360 Degree MemberBackground

Health Plans are facing increasing pressure to improve provider network performance and quality of service delivered while simultaneously controlling costs and maintaining a healthy bottom-line. Areas of concern in the current care delivery model such as lack of care coordination, unnecessary variation in care, and overutilization of healthcare resources can be attributed to widening gaps in information. Payers can combine every aspect of member information to streamline analysis of data. This leads to better care coordination and proactive treatment of at-risk members with the goal to ultimately lower costs and improve patient experience.

Challenges

Payers are uniquely positioned to identify and close gaps in information. Claims data submitted by care providers gives payers an exclusive view of member and patient care activities. However, establishing a sustainable process to connect with various data sources (both internal and external) is often complicated by political, technical and operational challenges. Data is often created and managed in silos; EMR systems and payer data warehouses often use different data standards and clinical terminologies which reduce system interoperability. Omni-HealthData is built to bridge these gaps in information by providing a single, complete and consistent view of members. It integrates patient demographic information with claims history and data collected from primary care physicians, hospitals, urgent care facilities, clinical laboratories and pharmacies.

Omni-HealthData

Omni-HealthData has a holistic approach to aggregating data from disparate sources of information. The solution provides a single platform to accomplish three important goals:

  1. Integration - Leveraging its extensive integration suite, Omni-HealthData gathers data from both external and internal data sources. The onboarding platform allows seamless integration across all source system formats (EDI, XML, Custom flat file) and message types (X12, HL7, CDA, CCDA).
  2. Integrity – Omni-HealthData employs domain specific data quality plans to cleanse and validate data. The reference data management component is used to map and translate different coding systems and healthcare terminologies with built-in support for reference data lookup, data validation, transformation and enrichment. Our master data management software then matches, merges and correlates the data across domains, producing a master record for each member.
  3. Intelligence - The Consumption and Metrics Layer built on top of the core data model allows business applications to consume and analyze the data to derive actionable insights. The powerful data visualization tools allow business users to create interactive reports and predictive content. 

The result is a complete, holistic view of every member enabling unprecedented insight into the member’s clinical history that helps identify and resolve gaps in care, as well as promotes coordination of care across medical providers.

Member Journey – 360 Clinical View

The Member Journey InfoApp, built on top of Omni-HealthData, provides a unique 360 view of a member’s clinical journey along with key health status indicators such as ER admits, pending vaccinations, or non-compliant preventative screenings. The dashboard includes interactive reports for different clinical event types such as surgical procedures, problem diagnoses, or lab results that users can filter by date range, code type, or event type. It is designed to be an integral part of the management platform where care coordinators or care providers can identify gaps and create interventions to proactively close those gaps. For example, a pending flu vaccination indicator could help a nurse practitioner proactively schedule an appointment with the patient to come in for their annual shot; a primary care physician can order a blood panel for a diabetic patient with pending LDL screening. When the patient’s blood report is processed by the clinical pathology lab, the data is integrated into the Omni-HealthData repository which automatically closes the outstanding LDL screening on the patient’s report.

Studies have shown that such proactive patient engagement along with preventative screenings and timely interventions can significantly reduce avoidable healthcare costs and positively impact healthier outcomes.