Defining a possible HIMSS Stage 8

By Cyrus Bahrassa

Jigsaw puzzle with one missing piece in the center

Last time on Nonstop Interop, I wrote that the time was ripe for HIMSS to add an additional stage focused on interoperability to its two most popular maturity models, EMRAM and O-EMRAM. Doing so would incentivize healthcare providers to embrace modern integration methods and would provide a strong roadmap of interoperability best practices that they can follow. Today I'd like to continue the discussion by outlining the key pieces to include in a possible Stage 8.

Themes and workflows

The first recommendation I would make is to anchor Stage 8 around specific themes. HIMSS does a pretty good job of this already within the models, so it would be consistent with what's currently in place. For example, in the EMRAM benchmarks are divided between key themes such as patient satisfaction, clinical workflows, and data analytics. Governance is another area of focus that's thoroughly incorporated into the existing stages, with change management processes required in Stage 2 of the EMRAM and system-wide governance with "a demonstrable history of solving problems" expected in Stage 7 of the O-EMRAM.

In addition, however, Stage 8 should target particular workflows where interoperability could have a powerful impact. It should require using data exchange technologies to automate workflows and free up staff for more complex problems. The models thus far shy away from being so prescriptive, so I recognize this would be a significant shift from the status quo. Nonetheless, it's the right move to accelerate the adoption of interoperable solutions.


I envision three themes forming the backbone of HIMSS Stage 8.


Interoperability deserves dedicated focus and oversight. Stage 8 should emphasize governance around interoperability, perhaps by encouraging each health system to form an interoperability council or to incorporate responsibilities into an existing governing body. The council would define and maintain the organization's roadmap for embracing higher levels of interoperability and would work with executives, department leads, vendors, and standards bodies to identify solutions to key problems.


FHIR is the future for healthcare data exchange; we've seen the federal government mandate its use in certain cases as it seeks to establish a common foundation for integrations. Stage 8 should require that health systems make FHIR APIs available to external entities—this should be easily satisfied by organizations using an ONC-certified EHR. Moreover, it should encourage them to participate in the advancement of interoperability standards through ways such as submitting comments to the ONC, serving on an industry workgroup, or participating in a connectathon.

That said, I strongly believe Stage 8 shouldn't mandate the use of FHIR. Not only is that a better role for regulators, but also it's important to give providers the flexibility to find the best solution for their circumstances and needs. Many would likely gravitate to FHIR wherever it could work, but there are a host of workflows where HL7v2, X12, or another standard may be the better fit.


It should be easy for the public to understand how to integrate with a health system and to what extent it is integrating with others. To answer the how question, a Stage 8 organization should publish full specifications for the APIs, web services, and interfaces it can support. (These could be as simple as linking to documentation hosted by its EHR vendors.) It should also outline the steps a patient, peer institution, or vendor must follow to establish a connection and provide a way to get in touch with an interoperability point person.

To shed light on the extent of interoperability, Stage 8 could encourage providers to post metrics annually on its public website. Perhaps a particularly enterprising health system could host a dashboard that updates on a regular basis and allows for deeper analysis. While health systems should retain some discretion on what to share, I would love to see them outline the number of unique systems they are connected to, a breakdown of connections by type (e.g., FHIR API, non-FHIR API, HL7v2 interface), the average daily transaction volume per month, and a list of the most common data types exchanged (e.g., a list of FHIR resource types or HL7 message types). Having this data would not only be informative but could also expose gaps and stimulate ideas for future innovation.


In terms of workflows, the below isn't an authoritative list; there are plenty of other possibilities that could make the cut. The emphasis, however, should be on workflows where the necessary technology and standards exist or will exist soon and where the benefits of interoperability and automation will reduce costs, alleviate burnout, and improve clinical care the most.

Virtual care

Even if in-person care continues to be the norm, virtual care should be embraced and offered by Stage 8 organizations. Video visits and messaging services that are tightly integrated with the EHR can make healthcare more convenient and accessible, especially for underserved populations and those without reliable transportation.

Patient data submission

Stage 8 should spur providers to allow patients to contribute to their clinical record. This could take the form of remote patient monitoring, patient-entered questionnaires, or integrations with consumer devices. I acknowledge that we'll need to balance this against the potential burden for clinicians, who should not have to review and reconcile enormous amounts of submitted data.

Electronic payments

This is a unique suggestion because the HIMSS maturity models have typically focused on the clinical side of healthcare. We can't ignore the financial side, though. This should be an easy win as the standards and technology for taking payments electronically have been available for more than a decade and most health systems do this already. Let's formalize it as a requirement in Stage 8; it should, however, only be required for organizations in countries where accepting patient payments is customary.

Electronic prior authorization

Like the previous one, this workflow is likely not as applicable outside of the US and a few other countries, but it's particularly timely given CMS' recent proposed rule. Prior authorization is a laborious and inefficient undertaking today, but we have the fundamental pieces to make it much better.

Automated release of information

I'll admit I'm casting a wide net here, because release of information encompasses so many potential request types, requesters, and data needs. It's unlikely that interoperability can allow us to automate every release request in the near future, but HIMSS Stage 8 could focus on pushing health systems to digitize the easiest use cases, such as delivering clinical abstracts to patients, releasing notes and lab results to life insurance companies, or allowing specialty providers to obtain complete patient and encounter summaries when they receive a new patient referral.


Photo by Pierre Bamin on Unsplash

Share this post

Subscribe to the blog

Get new post notifications in your inbox