Payer-provider clinical data exchange plays a critical role in payer operations, helping streamline workflows and improve patient care. Traditionally, this exchange was manual and time-consuming, increasing administrative burdens and error rates. However, advancements in real-time clinical data exchange can significantly benefit payers, providers, and patients alike.

Improve Patients’ Care Coordination

Effective management of patient care requires seamless exchange of healthcare service information between payers and providers. Payers often possess comprehensive insights into patients’ care histories, enabling them to play a vital role in treatment planning.

Timely access to medical records also accelerates coverage decisions, such as determining medical necessity and granting prior authorization for treatments. This rapid access improves patient outcomes by ensuring care delivery is not delayed.

Enhance Quality Scores and Close Care Gaps

Effective payer-provider clinical data exchange also helps payers identify and address potential gaps in care more quickly and effectively. Rapid data exchange allows treatments to reach patients more quickly when a care gap is identified. This, in turn, helps improve patient health and drive improved patient outcomes.

Streamlining payer-provider clinical data exchange—and the resulting closure of care gaps—can lead to quality score improvements. The National Committee for Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality, developed the measurement system known as the Healthcare Effectiveness Data and Information Set, or HEDIS^®, measures. HEDIS measures have become one of the most widely used performance improvement tools used in the healthcare industry today.

Part of the value of HEDIS measures is that these scores enable consumers and purchasers to compare and evaluate the performance of different health plans more easily. Currently, HEDIS measures are used by more than 90% of U.S. health plans to evaluate the quality of care provided to their members and report quality results.

However, the ultimate purpose of HEDIS measures is to help improve the quality of healthcare, and these measures are also used to help identify opportunities for healthcare providers and medical practices to improve their individual care delivery. Improving HEDIS scores is directly related to closing gaps in care and improving the use of preventive screenings and other preventive services, which lower costs by helping to decrease the use of expensive emergency services.

Enable Value-Based Contracts

Value-based care contracts rely on continuous and efficient clinical data exchange between payers and providers. By sharing comprehensive patient information, unnecessary and costly repeat treatments can be avoided, improving decision-making and patient outcomes.

For payers, clinical data exchange is essential to closing care gaps and enhancing HEDIS scores, both of which are crucial for success in value-based reimbursement models.

Reduce Healthcare Costs

Real-time data exchange helps lower healthcare costs by promoting proactive care and reducing inefficiencies, such as duplicate tests and unnecessary hospital admissions. Enhanced care coordination between payers and providers ensures cost-effective service delivery.

Veradigm Payer Insights: A Streamlined Solution

Health plans seeking to improve quality and manage member risks need robust tools for clinical data exchange. Veradigm Payer Insights offers a dynamic, free solution that integrates seamlessly into provider workflows.

This tool enables payers to analyze electronic health record (EHR) data to identify care gaps based on payer-specific criteria. Gap alerts are presented directly within providers’ EHRs, eliminating the need for external logins. This integration allows providers to address gaps in real-time without disrupting their workflow.

By delivering care gap alerts during patient visits, Veradigm Payer Insights helps providers focus on actionable, patient-specific interventions. Secure feedback loops enable providers to share necessary documentation with payers in near real-time, streamlining the review process.

Providers benefit from reduced administrative burden, while payers gain the insights needed to improve patient care and outcomes. Veradigm Payer Insights fosters better communication, ensuring providers have the tools to address care gaps efficiently.

Closing the Gap Between Payers and Providers

Real-time clinical data exchange not only enhances operational efficiency but also strengthens the relationship between payers and providers. Veradigm Payer Insights is a trusted partner in this process, enabling health plans to improve quality scores and deliver better patient care while reducing provider abrasion.