Data Quality & Interoperability in Value-Based Care

Value-based care (VBC) has been a buzzword for years, promising better outcomes at lower costs. Yet despite its promise, the healthcare industry is still struggling to achieve the results VBC set out to deliver. The shift from fee-for-service to value-based models was meant to reward providers for delivering high-quality, cost-effective care. But years into this transition, many organizations find themselves questioning why the expected improvements remain elusive.

The reality is, implementing VBC can be complex. Beyond aligning incentives and establishing quality benchmarks, the success of VBC hinges on the ability to make informed, data-driven decisions. In this blog, we’ll explore the key barriers that have hindered VBC success. Understanding these roadblocks is the first step toward creating a healthcare ecosystem where value-based care can thrive.

What Is Value-Based Care?

Before we dive into the roadblocks, let’s level set by going over what VBC really means to each stakeholder: payers, providers, and patients. At its core, VBC is about achieving better clinical results at a lower cost.¹ Providers are incentivized to offer coordinated, efficient care that focuses on prevention and overall wellness rather than just treating illness.² Payers, meanwhile, aim to reduce unnecessary spending while ensuring members receive high-quality care.

For patients, VBC ideally means more personalized, proactive healthcare with fewer gaps in care, lower out-of-pocket costs and better health outcomes.

While the transition to VBC has been challenging, momentum is building. Regulatory changes, increased data sharing capabilities, and advancements in analytics are driving progress. More organizations are recognizing the long-term financial and clinical benefits of VBC, making it a focal point for innovation and collaboration. However, there are still significant hurdles to overcome — and understanding these challenges is essential to making VBC a sustainable reality.

Key Barriers to Achieving VBC Goals

Data Silos and Interoperability Gaps

One of the biggest barriers to value-based care is the fragmentation of healthcare data across various systems, platforms, and organizations. Providers, payers, and even patients often lack access to comprehensive, real-time data that is essential for making informed decisions. These data silos hinder the ability to share information across the care continuum, leading to inefficiencies, duplication of efforts, and gaps in care. Without seamless data flow and interoperability, healthcare providers cannot effectively coordinate care, track patient outcomes, or measure the true impact of value-based initiatives.

Adherence and Adoption Risks

Transitioning from fee-for-service models to value-based models requires significant cultural and operational changes within healthcare organizations. Providers must adapt to new care delivery models, new reimbursement structures, and often unfamiliar technology platforms. The risk of non-adherence to VBC initiatives is high, particularly if the new approach leads to increased administrative burdens or shifts in care delivery that are difficult to integrate into existing workflows. Additionally, some organizations may be hesitant to fully adopt VBC models due to concerns about short-term financial implications, uncertainty about reimbursement rates, or the complexity of tracking and reporting outcomes.

Low Patient Engagement

Value-based care places a strong emphasis on patient-centered care but achieving this requires high levels of patient engagement and participation. Unfortunately, many patients remain disengaged or uninformed about their role in VBC, whether it is following treatment plans, attending preventive care appointments, or managing chronic conditions. Low patient engagement can lead to poor health outcomes, increased costs, and missed opportunities for preventive care. Without active patient participation, providers cannot effectively manage care, and the goals of VBC — improving health outcomes and reducing unnecessary costs — are difficult to achieve.

The Path Forward: Building a Data-Driven Foundation

The path forward to achieving value-based care success lies in building a data-driven foundation that empowers both providers and payers to unlock better patient outcomes. To fully realize the potential of VBC, healthcare organizations must accelerate the use of high-quality clinical data that drives informed decision-making and coordinated care.

Below are three key steps healthcare providers and payers can take to enhance their VBC efforts:

Secure the Right Data

VBC success relies on having accurate and comprehensive data to make informed decisions about patient care. However, acquiring and integrating data from multiple sources can be challenging. Health plans and providers often face high acquisition costs, complex integration processes, and inconsistent results due to the variety of vendors, systems, and formats. Different use cases frequently require customized data solutions, adding further complexity. Fragmented systems can also lead to incomplete records, making it difficult to achieve a holistic view of patient health.

