Making Payer-Provider Clinical Data Exchange as Smooth as Possible

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Blog Posts  |  21 February 2022

In healthcare, data exchange can cover numerous different types of data. It may include provider data for the healthcare providers connected to a health plan. It might also include administrative data, such as eligibility data, claims, and managed care encounters. Finally, it can include clinical data—information and results that are related to patients’ care, including medical records, encounter notes, medications and immunizations, imaging data, scans, orders, and more. Providers use clinical data for nearly every aspect of provider operations, from making treatment decisions to tracking and improving patient outcomes. They also use clinical data for submitting claims and managing prior authorization (PA) requests to health payers. Payers use clinical data to help determine medical necessity and to make PA decisions.

Traditionally, payer-provider data exchange relied primarily on extensive, time-consuming processes to track down clinical data, lab results, and other types of patient records.

There are numerous reasons that streamlining payer-provider clinical data exchange can benefit both payers and providers—and patients as well. In this article, we will look at the key arguments for making payer-provider clinical data exchange as smooth as possible. We will also share some solutions that can help streamline the process.

Benefits of smooth payer-provider clinical data exchange

1. Improved care coordination

Effective clinical data exchange can give providers actionable information to help them make more informed healthcare decisions for their patients. The Centers for Medicare and Medicaid Services (CMS) state that improved data sharing can help drive better care by better informing decision-making for patients and their providers. At the same time, it will decrease the administrative burden on both healthcare providers and payers, helping to lower healthcare costs.

This is, in part, the reason behind the CMS Proposed Rule in 2021, which seeks to improve care coordination by requiring providers to have access to patients’ healthcare information from payers through their Health Information Exchange (HIE) solution. This rule would:

  • Require payers to include information about patients’ pending and current PA decisions as part of the information accessed via the payer-to-provider and payer-to-payer Application Programming Interface (API), giving providers direct access to information about patients’ PA status
  • Automate and standardize the PA process by requiring payers to build an automated tool for providers to send PA requests and receive responses in return, all within existing provider workflows
  • Facilitate payer-to-provider clinical data exchange: providers must be able to request and access patients’ healthcare information from payers in real time, with the purpose of supporting care coordination

More effective clinical data exchange would make it easier for providers to:

  • Review patient data in a timely manner
  • Streamline administrative processes such as PAs, claims submissions, and claims payments
  • Help facilitate care management strategies for patients to help them make more informed decisions
  • Help patients receive more timely access to appropriate care

For instance, when a patient is hospitalized, the payer is informed of the event when the hospital contacts them regarding the patient’s coverage and request for reimbursement. However, the patient’s other providers—such as their primary care physician and any specialty providers they see—also need information about this event, and they need it while there is still time to coordinate the patient’s care. The payer can share this information with them. If the provider or providers do not realize the patient was admitted to the hospital, they won’t be able to provide follow-up care to prevent readmission.
Similarly, rapid access to patient records helps to accelerate payers’ ability to make decisions such as whether to grant PA or whether a treatment is medically necessary. It also helps to close care gaps as treatments can reach patients more quickly. Ultimately, it drives improved patient outcomes.

2. Manage patients’ healthcare more effectively

To manage patients’ care most effectively, providers and payers also need to exchange information about prior and current healthcare services received by or planned for a patient. Since most patients do not stay with a single provider throughout their lives, a patient’s current provider is unlikely to have that patient’s complete medical record on file. Payers, however, may have more information about specific patients than any single provider, because they have claims processing systems that gather all the relevant data for each beneficiary.

For providers to manage their patients’ care effectively, they need to be able to access payer information that they don’t already have in the patients’ medical history. Improving patients’ health outcomes depends on the ability for payers and providers to exchange patient-originated health information in near real time.

3. Lower healthcare costs

Healthcare data exchange is critical for controlling healthcare costs. Sharing healthcare data enables payers and providers to work together, providing healthcare services to patients proactively. This results in a lower cost of care. Data sharing between payers and providers can also help increase care coordination. This can also help reduce emergency room (ER) visits, as well as hospital admissions, duplicate testing, and medication errors. Together, these benefits function to decrease healthcare costs.

