Harnessing the full potential of healthcare data is transforming the industry, enabling organizations to deliver more personalized, efficient, and outcome-driven care. As the volume and variety of data grow, the challenge lies in effectively integrating and analyzing these insights to improve patient outcomes and operational efficiency. Central to this transformation are open and closed claims data, which, when combined with emerging real-world evidence (RWE) and real-world data (RWD), provide a comprehensive view of patient journeys and healthcare trends. This approach empowers organizations to make data-driven decisions that enhance care quality and business performance.
Healthcare organizations increasingly recognize that leveraging claims data is crucial for understanding patient behavior, managing chronic conditions, and identifying gaps in care. By harnessing both open and closed claims, providers and payers can uncover valuable insights into healthcare utilization, treatment patterns, and patient engagement. This integrated data ecosystem supports advanced analytics, enabling organizations to predict trends, optimize resource allocation, and personalize treatment plans. For a broader perspective on how artificial intelligence is revolutionizing healthcare, explore the evolution of AI in medical applications.
Open and Closed Claims Data
Open claims data reflects ongoing or recent healthcare interactions, capturing patient visits, procedures, and prescriptions as they are reported by clinicians, pharmacies, and insurance entities. This data is generated whenever healthcare providers or pharmacy benefit managers submit claims, including information from clearinghouses, labs, and various digital health platforms. These claims contain essential data elements such as ICD-10 diagnosis codes, CPT procedure codes, and provider identifiers (NPIs), which help form a detailed picture of a patient’s healthcare journey over time.
Organizations analyze open claims to gain continuous insights into patient interactions, allowing for longitudinal tracking and trend analysis. Such data is instrumental in identifying patterns, assessing the effectiveness of treatments, and understanding the progression of chronic diseases. Without access to open claims, healthcare entities would have a limited view, hindering their ability to detect emerging issues or adapt strategies proactively. To streamline healthcare workflows and improve efficiency, many are turning to support systems that utilize AI for process optimization.
Closed claims data, on the other hand, encompasses finalized claims submitted after services are rendered, providing a complete record of healthcare activities within a defined enrollment period. This data includes details from doctor visits, hospital stays, urgent care encounters, and pharmacy transactions. Because closed claims are comprehensive and validated, they enable detailed linkage between diagnoses, treatments, and outcomes, offering deep insights into the patient pathway during specific periods.
Combining Data Sets
While open claims are valuable for capturing ongoing patient interactions, they may not include data from every healthcare provider involved in a patient’s care. Conversely, closed claims offer a consolidated view of all activities within an enrollment window but lack the ongoing, real-time updates of open claims. Integrating both data types creates a richer, more complete picture of patient behavior, treatment adherence, and healthcare utilization across different settings and time frames.
This integrated approach addresses a critical need for healthcare leaders. As Jared Safran, PharmD, Director of Clinical Services at PurpleLab®, explains, “Greater visibility into claims data enables health plans to better manage members with chronic conditions. When members frequently switch providers or plans, relying solely on closed claims limits understanding. Open claims fill that gap, providing a broader perspective that enhances trend detection and proactive intervention.” Such comprehensive data integration is essential for effective population health management and personalized care strategies.
Leveraging Claims Data for Insights
Advanced analytics of combined claims datasets unlock powerful insights that inform clinical decisions, optimize resource allocation, and improve health outcomes. By analyzing open claims, clinicians and administrators can track patient progress over time, identify gaps in care, and tailor interventions accordingly. Closed claims data offers a detailed snapshot of healthcare activities within specific periods, facilitating retrospective analyses and outcome assessments.
The strategic use of RWE and RWD in analyzing claims data supports the shift toward personalized medicine. These approaches enable healthcare providers to move beyond traditional protocols and develop individualized treatment plans based on real-world patient experiences. Combining open and closed claims enhances the depth and accuracy of research, supporting patient-centered care, better treatment adherence, and improved outcomes.
In the context of healthcare business needs, harnessing the combined strength of claims data, RWE, and RWD allows organizations to address critical challenges efficiently. PurpleLab® simplifies access to these insights, empowering healthcare entities to innovate and transform their operational and clinical practices. By leveraging the intersection of sports and virtual reality, organizations can also explore novel engagement strategies that boost patient participation and adherence.
Organizations that utilize comprehensive claims data are positioned to accelerate the discovery of healthcare innovations and improve patient outcomes. Built upon one of the largest medical and prescription claims databases, PurpleLab provides solutions that foster collaboration across the healthcare ecosystem. This unified approach ensures that data-driven insights can be accessible and actionable for all stakeholders, ultimately driving better health results.
Originally published August 2024 on HealthcareDive, this article was created in collaboration with Industry Dive and PurpleLab®.
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