How Real-Time Clinical Data Exchange Can Help Improve Payer Operations

Written by: Katie Wilson and Cheryl Reifsnyder, PhD

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 while simultaneously introducing more errors into patient records. 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' healthcare, payers and healthcare providers need the ability to exchange information-specifically, information about patients' healthcare services. Which healthcare services are patients currently receiving? Have patients received any of those healthcare services previously? Which healthcare 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' healthcare records is also critical because it enables payers to make treatment coverage decisions more rapidly. 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 & close gaps in care

Effective payer-provider clinical data exchange also helps payers identify and address potential gaps in care more quickly and effectively. Rapid data exchange allows treatments to reach patients more quickly when a care gap is identified. This, in turn, helps improve patient health and drive improved patient outcomes.

Streamlining payer-provider clinical data exchange-and the resulting closure of care gaps-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 healthcare industry today.

Part of the value of HEDIS measures is that these scores enable consumers and purchasers to compare and evaluate the performance of different health plans more easily. Currently, HEDIS measures are used by more than 90% 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 healthcare, and these measures are also used to help identify opportunities for healthcare 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 the use of expensive emergency services.

Enable value-based contracts

Clinical data exchange is also critical to the transition from the traditional fee-for-service payment to value-based care reimbursement. Success in the new payment landscape requires payers to work toward improving HEDIS scores; for collecting the clinical data needed to close gaps in care and improve HEDIS scores, payers require a smooth and effective system of clinical data exchange. Value-based care contracts demand the ability for payers and providers to exchange clinical data continuously and easily, because doing so drives better decision-making and, ultimately, better patient outcomes.

To deliver value-based care, providers also need to know the full complement of care and services received by their patients so they can prevent unnecessary-and expensive-treatment repeats.

Lower healthcare costs

Healthcare data exchange is also critical for controlling and lowering today's healthcare costs. Its ability to help increase patients' care coordination enables payers and providers to work together, delivering proactive healthcare services to patients. Effective clinical data exchange also lowers overall healthcare costs by helping to reduce patients' emergency room visits, decrease unnecessary hospital admissions, and eliminate duplicate medical testing.

Veradigm Payer Insights: a solution for clinical data exchange

Health plans working to improve their quality scores and monitor members' risk scores need data-driven 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 (QRS), Star Ratings, Pharmacy Quality Alliance (PQA), and state-specific quality measures. The 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 healthcare providers need a way to exchange patients' clinical information in an easier, faster, confidential, and trustworthy manner. 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.

Veradigm Payer Insights enables payers to analyze electronic health record (EHR) 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 or other external sites. Care gap alerts are delivered to providers within their individual patients' electronic health record, as part of a network of over 100 payers.

If gaps aren't documented and accessible during the provider's typical workflow, their potential to positively impact patient care is greatly diminished. However, this alert process saves time for providers and staff. Providers don't have to independently seek out care gaps; They can address existing gaps directly in the patient care workflow. Any feedback they wish to submit flows securely back to payers in near real-time, including any patient documentation for payer review.

Targeted interventions and gap closures are essential for improving patient care and health outcomes, but providers are not always aware of existing care gaps. Veradigm Payer Insights reduces provider abrasion by delivering a free and easy-to-use solution to the known challenge of payer-provider clinical data exchange. 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.

Veradigm Payer Insights helps medical practices feel less pressure from their patients' payers, helps providers feel more confident that they are meeting their patients' needs, and gives providers the confidence that they have the information they need to help improve patient care at their practice.

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