Insights from Heather Crosby, AVP of Clinical Strategy at b.well Connected Health
Ask a quality or care management team at a health plan what care gap closure looks like today, and the answer usually involves a phone call, a fax, or a PDF. Teams still collect most supplemental data, the clinical evidence that lives outside the plan’s own claims, by hand. Nurses chase charts instead of providing care. Plans refresh measure performance monthly, so outreach runs on data that has already gone stale by the time a member hears from the plan. Members notice. When recommendations arrive late, conflict with what another system told them, or ask for a screening they completed months ago, they stop listening.
Digital quality measures (dQMs), on multisource data, are the industry’s answer to this problem. Plans calculate measures from standardized FHIR data as care happens instead of after the fact. CMS is steering quality programs in this direction, NCQA is already there, and most of the conversation so far has focused on the back end, on measure engines, data pipelines, data quality, and reporting. We will cover each of those in depth in the pieces that follow. This one starts with the member, because the data that powers a digital quality measure begins the moment a person connects their health records.
Why Care Gap Closure Depends on Consumer Activation
A plan’s view of a member is limited to what the plan can see. Claims only show what was billed since enrollment. Claims cannot show a depression screening documented in a clinical note. They miss a colonoscopy performed eight years ago at an unaffiliated health system. They also miss an immunization history that stretches back decades. In our own validation work, measures that depend on clinical data were unmeasurable or delayed from claims alone. Members with a connected clinical record showed materially higher capture rates on the same measures. Today, a data connectivity gap is a care measurement gap.
Consumer activation changes what the plan can see. When a member connects their records inside the plan’s own experience, the plan gains clinically rich data across that member’s full history. That data arrives in a form that can feed a measure engine directly. The same connection gives the member something in return. They get one place to see and manage their health information. They also get clear, accurate, and timely guidance on what to do next. Here is what that looks like in practice.
Getting Started
A member opens the plan’s app or member portal and creates an account. As a plan member, much of their information is already there. Insurance claims, benefits, and their ID card are preloaded, so the experience is useful from the first session. A quick identity verification step confirms who they are, which lets the platform find their records elsewhere on their behalf.
Connecting Records
The member is invited to connect their other data sources through a process we call Smart Connect. Using the verified identity, the platform searches b.well’s network partners for the member’s records. It connects them to data from past and current providers, health systems, retail pharmacies, wearable devices, and prior insurance plans. The member does not need to know which portal holds which record or remember a login for each one. They confirm who they are, and the connections are made for them.
Behind the scenes, this data arrives in many different formats. Sources use different structures, value sets, and code ranges, and many send incomplete records. Across billions of FHIR records, b.well has found that 58 percent of the source data entering our system arrives non-standardized. Every record runs through our 13-stage data refinery, which cleans, normalizes, and enriches it, raising the standardization rate to over 90 percent and up to 100 percent. That step is what makes the data usable and actionable both for the member reading it and for the measure calculations running underneath.
Seeing the Full Picture
The result for the member is a health summary that brings together diagnoses, conditions, procedures, lab results, medications, and clinical notes from every connected source, organized over time. A lab value is no longer a single number on a printout. It is a trend, with the reference range, the ordering provider, personalized insights, and the source visible alongside it. The member and the plan now see the same complete record.
Care Gap Closure in One Tap
With the record assembled, the platform runs HEDIS measure logic, written in Clinical Quality Language, against the member’s data to identify any care they are due for. Each open need surfaces in the member’s Health Journey as a personalized insight with plain educational content and a single call to action. A member due for a breast cancer screening sees why it matters and a button to schedule it with an in-network provider seamlessly.
Once the member completes the appointment, the platform sends the closure back to the plan in near real time and links it to the FHIR encounter that proves it happened. The member closed their own gap, and the plan has the evidence without anyone chasing a chart.
What the Plan Gets
Every step above is a member action, and each one improves the plan’s quality data. Records the plan could never have pulled on its own become part of the measure denominator and numerator. Supplemental data collection moves from phones and fax machines to automation. Measure performance updates within minutes to hours of care taking place rather than at the end of the month, so care managers can direct outreach to the members who need it, when they need it. Outreach built on current, complete data is outreach members trust, which is the difference between a nudge that gets acted on and one that gets ignored.
All of this runs on one core platform rather than a quality system operating in parallel to everything else. That is where the conversation turns to the back end. In the next piece, we will look at what real-time quality performance monitoring makes possible for plan teams. Plan teams that know where their measures stand today, which members to prioritize, and how to prove every care gap closure with evidence can close gaps while there is still time to act, instead of reacting to a year-end surprise.