Driving efficiency in clinical data exchange between payers and providers could also lower costs simply by making the process more efficient. Currently, it’s estimated that the U.S. healthcare system wastes approximately $248 billion annually on administrative complexity. Of over 100 million medical records requested of providers each year, 90% are exchanged using traditional paper or analog fax methods. Providing payers with remote access to data would lead to greater efficiency in clinical data exchange. It would also eliminate the need for payers to make on-site visits to providers’ offices, saving payers time and travel expenses while saving providers the disruption and expense of assigning staff to assist with pulling records.

Currently data sharing in the healthcare industry is primarily paper-driven. Most of the time, payers and providers send documents using fax machines or snail mail. A 2019 survey of 200 healthcare professionals revealed that 89% of healthcare organizations are still using fax machines. Although electronic claims submissions are more common, attachments are still frequently exchanged manually; in 2017, only 6% of 100 million medical attachments submitted annually were sent electronically.

However, manual data exchanges present risk of errors, privacy violations, and delays for processes such as PAs and referrals, which can then delay patient care.

4. Enables value-based care, helps improve quality scores, and simplifies risk management

Improving the quality and cost efficiency of healthcare is data-dependent: value-based care requires fluid, continuous data exchange. One of the benefits of sharing healthcare data between payers and providers, though, is that it enables value-based care. To provide value-based care, providers need to know all the services and care a patient has received to avoid unnecessary—and expensive—duplication. At the same time, payers require transparency across all venues of care to monitor protocol adherence and create improvements in the health plan design.

Improved clinical data exchange can also help payers achieve higher scores on the Healthcare Effectiveness Data and Information Set (HEDIS®) measures and Medicare Star ratings. Achieving these high scores is of crucial importance for health plans. One study showed that boosting a plan’s rating by one star can lead to an 8-12% increased enrollment rate, which can increase total revenue by up to 17%.

Near real-time access to clinical data can help payers improve HEDIS and Stars ratings in two ways:

  • It accelerates HEDIS and Stars scoring, allowing payers to use that information more quickly to improve member care
  • It streamlines payers’ access to in-depth data on the populations they are serving, so they can improve plan design, interventions, and improve management of member risk profiles

Veradigm’s solutions to streamline payer-provider clinical data exchange

Veradigm offers two solutions that can help improve patient care by facilitating clinical data exchange.

1. Veradigm eChart Courier™

Veradigm eChart Courier is an easy-to-use solution that can help save time, office resources, and expense by automating the medical chart retrieval process. Retrieving medical charts manually is a time-consuming and resource intensive process. Typically, charts are pulled individually, and each is driven or mailed to the requesting health plan, where they are reviewed manually—for 160,000,000 medical charts each year. Medical practices must designate staff to sort through patients’ charts and respond to requests, which diverts resources from supporting patients and providers.

With Veradigm eChart Courier, medical chart retrieval is automated. This increases efficiency: eChart Courier operates through your electronic health record (EHR) system, allowing you to access and supply requested patient charts from within your existing workflow. Automated medical chart retrieval helps ensure security, by sending all information in an encrypted format that can be viewed only by the intended users. eChart Courier also supports value-based reimbursement by aiding data collection for quality measures that impact reimbursement for value-based care models.

Veradigm eChart Courier is offered at no additional cost to healthcare providers. It is available with the Practice Fusion EHR, Allscripts TouchWorks® EHR, Veradigm EHR™, and Allscripts Sunrise™ EHR.

2. Integr8: Electronic Medical Record (EMR) analytics and integration software

Integr8 helps health plans to manage EHR data from multiple sources. This enables health plans to make more informed decisions about their patients, identify conditions that may be present, and close risk/quality gaps that may have already been addressed by providers.

Integr8 improves practice efficiency by automating exchange of Continuity of Care Documents (CCD) and medical record information, rather than relying on more expensive and labor-intensive means of data collection. It also allows better care coordination.

The increased efficiency from Integr8 results in faster turnaround times and better care coordination, which, in turn, increase closure rates for documentation, coding, and quality gaps. It also improves payer-provider relations because EMR integration offers the least intrusive means of collecting data from and returning insights to providers.

To learn how Veradigm can help streamline clinical data exchange and improve patient outcomes for your practice, contact us.

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