Holistic Member Records

The key challenges in creating holistic member records

There is growing demand in healthcare to build more holistic member records as CMS policies, digital transformation in healthcare and the need to overcome the operational friction between payers, providers and members align.

With the growth of value-based care contracts, providers are seeking the most efficient means to verify member benefits and payment accountability between payers and members, all before administering care. After delivering care, the outcomes are measured to determine possible reimbursement incentives and penalties.

There are many contract types and different adjustments to make, but having administrative and clinical data integrated and easily accessible in a holistic member record would help reduce costs because of lower administrative burden and fewer errors. It makes sense that payers and providers are aligned in seeking a more unified and dynamically updated view of all core and administrative data.

In this post, we’ll discuss what a true holistic member record might look like and outline the challenges to improving the access and use of clinical data.

A dynamic, longitudinal view

Ideally, a holistic member record would be made up of clinical data including:

  • Medical records–from electronic information, paper charts or both
  • Medical and pharmacy claims
  • Diagnostic tests, such as labs or imaging
  • Care and case management systems
  • Patient surveys
  • Wearables and remote patient monitoring devices

It would also include administrative data such as:

  • Health plan enrollment and benefits eligibility systems
  • Medical and pharmacy claims
  • Payer CRMs and call centers

Today, there’s no such thing as a holistic member record offering a dynamic, longitudinal view of all member encounters with their providers and health plan. Instead, pieces of it are scattered across different sources. Each time a member changes health plans, employers or employment status, benefits selection, or provider—the problem is exacerbated. Often, those changes mean accumulating member data anew and entering it into different software systems and data models.

Maintaining the continuity of a member’s identity and the portability of their clinical history is complicated by several distinct challenges. But those challenges are beginning to give way to market forces demanding more efficient, transparent and convenient transactions and encounters.

Political and economic challenges

Given the structure of the third-party payment system in the U.S. and the extent of member mobility, there is little willingness to invest in collecting and storing longitudinal patient history. American workers churn through a dozen different jobs in their lifetime, on average. Based on data from the Bureau of Labor Statistics, we can expect at least 2 million workers and their families will lose or transfer to new commercial health plans each month.

That places enormous stress on plan enrollment processes and admissions systems. In many cases, it’s cheaper to start from scratch than to absorb the costs of hunting for, ingesting and normalizing patient history from other plans and health systems.

Furthermore, the third-party payment system stokes competition for member loyalty between payers and providers. Because member data is seen as a competitive advantage for retention and referrals, the two sides get territorial about data, data sharing and data rights.

As health plans and health systems consolidate and see their margins tighten, many seek out alternative revenue streams. With the infusion of capital into life sciences in pursuit of personalized medicine, there’s growing demand for access to patient cohort data for research and innovation of new treatments. As a result, payers and health systems want to obtain secondary use rights for their member/patient data to commercialize it for sale to big pharma, which could help overcome territoriality over data and encourage collaboration around specific clinical data needs.

Privacy and security challenges

The latest HIPAA Notice of Proposed Rulemaking is generally focused on expanded information sharing due to social determinants of health (SDoH), concerns about the opioids crisis, COVID-19 and more, including exploring ways to share outside the core HIPAA system of EMR and claims systems.

It’s now widely recognized that “non-health” factors such as poor nutritional habits and inadequate housing play important roles in individual health and health care. Both factors disproportionately impact indigent patients and have been accentuated by the COVID-19 crisis.

The HIPAA rules do not appropriately address these health-related implications outside of the traditional healthcare system, but with state Medicaid agencies increasingly seeing these issues through a clinical lens, there will be more attention placed on them. Payers that anticipate the incorporation of SDoH data into clinical data sets will be better prepared for compliance and market expectations.

The issue of social determinants of health underline the longstanding need to rethink the increasing amounts of “non-HIPAA” health data coming from sources like wearables, mobile health apps, and community and patient support sites. The New York and California attorneys general have used enforcement to create new standards for this non-HIPAA health data, so payers in those states will need to navigate the local level implications of these privacy movements — especially those promoting mobility devices as part of care management.

Technical challenges

One of the many benefits of adopting the FHIR interoperability standards is to support technical solutions that simultaneously make it less labor intensive to extract clinical data and improve data quality and completeness closer to the source. The more clinical data that can be structured, grouped by encounter and digitized, the better for downstream construction of the holistic member record.

How can payers do this?

  1. The first step is to fine tune incentives around reducing the volume of paper, faxed and PDF versions of records. Each field of a patient record that can be standardized and digitized creates the potential for leveraging FHIR standards to achieve greater scale.
  2. They can use incentives to ensure data is collected and stored at the encounter level, which is key to achieving a useful, longitudinal view of the holistic member record. Often, data collected during an encounter is split between coding systems that feed billing and payment operations and clinical orders and documentation. Furthermore, patient data batched into spreadsheets or chart pulls lacks the context of the encounter, so downstream analysts may need to “unpack” the data to recreate specific episodes of care. By ensuring data is grouped into encounters as close to the source as possible, payers can get a more accurate picture of what occurred during the visit, see gaps in care, and find potential medical waste and issues with duplicate testing, non-essential screenings, etc.
  3. Third, they can consolidate information about a member’s medical issues and progress from EMR entries, notes in care and case management software, and interactions with a payer’s call centers. Written notes are all considered unstructured data, and without a meaningful, structured data field, it’s difficult to extract useful clinical insight accurately and cost-effectively. Any care pathway element that can be documented in a structured way can be more readily added to an EMR, which in turn can be accessed through FHIR standards to pull clinical data in a more scalable manner. Because clinical notes are hard to structure, AI, machine learning and natural language processing will need to be employed to extract and codify meaningful narratives. That technology is far from ready to tackle unstructured text across multiple disease conditions, but it’s advanced enough to cherry-pick targeted insight for members with specific diseases of interest to payers.