Clinical Data, Claims Data: Working Together to Improve Population Health

Clinical Claims blog.jpg

Co-authored by Suzanne Kunze, RN, CCM, MBA


When you hear the terms clinical data and claims data, what do you think of?

Claims data is often thought of as information on the patient’s procedures and how much the insurer is paid. Typically, claims data does not have details on what took place or how the patient got here. Claims data represents one aspect of their care, not the entire picture.

In addition to telling one part of the story, claims data can also retrospectively show what treatments occurred, and what was subsequently paid for; it can also show whether the plan member filled a prescribed medication. And, can also begin to define what population health resources an organization should be focusing on.

Clinical data, on the other hand, tells a different part of the story. It includes demographics, and really gives the entire picture of a patient’s care, where they were treated, what procedures they had, who the provider was, and any medications that were prescribed. It does not include any information about what was paid for or the patient’s financial obligations.

Clinical data also provides insight into a population’s health, identifying trends and things that may become larger issues if not addressed. Clinical data is obtained through patient assessments or is self-reported by the member through the portal.

How do we confirm, or validate the data’s accuracy? And, how can we best use the data that’s been provided?

Claims data has its shortcomings, though, including latency, with more than 30 days typically for claims data to be processed.

Bringing clinical, claims data together

What if these two sets of data were somehow brought together in a meaningful way? Is there a way for the healthcare industry to marry the two sets of data to improve population health?

According to a 2015 HealthcareITNews article, claims and clinical data complement each other. Claims data has value in the complex and quickly evolving healthcare marketplace because it offers a retrospective look at what actually occurred. In addition to revealing facts about an individuals’ health and where to focus population health resources, claims data can show what prescriptions were ordered, and filled, and whether lab tests were completed. 

Combining claims data and clinical data provides value when comparing recommended care against evidence-based practices. The combination of clinical and claims data may also be able to help identify early risk factors before an issue leads to an acute event or hospitalization. Because clinical data is clinically validated, it requires less time than claims data to confidently assert a member has a condition or that the provider needs to take-action to improve population health.

Data from the EHR

With today’s electronic health records (EHRs), a provider is able to track clinical data through a patient portal, which can point to opportunities for population health improvements. For example, the EHR can show when a member’s flu shot was administered. Tracking this in the EHR gets at better data, which is beneficial to the patient and improves their overall care. However, if the plan member had a flu shot at a clinic or through their employer, then this information may not be tracked. There may or may not be a claim associated with the flu shot.

This means there are still some issues with clinical and claims data. For example, a woman who has had a mastectomy and continues to receive reminders about the need for a mammography, does not provide a good patient experience.

And, the benefit of the EHR is to always improve the patient experience, so we need to know who needs the data, and what it will be used for.

The EHR does a good job of setting patient appointments and reminders, as well as alerting the provider to anything abnormal in a patient’s lab work or other tests that were ordered.

In the new NCQA Population Identification category (Category 2) standard, there’s a reference to how data unlocks population information to discover needs and create a more person-centric intervention. A provider uses clinical data to make member-specific care decisions, and the health plan uses claims data to make population-level decisions.

Sharing these two data types can lead to more information on which to base quality care improvements and resource utilization. For example, a health plan’s case manager discovers that a member lacks transportation to a doctor’s appointment and feels socially isolated due to an inability to visit friends or family. The health plan transmits the information to the provider.

While the case manager works to find appropriate transportation, the provider may offer the member telehealth visits. Without this kind of data sharing, the connection would not have been made and the member’s health may have declined.

Data validation

Depending on who needs the data and how it will be used, will determine which data is most beneficial. Having clinical and claims data together can go a long way towards improving a member’s initial assessment.

Anecdotal evidence suggests that it can take several hours to complete a member’s initial assessment, with 90 minutes not being unusual for the initial assessment. Anything longer than that usually requires an additional assessment, meaning they pick up where they left off previously.

Many of the questions being asked during the assessment help get at what’s being referred to as social determinants of health, and are invaluable for creating the member’s care plan. Questions about whether the member has enough food (because if they’re forgoing getting medications because they are costly and instead need to purchase food, then that needs to be addressed) in order for the care plan to be successful and getting the member working towards their healthcare goals.

That’s also why there are questions in the initial assessment about the member’s finances, because we need to make sure the member is getting the treatment and/or medication they need — all with the goal of getting the member as healthy as possible.

Using the clinical data

To be most effective, assessments could be shorter, and this is where previous clinical data can come to bear on how an assessment is populated. When an assessment is populated this way, the patient is then not being asked every question, but a populated assessment can validate the data that was previously collected.

For example, a patient assessment interaction may look something like this:

Case Manager: “I see you had a lab test on October 1. What were the results of that lab work?”

Patient: “Oh, I didn’t get the test yet?”

Case Manager: “Oh, was there something preventing you from obtaining the test? Is there anything we can do to help you to get the test?”

This interaction may point to a social determinant of health literacy. Validation questions like this can identify that the patient was not able to get to the testing center, because he doesn’t drive, or the patient couldn’t keep an appointment because she needed to care for her three-year-old child. 

What we can do for you

HighPoint can help health plans capture claim data and clinical data by developing tools that capture the information. Through the use of data fields in assessment, clinical data can be gathered.  Highpoint clinical and business experts can assist with the development of workflows, training materials and job aides to support the practice of capturing clinical data. Once the clinical information is available, actionable care plans can be created to address the needs of the members and the organization’s populations.

Highpoint is skilled at evaluating and developing processes to allow for the integration of claims, electronic health record, clinical data, and care management data. Through data integration and process engineering Highpoint’s team of data integration experts, can help ensure that you capture good clinical and claim data that can be used to meet your organization’s goals today and for many years to come.

Improving patient outcomes and population health requires that clinical and claims data be aligned.

As we close out this blog, we want to hear from you as to what’s the one thing that keeps you from doing the things you know you should to improve your health? We welcome your comments.

To learn more about the HighPoint Solutions Population Health practice, please reach out to Chris McShanag, vice president, population health.


Co-authored by Suzanne Kunze, RN, CCM, MBA

Tags: population health, healthcare, data

   

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