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 Support Quality Management
Use Case Description
Payers need to augment claims data to satisfy quality reporting requirements and improve quality care scores, and to reduce preventable medical errors. Currently, they gather this clinical information a minimum of twice per year, sometimes monthly. Receiving information more frequently would help improve scores. The information helps payers improve scores and also provides for more accurate member/ provider outreach for gap closure and data completeness for payer value based provider contracts. The information can come from any provider. However, it typically comes from outpatient providers who are network providers. Payers use a combination of claims and clinical info to assess care quality. The may use information gathered from HIEs if available to Payers. However, some auditing issues exist when getting data from an HIEs because more work is required for proper attestation. Information from the patients medical record can be used, as well as progress notes or visit summaries. C-CDAs of various types may be useful, but in this use case, Payers are more oriented toward specific data points. They are looking for medications, allergies, immunizations, lab results, procedures, diagnoses, vital signs (e.g. BP, BMI), and narrative information (clinical notes) pertinent to a quality measurement program.
Examples
Payers review member information to identify gaps in care. They work with providers and hunt down information showing the gap in care has been closed. Improving HEDIS measure scores has a positive impact on revenue for payers and reimbursements for providers.
Clinical data, especially that which is not typically found in health plan claims, creates a more accurate picture of each member’s health. This is turn allows payers to more accurately assess quality of care. 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 would show the lack of recent mammogram as an open care gap and may engage the member in an effort to close a gap that really doesn’t exist. Care quality assessment measures would be improved if health plan quality management programs had accurate data about each member’s health status.
