Episode 16 - From Blue Button to Bulk FHIR with Mark Scrimshire

In this episode, I speak with Mark Scrimshire, Chief Interoperability Officer at Onyx, about his extensive journey in healthcare interoperability, the evolution of data sharing standards, and the future impact of regulations and technology.

Mark Scrimshire’s Journey to FHIR®

Mark recounts his two-decade career, which provides a vivid history of modern interoperability. His journey began around 2009 during the American Recovery Act, where early initiatives like CMS’s “Blue Button 1.0” allowed patients to download their claims history—often as a massive, unusable text file thousands of pages long.

His pivotal moment came as an Entrepreneur in Residence at CMS, where he was tasked with building a modern API for Medicare beneficiaries. Instead of creating a proprietary standard, he chose to adopt the emerging HL7® FHIR® standard. This project evolved into Blue Button 2.0, a landmark API that proved the viability of using FHIR® at a national scale. He was instrumental in defining key resources like the Explanation of Benefit..

This work at CMS laid the groundwork for the 2020 CMS Interoperability and Patient Access final rule, which mandated that payers provide patient access via FHIR® APIs. Seeing this regulatory shift coming, Mark co-founded Onyx to build a platform that helps healthcare organizations comply with these rules and leverage the new data-sharing paradigm.

The Power of Regulation as a Catalyst

A central theme of the conversation is the role of government regulation in driving change. Mark argues that mandates are essential for overcoming industry inertia. He uses the upcoming Prior Authorization rule as a key example. While the rule only mandates the API for certain government-funded plans, he predicts that the efficiency gains (getting an answer in 15 seconds via an API versus days via fax) will create immense market pressure for payers to offer the same capability for their commercial plans. This transforms a compliance requirement into a strategic business transformation.

Interesting Observations

* Flipping the Script on Data Integration: Mark powerfully articulates a common problem in healthcare IT: an “80/20 rule” where organizations spend 80% of their effort just trying to get the data and only 20% actually using it for analysis and insight. He argues that standardized FHIR® APIs and trust frameworks are designed to “flip this script,” allowing organizations to spend only 20% of their effort on connectivity and 80% on creating value from the data.

* The Core Challenge is Trust, Not Technology: Mark asserts that the biggest barrier to seamless interoperability is not a lack of technology but a lack of scalable trust. Establishing individual connections between thousands of payers and providers is a manual, time-consuming process that costs “man-years” of effort. The solution lies in building robust trust frameworks (like TEFCA or security protocols like UDAP) where an entity can be vetted once and then securely connect with anyone else in the network, dramatically reducing friction.

* Regulation as a “Bridgehead” for Market Transformation: Mark views regulations not as the end goal but as a “bridgehead” a starting point that establishes a new technical and business reality. Once the infrastructure (like FHIR® APIs) is in place due to a mandate, the market naturally finds innovative and more efficient ways to use it, pushing adoption far beyond the original scope of the rule.

* FHIR® as an Enabler for AI, Not a Relic: Addressing the question of whether AI makes standards obsolete, Mark argues the opposite. He states that having well-structured, standardized data from FHIR® APIs makes AI more efficient, accurate, and less resource-intensive. Without standards, AI models would have to waste immense computational power on parsing unstructured documents (like PDFs) and de-identifying data, a process FHIR® makes unnecessary. Standardized data is the clean, reliable fuel that will power the next generation of healthcare AI.