs. Partnering with high-quality experts can help address specific market needs, identify opportunities, and design effective strategies while complying with regulatory requirements.
• Establish strong data management processes: Adopt industry standards like HL7 and FHIR to streamline data retrieval and exchange. Focus on robust data mapping and quality management strategies. Conduct regular data quality audits and collaborate closely with data partners to ensure data accuracy and continuous improvement.
Interoperability is transforming health care data management by advancing data acquisition, standardization, and integration. As regulatory changes reshape the industry, health care organizations must adapt and innovate to maintain compliance and enhance patient care. Embracing interoperability unlocks new opportunities for greater efficiency, improved accuracy, and better patient outcomes.
About the author
Katie Devlin, DHSc, MS, CPHIMS, vice president of interoperability for Cotiviti, is responsible for creating an enterprise-wide health data exchange strategy to address clients’ unique business needs while reducing provider abrasion, maintaining regulatory compliance, and optimizing value. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, including the expansion of Cotiviti’s electronic health data networks and strategic partnerships. Drawing on her extensive informatics and health information exchange experience, she is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience.