Effective data analytics are possible with HIT optimization

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Lynn Handy, CPC, CPC-I, CPC-H, CCS-P, LPN, CHC, Senior Director of Professional Coding and Educational Services, Altegra Health

“Water, water everywhere/Nor any drop to drink” is a famous verse from Samuel Coleridge’s epic poem, The Rime of the Ancient Mariner. Coleridge was writing about the sea, but healthcare provider organizations could write a similar verse about the data they are drowning in from their electronic health record (EHR) systems and other sources.

The challenge is harnessing all this data to guide care-quality and financial performance improvement efforts, which many provider organizations lack the time and professional resources to accomplish. Combined with pressures from government and commercial health insurers to improve care-quality metrics while reducing costs, this sea of untapped data has two-thirds of provider organizations naming data analytics as one of their top three priorities this year.[1]

Despite this goal, clinical and financial data is still stuck in silos in most health systems, communities and states. However, there is good news! Providers accessing the information they need for effective analysis may be easier than they think and they may already have all the HIT they need in their EHR and financial systems. The next step is to optimize the existing technology and develop workflows that will leverage these tools to improve clinical outcomes, lower costs and meet quality guidelines. Here’s how:

Targeted risk stratification

The timeliest information on a patients’ health statuses is inside the providers’ charts. When analyzed with the right risk stratification algorithms, provider data captured from the hospital, physician practices and other care venues can deliver insight into which patients are in need of a clinical intervention before an adverse event occurs. Ensuring accurate stratification requires information to be standardized across the enterprise and that existing information systems normalize captured data in real time. Measuring quality improvement and its impact on reimbursement will not be possible unless an organization is using the same data languages across its inpatient and outpatient facilities.

For even greater precision, EHR data can be combined with claims data from payers, who have extensive experience with risk management of their members. While payers and providers have a historically contentious relationship, now the time is to put those feelings aside and collaborate. This insight can guide provider outreach to prevent a potential hospitalization or visit to the emergency room. 

Revenue cycle integrity

Ask provider organizations how much they bill a certain payer for a certain procedure and they can tell you right away, but ask how much it costs to deliver the procedure and they will likely have no idea. Provider organizations have a plethora of information about how much care costs to deliver, but the data is spread out in different IT systems and with different providers. Determining how to integrate this data for a precise cost-of-delivery estimate will require multiple stakeholders, including clinical, revenue cycle, IT, HIM and administration. Collectively, they must work across the organization as a team to design the workflows and develop the infrastructure needed to determine the true cost of care and if they are being adequately reimbursed.  

Understanding costs is not only essential for revenue cycle integrity, but also for provider organizations transitioning from fee-for-service to value-based payment contracts where they will risk losing money if care costs are too high. Despite the urgency of this issue, only 15 percent of finance department leaders in healthcare organizations say they have “very sophisticated” capabilities to support capitation, bundled payments, and quality-based payments that account for an increasingly larger component of revenue.[2] Collaborating across the enterprise to determine the true cost of care can help prepare the organization for that shift.

Improve engagement

With the ability to capture and analyze data from outside the organization, either through claims, pharmacy, lab, or patient-reported information to the health plan, organizations can have better insight into where patients are seeking care outside of their physician network. Organizations can then contact patients to re-engage with a network physician, or, at least, contact the provider to obtain a copy of the Continuity of Care Document or other clinical data. This out-of-network care can impact the quality and cost metrics providers report to payers under value-based payment models. An analytics platform that can determine if outside providers are following evidence-based care protocols, closing care gaps and encouraging better disease management is in the provider organization’s best interest.

Optimizing existing HIT systems to improve care-quality and manage costs is only the beginning. Once data is available to identify and intervene with highest-risk patients, provider organizations still need to conduct outreach and help overcome obstacles they face in adhering to their care plan. With the right information and tools at care managers’ fingertips, this process can be more seamless for both providers and patients, resulting in better outcomes and efficient spending.

[1] CDW Healthcare. “Analytics in Healthcare.”  2015. http://www.cdwnewsroom.com/wp-content/uploads/2016/01/CDW_Healthcare-Analytics-PR-Report_FINAL.pdf

[2] KPMG. “Healthcare Provider Finance Trailing New Demands Tied To Value-Based Contracts: KPMG Survey.” Press release. June 30, 2015. http://www.kpmg.com/US/en/IssuesAndInsights/ArticlesPublications/Press-Releases/Pages/Healthcare-Provider-Finance-Trailing-New-Demands-Tied-To-Value-Based-Contracts-KPMG-Survey.aspx

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