What to Do	Benefit
Partner with a vendor with multi-channel connectivity capabilities that can aggregate data from diverse sources—including electronic health records (EHRs), health information exchanges (HIEs), claims data, clinical quality validation (CQV) and risk condition validation (RCV) applications, and other data sources.	Having one acquisition partner with multi-channel connectivity streamlines the data integration process, reducing complexity, lowering costs, and providing a more comprehensive and accurate view of patient health for improved care decisions and outcomes.

Validate and Improve Data Quality

Data from multiple sources often comes in different formats and may include issues such as incomplete codes, outdated information, or missing data. Inaccurate or inconsistent data can lead to poor care decisions, such as misdiagnoses or inappropriate treatments, ultimately undermining the goals of value-based care. Ensuring high-quality data — free from errors like duplicate records or formatting issues — is essential for achieving positive patient outcomes.³

What to Do	Benefit
– Establish processes or integrate solutions that consistently validate and clean your data, ensuring it remains accurate, current, and optimized for interoperability. – Use data quality monitoring tools to identify data gaps or errors and address them proactively. – Continually improve data quality by setting up feedback loops and performance metrics.	Data quality in value-based care is vital for accurate risk profiles, effective care coordination, and reliable performance measurement. It ensures proper risk adjustment for reimbursement, up-to-date information for care coordination, and accurate reporting of healthcare outcomes and financial performance.⁴

Incorporate Fit-for-Purpose Data into Workflows

For data to drive better outcomes, it must reach the right person, in the right format, at the right time—embedded directly into the workflows that shape care and operational decisions. Value isn’t in the data alone, but in how effectively it supports day-to-day activities like Healthcare Effectiveness Data and Information Set (HEDIS®) reporting, risk adjustment, and care management.

Achieving this requires more than just data access—it demands a partner who can deliver data that is accessible, contextualized, and tailored to each use case. Whether it’s in a standard format like Consolidated Clinical Document Architecture (C-CDA), Fast Healthcare Interoperability Resources (FHIR®) , or a custom structure suited to your system, the data must be actionable for clinicians, care coordinators, and payers alike.

What to Do	Benefit
Integrate clinical data into existing workflows in a way that aligns with the needs of the healthcare team. This may involve delivering real-time access to patient data at the point of care or enabling care teams to track patient progress across various stages of care.	When data is timely, relevant, and embedded into daily workflows, care teams can make faster, more informed decisions. The result: improved outcomes, fewer errors, and stronger performance in value-based care programs.

How Availity Can Help

As the healthcare industry continues to shift toward VBC, the path to success is clear: achieving better patient outcomes and reducing costs requires a robust data foundation. The challenges—data silos, low patient engagement, and complex adoption processes—are significant but not insurmountable. By securing the right data, ensuring its quality, and integrating it seamlessly into workflows, healthcare organizations can unlock the full potential of VBC.

Partnering with Availity can help streamline this process. With Availity, you’re positioned to:

Optimize the cost of clinical data acquisition
Eliminate the burden of managing multiple data vendor relationships
Gain high-quality, actionable data ready for immediate use
Support a wide range of downstream business functions from one connection

Want to see how Availity can help you access fit-for-purpose clinical data and advance your value-based care goals? Click below to learn more.

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Author Bio

Dr. Ruben Nazario is a board-certified physician informaticist with over 20 years of clinical experience and more than 15 years of expertise in clinical informatics. As the Medical Director of Clinical Informatics at Availity Clinical Solutions, he leverages his deep understanding of healthcare systems to drive innovative solutions at the intersection of medicine and technology. Dr. Nazario holds an MBA from The Johns Hopkins University and a Medical Degree from the University of Louisville School of Medicine, combining clinical insight with strategic leadership in healthcare innovation.

Dr. Ruben Nazario

Medical Director of Clinical Informatics at Availity

References

¹Porter, Michael E., and Elizabeth O. Teisberg. Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press, 2006.

²CMS’ value-based programs (no date) CMS.gov. Available at: https://www.cms.gov/medicare/quality/value-based-programs (Accessed: 20 December 2024).

³AHIP, AMA, & NAACOS. (2023). The Future of Sustainable Value-Based Payment: Voluntary Best Practices to Advance Data Sharing. Retrieved from https://www.ama-assn.org/system/files/data-sharing-playbook.pdf

⁴NEJM Catalyst. (2018). Healthcare big data and the promise of value-based care. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0290

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