Tenasol 2025 Health IT Perspectives

The healthcare data industry feels poised for policy transformations with the adoption of AI, healthcare interoperability, and introduction of HL7 FHIR. Here we look to 2025, highlighting areas we see as the most impactful.

Nationwide Network Healthcare Interoperability or Not?

National exchange networks have operated largely unchanged, from the early days of NwHIN and Carequality, offering broad support for treatment while other use-cases trailed. The Cures Act of 2016 sought to change this by refocusing our industry on a “single onramp” for healthcare interoperability.

Eight years in, how much progress has TEFCA made? Several leading organizations have joined as QHINs and exchange went live in 2023 (for treatment and IAS, adding public health in 2024). IAS is a welcome and long overdue REQUIRED addition; however, a less optimistic view suggests this progress is marginal at best. Every QHIN (or sub-participant) that exists today is already exchanging for these purposes via an existing public or private network (IAS not withstanding). While the TEFCA SOP process is working to expand to other use-cases, new SOPs being developed are generally still ‘optional’ and permitted purposes are becoming more granular and fragmented.

Can TEFCA meaningfully change the trajectory of nationwide healthcare interoperability?

We believe 2025 is the year tough questions are asked about our current trajectory, in the hopes of accelerating the progress that we desperately need.

Transforming Healthcare Data Extraction with AI

Value-based care has resulted in payers generating a lot of data, from risk adjustment assessments, retail encounters, home health visits, EHR data, wellness visits and more, yet when it comes to healthcare interoperability, plans were never really required to share this data with the patients and providers they serve.

In recent years health plans have caught the attention of both ASTP (Assistant Secretary for Technology Policy) and CMS, with policies requiring FHIR APIs to reduce administrative processes through prior authorization and requiring that plans share data with patients, providers and other plans using FHIR.

Today, clinical data processed by health plans are housed across a patchwork of applications and vendor processes, the vast majority of which are unstructured. Payers are racing to retrofit systems that never benefited from a HITECH Act funded overhaul the way health systems did. As a result, plans are struggling to comply with these new rules and make “meaningful use” of mandated APIs.

Healthcare date extraction AI is presenting new opportunities to overcome these challenges by enabling extraction from any healthcare data format, and outputting output data in modern formats such as HL7 FHIR. Most interoperability systems are best at structured healthcare data integration, but fall short at delivering enterprise value by also including unstructured healthcare data source. Integrating AI across all clinical data processing drives significant value, from medical record review efficiencies to generating new member insights from previously unused data. 

In 2025, we believe AI-powered healthcare data extraction will become a standard capability within the tech stack to realize the full potential of clinical data for payers.

HEDIS/Quality NLP: An AI Success Story

AI has made headlines for its ability to transform and automate processes, but also for being expensive to operate, and prone to errors and hallucinations. This presents a challenge for healthcare, especially for quality improvement, where processes are audited and the penalty for error is high.

Over the past year, HEDIS NLP has been all the rage as plans navigate post-pandemic policy changes and their impact on quality scores. From CMS lawsuits to NCQA program changes, there are a convergence of factors making quality improvement success essential for health plan performance. Organizations like HL7, NCQA, Microsoft and others are collaborating through the Digital Quality Implementers Community (DQIC) to accelerate digital quality by improving CQL and its underlying FHIR data model.

As we’ve written in previous blogs, Tenasol is seeing early success in AI and HEDIS/quality improvement, both in terms of ROI and precision. We expect this to be an area of growth in 2025 for the industry overall.

Faster Prior Authorization

See our blog on prior authorization NLP for an in-depth dive on this topic.

Federal policy, via HTI-2 has accelerated the time required for prior authorization approvals. This has huge pressure effects on pharmaceutical, payer, and provider healthcare interoperability, and is expected to boost connectivity speed and tech.

In addition to this, the methods by which prior authorization are expected to be approved are going to diversify to include AI parsing of unstructured medical data to reach conclusions faster and reducing payer float. 2025 will push this topic to center stage.

Future of Health-IT Policy

As a new administration takes the helm at ASTP in 2025, it’s natural to speculate what the future of Health IT policy will look like, especially given heightened focus on government efficiency and reduced spending. ASTP was reorganized in 2024, but it is unclear what congress views of this increased role. Additionally, with the country hovering at 98% EHR adoption, much of ASTP’s original mandate has been fulfilled.

So what is next? It could take on new responsibilities such as AI, accelerate TEFCA implementation or focus on harmonizing standards across other federal agencies (CDC, NIH, FDA, etc). The latter of which was announced in summer 2024. Given we are not policy experts, we will await the opinions of others on what the future of Health IT policy will look like. All we know is it will look different in 2025. How different is anyone’s guess for now.

Conclusion

The healthcare IT landscape is set for significant transformation, driven by advancements in AI, expanded interoperability efforts, and evolving policy mandates. While TEFCA aims to unify nationwide data exchange, its current progress raises questions about its broader impact. Simultaneously, AI-powered data extraction and quality improvement tools are becoming indispensable for unlocking the value of both structured and unstructured healthcare data, offering promise for payers navigating regulatory and operational challenges. Policies like HTI-2 are reshaping prior authorization processes, further emphasizing the need for rapid innovation. As a new administration shapes the future of health IT, the industry faces a pivotal moment, balancing progress in AI integration and interoperability with the need for cohesive, forward-thinking policies. With these changes, 2025 holds the potential to redefine how healthcare data is leveraged to improve outcomes, efficiency, and the patient experience across the ecosystem.