Using Clinical Data to Succeed in Uncertain Times

  • May 19, 2020
  • 1:00 PM – 2:00 PM ET
  • Online

Acquiring, synthesizing and sharing clinical data is no longer optional. CMS has put the heat on health insurance providers to give members access to their health data using the FHIR standard by July 1, 2021. Even in the absence of government regulation, effective use of clinical data has become more urgent for health plans. Now more than ever, direct electronic access to clinical data is imperative to succeed with HEDIS/Stars, Risk Adjustment and other use cases related to quality and revenue. Chart chasing and the burden it places on plan and provider personnel is no longer viable. In this roundtable discussion, industry experts will share best practices in acquiring and normalizing clinical data and how to overcome the internal and external challenges of integrating clinical data into their business operations.

Use of clinical data is increasingly important to health plans who need to ensure members are receiving the appropriate care, and that their products are meeting quality, revenue, profitability and compliance goals. Business processes such as HEDIS reporting, care gap analysis, and risk adjustment require up-to-date clinical information such as vital signs and test results that are not available in claims data alone.

The challenge is that usability of raw clinical data is limited for the downstream applications supporting such business processes. Although clinical documentation may be understood by a clinician, the sheer volume of raw data issues, variation, redundancy and disorganization inhibits effective processing by software applications. Our studies show that more than 50% of data may be unusable because of incorrect or missing codes, missing or incorrect units, as well as the presence of narrative notes instead of structured data fields.

Poor data quality is caused by persistent factors:

  • Sheer volume of data that can’t be managed using existing manual processes
  • Wide variation in how individual clinicians document care
  • Inconsistencies in how information is organized, which depends on the EHR/EMR system, and even differs between instances of a vendor’s product
  • Disparate sources of clinical documentation for a patient receiving care at multiple facilities

Now, in addition to the use cases noted above where clinical data is needed, CMS has mandated that health insurance providers offer patient access to clinical data as well as claims data by July 1, 2021, using the new FHIR (Fast Healthcare Interoperability Resource) data standard. While the new standard has many advantages, it will not reverse the factors that cause poor data quality.


John D’Amore
President & Chief Strategy Officer
Diameter Health

John D’Amore is co-Founder of Diameter Health and is dedicated to improving healthcare quality and efficiency through the intelligent use of data. He has more than fifteen years of experience providing informatics and strategic insight to healthcare organizations. Previously, John was Vice President at Eclipsys (now Allscripts) overseeing enterprise performance management solutions.

Hayes Abrams
Executive Director of Provider Connectivity & Health Data Exchange
Health Care Service Corporation

Hayes Abrams holds a corporate role as an Executive Director of Provider Connectivity & Health Data Exchange at Health Care Service Corporation. This role is part of a team responsible for developing and implementing the future healthcare vision.  As part of that role, Hayes is responsible for identifying and establishing Health Data Exchange opportunities with the provider community. Health Data Exchange is a collection of capabilities to electronically transfer health information and insights between disparate healthcare systems at provider, patient and payer settings.

Mike Baillie
Senior Vice President Business Development
UnitedHealth Group

Mike Baillie is Senior Vice President, Business Development at UnitedHealth Group.  Previously, he was Vice President of Strategy Clinical Data Integration & Interoperability at UHC and prior to that served as Vice President Strategy for Optum Data Exchange.  Before that, Mike was IT Solutions Vice President for ALN Medical Management and previously was Vice President Sales and Business Development at MD-IT.

Tracy Rico RN, MHA
Director – Telehealth Services
Superior Health Plan

Tracy Rico MHA, RN, is focused on improving health outcomes through interoperability and innovation. She has spent the last 4 years developing and implementing the first clinical interoperability strategy for Superior Healthplan.  She currently participates in several Texas HHSC committees to support interoperability and telehealth initiatives. She is also a Board Member for the Texas e-Health Alliance.  Her most recent project is increasing access to care by building the telehealth strategy of Superior Healthplan and Centene Corporation.

Tracy’s real passion lies in creating partnerships that build resources (financial and talent) to impact our neediest populations and support continuity of care.  Examples include implementing Teladoc for our Medicaid population to increase access to specialists in rural areas, running a school based telemedicine program to keep students in schools and assisting national and local projects to provide emergency access to health records during disaster situations.

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