This page is part of the Da Vinci Clinical Documentation Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
CDex Improve Member Experience
Use Case Description
Payers want to improve member experience by improving processes between the payer and provider so members have fewer issues, less waiting, better planning information, and more cost transparency. Access to clinical information allows the payer to have a more informed conversation with the member. This use case requires the payer to have real-time or ongoing access to information that is closely tied to the point of care. This isn’t another ask that adds burden for providers. Its about using the existing clinical information shared with other care team members to make the total process of care (which includes payment) run more smoothly. As clinical information flows from the ordering provider to a servicing provider, or as documentation passes to a consulting providers to support care, this same clinical information can flow into payer systems to improve the members experience of care. (Note: Direct collection of Patient info is out of scope for this use case.)
Examples
Payers need information that helps them meet new regulatory requirements that promote patient access and exchange of information.
Clinical data, especially that which is not typically found in health plan claims, creates a more complete picture of the members health. This is turn allows payers to more accurately target member outreach. For example, if a member had a double mastectomy years before starting coverage with their current health plan, the payer may not know that member no longer needs to receive a mammogram. Without the additional clinical data of the members mastectomy, the payer may engage the member in an effort to remind patients to schedule an annual mammogram. Inappropriate outreach may make a member feel as if his or her health plan doesn’t have accurate information about their health. Member experience would be improved if member engagement was tailored to each patient’s health status.
