Addressing Data Integrity in Value-Based Care Arrangements—For Providers

By Raj Lakhanpal, MD, FACEP, CEO, SpectraMedix

This is part two of a three-part blog series exploring from both a provider and payer perspective a topic that impacts the entire healthcare industry—data integrity—including the various challenges it poses, the negative implications of those challenges, and how best to address them. You can read part one here.

Part 2: Addressing Data Integrity in Value-Based Care Arrangements—For Providers

Providers need data from a variety of sources to impact change. These include adjudicated claims data from payers, as well as data sets from their electronic health records (EHRs), practice management, care management, and other systems. Capturing this data can be a challenge though, as a recent survey conducted by HFMA of health system executives found that 36% listed data integrity, reporting, and cost of technology as their top internal challenges to taking on increased risk.[1] So how do risk-bearing providers entering into value-based care arrangements make sure that they have clean, relevant data to create actionable insights and succeed as they take on greater risk?

A key component of data integrity is receiving accurate data from payers. Providers will need to partner with their payers to receive harmonized adjudicated claims data. Each health plan provides data in their own unique format, so providers will need to build an understanding of each plan’s data and work with them to improve the data sets they have received. Building rules based on data quality and attributes is essential. Applying groupers and risk adjustment to the data is required, especially if that has not been done by the payer. Different health plans use different risk adjustment methodologies, so it's important to have a process in place to address them. The provider groups will also need to incorporate Master Data Management (MDM) processes to ensure overall data accuracy and integrity.

Having good clinical datasets (EHRs and care management datasets) are of the utmost importance for providers as they deliver actionable insights to their network in real-time. Maintaining clean data is hard work, and a clear strategy with a well-defined plan of action is necessary for maintaining a high standard of data integrity. Certain core practices should be a part of every clinical data strategy and will lead to better data. These include:

  • Embracing good data governance policies
  • Engaging in continuous clinical documentation improvement
  • Ensuring accurate patient record matching for care coordination
  • Adopting interoperability and emerging data standards

What really drives the transition to value-based care for providers is integrated claims and clinical data. Integrating claims and clinical data, along with other data sets (e.g. SDoH or health equity data) creates the need for a unifying patient identifier, or an EMPI (Enterprise Master Patient Index). The purpose of an EMPI is to make it more convenient to aggregate records by patients when doing calculations or creating chase lists. EMPIs use algorithms and processes to programmatically recognize that two sets of demographic data are for the same person and assign the same ID to both records. This way, every record with the same EMPI ID can be treated as belonging to the same patient.

Using publicly available datasets (from CMS, state Medicaid agencies, or other commercial entities) to augment missing data should be undertaken to create a holistic actionable dataset. It can also help risk-bearing providers gain advanced insights into geographic regions or incorporate additional TINS where prior adjudicated claims are not available. Publicly available datasets can be used in many other ways as well, such as to evaluate the impact of value-based care programs, determine appropriate interventions, and monitor progress.

By focusing in on these key areas, your health system will go a long way in assuring that you maintain a high standard when it comes to data integrity.

In the last post in this three-part series, I will discuss different approaches deployed to address data integrity issues for payers. Please feel free to email me at with any questions or thoughts.

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