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Clean Clinical Data to Improve Quality Measure Reporting is Essential for Health Plans and Providers

Payers and Providers

doctor explaining instructions to her patient

Submitting quality measure data can be a challenge. It’s difficult for regulatory programs, for pay-for-performance or value-based care programs, or as part of health plans’ HEDIS (Healthcare Effectiveness Data and Information Set) or Medicare Advantage STARS requirements. Some of the hardest measures to meet are those that use clinical data (called hybrid measures). For example, to determine if a patient’s HbA1c is in check for diabetes blood sugar control, you need a lab result. Paying third-party vendors to extract that data from electronic health records (EHRs) has been one way to get it – but it’s costly and takes time. A 2015 Health Affairs report suggests that medical records review costs providers about 15.1 hours per week and an estimated $15.4 billion annually to report quality measures.

Quality measure reporting is a $15.4 billion annual hit to the bottom line1

Aggregating and Using Clinical Data for a 20-40% Improvement in Performance Measures

A Clinically Integrated Network (CIN) in the Midwest, encompassing many health systems and independent providers, must bridge data between its provider members and the payers with whom they contract.

Eighty percent of the CIN’s members use the Epic electronic health record system. And the organization’s health information technology philosophy is “Epic first.” The Sr. Director, health information technology, explains, “When we need a report or other information, we look first to get that from Epic. When we can’t, then we look to other solutions.” In these cases, they use InterSystems HealthShare® software to fill the gaps. HealthShare Unified Care Record aggregates information from Epic and non-Epic EHRs across the network into a single, continuously updated longitudinal patient record.

Access to data from diverse EHRs
The CIN has an internal clinical performance improvement program that rewards providers if they meet certain performance levels on their HEDIS measures. The problem is that different payers have different forms and delivery requirements for supplemental (clinically derived) quality data. Collecting the data and reporting it to multiple payers via so many methods places a huge administrative burden on provider organizations. Although the CIN’s hospital systems use Epic – and some of the practices outside of the hospitals use the same instance of it – this accounts for only 80% of the data they need to report. The remaining 20% of the CIN’s data is held in other EHRs.

Better performance measures with HealthShare
Using HealthShare, the CIN created “lightweight” connections to these other EHRs. The connections pull in just the observations and lab results needed for HEDIS supplemental data and deliver it to the payer in whatever format they need. Not only does this reduce the administrative burden for providers, but the CIN expects a 20-40% increase in its performance measures just by leveraging the data it now has in HealthShare.

Closing Gaps in Care – HIE (Health Information Exchange) Data for Public and Population Health

Hixny, a Health Information Network in eastern New York that serves 5 million people, connects providers, patients and organizations to better coordinate care and reduce healthcare costs across its community. Using InterSystems HealthShare, their system pulls near real-time data from the entire healthcare community and then uses it to filter each provider’s patient population. Patients are placed within actionable categories based upon most recent medical history, known conditions and identified gaps in care. This accurate and up-to-date information allows providers to quickly identify next steps for higher risk patients.

Closing 15-20% of gaps in care using HIE data
Some of Hixny’s members participate in a CMS Accountable Care Organization (ACO) – meaning they are on the hook for improving population health and reducing the cost of care. Using data available through Hixny, these ACOs track their quality measure performance in near real time. An in-workflow dashboard created by Hixny enables practices to identify gaps in care for their patients at a glance. Hixny’s CEO estimates that 15-20% of gaps get closed as a result of this data availability.

Reporting on quality measures
Beyond patient care, the reporting Hixny provides is useful when it comes to measuring mandated care quality standards. A provider can, viewing a single report, identify all patients from their panel who are due for preventative screenings — such as blood pressure readings for hypertensive patients or HbA1c tests for diabetics. Providers can also use reports labeled as “quality indicators” to track performance toward HEDIS requirements and benchmarks established by the National Committee for Quality Assurance (NCQA), in addition to tracking adherence to performance-based contracts.

7% Performance Boost for Time Sensitive HEDIS Measures

The ongoing shift to value-based care emphasizes provider performance and care outcomes over outputs. Measures of quality are a requirement for value-based care, but some time-based measures are challenging to achieve. Sometimes the follow-up or action that’s part of the measure needs to happen faster than a claim, and awareness of an event, can get processed by a payer. One such measure is Follow-Up After Emergency Department Visit for Mental Illness (FUM). It requires a follow-up within seven days of the emergency room visit. Obviously, if the follow up visit is missed the opportunity is missed for that event to contribute to the overall quality score.

Faster than the speed of claims
A New York health plan serving 1.8 million members uses clinical data derived from its provider network and public HIEs to help providers improve performance on time-sensitive measures. InterSystems HealthShare Unified Care Record and Health Insight provide the software power behind the effort. In the case of FUM, whenever a member is seen at a local Emergency Department with a diagnosis of mental illness, the alert is sent via HealthShare so that it can be reviewed by a care manager.HealthShare’s analytics engine runs a query to assure that the memeber meets the denominator for the measure and, if so, sends a notice to the member’s PCP that a follow up visit is required. Because of this approach, the payer has seen a 7% performance boost in FUM and other time-sensitive measures.

Learn More

Multi-source clinical data may be messy, but InterSystems technology brings it together as a single, trustworthy, and clean resource for use in achieving and reporting on performance measures. Learn more about Enterprise Data Management Strategy for Public & Private Payers.


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