How Building an Accurate Clinical Profile Benefits

What Is Clinical Profiling?

The process of clinical profiler (the term also refers to the healthcare providers’ networks and hospitals) is the method by which providers, as well as health insurance providers, managed care Solutions, and government agencies, employ performance indicators based on patterns to assess the services, quality of care use, and costs.

These assessments are based on standardization or community-based criteria.

Clinical profiling is an important performance benchmark to identify areas where a healthcare provider is not performing. 

The measures are based on specifics for members like the length of stays inpatients have mortality rates, costs, readmission rates, and satisfaction of patients.

Who Supports Clinical Profiling?

Three companies offer performance measures to evaluate and monitor the performance of healthcare providers:

  • The National Quality Forum promotes and assures protection of patients and health quality improvements through the measurement of quality and reports to the public.
  • The Agency for Healthcare Research and Quality keeps its Consumer Assessment of Healthcare Providers and Systems survey that evaluates the experiences of patients with primary care hospitals, hospitals as well as nursing homes. It is the Centers for Medicare & Medicaid Services (CMS) makes use of the results of this survey in its online tool for comparison of hospitals and also in its rating for providers system.
  • The National Council for Quality Assurance is in charge of keeping the Healthcare Effectiveness Data and Information Set (HEDIS) for special needs services, which covers more than 90 aspects of care, which affects more than 100 million individuals within the United States.

Benefits of Clinical Profiling

Clinical profiling is beneficial to members as well as providers. Here are some ways that it can benefit both:

Benefits for Members:

  • Clinical profiling offers members valuable information about the comparative performance of different providers. This allows them to be knowledgeable about the healthcare market. By doing so they are contributing to the pressure to improve the quality of healthcare providers.
  • Health insurers, as well as employers and health plan companies, utilize HEDIS information to assess the providers they partner with and select which to collaborate with.

Benefits for Providers:

  • Clinical profiling provides providers with an objective way to assess their performance in the marketplace for healthcare. While internal quality improvement initiatives are beneficial, however, without the perspective of peer-level benchmarks, it is difficult to judge what their value is.
  • Clinical profiling encourages healthy competition between providers. It helps them understand the areas where they could or should improve the quality of their services to their clients. It also helps identify poor performers, and improve the overall quality of care.
  • Clinical profiling could lower the chance of claims for hospital negligence. The claims do not rest on the individual’s negligence, but rather on what the average doctor will take care of. If data from clinical profiling reveal poor care for members in any particular area the doctor can correct the problem prior to it becoming a legal matter.

How Are You Using Clinical Profiling?

Clinical profiling is a vital instrument to evaluate the performance of a provider. If you are a medical care provider or healthcare provider looking to establish complete profiling of your members or patients? 

The first step is the quality of the information that you get. On the top of this page, you are able to select the Solutions menu to look into our risk adjustment software and quality improvement and services.