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Why population health programs need payer data to succeed

Breaking down data silos is becoming increasingly important as healthcare starts to manage complex diseases in new ways.

Jeff Lagasse, Associate Editor

As healthcare continues to shift toward value-based care, the industry is turning its focus to positive outcomes across populations, and with that comes the realization that curation and use of data is the key to addressing population health.

Electronic health records aren't the only source of important data. There are several other sources that are an important component in realizing the true value of population health, and to succeed, the industry needs to start combining all of this data together.

These types of patient information include clinical information from EHRs, diagnostic and genomic data from laboratories and pathology departments, and financial information from the billing side -- in other words, payer data.

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The combination of this data becomes critically important as the industry looks to treat complex diseases like cancer. It's difficult to derive meaning from cancer data; the amount of information is large, complex and multifaceted, but it's also siloed. With cancer diagnoses depending on accurate and timely coordination of care, it has become critical to unify the information: clinical, diagnostic and financial.

"We talk about population health, and everyone understands it's great around certain disease outcomes," said Patricia Goede, vice president of clinical informatics at laboratory revenue cycle support company Xifin. "It's very well established. But in this area of preventive medicine and cancer diagnostics, some of those traditional approaches really aren't applicable."

What often happens is that multispecialist care teams, who are frequently not in the same health system, generate important information on a patient that isn't connected to any of the patient records. Distributing data becomes a problem, and makes it  almost impossible to bring it all together to analyze and tease out any larger trends.

Due to the nature of some data being text-based and some imaging-based, cancer in particular generates information that lives in these disconnected ecosystems, said Goede.

"When you look at disparate data, it resides oftentimes in the patient record, and the clinical data resides in the oncology department, and the genomic information is also disparate," she said. "It's not linked to any of the clinical information, and then you have financial information, which is sometimes captured in the patient record, but for these cancer tests, it's not always available."

Goede sees the onus as being on payers when it comes to ameliorating the data headache. Some of the bigger players, she said, are starting to determine how to derive information on patient outcomes through health management strategies -- a shift heralded by value-based care.

"With claims information and their tight relationships with healthcare systems in general, they could really drive this change," said Goede. "They can make it meaningful, and make it so people like myself can develop predictive analytics.

"It's all about the money," she said. "It's all about reimbursement. Hospitals have to maintain a margin, laboratories have to maintain a margin. Seventy-five percent of diagnostics is driven by laboratories, and it has to get to doctors and physicians in an efficient way. Physicians can't be expected to stay up until midnight charting patients and then get up the next day. They need to have access to data in a timely manner. They're a big piece of the puzzle."

Goede called traditional cancer treatment "taking a firehose to the patient." The costs of precision medicine treatment are comparable to traditional chemotherapy, but if someone on the care team misses a crucial piece of information because it's buried in inaccessible data, chemotherapy might start even if it's not strictly necessary. The chemo then has to continue, unless the patient asks for it to stop, because the payer has already paid for it.

Health risks ensue, not to mention inefficient care. But it doesn't have to be that way.

"All indications are that payers are taking the lead," said Goede. "Some of the big ones are starting to take on that responsibility. … It will be a great opportunity, and I think they'll adopt these opportunities because of the savings."

Twitter: @JELagasse
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