The journey towards value-based care (VBC) is becoming more dependent on a key capability: the seamless integration of electronic health records (EHRs) with claims data. This clinical integration enables healthcare organizations to gain a more complete understanding of patient care and outcomes, providing the extensive insight needed to propel forward.
Alone, neither clinical nor claims data offer a comprehensive view. Claims data, while providing a broad view of billing and insurance information, frequently omits vital details like recent laboratory results, resulting in data connectivity gaps. Clinical data, on the other hand, offers in-depth insights into specific medical events and enhances the understanding of a patient’s health status. However, the complexity of records among various providers can cause inconsistencies in data and lead to disjointed care. Varying data formats and the use of different systems can make the integration of clinical EHR data with claims data particularly difficult, requiring significant time and work to align the data correctly.
To help healthcare organizations make the most of their data, Milliman MedInsight effectively integrates EHR data with claims data through its esteemed Data Confidence Model. This method cleanses, standardizes, and audits the data, preparing it for analysis. Moreover, a specialized algorithm has been developed to synchronize member and provider IDs, enhancing Milliman MedInsight’s analytical and integration capabilities and resolving compatibility issues between EHR and claims data. With our thorough clinical data integration process, our customers are better prepared to advance their VBC initiatives confidently.
Below are examples of how leading organizations have effectively leveraged integrated data for informed decision-making, improved patient outcomes, and enhanced value-based care strategies with Milliman MedInsight.
Targeted screenings & care for optimal outcomes
Currently, U.S. healthcare organizations are grappling with a host of significant challenges, such as staffing shortages, reimbursement issues, gaps in preventative care, and increased financial scrutiny. In addition, the COVID-19 pandemic significantly disrupted cancer screening rates, leading to widespread delays and cancellations of routine screening appointments.1 This reduction in screenings has raised concerns among healthcare professionals about potential increases in late-stage cancer diagnoses and poorer outcomes for patients. Furthermore, the American Cancer Society has indicated that in the coming year, we are nearing a grim milestone—the first time that new cancer cases are expected to exceed two million.2
In response to these pressures, Lucem Health, a frontrunner in AI-powered healthcare solutions, has developed early disease detection technologies. These innovations are designed to help healthcare providers allocate their limited clinical resources more effectively by prioritizing patients who require the most urgent care. The rationale behind this approach is clear: early intervention not only leads to better patient outcomes but also reduces the overall cost of care.
For example, colorectal cancer represents a significant public health issue, with nearly one-third of U.S. adults behind on their screenings according to the Centers for Disease Control and Prevention (CDC).3 Early diagnosis of colon cancer and its precursors is crucial, as it is almost entirely treatable at this stage. Facilities, however, may lack the capacity to significantly increase the number of colonoscopies performed.
To address this, Lucem Health utilized lab and demographic data to prioritize patients who were overdue for colorectal screening and were at highest risk. Their AI model successfully pinpointed the top 3% of at-risk individuals, who were 8 to 10 times more likely to develop colon cancer. This approach proved efficient and effective, as screening just over 200 targeted individuals revealed 9 colorectal cancers, 26.2 advanced adenomas, and 57.8 polyps or $1.25 million in projected savings over four years.
A strategy for enhanced care coordination
Clinical data integration is a fundamental component of VBC. Navigating the complexities of performance in contract-based healthcare, however, can be a formidable challenge for any organization. There are often quality gaps or unseen activities (e.g., procedures or labs performed elsewhere) that can impact an organization’s understanding of their true performance.
For SSM Health, a not-for-profit, integrated health system serving communities across the Midwest, its goal is to bridge these gaps by leveraging the data they have: claims data and EHR data available through vendor alliances with Milliman MedInsight and Epic. This endeavor would allow them to identify and address quality deficits for over 600,000 individuals in various value-based arrangements, ranging from partial to full risk, across all lines of business. By doing so, SSM Health can strategically direct their resources and efforts to support patient care effectively and minimize medical waste.
In addition, the use of disease registries—like those for diabetes, CHF, COPD, and cancer—enables better alignment of disease management programs and a comprehensive view of patient care, both before and after interventions. By integrating these registries into their electronic medical record (EMR) system, SSM Health can compare the healthcare costs of patients with specific health conditions to those without. This comprehensive approach enables a deeper understanding of prevalence rates within their populations and the overall financial impact of their care programs, further improving care delivery across the board.
Closing care gaps & supporting population health goals
EHR data is vital for enabling targeted interventions and monitoring enhanced outcomes. It’s essential not just for gauging performance against population health metrics, but also for comprehending the chronic conditions common within a population. To realize its objectives, Advanced Health, a Coordinated Care Organization (CCO) established by the state of Oregon, collaborated with Milliman MedInsight to establish an effective population health data flow.
This was a critical step as Advanced Health manages the healthcare needs of 26,000 members who receive health care coverage under the Oregon Health Plan (Medicaid). Each year, the Oregon Health Authority sets 14-16 measures and provides financial incentives to CCOs based on their performance. Key health measures tracked through EHR data include controlling high blood pressure, diabetes HBA1c control, depression screening, and monitoring alcohol, drug, and tobacco use.
Working together, Advanced Health and Milliman MedInsight integrated both claims and clinical data feeds and leveraged the Milliman MedInsight VBC Platform to generate monthly reports. This collaboration enabled Advanced Health to monitor population health metrics and drive meaningful interventions for improvement. In addition, the partnership provided Advanced Health with customized data for measuring and demonstrating progress to the state, and ultimately driving meaningful interventions for improvement. In fact, Advanced Health achieved 100% of the available incentive funding by showing improvement in 11 out of 14 quality measures in 2022.
Explore our webinar & case study
Learn more about these success stories by watching the webinar titled “How does clinical data integration drive value-based care? Lessons learned from leading health systems.” Discover how Lucem Health, SSM Health, and Advanced Health collaborate with Milliman MedInsight to improve operational, clinical and financial outcomes with EHR and claims data integration.
Connect with one of our healthcare analytics team members to learn more about how we can help pave the way for success in value-based care settings.
References:
1. Impact of COVID on the April 2024 SEER Data Release (cancer.gov)
3. Use of Colorectal Cancer Screening Tests | Colorectal Cancer | CDC