All Payer Supplemental Clinical Quality Data

This scenario enables providers and health plans to consolidate and standardize the electronic exchange of quality-related data and performance results.

At this time, the burden of collecting, calculating and reporting quality measure information is borne by physicians and payers (both government and commercial health plans). This quality information is used to measure performance within provider incentive programs and to calculate payer quality measures required by national measure sets such as the Healthcare Effectiveness Data and Information Set (HEDIS), the Quality Rating System (QRS), and electronic Clinical Quality Measures (CQMs) for various federal and state quality reporting programs.

Due to a lack of standards, the electronic formats required by various health plans, federal, and state quality measure reporting programs can vary significantly. These discrepancies add work burdens to physicians and physician organizations because each quality measure must be sent in many different formats to satisfy the requirements of all health plans and programs.

Health plans also suffer from this lack of streamlined processes, as each health plan must work with each physician or physician organization separately to gather the data necessary for each applicable quality measure. As a result, each physician organization establishes its own separate technical connection with every health plan. This creates a point-to-point tangled web of redundancies, inconsistencies, and inefficiencies.

The “All Payer Supplemental Clinical Quality Data” use case scenario is under the Quality Measure Information use case.

The following document(s) are available for this scenario:

MiHIN Commercial Payers (PPQC) & SIM Data Aggregator Use Case Implementation Guide

The “Persona” Story

Regina Klausen is a quality data analyst with the Mayberry Medical Group. Each day presents a new set of challenges and potential solutions in terms of physician quality metrics. On a typical day, Regina may receive numerous electronic reports and data extracts from the various practices and providers throughout Mayberry, which includes patient electronic health record information.

Regina serves as the “middle woman” between physicians who need to send patient information for quality evaluation and the health plan or other organization that calculates quality measures. The data elements that providers are required to send sometimes require Regina to juggle multiple data sources that she must consolidate manually.

Once a month, Regina must aggregate all data within her repository, compile it into the required format specifications, to the various health plans. Regina then has to wait for a feedback and error report. If errors are present, Regina must correct the data and resend to the health plan.

Regina’s workload becomes nearly unmanageable when she is required to sort and categorize the various quality data prior to sending them to out. Lab results, x-rays, and immunizations are just a few of the categories of information that Regina must group into a single file report. Each health plan requires the data to be arranged into its own specific format

Regina is greatly relieved to discover a new solution in which all the patient information measures from Mayberry’s practices and physicians are sorted according to quality category prior to sending to the repository using a single standard format for all payers. When patient information reports are sent to Regina, the data is pre-sorted by category into one single report instead of the multiple reports that Regina handles daily. This repository report is then sent over to HIN in a single feed, rather than in the format of multiple quality points. Every time Regina has used this new system, she feels relieved.

Thanks to the All Payer Supplemental Clinical Quality Data use case scenario, Regina can now focus less on paperwork and more on assisting Mayberry’s providers in achieving the ever-increasing high standards of payer incentive programs.