Guide to Achieving Seamless Digital Integration

Table of contents

Make risk adjustment more efficient, accurate and compliant

In the world of healthcare, digital transformation is a necessity. At Optum, we approach digital solutions in three key areas: data acquisition, insight sharing and enhanced functionality. These components work together to create a seamless and efficient process for both payers and providers, ultimately facilitating accurate and timely risk adjustment.

1. Efficient data acquisition

The first step in our digital approach is the efficient acquisition of clinical data. Traditionally, providers have had to upload charts or manually input data, which is both time-consuming and resource intensive. Optum has developed a system that allows us to acquire both structured and unstructured data from providers in a streamlined manner. This means that providers don't have to leave their EMR systems to upload charts or data. Instead, we can integrate directly with their systems, making the process more streamlined.

2. Insight sharing at the point of care

Once we have the data, the next step is to share our insights with providers in a way that is both useful and actionable. Health plans and organizations like Optum run extensive analyses on claims data and clinical data to identify potential gaps in care. However, the challenge lies in getting this information to providers in a format they can use. Providers don't want to leave their EMR systems to access this information, rather they want it integrated directly into their workflow.

Optum has worked with various EMRs to integrate our insights seamlessly. For example, if a provider has an appointment with a patient, an API (Application Programming Interface) can trigger a request to Optum. We then send back any identified gaps or conditions that the provider should be aware of during the visit. This helps provide clinicians with necessary information to close potential gaps at the point of care, so the process is more efficient and effective.

When we present a suspected condition to a provider, we provide clear and high-quality evidence to support our suspicion. This helps providers understand why a condition is being flagged and increases their confidence in the information.

3. Enhanced functionality: Documentation assist and specialist rules

The third aspect of our digital approach is enhanced functionality, which includes tools like documentation assist and specialist rules.

Documentation assist helps guide providers through compliant documentation as they evaluate a member. For instance, if a provider notes that a member's condition is stable, the system can guide them through the necessary steps to document this accurately. This not only supports coding accuracy but also helps in capturing all relevant conditions.

Specialist rules are another key feature. Different specialists focus on different conditions, and our system can tailor the gaps presented to the provider based on their specialty. For example, if a patient has a gap in diabetes management, the system will present this gap to a primary care provider. If the same patient has a gap in their cardiology care, the system will present it to a cardiologist. This tailored approach helps present the right information to the right provider at the right time.

Future innovations

We are continuously expanding our digital capabilities. This includes broader EMR connectivity. We are exploring opportunities to connect with additional EMRs, both cloud-based and locally installed, to broaden our reach.

Optum has the scale to process over 60 million charts per year. We not only can connect to a wide range of EMRs but we can also help to ensure that the information is presented in a standardized and high-quality format. This is particularly important in a multi-payer setting, where different plans may present information in different ways.

Optum digital solutions are designed to help make the risk adjustment process more efficient, accurate and complete. By integrating with EMRs, providing high-quality evidence and facilitating a smooth provider experience, we are helping health plans and providers achieve their goals. Our comprehensive approach combining AI, efficient data flow and local market support positions Optum as a leader in the industry.

As we continue to innovate, we are committed to advancing digital healthcare solutions.

About Jeff Dumcum

Jeff Dumcum leads clinical performance and growth for Optum risk adjustment, quality and member engagement solutions. He has nearly 3 decades of industry experience and spent the first 10 years of his career working at health systems in various roles including finance, Medicare, operations and strategic planning. Jeff has been with Optum for 20 years. He works with both payers and providers, helping them to achieve their risk and quality goals.