Harnessing clinical data to surpass the limits of claims information

As published in: 

In all aspects of healthcare management—from population health and care management to risk adjustment, quality improvement, and payment integrity—there is a common thread: Payers and providers need timely, relevant, high quality patient data. They need precise, accurate, and contextual data that’s purposely configured to support use cases and more streamlined healthcare operations.

Historically, our healthcare system has relied on claims data to run the business of healthcare. The system also heavily relied on paper to keep and update patients’ medical records. Since we’re now decades into most providers using electronic medical records, it’s high time we use all that digitized clinical data to help deliver higher quality, more cost-effective care. Wasn’t that the point of EHRs, anyway? 

Claims data still has a place

Organizations working to improve the healthcare system have long used claims data to understand the cost of care, verify the integrity of payments, and identify patients who may be at risk of developing chronic conditions. Claims data has provided value, and it continues to do so.

Claims data provides us with essential information about a patient’s use of the healthcare system and associated costs. It also offers important insights that can help create a fuller picture of a patient’s health status and behaviors. For example, while clinical data shows us that a clinician prescribed a medication, it doesn’t tell us whether a patient is taking that medication. Claims data gets us a step closer, as a claim submitted from the pharmacy can at least tell us that the patient picked up their medication. 

Because claims data spans multiple healthcare organizations, it can tell us about past procedures, diagnoses, or preventative care that patients may not self-report. Having additional background information on a patient can help clinicians make more informed decisions about their care.

Continue to Health Data Management to read the full article.

About Mike Coyne

Mike Coyne is a proven leader with significant experience growing, scaling, and optimizing healthcare technology and information services businesses. In roles that include CEO, board member, advisor and practicing lawyer, Mike has overseen the successful growth of technology startups, health plans, and multi-billion dollar companies. At Moxe, Mike lends his extensive experience to advance our strategy, operations, and business development efforts to meet the evolving needs of our clients.