Opportunities for Health Information Exchanges in Value-based Care

Opportunities for Health Information Exchanges in Value-based Care

Opportunities for Health Information Exchanges in Value-based Care

Now more than ever, organizations like Centers for Medicare & Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC) and National Committee for Quality Assurance (NCQA) are leveraging health information exchanges (HIEs) to improve interoperability and health information access for patients, providers and payers.

When implemented effectively, HIEs can help reduce administrative processes, such as prior authorization. Below, we discuss several initiatives designed to help drive change in how clinical and administrative information is exchanged. Understanding these initiatives can help position you as a leader in value-based care.

Interoperability and Patient Access Final Rule

The CMS regulations include policies that require or encourage payers to implement Application Programming Interfaces (APIs) to improve the electronic exchange of healthcare dataCMS Interoperability and Patient Access Final Rule (CMS-9115-F) puts patients first by giving them access to their health information when and where they need it. The proposed rule emphasizes the need to improve HIEs to achieve appropriate and necessary access to complete health records for patients, healthcare providers and payers. Additionally, it focuses on efforts to improve prior authorization processes through policies and technology, which in turn helps ensure that patients remain at the center of their care.

Emerging Data Aggregator Validation

The time and expense required to verify original data often discourages plans from working with data from aggregators. NCQA’s Data Aggregator Validation (DAV) program validates HIEs that collect, aggregate and transform data from original sources on behalf of vendors and healthcare organizations. Under this initiative, HIEs and other aggregators that demonstrate high standards can provide validated data to health plans as standard supplemental data or abstracted medical records, thereby eliminating the administrative burden of primary source verification.

Electronic Clinical Data System Reporting

Electronic Clinical Data System (ECDS) is a reporting standard for NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) and a network of data containing members’ personal health information and experiences within a healthcare system. Because health data lives in numerous electronic systems and some specifications do not always align with how the data is stored, it can be difficult to ensure quality measures. ECDS measures help overcome these obstacles to ensure the data – despite living in different databases – can be queried efficiently and effectively for more patient-centric quality measures. 

Trusted Exchange Framework and Common Agreement

The Trusted Exchange Framework and Common Agreement (TEFCA) includes common terms, principles and conditions set forth by ONC that enable electronic health information sharing across different networks. The TEFCA is designed to scale electronic health information exchange (EHI) nationwide and helps ensure that health information networks, healthcare providers, health plans, individuals and other stakeholders have secure access to exchange health information at all times. This, in turn, allows HIE networks to establish deeper trust when exchanging data between participants. Providing HIE services that are compliant with CMS, ONC, NCQA and other national organizations enables payers to develop thorough understandings of their attributed populations. The byproduct of this technology is improved understanding and increased awareness of performance, which directly benefits payers and indirectly impacts providers, teams, patients, communities and the system as a whole.

To learn more about the benefits of HIEs, download our white paper:
The Indispensable Value of Health Information Exchanges.


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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