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Utilizing Near Real-Time Data from Payer HIEs to Identify Qualifying Events & Close Time-Sensitive Care Gaps

KLAS Research: Points of Light 2025 Case Study 4

Executive Summary

Providing timely post-discharge care to at-risk patients is a national challenge. Due to lags in claims processing, clinicians often struggle to identify recently discharged patients and schedule needed follow-up visits within the limited time frame required by HEDIS.

This challenge can result in suboptimal care, costly readmissions, and avoidable acute care episodes. Working with InterSystems interoperability tools, Healthfirst—a provider-sponsored health plan—began leveraging clinical data from near real-time HIE feeds to identify members experiencing a qualifying event for a time-sensitive HEDIS measure.

The tools then send automated alerts to clinicians so they have sufficient time to schedule follow-up care. Additionally, Healthcare Organizations 4-1 and 4-2 worked with Healthfirst to refine workflows and processes to enable quick action on the alerts.

Outcomes include improved performance with targeted HEDIS measures and a reduced administrative burden.

Points of Light—Outcomes Achieved through Collaboration
  • Healthcare Organizations 4-1 and 4-2 exceeded or far exceeded benchmarks for care gap closure
  • Healthfirst improved their overall performance for targeted time-sensitive HEDIS measures
    • FUM: The test group's adherence rate outperformed the control group's by 13%
    • FUA (Follow-Up After ED Visit for Substance Use): The test group's adherence rate outperformed the control group by 8%
    • TRC medication reconciliation: The test group's adherence rate outperformed the control group's by 9%
  • Minimized admistrative burden for clinicians

Download the full report below to for more lessons learned, including best practices other organizations can replicate and a look at the vision for the future.

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