Existing Wording: 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.

Proposed Wording: Payers need to document, monitor, evaluate, and pursue improvements in the quality of care deliveredto its members by providers. They often use claims data, but are increasingly augmenting this data with clinical information currently collected periodically (twice a year, quarterly, monthly) through abstractions of medical records from providers, as well as some electronic submissions between providers and payers. In addition to allowing payers to monitor and seek quality improvements and reduce preventable medical errors , it also supports external quality assesssments (such as Medicare, HEDIS, and others) and improvement in overall quality scores. Receiving information electronically and more frequently would help improve quality monitoring, improvement actions and quality scores. It 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 may use information gathered from HIEs if available to them. 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 include 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.

Comment:

The use case description would benefit from some editing, eliminating redundancies and focusin attention on most important element (quality measurement) rathet than 'scores'. Se suggestions in Proposed Wording

Summary:

The use case description would benefit from some editing, eliminating redundancies and focusing attention on most important element.