Hedis Measures & Prior Authorization With CQL and CDS Hooks
Executive Summary
Regulations mandating the use of new standards and specifications present a double-edged sword. On the one side, there is the promise of a cure-all for the interoperability challenges in the healthcare system. The bitter pill comes in the technological implementation of these rules. That said, when stakeholders leverage technology in use cases—like quality measurement and prior authorizations—the potential game-changing benefits outweigh any short-term pain.
HEDIS Scores Help Assess and Compare Plan Value and Performance
Developed by the National Committee for Quality Assurance (NCQA), the Healthcare Effectiveness Data and Information Set (HEDIS) comprises of over 90 performance measures for health plans. HEDIS scores provide the information that regulators and consumers need to assess and compare plan value—and hold plans accountable for their performance. Moreover, the Center for Medicare and Medicaid Services (CMS) bases financial incentives for commercial and public payers on their Medicare Star Ratings derived from the metrics.
Current methods to abstract clinical and administrative data are painstaking. Plans send teams of nurses to provider offices to review thousands of charts in a process known as chart-chasing. Despite being expensive, time consuming, and disruptive, chart-chasing does not guarantee performance measure accuracy. Each organization uses a different system, schema, nomenclature, and terminology, so data formats are not standardized. Plus, the substantial dollar values associated with a top 5-Star rating can motivate payers to provide data in a way that skews measurement.
These circumstances are about to change. The CMS has adopted Clinical Quality Language (CQL), a human-readable language standard structured enough to simplify the electronic sharing and manipulation of healthcare data. CQL logic is valuable in Clinical Decision Support (CDS) and Electronic Quality Measures (eCQM) reporting, as it standardizes and integrates data across different systems. As a result, data is not open to as much interpretation, making it more transparent and consistent. In turn, reliable data improves HEDIS audit precision, and helps determine accurate plan value. Furthermore, by writing a query in CQL and disseminating it to everyone who has data in FHIR, implementers can automate processes to reduce the administrative burden placed on measurement professionals and providers.
CAQH Estimates $13.3 Billion in Potential Savings, $9.9 Billion for Plans and Providers
Automated access to quality data has significant financial implications. In addition to more efficient and cost-effective workflows, payers can act on insights quickly to realize far greater returns on their Value-Based Payments. The Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and related associations, has gone so far as to quantify the benefit of automation. CAQH estimated $13.3 billion in possible savings—$9.9 billion of which stands to be saved by plans and providers.
While the deadline for organizations to adopt the standard is still on the horizon, some HEDIS metrics are already drafted in CQL and piloted. The move paves the way for efficiencies in the measurement process, monetary benefits, and greater accountability and value in healthcare.
The prior authorization process, where providers submit requests for approval to payers before rendering a medication, service, or supply, is another application where CQL can make a difference. Evidence-based checks by insurance plans may help determine the most cost-effective choices but often use labor-intensive methods, like phones, faxes, and portals, to exchange requests and medical records with providers. It is time-consuming and inefficient. Rule checking will always need to happen, but having the rules encoded in CQL automates the process. Additionally, thanks to the standardized clinical terminology of CQL, there is greater consistency in the data, with less latitude for miscommunication, unnecessary expenditures, and abuse of the system.
CDS Hooks Enable Seamless Data Sharing Between Payers and Providers through Immediate Notifications.
With Smile deployed in production on Microsoft Azure, this now opens up future opportunities like healthcare third-party applications to access clinical data through FHIR APIs. Applications that adhere to SMART on FHIR can follow this universal API for accessing clinical data, by following a secure authorization and authentication process to make access requests to FHIR resources in the form of OAuth 2.0-compliant authorization and OpenID connect for authentication.
Furthermore, Risk Adjustments and Prior Authorization are also opportunities that The Company is now in a position to accomplish with Smile. With data stored as FHIR resources inside Smile, applications specialized in risk adjustments and prior authorization can access this data and provide the business value in a more efficient manner.
Lastly, The Company is also now in a position to improve their HEDIS score and STAR rating. With data readily available as FHIR, The Company can now determine how members receive their care and use this information to report to CMS more accurately.