How Value Based Care Software Improves Health System Performance

Before a scheduled visit, a population health team may use value based care software to compare the electronic health record with claims history for a due preventive screening. If neither source shows a completed service, then the team considers possible delays in filing claims or even external evidence prior to classifying it as a care gap. After verifying the gap, ownership of communication lies with the care coordinator.

A separate workflow handles HCC review. A coding professional checks the flag against chart documentation. The clinician confirms clinical relevance. The coding professional records whether the documentation supports coding or needs follow up. Teams track HCC validation under risk adjustment rules and screening closure against applicable contract quality measures.

What Value Based Care Software Manages

Value based care software organizes data by attributed population and contract measures. Its role spans existing clinical and billing systems. It groups records for review and reporting after teams align patient identifiers and measure definitions.

Key Takeaways

1. Patient attribution: Patients are grouped according to each program’s criteria with an individual or group of accountable providers. Using the criteria, the software then categorizes patient data and performance reports. A health system may maintain separate populations across programs.
2. Data sources: Teams may use electronic health record documentation plus claims data and eligibility records. They examine the origin and dates of each record, as claims may be delayed, and feeds may differ.
3. System roles: Revenue cycle management systems perform billing functions such as claims and payments. Value based care management software can use approved data from both systems for contract reporting without replacing either one.
4. Data exchange: EHR integration services enable exchanging and utilizing the data that is validated within standardized formats. Teams still own measure definitions and resolve mismatched data.

Move HCC Insights Through the Visit

Hierarchical condition category review carries prior evidence through clinical assessment and coding. A flag in value based care software sends a record for review. It does not confirm a diagnosis or establish that a code is reportable.

Before the visit

The record may enter the queue due to the documentation and claims that suggest the need for verification of a certain condition or due to a lack of details in the chart. The coder or risk adjustment reviewer verifies the source and date and passes the query to the physician.

Claims can flag a record to check but cannot replace clinical documentation. If evidence is incomplete, the reviewer notes what needs assessment.

During the visit

The clinician reviews the patient’s history and assesses the condition using available electronic health records and relevant clinical documentation. 

• The clinician reviews relevant history and test results.
• The clinician determines whether the condition is still active and impacts treatment.
• If this is no longer an issue or can’t be verified, the clinician documents this decision. The prompt does not determine a diagnosis.

After the visit

A coding professional checks the signed documentation against coding rules. Population health or risk adjustment teams track open reviews and direct follow up.

• Supported documentation proceeds through HCC coding validation.
• If there is no clarity in the support, then the review is sent to the appropriate workflow, where it stays pending.
• The system records review status so teams can assign next steps.

The function of HCC risk adjustment and quality measures is not the same. Risk adjustment using HCC diagnoses in the Medicare Advantage plan allows cost estimation. A risk adjustment factor summarizes risk. It is not a quality score. Contract quality measures assess defined care processes or outcomes. CMS checks whether submitted diagnoses are supported by medical records.

Close Care Gaps With Clear Ownership

Value based care management software routes care gaps into care coordination tasks. Each task needs an owner and due date so teams can see what is still open.

Detect

EHR indicates no results for the pending screening test. The claim history does not show any services performed recently, and hence an alert is generated.

Verify

The coordinator searches for any late claims made and makes inquiries to the patient regarding any treatments made elsewhere. The patient replies that there was a screening conducted at another center recently. The coordinator requests the result before treating the gap as unresolved.

Assign

A named coordinator owns the records request. The task includes a due date and names a team lead who receives overdue alerts.

Contact

If there is no outcome within the due period, the coordinator calls the patient for screening arrangements. All failed calls and reminders will be documented by the coordinator. If the patient refuses, then the refusal along with the follow-up is documented.

Complete

The gap closes only after the expected results are achieved. It is not an assurance that the process has been done.

Document

This documentation shows the action performed and the source of the evidence. This also involves the review date and incomplete work. This information is used by teams to generate quality reports and close gaps in care.

A team lead can reassign overdue work or approve a revised due date. The gap stays open until applicable measure rules support another status.

Combine Analytics With Expert Review

value based care health system solutions software can show utilization changes across an attributed population. If the system has this capability, artificial intelligence could be used to rank the records to be reviewed.  These signals help staff prioritize review while leaving clinical judgment to qualified professionals. They do not explain causes or establish diagnoses. 

