Closing data gaps to promote integrated health care

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The electronic health record (EHR) provides a wealth of information that can capture the health condition and status of people receiving care. Through the EHR, caregivers can understand the patient's course of illness and overall health to promote care coordination – which is required for integrated, or whole person care.

But the EHR alone is not enough. Patient care is enhanced by integrating many different data sources such as clinical, pharmacy and claims data. Integration with other pertinent data sources will:

  • Identify gaps in care (annual screenings/vaccinations).
  • Inform providers of treatments sought outside of their practice.
  • Aid in medication adherence.

Historically, claims data has not been highly used by clinicians because of the perception of "upcoding." Often the diagnosis with the most profitable reimbursement was coded for claims, leaving out secondary and chronic diagnoses.

Claims data displays a single point in time, whereas the EHR is a more longitudinal record. But there are many good reasons for using claims data. For one, it provides valuable information in terms of gaps in care.

Consider that most payers no longer require a referral for routine screenings. This bypasses the primary care physician (PCP) who ordered such screenings in the past. Today, patients often seek care from many different providers in a multitude of settings. The PCP is most likely unaware of encounters outside of their practice. Health information exchanges (HIEs) are essential partners in providing "one-stop shopping" for such encounters.

Claims data

Centers for Medicare and Medicaid (CMS) and Office of the National Coordinator recently finalized rules related to interoperability and patient access that require increased data sharing around clinical and claims data using APIs. Claims data includes claims submitted for tests, procedures and other services rendered – such as routine screenings for hearing, dental and eye exams. Often providers aren’t aware of imaging studies that have been completed – especially routine screenings that don’t require a doctor’s order, such as mammograms and colonoscopies.

Claims data provides information to close gaps in care through the identification of overdue screenings. It also improves outcomes by providing testing and procedure information to identify at-risk populations. In addition, claims data aids payers in identifying billing issues such as fraud.

Pharmacy data

Pharmacy data is another rich source of information. When integrated into the EHR, this data can provide valuable insight into medication management, specifically medication adherence. Having data on medications dispensed and refill history is essential to determining whether the patient is taking medications as prescribed. This is significant – because not adhering to prescribed medication regimens often leads to progression in the disease course and increased use of health services. The information included on the dispense of medications – such as dosage, frequency and the number of refills – helps providers with the medication reconciliation process.

The medication list within the EHR or HIE is a snapshot in time, though. It does not tell the full story as medication changes occur. Pharmacists are proactive in providing a clear picture of the patient medication history through pharmacy care plans, or Pharmacist ecare Plan (PeCP). The goal of the organization that developed the PeCP (National Council for Prescription Drug Programs) was to create an interoperable plan of care that could be shared electronically using HL7, or international data sharing standards. As we know, creating a plan of care is the first step. Being able to electronically share the plan significantly increases its value in terms of reducing medication errors and improving outcomes.

Consider the PeCP as a pharmacy consult that considers full patient history affecting the medication regimen. This includes details such as laboratory values, allergies, vital signs, current and historical medications, encounter data, and payer information in terms of coverage and out of pocket expenses. The PeCP then develops interventions and goals for the patient related to provider-ordered medications.

How SAS can help

Integrating EHR data with pharmacy and claims data provides a rich source of information for better managing patient care – and helps promote a more holistic approach to care planning. SAS understands the significant impact this approach to integration will have on patient safety and access to care. It’s one reason why we’re working actively with HIE partners to integrate pharmacy and claims data.

Learn why analytic interoperability matters in health care

About Author

Lisa Lucas

National Director Healthcare Informatics

Lisa is currently the National Director of Healthcare Informatics at SAS. Lisa has supported healthcare informatics and analytics for many years both in acute care settings and private sectors. She is working closely to support federal and state initiatives at SAS by refining and implementing analytic services from a clinical perspective. She is a faculty member at the University of Mary Washington, teaching Healthcare Technology and Informatics. She has a Bachelor of Science degree from George Mason University, dual master’s degrees in Business Administration and Healthcare Management, and a Doctor of Nursing Practice from American Sentinel University in Colorado. She also holds certifications in Nursing informatics, Certified Professional in Health Information Management from HIMSS, and Certified Nurse Educator.

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