Unlocking hidden insights for health plans to more accurately assess member risk

By David Quickstad

As the volume of clinical data grows, so does the need to structure, code, consolidate, and standardize clinical data to ensure risk calculations accurately reflect patient risk. Risk adjustment (RA) teams at health plans face significant challenges with extracting insight from the vast amounts of messy and unstructured patient data within electronic health records, or “EHRs”. Inaccurate risk assessments – either too high or too low – can result from missing data due to uncoded concepts and unstructured free text data scattered across disparate records. API technology offers a solution to automate the process of cleaning and integrating large volumes of patient records, minimizing human error, while ensuring critical data is preserved and factored into risk adjustment calculations.

3 Ways APIs are game-changing for risk adjustment

Data versatility: Reliably use EHR data across different third party and home grown systems from many sources.

Health plans commonly face data management challenges and fail to maximize the benefits of data from providers, HIEs, and patients due to difficulties in reliably ingesting, combining, and interpreting scattered clinical data across different formats and systems. During data conversion, critical details are often left out of risk adjustment calculations due to ingestion failures and non-standard or ‘dirty’ data.

That is why the Convert API is often adopted by risk adjustment and other teams using patient data at health plans, to transform data between standardized formats (e.g., FHIR, HL7, C-CDA) and enhance it through terminology normalization, de-duplication, and consolidation. The API creates unified records that can be output in various formats like FHIR(R4), CDA, or PDF, ensuring high ingestion success and usability across systems.
New Data Insights: Improve risk assessment accuracy with more correctly interpreted patient records.

Another way data can get left out of risk calculations is if it’s hidden within non-standard, uncoded or free text notes. Thankfully, APIs can ingest, clean and enrich clinical data, uncovering insights buried within unstructured or poorly coded patient files.

The Terminology API, for example, standardizes terminology and applies industry code sets like ICD-10-CM, SNOMED, and LOINC® to relevant clinical terms in patient records. This ensures all critical health information is factored into risk assessment calculations.

The result is enriched, fully coded clinical data that supports more accurate HCC risk profiles and deeper risk insight based on more complete underlying clinical data. This enhances risk score calculations, adjustments and stratifications, leading to more reliable predictive modeling and a clearer view of patient health.

The Terminology and Convert APIs are part of CareEvolution’s Orchestrate technology and can be tested for free in our sandbox.

Try the Orchestrate APIs

Rapid Integration: Accelerate adoption without disruption.

One of the biggest data challenges health plans face is the significant time and expense required to overhaul legacy systems. CareEvolution’s Orchestrate APIs integrate seamlessly with existing workflows and infrastructure – whether it’s risk analysis systems, HEDIS engines, clinical repositories, or claims processing systems. This effortless integration allows the clinical data and technical operations teams to modernize workflows quickly and efficiently, delivering access to more accurate data without the need for an expensive and disruptive IT overhaul.

Upgrade your risk adjustment profiling without disruption

CareEvolution’s Orchestrate APIs power more precise risk adjustment calculations and Risk Adjustment Profiles (RAPs) by automatically creating an enriched, unified view of patient health.