Claims vs. EHR data in Direct Primary Care

Claims vs. EHR data in Direct Primary Care

As data becomes a larger ticket item for direct primary care practices (DPCs), we wanted to share perspective from a DPC lens on the most common data sources: Electronic Health Records (EHR) and Claims.

How can EHR data be leveraged in DPC?

EHR data contains real-time information on patient’s history, encounters, problems, vitals, labs, medications, diagnosis, services, etc. There is a lot of information that can be used.

Examples include:

  • Chronic condition prevalence (e.g. Diabetes, Hypertension, etc.); knowing when they have been seen in the clinic; trending A1cs and blood pressure values over time
  • Tracking improvement or deterioration on key biometrics for the patient population
  • Gaps in recommended prevention and screening measures like mammogram, colonoscopy, etc.
  • Identifying patients that have not been seen in the last 3/6/12 months, which could impact panel churn rate
  • Can be used to develop disease registries and support care management efforts

Disadvantages of relying solely upon EHR data in DPC

  • Information about patient’s activities outside of the DPCs (ER visits, Inpatient visits, specialist visits, etc.) is typically not available
  • Requires provider documentation – if it’s not documented, it’s not captured
  • Does not include cost data for outside services

How can Claims data be leveraged in DPC?

Claims data includes diagnosis, procedures, cost, provider specialty, facility type and location, etc. As DPCs support more self-insured employers, the importance of utilizing claims data becomes critical to better manage populations, and accurately measure impact on access, utilization, quality, and cost.

There are several advantages of using claims data in DPC:

  • Identifying and getting in front of costly or high-risk patients
  • Measure downstream spend and utilization beyond the DPC practice
  • Demonstrate the value of DPC to stakeholders

Disadvantages of relying solely upon Claims data in DPC

  • Data is not timely. The industry standard run off for claims is at least 3 months. This data lag hampers providers’ ability to use this data for quality improvement.
  • Focuses on billable data. Services which aren’t billable aren’t tracked.
  • Does not include the results of labs or biometrics. Meaning it cannot pick up if a patient’s blood pressure has risen over the past 18 months; or if they purchased medication without using insurance, such as using cash or GoodRx.

Relying solely on claims data removes the ability of a DPC to fully tell its story

In DPC, why is it important to understand the differences in data between EHR and claims?

One of the main purposes of Direct Primary Care is to cut out insurance related activity. Yet, there is demand for data to demonstrate the value of DPC, especially when working with employer groups or advocating policy.
Because DPCs do not submit claims, this data is not being captured. Creating a large doughnut hole of missing data.

Impact of this missing data donut hole

  • Missing data reduces population risk score. Meaning it will look like you are treating healthier patients in the eyes of those who use these risk scores (employer data vendors, brokers, health plans) … aka they can argue that you are cherry picking.
  • Gap scores will be inaccurate. Are employer data vendors measuring to ensure all patients received a wellness visit? Are they measuring to see how many medications were dispensed?

Our Recommendations

  • EHR data (coupled with telehealth and membership) is foundational in DPC to best track, understand, and manage populations.
  • Utilize both EHR and claims data to identify patterns in cost, quality, and utilization.
  • When you work with employers, brokers, and health plans, understand how they will be utilizing and interpreting data.
  • Tell the story of your practice accurately and from all angles. Tap into all data sources available.
  • Keep in mind, being able to extract, utilize, share, and ingest data is the future of the overarching healthcare system, as can be seen in the CMS Direct Contracting model application requirements and policy pushes on interoperability and access to data. As CMS goes, others follow.

About KPI Ninja
KPI Ninja is a data analytics company that helps healthcare organizations accelerate their quality, safety, and financial goals with a unique combination of software and service. We are differentiated by our signature mix of technology, performance management consulting and healthcare expertise. We don’t merely offer software solutions but work shoulder to shoulder with clients to help them draw on the power of analytics and continuous improvement methodologies to become more efficient. In harmony with our data-centered ethos, we truly believe that our success is strongly co-related with yours.

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