Payer-provider clinical data exchange plays a critical role in payer operations. Health payers require timely access to patients’ clinical data when processing claims, for risk adjustment, to identify potential gap closure opportunities, to evaluate the necessity of requested services, and more.
Traditionally, payer-provider clinical data exchange occurred manually, often via extensive and time-consuming processes that placed a significant time and energy burden on both practice and payer staff. However, streamlining clinical data exchange can significantly benefit payer operations—while also benefiting both patients and providers. In this article, we review some of the ways that improving clinical data exchange can positively impact your payer organization.
Improve patients’ care coordination
For most effective management of patients’ health care, payers and health care providers need the ability to exchange information—specifically, information about patients’ health care services. Which health care services are patients currently receiving? Have patients previously received any of those health care services? Which health care services are planned for future use with patients? Payers frequently have access to more information about the specific care accessed by patients than individual providers, making them an invaluable resource when creating the patient’s treatment plan.
Rapid access to patients’ health care records is also critical because it enables payers to quickly make treatment coverage decisions. Payers require patients’ medical records to make decisions such as whether a specific treatment is medically necessary and whether to grant prior authorization for a specific treatment plan.
Improve quality scores and close gaps in care
Effective payer-provider clinical data exchange also helps payers to identify and address potential gaps in care more quickly and effectively. When a care gap is identified, rapid data exchange allows treatments to reach patients more quickly. This, in turn, helps drive improved patient outcomes.
Streamlining payer-provider clinical data exchange can lead to quality score improvements. The National Committee for Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality, developed the measurement system known as the Healthcare Effectiveness Data and Information Set, or HEDIS® measures*. HEDIS measures have become one of the most widely used performance improvement tools used in the health care industry today.
Part of the value of HEDIS measures is that these scores enable consumers and purchasers to more easily compare and evaluate the performance of different health plans. Currently, HEDIS measures are used by more than 90 percent of U.S. health plans to evaluate the quality of care provided to their members and report quality results.
However, the ultimate purpose of HEDIS measures is to help improve the quality of health care. These measures are also used to help identify opportunities for health care providers and medical practices to improve their individual care delivery. Improving HEDIS scores is directly related to closing gaps in care and improving the use of preventive screenings and other preventive services, which lower costs by helping to decrease use of expensive emergency services.
Lower health care costs
Health care data exchange is also critical for controlling and lowering today’s health care costs. Its ability to help increase patients’ care coordination enables payers and providers to work together, delivering proactive health care services to patients. Effective clinical data exchange also lowers overall health care costs by helping to reduce patients’ emergency room visits, decrease unnecessary hospital admissions, and eliminate duplicate medical testing.
Solutions for clinical data exchange
Health plans working to improve their quality scores and monitor members’ risk scores need data-driven solutions, solutions that specifically analyze member data to identify areas of opportunity.
For instance, Veradigm Quality Analytics applies precision analytics to patient data to identify gaps in HEDIS, Quality Rating Systems, Star Ratings, Pharmacy Quality Alliance, and state-specific quality measures. Veradigm Risk Adjustment Analytics solution applies precise, advanced risk adjustment algorithms to patient data to enable more efficient targeting of gap closure interventions—leading to earlier, more appropriate treatment of patient members by earlier detection of their health conditions.
However, these analyses require streamlined access to patients’ clinical data—which means payers and health care providers need a way to exchange patients’ clinical information in a manner that is easier, faster, confidential, and trustworthy. They need a tool that permits information exchange without requiring time-consuming extra steps such as having providers log into different health plan portals for every patient. Veradigm Payer Insights is a dynamic new solution, free for providers, that addresses this need.
The solution enables payers to analyze electronic health record data to identify and assess care gaps based on specific payer criteria. Gap information can then be presented to providers without requiring them to log into an external payer portal.
Targeted interventions and gap closures are essential for improving patient care and patient health outcomes, but providers are not always aware of existing care gaps. With Veradigm Payer Insights, care gap alerts are presented as part of providers’ existing workflow, within individual patients’ records. Alerts contain relevant, patient-specific considerations for providers to evaluate, respond to, and address with patients. It reduces provider abrasion by delivering a free and easy-to-use solution to the known challenge of payer-provider clinical data exchange.
*HEDIS® is a registered trademark of National Committee for Quality Assurance (NCQA) and any reference thereto by RISE Health does not imply any endorsement by NCQA of RISE Health and its offerings.