Quality’s Next Chapter: Unlocking Clinical Data Across the Enterprise

By Blesse Hicks, Senior Director of Payer Solutions at MRO

Health plans are under pressure to do more with less. An aging population with complex care needs is driving demand for services while financial and regulatory pressures push organizations to operate more efficiently. Clinical data has immense potential to help health plans address these pressures, but only when it is put to full use: when it determines the next best action for patients, when it is fast and reliable and when it is used to create a prospective view of members’ clinical status and predict outcomes.

When harnessed strategically, clinical data can empower health plans to improve operational performance and maximize the value of their technology investments. Too often, though, that data remains siloed.

The same clinical data that supports quality measurement can also power a broader digital transition. When standardized and aligned across the entire organization, that data can improve how health plans verify eligibility, configure benefits, manage utilization, support members and providers, and more. By strengthening data exchange and access, health plans can improve efficiency, support strategic decision-making and elevate performance.

Why Data Silos Occur

Health plans often rely on multiple vendors for different clinical data needs. Without a roadmap for how the organization should source and use data, divisions may manage them independently, leading to duplicated systems and inconsistent standards.

Navigating clinical data exchange with providers adds further complexity. Providers approach payer access differently, with wide variations in how much access they are comfortable granting and what types of access they allow. As a result, data sharing tends to be inconsistent, slowing processes and increasing administrative burden for staff.

These challenges impact health plans both strategically and operationally. Strategically, fragmented data limits the population-level insight—like identifying members who may benefit from earlier intervention—that needs a fuller clinical picture. Operationally, it forces day-to-day decisions to be made with incomplete information. In both cases, the imperative is clear: health plans need to align their clinical data efforts across the enterprise.

Maximizing Clinical Data Assets Across the Enterprise

Improving how data is shared and used requires treating data integration as a strategic priority. The strategies below outline how health plans can put this into practice.

• Build an enterprise data roadmap. Instead of allowing divisions to manage data independently, health plans should create a roadmap for how data are sourced, integrated and used throughout the organization. A shared roadmap keeps data investments aligned to strategic priorities and avoids duplicative processes.
• Standardize data across systems. To improve data access and quality, organizations need a way to work with data across all types of Electronic Health Record (EHR) systems. Working with a partner that can normalize and standardize data from a large variety of EHRs, including smaller ones, ensures that the data are consistent and usable once they reach the health plan.
• Find a true enterprise partner. Exchanging clinical data is only part of the equation; the real value comes from applying it across functions like quality measurement, utilization management and payment integrity. Rather than using several different vendors, health plans should consolidate partners where it makes sense, prioritizing those that understand their needs and can translate clinical data into results across every function. In addition to streamlining operations, this reduces the costs and complexity of managing multiple vendors.
• Make data sharing worthwhile. Providers are more likely to share data consistently when they trust it is handled carefully and see clear value in return. To build that trust, health plans can communicate the value to providers—whether that’s faster turnaround on prior authorization, transparency in how the data are used, or financial incentives—and work with a data exchange partner that follows strong privacy and security practices and facilitates sharing only the minimum data necessary for each specific use. This ensures providers are granting the right access to the right systems at the right time.
• Measure value on an ongoing basis. Defining success metrics—such as efficiencies gained in risk adjustment processes and medical records retrieval for measure calculations, reduced prior authorization turnaround, or more accurate payment processing—demonstrates the return on a shared data investment. Tracking these metrics supports quality improvement efforts and helps organizations identify where data are delivering value.

Looking Ahead

As payers and providers face increasing pressure to deliver high-quality care at lower cost, and as quality measurement becomes more digital, the need to securely access and share data more effectively will only grow. By improving how clinical data is shared and used, and how it is incorporated with administrative data to get a better view of patients’ health status, health plans can respond faster to new demands, perform prospective improvement initiatives, identify the next best action for their members, reduce unnecessary costs and build a stronger foundation for growth.

This blog is brought to you by MRO, and the views expressed are solely those of the sponsor.