As healthcare becomes increasingly data-driven, payers are turning to clinical health record data to strengthen claims processing, care coordination and risk management. This shift reflects a broader industry trend toward more integrated, real-time data use across the care continuum.
With deep expertise in data aggregation and exchange, state and regional health information exchanges (HIEs) are well-positioned to support payer organizations by providing timely, actionable clinical insights that enhance both operational efficiency and patient outcomes.
To learn more, Becker’s Healthcare recently spoke with Mike O’Neill, CEO of MedicaSoft.
Question: Payers are increasingly recognizing the value of clinical health record data. What are some of the biggest barriers you see preventing payers from fully leveraging the data today, and why is overcoming these challenges so important?
Mike O’Neill: The first challenge is how to efficiently access clinical data. It’s fragmented; there’s no single place, like a national registry, where payers can get clinical data.
Complying with the policies and regulations that govern how health record data can be used for different purposes is another challenge. Once payers get data, how can they be sure their use of it is compliant? The allowable data for claims adjudication, for example, is different from the allowable data for quality measure of work or care coordination.
Aggregating clinical data from multiple healthcare providers also creates challenges. First, payers must be sure that the information is matched to the correct patient. The quality of clinical data – EHR data can come in many formats and varies in its completeness and consistency – must be addressed so it can be used effectively.
With all that said, despite these barriers, payers are finding that it’s definitely beneficial to add clinical data to use cases like claims adjudication, claims processing, care coordination, prior authorization and more.
Q: Given the regulatory complexity surrounding health data — HIPAA, 42 CFR Part 2 and more — how can payers use clinical data responsibly and effectively while staying compliant?
MO: Today, many payers implement point solutions. In essence, compliance is achieved by segregating data and systems to match different use cases. To use clinical data to compute quality measures, they put that information into a database and access it for computing quality measures. For care coordination, they set up a different system and database so that they can be sure it is used in the right way. And so on.
As payers handle larger volumes of data and more use cases, a more effective solution would be a platform architecture that aggregates all the data, organizes it, and applies access rules that ensure data is always used in a compliant way. For example, a payer team doing care coordination only gets access to allowable data for specific patients.
Q: Health information exchanges have long served as trusted sources for clinical data aggregation. How are HIEs evolving to provide more value to payers in areas like care management, risk adjustment, and utilization review?
MO: HIEs have invested a lot in aggregating data from many sources, handling patient matching, and dealing with variations in data quality. Many of them provide data to payers in their community. They are in a good position to evolve from providing data to providing information extracted from the data.
One example is organizing data into longitudinal health records, so payers involved with care coordination can access data as an end-to-end health record for patients. HIEs are also leveraging their data for analytics to identify things like at-risk patient populations, or gaps in care for health plan members. Because HIEs have data that spans large numbers of providers, and they understand the complexities of clinical data, they can provide insights to their payer stakeholders beyond being a source
of raw data.
Q: Interoperability is often the linchpin for data sharing across organizations. What are some of the most important standards or technologies enabling collaboration between payers and HIEs today?
MO: The predominant standards for exchanging healthcare information have been document-based.
Most payers, for example, use EDI X12 standards to exchange claims data. The clinical world’s HL7 standards also provide a document format to capture clinical data from an encounter or the medical history for a patient. While it may be relatively easy to exchange clinical documents, it’s often not the most efficient way to share the data.
To address this challenge, the industry is moving toward API-based standards. An API-based data standard allows organizations to exchange as little or as much data as they need, based on what’s needed for specific use cases. For example, with APIs payers can access medications for one patient or three years of medical history for a 5,000-patient roster.
The payer community is just learning about the benefits of the API-based HL7 FHIR standard as an interoperable way to exchange data. FHIR also includes a data model that defines how data is described and stored.
