Poised for Breakthrough: Integrating Claims Data and EHR Data

By Brian Studebaker

4 October 2013

Up until now, the integration of claims data and EHR data has been an often sought, but seldom realized goal in the healthcare analytics world.  It’s a business intelligence idea with so much potential benefit, and it seems like it just wouldn’t be that hard to do. In reality, unifying these two types of data is enormously complex. To date, there have been too many barriers to sourcing this data, and a clear vision of the true ROI has not really emerged. So why are we poised for a breakthrough now?

The Convergence of Need and Availability

For the first time there are entities that have both access to the data and the interest to leverage it. Accountable Care Organizations (ACOs) need better support in understanding and managing the risk of their populations. Provider-Owned Health Plans (POHPs) must improve the efficiency of medical management in order to survive in the new healthcare market.  With the Accountable Care Act and meaningful use, the penetration of EHR systems is growing, creating electronic data that is accessible and increasingly coded rather than free-form.

Rather than admit that integration of this data is a Mount Everest-level task beyond its worth, ACOs and POHPs are now examining the data and data sources to locate the first foot-hold.  They’re finding strengths, weakness and characteristics in the two data types that are complementary. Indeed, the combination of claims data and EHR data will permit advanced analytics at the individual patient and patient population levels that could drive significant improvements in health outcomes and financial performance.

EHR 10.04.13

How We Can Get There

Let’s take an “If You Build It, They Will Come” approach, in two phases. Phase 1 starts with a focus on a single EHR system, perhaps one that is chosen as a pilot. The data is loaded from the EHR system and unified with the claims data in a data warehouse. It is transformed, meaning the coding is synchronized so distinct data, duplication and gaps are identified.  Then it is presented in a unified, logical way using dashboards, member profiles and other analytic tools. At this stage, the two data sets are not fully integrated, but value can still be derived from the aggregation and normalization work that have taken place.

Phase 2 involves building the data set, then developing/applying advanced analytics such as clinical opportunity identification, development of hybrid risk scores and stratification of better episodes of care. The business intelligence that results could be used in many ways, such as:

  • to provide greater levels of disease monitoring to ACOs and POHPs, leading to more informed decision-making at the enterprise level
  • to support clinicians and patients in more informed decision-making during visits, and limiting unnecessary tests or treatments
  • to guide medical research on disease prevention and treatment

Yes, the integration of claims data and EHR data will be messy at first. However, the potential gains for all parties to the healthcare system in our country are enormous. It’s time we pursue them.

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