Harnessing clinical data to surpass the limits of claims information

Why healthcare organizations must embrace the potential of EHRs and interoperability to achieve smarter, more effective patient care.

In all aspects of healthcare management — from population health and care management to risk adjustment, quality improvement and payment integrity — there is a common thread: Payers and providers need timely, relevant, high-quality patient data. They need precise, accurate and contextual data that’s purposely configured to support use cases and more streamlined healthcare operations.

Historically, our healthcare system has relied on claims data to run the business of healthcare. The system also heavily relied on paper to keep and update patients’ medical records. We’re now a couple decades into most providers using electronic medical records, so it’s high time we use all that digitized clinical data to help deliver higher quality, more cost-effective care. Wasn’t that the point of EHRs, anyway?

Claims data still has a place

Organizations working to improve the healthcare system have long used claims data to understand the cost of care, verify the integrity of payments and identify patients who may be at risk of developing chronic conditions. Claims data has provided value, and it continues to do so.

Claims data provides essential information about a patient’s use of the healthcare system and associated costs. It also offers important insights that can help create a fuller picture of a patient’s health status and behaviors. For example, while clinical data shows that a clinician prescribed a medication, it doesn’t tell whether a patient is taking that medication. Claims data gets a step closer, as a claim submitted from the pharmacy can at least tell whether the patient picked up their medication.

Because claims data spans multiple healthcare organizations, it can tell about past procedures, diagnoses or preventative care that patients may not self-report. Having additional background information on a patient can help clinicians make more informed decisions about their care.

The limitations of claims data 

In thinking about improving the health of populations, one of the biggest pitfalls of claims data is that it’s only collected on insured patients. Some of the most vulnerable patients in healthcare systems are those who are uninsured. Without clinical data, those patients would be invisible.

In addition, claims data is limited. A claim captures the encounter a patient has with the healthcare system, but not the overall context. For example, if a patient goes to the ER with a wound sustained from a fall, the claims data will show the laceration diagnosis and repair codes, but it’s unlikely to show that the patient's weight was up from baseline and that they had lower extremity edema during the visit, which could infer a bigger health concern.

Claims data is also time-lagged. Organizations get data on a patient 30 to 60 days after that data was collected. Clinical data, on the other hand, can be sent, analyzed and used for good in a matter of seconds. 

The power of clinical data

While claims data has value, clinical data is more powerful in trying to surmise a patient’s health status. Clinical data is much timelier than claims, giving an almost real-time picture of a patient’s health status. Claims data tells what happened in the past, while clinical data tells what is happening now. 

Clinical data opens a world of opportunity in population health, closing care gaps and reducing health inequities. For example, patients living with diabetes may reduce their risk for developing chronic comorbidities by actively managing their health and adhering to their care plans.

Clinical data can provide context to better understand how a patient living with diabetes manages their condition – what are their A1C levels, did they have their recommended annual exams (such as eye and foot), how do they manage stress and what are their exercise habits. Clinical data may include family history, support system and barriers such as limited access to healthy foods. This information helps clinicians coordinate care, address gaps in care and support each patient based on their unique needs and goals.

Using clinical data to run the business of healthcare is essential to evolve the system from one that treats sick people to a system that prevents people from getting sick.

Getting clinical data into the right hands

If clinical data is king, how can it be delivered into the right hands, in the right format, at the right time?

That’s where effective interoperability becomes critical. Clinical data doesn’t do much good just sitting around in the EHR. It’s powerful when people making care decisions have access to data they can easily understand and act on.

To unlock the power of clinical data, it must be safeguarded to ensure patient confidentiality. It’s imperative that data exchange solutions balance connectivity with control. Effective interoperability must be privacy-centric, precise and actionable to meaningfully power the healthcare ecosystem.

When I think of the future of healthcare, everything runs seamlessly and there is no friction between payers and providers. Healthcare expenditure no longer accounts for a whopping 18 percent or more of GDP (a man can dream, right?). And clinical data is used as the primary data source with claims playing a complementary role.

In this future, where clinical and claims data are happily married, we get a more comprehensive picture of a patient’s health status and how their care can be optimized. The marriage of clinical and claims data also provides a fuller, more informed picture of a population’s overall health. This is how healthcare gets smarter, stronger and more affordable.

Mike Coyne is COO of Moxe Health.

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