By Vincent P. Tumminello, Senior Director, Solution Strategy

Despite substantial financial investments annually, payers are grappling with outdated methods when it comes to clinical data. It’s as if they are trapped in an operational time warp of manual processes — inputting data from PDFs into internal member systems and piecing together Excel spreadsheets from dozens of disconnected and incompatible sources, applications and vendors.

These are hardly the only problems. Core administrative systems remain siloed, single-purpose and best-of-breed, and thus not conducive for integrating and creating interoperable views of members, including their relevant clinical data. Then there’s the data itself, which rarely rises to the gold standard of usability—defined as accurate, complete, timely, relevant, versatile, and formatted and ready for specific use cases and applications.

Clinical data breaking point

Payer tech teams are doing their best to manage the many disparate systems and develop unified clinical data assets. Business teams including quality, risk adjustment, value-based care, care management, and finance also spend an inordinate amount of time and effort merging and massaging clinical data. Their intervention is essential to getting the data needed for their work, such as calculating risk scores, managing program performance, executing interventions to close care gaps, designing value-based contracts, and making underwriting decisions.

It’s reaching the point where manual efforts, workarounds, and patching together disparate clinical data sources aren’t good enough. Because of clinical data shortcomings, payers are facing:

• Increased CMS risk adjustment scrutiny and audits for Medicare Advantage plans
• An inability to meet HEDIS measures that require an integrated view of clinical data from many disparate systems
• Non-compliance with CMS interoperability mandates for data sharing with members, other payers and providers
• Lower STAR ratings, costing them tens of millions of dollars in lost opportunity
• Information and analytics gaps that undercut population health initiatives

More fundamentally, payers are unable to maximize the use of clinical data to make strategic gains in care quality, cost, access, equity and experience—gains that would accelerate sustainable improvement in member outcomes and overall health.

Not surprisingly, more effectively leveraging interoperable clinical data is at the top of payer CEO agendas. In response to a 2023 Gartner Healthcare Payer Client Survey, nearly 75% of payer executives named quality measure performance as their top priority, nearly 50% named risk adjustment and about 40% named member experience.

Getting to usable clinical data

Payers do not have to settle for the status quo. The problems with clinical data are far from insurmountable.

While payers are reluctant to swap out their current systems on the front end and their applications on the back end, they can focus on technology and data solutions in the middle. Payers can combine technology, such as FHIR servers, with data solutions that integrate clinical data from HIEs, EHRs, digital apps and other external sources with core payer data including claims, eligibility, and case management to make data usable for their chosen applications. Solutions that rely on a flexible data integration framework also enable bidirectional data exchange with vendors, providers and other partners.

Beyond integration, the best solutions act like air traffic controllers. They handle data arrival and departures and make sure data is ready for takeoff by aggregating, cleaning, standardizing and otherwise making it usable.

This approach lets payers shift their efforts from low-value clinical data wrangling to operationalizing data for generating high-value insights and making strategic decisions. Payers can:

• Create 360 views of their members and longitudinal patient record.
• Identify high-risk members and design intervention.
• Demonstrate adherence to quality, performance and other standards required for participation in federal programs
• Enhance VBC contracting and financial incentives with better forecasts and tracking of spending, costs and outcomes to improve care and affordability
• Segment members, identify specific needs, deliver care, measure outcomes and share that data with providers and other key stakeholders to scale population health efforts

Ready or not?

The state of payer clinical data is reminiscent of providers before the federal government’s Meaningful Use mandates in the 2010s. Those requirements compelled the near-ubiquitous adoption of EHRs and the resulting improvements in care coordination, decision support, quality, and safety. First using incentives and then fines, CMS forced foot-dragging providers to use certified EHRs to capture and electronically exchange clinical data, digitally submit clinical quality and other measures, give patients electronic access to their records and much more.

Payers are at a similar fork in the road. Instead of waiting for a government mandate or the situation to keep deteriorating, payers could seize the initiative to fundamentally improve clinical data usability to power their strategic priorities. The opportunity is immense: Technology leaders grow 5X faster than laggards, according to 2021 Accenture research. Payers need to ask themselves: What side of history do they want to be on?