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

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.

Download the KLAS Research Points of Light Case Study to learn more about:

• Points of Friction—Challenges to Be Solved
  
  • Systemic processing lags prevent healthcare organizations from being able to rely on claims data to trigger timely post-discharge care for at-risk patients:
• Action Plan—How the Collaborators Worked Together to Reduce Friction
  
  • Healthfirst enabled bidirectional data exchange with healthcare organizations via private and public HIEs
  • With the aid of authoring tools provided by InterSystems, Healthfirst piloted an HIE use case for improving performance on a time-sensitive HEDIS measure
  • Healthfirst expanded their successful TRC pilot to multiple time-sensitive HEDIS measures
  • Healthcare Organizations 4-1 and 4-2 spearheaded efforts to minimize seemingly small delays in scheduling follow-up care that collectively risk delaying care beyond required time frames
  • Healthfirst established a process to continually refine the alerts that notify clinicians of qualifying events for treated patients
• Lessons Learned—What Best Practices Can Other Organizations Replicate?
  
  • Educate healthcare organizations on the benefits and policies around sharing sensitive patient data concerning mental health and substance use
  • Ensure that timely qualifying event alerts flow directly into clinicians’ workflows
  • Analyze the root causes of differing adherence rates to enable best practice sharing
  • Establish a partnership of understanding and trust between healthcare and payer organizations
• What’s Next?—Vision for the Future
  
  • Healthfirst continues to expand the program to additional time-sensitive HEDIS measures
  • Provider organizations are working with Healthfirst to collate all reports