For payers still relying solely on claims data, the margin for improvement is shrinking. One regional health plan’s experience offers a blueprint for what’s possible when clinical data is put to work.
For years, claims data has powered payer analytics. Yet in a value-based care landscape, claims alone no longer provide the strength or clarity payers need. Lab values, vital signs, screening results, and chronic disease indicators — the clinical details that matter most for quality measurement — live in EHRs, not claims systems. And as HEDIS and Stars programs increasingly require electronic clinical data system (ECDS) submissions, payers that can’t access that data are operating at a structural disadvantage.
One regional health plan serving North Dakota recognized this gap early. Rather than retrofitting workarounds into an aging claims-only infrastructure, the organization made a strategic decision: build a scalable clinical data enablement program from the ground up. What followed was a statewide implementation, completed in under two months, and the early results that are now redefining how the group approaches quality improvement.
From Claims to Clinical: Why the Shift Matters
The limitations of claims are well-documented. Data lags weeks or months behind clinical events. Blood pressure readings, A1c results, BMI, and cancer screening details are routinely absent. And when a member sees multiple providers across disparate systems, claims paint an incomplete, sometimes misleading, picture of their health.
The National Committee for Quality Assurance (NCQA) has been clear that electronic clinical data leads to more reliable quality reporting and reduces administrative burden across the ecosystem. Meanwhile, CMS and the Office of the National Coordinator (ONC) have accelerated interoperability mandates under the 21st Century Cures Act, making EHR data more accessible than ever before.
For the North Dakota plan, the business case was clear: without clinical data, they couldn’t fully close care gaps, couldn’t produce audit-ready HEDIS submissions, and couldn’t build the kind of provider relationships that value-based performance demands. But once clinical data was introduced, those “couldn’ts” started turning into “coulds.”
A Statewide Program, Built in Only Eight Weeks
Working with enterprise data management partner ELLKAY, the plan developed a program centered on four key priorities. These included supplemental data acquisition to support HEDIS and Stars reporting, engagement with provider organizations across the state, seamless integration with existing analytics infrastructure, and full audit traceability from data retrieval through measure calculation.
Within two months of contract signature, the implementation was live across 38 provider organizations, part of ELLKAY’s broader network spanning 750+ EHRs and 58,000 practices nationwide. That speed was made possible by strong internal governance, cross-departmental alignment, and clear executive sponsorship — and by a partner with nearly 25 years of implementation experience in healthcare data. Critically, 29 of those 38 organizations adopted API-based data exchange, a rate that significantly outpaces the national average. According to ONC, roughly 60 percent of providers were exchanging data via APIs as of 2023.
Trust as Infrastructure
Perhaps the most underappreciated dimension of any clinical data initiative is the provider relationship. Data sharing only works when providers trust what happens with their data, and that trust must be earned.
The plan addressed this directly through a provider-facing portal that gave organizations full visibility into what data had been retrieved and how it mapped to quality measures. Providers could validate coding, documentation, and measure impacts in real time. The result was fewer manual chart requests, less friction, and a shared language for quality improvement. It was the kind of payer-provider alignment value-based contracts require but rarely achieve — and a sign of what’s possible when data infrastructure is treated as a long-term strategic investment, not a compliance checkbox..
Early Results and a Broader Vision
The program delivered measurable early outcomes: successful submission and audit of HEDIS measures using clinically enriched datasets, increased availability of clinical values that claims could not capture, and enhanced visibility into care gaps that had previously gone undetected.
Those results are meaningful on their own. But for the organization’s leadership, the ECDS foundation represents something bigger, enabling predictive analytics, advancing population health management, improving risk adjustment, and ultimately supporting the integration of social drivers of health data. What began as infrastructure for quality reporting is quickly becoming the backbone of a broader enterprise data strategy — one that connects across the full data lifecycle: interfaces for ingestion, network for ecosystem reach, and data for analytics activation.
For payers still weighing the investment, the lesson from North Dakota is straightforward. The technical barriers are lower than they’ve ever been, and the path forward is clear. Payers that invest in clinical data capabilities now, with one partner across the full data lifecycle, will be best positioned to meet rising quality expectations, strengthen provider relationships, and deliver better outcomes for the members who depend on them.
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