Healthcare organizations may also evaluate how healthcare software solutions support data access and coordination between review teams 

Trace a pattern

Suppose emergency department claims rise for one group during a reporting period. An analyst checks for a real pattern or data issues such as duplicate claims. The analyst compares the change across periods to see if it persists. AI may prioritize records with missing context. It does not label visits as avoidable.

Assign the review

A population health lead assigns cases to staff. A clinician reviews history and encounter notes for context. A coding professional checks code support if needed. The reviewer records the finding and next action.

Monitor review signals

False positives are flagged records with no relevant issue. Missed signals are issues the system did not surface. Teams review examples and document corrections. Repeated misses may point to data feed or review rule changes. Later reviews show whether similar cases recur.

Use advice carefully

Expert advisory services can help teams interpret these findings and identify workflow changes for the health system to assess. Health system staff retain responsibility for clinical and coding decisions and decide which operational recommendations to implement. 

Measure Workflow Progress and Outcomes Separately

Separate process activity from program results to assess how value based care solutions align with defined contract goals. Record reviews completed before a deadline show work performed but do not prove contract success.

Process measures	Program outcomes
Records reviewed before reporting deadline	Eligible member screening rate
Median time from assignment to resolution	Emergency department utilization
Overdue care gap tasks by clinic owner or screening type	Cost per member
HCC reviews completed versus awaiting clinician clarification	Shared savings or contract quality results where applicable

For example, the team may finish most chart reviews before the deadline while outside screening results remain outstanding. The process measure looks strong. The eligible member screening rate may not improve until qualifying results are counted for the contract period.

The quality report should use the attributed population and include the eligibility and exclusion criteria for that measurement period. Risk adjustment and shared savings can be part of contract performance if they have been defined in the agreement.

Manage Risks Before Launch

Prelaunch testing can expose data and workflow risks before rollout. This helps limit inaccurate reports and avoidable staff work.

Duplicate and missing records

Duplicate identities distort reports. Missing screening data can make completed care appear overdue. Use identity matching and feed reconciliation reports.

Interface failures

A failed claims or EHR feed leaves data stale. Set failure alerts and name a technical response owner.

Alert fatigue

Low value alerts can bury actionable cases. Set priority thresholds and test alert volume with staff.

Stale rules

Old rules can flag ineligible records. Review them regularly against current contract specifications.

Unowned tasks

Missing evidence can sit idle without ownership. Name an owner and due date.

Validate before launch

Test duplicate identities, missing data, failed feeds, and overdue tasks. The audit trail should record the data source, rule version, error, corrective action, and resolution. These checks improve data quality and reduce integration errors. They also support workflow adoption.

Choose Software That Fits Existing Workflows

A useful vendor demonstration should show how value based care software handles the health system’s data and daily work. Use representative test records and agree on what a passing result looks like.

Data matching

Have the vendor process records with different patient identifiers plus a duplicate and a conflicting screening result. Inspect how the system matches identities and displays unresolved conflicts. A successful test should not silently combine records or hide conflicting information.

Attribution and data freshness

Use sample patients who meet or fail the contract’s attribution criteria. Confirm that population assignments follow those rules. Review feed timestamps and check how staff can identify delayed or incomplete data.

Workflow fit

Have a coordinator complete a representative task in the current workflow. Count the steps and application changes required. Confirm that task updates and handoffs do not require staff to enter the same information twice.

Permissions and audit logs

Use coordinator and administrator accounts to test access controls and assess HIPAA compliance requirements. Inspect the audit log for the username and timestamp, plus the previous and updated status. Verify that each role has only its intended access.

Error handling

Simulate a failed interface in a test environment. Check that the alert identifies the affected feed and its last successful update. Confirm that a named team receives the issue and that recovery is recorded. After restoring the feed, verify that corrected data updates the affected report.

Implementation and support

Set owners and deadlines for measure setup and testing, plus validation and staff training. Organizations may work with healthcare app developers to support system integration and technical implementation.  Agree who maintains interfaces and who handles overdue fixes. Define how unresolved issues are escalated.

Final Thoughts

A health system can judge whether value based care software is ready by seeing how it handles the work when normal processes break down. Is it guaranteed that accountability would stay transparent when there is not enough data available or when tasks are delegated? Does it follow the local policy and capabilities of the personnel without requiring any additional steps to be taken?

Before a broader rollout, select one representative workflow and test it with the staff who will use it. Include a routine case and an exception. Determine what the desired outcome looks like before conducting the test. The input provided by the group will determine if proceeding is necessary or not.