On HIEs, Data Quality, and the NCQA DAV Program

Introduction

Life insurance companies rely on access to accurate, reliable, and readily available health information to support the underwriting process. In this article, we examine a new data quality initiative that is gaining traction among health information exchanges (HIEs) and other data aggregators, including a majority share of those participating in our EHR+ network.

About NCQA

Founded in 1990, the National Committee for Quality Assurance (NCQA) sets standards and creates accreditation, certification, and recognition programs focused on measuring and improving healthcare quality. Through these programs, NCQA’s reach extends broadly throughout the healthcare market. For example, more than 227 million people are enrolled in health plans that report quality results using NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS), which spans more than 90 measures covering effectiveness of care, access and availability of care, utilization, risk adjusted utilization, and measures reported using electronic clinical data systems. One of these measures is hemoglobin A1c control for patients with diabetes, an effectiveness of care measure that “assesses the percentage of members 18-75 years of age with diabetes (type 1 or type 2) whose HbA1c was at the following levels: HbA1c control (<8.0%), and HbA1c poor control (>9.0%).”

Data Aggregator Validation

Launched in 2021, NCQA’s Data Aggregator Validation (DAV) program evaluates an organization’s management and exchange of clinical data from ingestion at primary sources, through aggregation and transformation, to transmission to end users. The DAV program gives health plans, government entities, and care delivery organizations confidence in the validity of aggregated clinical data used for HEDIS reporting, value-based contracting, gaps in care closure, risk adjustment, population health management, and other quality initiatives.

Organizations seeking to validate clinical data streams must undergo a third-party audit to demonstrate adherence to NCQA’s process, system, and data standards across the following activities:

• Ingestion: Evaluates the documentation and workflows for inbound data, including policies and procedures for data capture, integrity, and mapping.
• Data Management: Evaluates quality assurance, change management, governance, and data security from the point data is inbounded through the point when it is added to a data repository.
• Output: Evaluates the outbound CCD or FHIR data for conformance to the relevant HL7 C-CDA R2.1 and FHIR STU3 implementation guides, and verifies that the information matches the primary source data found in the EHR.

This validation process may take up to 12-18 weeks, depending on the number of ingestion sites (i.e., unique data sources where clinical services are rendered, such as a provider, practice, or hospital), clusters (i.e., groups of similar ingestion sites based on the EHR vendor and care setting), and data streams (i.e., one or more clusters), as well as the complexity of the validation.

Why DAV Matters

Health plans increasingly rely on HIEs to acquire supplemental data for HEDIS reporting at a lower cost, while simultaneously reducing administrative burden for healthcare providers associated with the traditional record retrieval process. In most cases, health plans acquiring aggregated clinical data for this purpose would be required to complete primary source verification during HEDIS audits to ensure that the data is consistent with the EHR. However, health plans can bypass this expensive and time-consuming process for HIEs offering validated data streams that have passed all DAV standards and met supplemental data auditing requirements.

Likewise, the DAV program positions participating HIEs to demonstrate data quality, launch new use cases, establish relationships with health plans, distinguish themselves from their peers, and win revenue-generating contracts to ensure long-term financial sustainability.

HIEs, DAV, and the EHR+ Network

Early on, we recognized that HIEs displayed unique proficiencies in activating non-treatment use cases, combined with a compelling value proposition ideally-suited for life insurance underwriting:

• Offer rapid turnaround times with near-instant patient discovery and record retrieval (i.e., within a few seconds to a few minutes).
• Deliver high fulfillment rates and serve as a valuable alternative in situations where a special authorization is required or an EHR may not otherwise be available.
• Provide a broad, longitudinal view of an individual’s healthcare utilization across an entire geographic region (rather than with specific healthcare providers).
• Function as a supplemental input to enable underwriting triage, identifying requirements that can be waived and determining where additional requirements may be necessary.
• Grow organically over time as they onboard more participating healthcare providers as data contributors.

We also hypothesized that if HIEs can be utilized by healthcare providers for treatment purposes, and by health plans for complex activities like quality measurement and improvement, then HIEs should be able to show value for life insurance underwriting as well. This hypothesis was confirmed by our earliest protective value studies using HIE data only, and has been validated by recent studies utilizing our complete EHR+ network.

As of Q2 2024, >80% of covered lives in our EHR+ network are available via EHRs as primary sources or DAV-certified HIEs offering validated data streams. We’re also pleased to share the following updates regarding DAV program participation in our EHR+ network:

• Collectively, six DAV-certified HIEs that offer validated data streams (and/or are in the process of validating data streams) account for >55% of our total HIE coverage.
• We have signed agreements with and are onboarding two additional DAV-certified HIEs that offer validated data streams.
• We are conducting a pilot with a previously undisclosed DAV-certified health IT partner that also offers validated data streams.

Conclusion

At this time, DAV certification is not a prerequisite for HIEs to join our EHR+ network given the significant cost and intensive commitment of time and resources necessary. However, we are closely monitoring which HIEs are DAV-certified, preparing to enter a DAV cohort, or considering the DAV program, along with HIEs that have implemented other data quality initiatives. Given prevailing market trends — combined with the DAV program’s advantageous alignment of data quality goals with revenue growth opportunities — we expect that the number and share of DAV-certified HIEs in our EHR+ network will continue to grow over time.

About Clareto

Clareto, a Munich Re company, operates the largest healthcare interoperability network purpose-built for superior risk assessment via authorization-based disclosures. With connections to EHRs, HIEs, and other sources covering >75% of the US population, Clareto enables access to digital health data to transform underwriting, claims, and other business processes for the life insurance industry. The company’s EHR+ network offers a frictionless experience with no consumer involvement required, smart record retrieval to maximize protective value, algorithm-ready data for enhanced usability, and an open partner ecosystem featuring integrations with complementary solutions and services.

Clareto is a wholly owned subsidiary of Munich Re Life US, one of the leading life reinsurers in the United States. Through its partnership with Munich Re Life US, Clareto aims to provide life insurers with a new set of solutions that assist in the digitization of underwriting processes — driving quicker decisions, greater policyholder satisfaction, and new business growth.