The importance of health insurance claims data in creating learning health systems: evaluating care for high-need high-cost patients using the National Patient-Centered Clinical Research Network (PCORNet)

J Am Med Inform Assoc. 2019 Nov 1;26(11):1305-1313. doi: 10.1093/jamia/ocz097.


Objective: Case management programs for high-need high-cost patients are spreading rapidly among health systems. PCORNet has substantial potential to support learning health systems in rapidly evaluating these programs, but access to complete patient data on health care utilization is limited as PCORNet is based on electronic health records not health insurance claims data. Because matching cases to comparison patients on baseline utilization is often a critical component of high-quality observational comparative effectiveness research for high-need high-cost patients, limited access to claims may negatively affect the quality of the matching process. We sought to determine whether the evaluation of programs for high-need high-cost patients required claims data to match cases to comparison patients.

Materials and methods: A retrospective cohort study design with multiple measures of before-and-after health care utilization for 1935 case management patients and 3833 matched comparison patients aged 18 years and older from 2011 to 2015. EHR and claims data were extracted from 3 health systems participating in PCORNet.

Results: Without matching on claims-based health care utilization, the case management programs at 2 of 3 health systems were associated with fewer hospital admissions and emergency visits over the subsequent 12 months. With matching on claims-based health care utilization, case management was no longer associated with admissions and emergency visits at those 2 programs.

Discussion: The results of a PCORNet-facilitated evaluation of 3 programs for high-need high-cost patients differed substantially depending on whether claims data were available for matching cases to comparison patients.

Conclusions: Partnering with learning health systems to rapidly evaluate programs for high-need high-cost patients will require that PCORNet facilitates comprehensive and timely access to both electronic health records and health insurance claims data.

Keywords: case management; comparative effectiveness research; electronic health records; health care administrative claims; learning health systems.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Case Management
  • Comparative Effectiveness Research
  • Electronic Health Records
  • Health Care Costs*
  • Hospitalization
  • Humans
  • Insurance Claim Review*
  • Insurance, Health*
  • Learning Health System*
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care
  • Patient-Centered Care
  • Retrospective Studies
  • Socioeconomic Factors
  • United States