Combining Clinical and Claims Data Is the Future of HIE

This week, Manifest MedEx (MX) took a major step forward in bringing together California’s plans and providers, making claims data from Blue Shield of California and Anthem Blue Cross of California directly available alongside clinical data in our longitudinal patient records. Claims data are a powerful tool for providers working to reconcile medications, improve patient experience, close gaps, and manage care, especially for high-risk patients. Our nonprofit system now shares records for 17 million people.

Across the nation, there’s surging demand for integrated claims and clinical data to drive and support value-based care programs led by hospitals, health plans, and medical groups. These groups can’t manage what they don’t know about and can’t measure. Clinical and claims information from more than a single organization is the only way to get a true picture of patient care. Health information networks like MX can meet this need, but there’s a lot of work to be done, according to a new survey from the eHealth Initiative Foundation:

“An HIE’s ability to integrate clinical and claims data enables and supports value-based care, allowing stakeholders to monitor their quality and cost of care, leading to improvements in care quality and care coordination, and eventually, cost savings. However, not all HIEs are able to integrate data and are challenged by limited resources, tools, capable staff, quality data, and access to claims data.”

This survey demonstrates what we see on the ground in California: Hospitals and health systems are asking for integrated clinical and claims data. They need health plans in the mix. They are asking HIEs to deliver modern technology, analytics tools, real-time notifications, and API-driven integrations. HIEs need to move fast and execute beautifully.

MX is making great progress to meet these needs in California, thanks to strong collaboration with six leading health plans and more than 400 participating organizations. Over the next few months, we will work with our four other partner health plans to integrate their claims data.

Here are some of the lessons we have learned along the way:

  • Governance and data use — From the start, we set clear rules on data use for providers and health plans in our network. Health plan participants may access clinical data of their current members for treatment, payment, or healthcare operations, as allowed today under state and federal law. This approach aligns with the proposed information-blocking policies the federal government is now finalizing.
  • Choose vendors that can support scale — MX recently restructured our health data platform to ensure we can manage large volumes of complex data securely, accurately, and with high performance. We work with a suite of best-in-class partners, including InterSystems, Verato, HBI Solutions, Audacious Inquiry, NextGate, and Care.Com that are built for scale.
  • Relentlessly focus on value for customers — Although value-based care is driving major alignment in healthcare, working with many different customers and stakeholders still requires careful diplomacy, deep listening, and an ability to build new products and strategies to meet emerging needs. MX’s product and customer success teams are our secret sauce to keep listening and improving.
  • Make signal from noise — We’ve seen substantial progress in data sharing across provider organizations in the last few years. Many organizations are now inundated with information and are struggling to make sense of it. MX helps our provider participants manage this complexity and make signal out of noise. We know who their high-risk patients are and can send alerts when these patients visit the ED. We can extract medications from claims data and pipe just this information to hospitals to help with patient intake.
  • Focus on security — Maintaining security requires diligence and resources. We recently rolled out multi-factor authentication to make our platform more secure and are currently undergoing HITRUST Certification, a rigorous standard for health data compliance and risk management.

MX and our partners are committed to making information the lifeblood of health improvement. Health data networks are a vital utility to advance the triple aim of better experience, better care, and lower cost. It is thrilling to see that healthcare organizations across the country share this view.