Interoperable Claims Data: Not Just a Pie in the Sky

Interoperable Claims Data

Among all the healthcare stakeholders, payers capture the most data. Their giant claims processing machines gather up information from the entire provider community, not just a single silo. Their patient records also contain a universe of clinical info that is increasingly being supplemented with new indicators, such as social determinants health.

Obviously, it makes sense to share that rich data source to support comprehensive patient care. What provider wouldn’t want to know about a patient’s past hospitalizations, for example? However, let’s remember that claims are designed to render payment, not to chronical health services.

That’s why we’re keeping an eye on a new project that CMS is launching which will allow providers to access Medicare claims data at the point of care. The main idea behind the Data at the Point of Care program is to build a more structured and complete patient history. (CMS)

Clinicians participating in the pilot will be able to request a Medicare beneficiary’s claims data to get a full snapshot of their care, including services from other providers. What’s good about this effort is that developers are on task to make sure the information sources are interoperable.

Ideally, the doctor will view the claims data within his or her normal workflow at the bedside, without the frustration of clicking on a whole bunch of other screens and applications. An interface will sync the information seamlessly in the provider’s EHR with an emerging interoperability standard known as FHIR (“fire”).

Anyone who knows anything about interoperability believes FHIR is the way to go if stakeholders have any hope of sharing data across the patchwork of today’s healthcare technology systems. Essentially, FHIR provides a structure to align applications so they can exchange granular information across systems that don’t normally “talk” to each other.

[Related reading: Business Incentives Will Fuel Healthcare Interoperability]

We can agree that interoperability is a really good thing, but it’s certainly not the only thing.

In order for Data at the Point of Care to be successful, the information it heaps into the EHR also has to be useful. Yes, physicians typically want to have reliable patient histories, but the additional claims data must be filtered and packaged in a way that’s logical, relevant, and actionable. Docs simply don’t have time to search for needles in haystacks.

We know that more than 35% of family medicine providers report being burned out by the burden of health IT use — the highest of any specialty — and many report having to complete their digital documentation tasks after hours. Only about half of physicians say EHRs improve patient care or clinical workflow. (AAFP)

So, the developers working on Data at the Point of Care clearly have their work cut out for them. Once the project gets off the ground — which might take a while — we expect that other payers will be prodded into creating similar programs. In fact, CMS recently proposed a rule that would require Medicare Advantage, Medicaid, CHIP, and health plans sold on the federal marketplace sites to similarly make patient data available to providers through an application interface.

Sharing claims data is a foundational step that will support clinical decision-making and reduce waste. If it’s done well, it will improve quality and outcomes.

Our Take: Many consumers believe there’s a great big health record in the sky that contains all of their information. How many of them would be surprised to find out that’s not at all the case! The Smart Health Market simply can’t be achieved without radically interoperable health data gathered from a constellation of sources, including the payer community.