Interoperability and Bridging the Payer-Provider Divide - Cover

Interoperability and Bridging the Payer-Provider Divide

The K2 Collaborative and its related summit each year bring positive examples of payer and provider collaboration to the forefront. These stories show what is possible in payer-provider relationships. Micky Tripathi, the national coordinator for health IT in the US Department of Health and Human Services, graciously accepted KLAS’ invitation to give the keynote address.

His excitement filled the room as he shared an update on the federal government’s healthcare IT strategy behind encouraging payers and providers to adopt FHIR APIs to improve interoperability. Both provider and payer organizations’ interoperability strategies are tied to policies and regulations, so this was a crucial topic. A few of Tripathi’s key points are highlighted below.

Laying the Foundation

Tripathi used the analogy of plumbing, with himself as the plumber, to describe the overall focus of the ONC on interoperability as setting up the pipelines of information between stakeholders. He expressed, “For the ONC, we want to . . . have an ecosystem where you can share information appropriately and use technology in the best way possible so that it’s as easy as possible. At least we take that off the table . . . and then we can work on restructuring the incentives.”

The current government strategy is to encourage payers and providers to adopt FHIR APIs to improve data sharing. Documentation at provider organizations is highly variable, while payer organizations have different internal processes. With FHIR-based APIs, we can create a nationwide governance structure for health information exchange, thus bridging the gap of payer and provider interoperability.

The digital foundation built with the HITECH Act and the 21st Century Cures Act gave the ONC power to certify EHRs, which 97% of hospitals and over 80% of physician offices use. All certified EHR vendors are required to provide a standard FHIR API to customers.

While this is the government standard, Tripathi is aware that health systems are on their own upgrade cycles and that not all have adopted the standard yet. But CMS rules are also pushing providers to adopt that software version, and since the requirement went into effect, FHIR APIs are now more universally available.

Making Interoperability Easy

FHIR APIs are well and good, but it isn’t possible to scale them if the network infrastructure is not in place to allow scalability. This is why the TEFCA (Trusted Exchange Framework and Common Agreement) is needed. Tripathi states that the “TEFCA is the opportunity to break through the gap between payers and providers in national-scale network interoperability.”

Tripathi compares the TEFCA with cell phone networks today. While we have a variety of phone networks, our user experience is as if there were a single network thanks to a variety of governance, market incentives, and technical agreements. This gives every customer a seamless experience. The TEFCA does something similar in healthcare and makes health data exchange scalable, and that means organizations can avoid multiple contract negotiations with each payer or provider partner.

The TEFCA is also the technical approach that makes it possible for QHINs (Qualified Health Information Networks) to be connected. There are currently seven QHINs that voluntarily signed the common agreement on December 12, 2023. The QHINs are similar to the AT&T and the T-Mobile networks. Tripathi says, “Once [QHINs] hit the data threshold and meet the criteria and they decide they want to do it, then they can exchange information within the TEFCA umbrella.” There are live transactions happening across the seven networks currently live.

Joining the Effort

It is important to understand what the TEFCA does not do. Tripathi says, “The market should determine what a network looks like. That shouldn’t be for [government] to determine. . . . We want to say, let’s agree that when you exchange information with each other, you all have the same baseline so there is a foundation to count on regardless of how you connect.”

Bringing together public health and private healthcare is no easy feat, but interoperability clearly has a way forward now. During his keynote, Tripathi invited all the payer and provider attendees to volunteer for the payer and provider the TEFCA exchange in 2024 using the QHINs and FHIR APIs.


For more information or to join the K2 Collaborative, please visit the K2 Collaborative page.

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