HIMSSCast: One clinical data set for payers and providers

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CareFirst BlueCross Blue Shield, in partnership with MRO, has a clinical digital exchange platform that both payers and providers can access.

The platform gathers member data across 44 disparate EHRs, improving clinical insights for both payer and providers. It also complies with interoperability rules for both, according to Piyush Khanna, vice president of clinical support services for CareFirst BCBS, who leads this work for the nonprofit insurer that has dual headquarters in Baltimore, Maryland, and Washington, D.C.

It's one data set, available for both payers and providers. 

It gets rid of the fax.

"Part of the journey we're on is not just looking at data exchange but making the process simpler for providers. How can we leverage technology and digital channels to reduce administrative burden?" Khanna said. "We are beginning to see the value of this data set become more and more meaningful for large swaths of our community."

Listen to more of Khanna's conversation with Susan Morse, executive editor of Healthcare Finance News.

Talking Points:

• The platform offers bidirectional sharing, connecting to 44 EHRs. 
• Data can be pulled from automatically on a scheduled basis.
• The turnaround time is reduced from weeks and months to 24 hours.
• By extracting information, payers do not need to contact providers multiple times on such issues as prior authorization. 
• If there is a denial, providers can better understand what happened, without a fax-based process.
• Payers get better risk adjustment and Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. 
• CareFirst's Medicare Advantage star ratings went up by 0.5, based on improved HEDIS scores.
• The organization saves 17,000 staff hours for quality reporting per year.
• Data can be pulled from an oncologist, primary care physician and other doctors for a single longitudinal record.
• There is currently a 1.2 million member record with the goal for 2 million members.

More About This Episode:

CMS releases Interoperability and Prior Authorization Final Rule 

Mayo Clinic, Mercy partner to de-identify clinical data

Most data generated is not used to its fullest potential

CMS issues final rule on Medicare Advantage risk adjustment

Surescripts is being considered as a hub for data exchange under QHIN

Oracle at HIMSS24: Rolling out AI, back-office fusion and simplifying data exchange

Email the writer: SMorse@himss.org