Navigating healthcare’s value set dilemma

Using value sets for cohorting patients who share clinical characteristics is both essential and burdensome for many healthcare stakeholders. Here’s why.
cohorting patients

Most of us can look back at a time in our lives when we struggled to “find our people.” Whether it was starting a new school or moving to a new city, the task felt – or perhaps still feels – daunting. But what if this challenge was a constant for healthcare professionals: a persistent barrier to accomplishing important goals tied to initiatives like quality reporting, clinical trials, or clinical decision support?

For those who rely on value sets to identify populations of interest, the challenge is real. Value sets use reference or billing codes for cohorting patients that share specific clinical characteristics such as diagnoses, labs, and medications. But out-of-the-box and industry standard value sets often fall short of what’s needed, and in-house solutions can be difficult and expensive to build and maintain.

In our latest insight brief, we delve into the important role of value sets across the healthcare ecosystem; the manual processes that make upkeep so problematic; and how robust clinical terminology and code maps can help streamline value set development.

Keep scrolling for an excerpt or to download the full brief, click the button below.

Organizations like the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) publish value sets for the purpose of standardizing certain measures. However, these industry-standard value sets often cannot be used out of the box without customization since they don’t account for the unique data and initiatives of each organization.

To make the necessary modifications, organizations will often look to online tools and electronic health record (EHR) systems to create value sets using standard code sets like ICD-10-CM or SNOMED CT®. But while these tools offer basic capabilities to create value sets, the exclusive use of administrative code sets is limiting, and can lead to inaccurate value set data and definitions.

To get precise value sets that meet specific objectives and requirements, clinicians and analytic teams must search for terms that accurately describe clinical conditions with appropriate detail. And to do this, one must have intimate knowledge of clinical terminology beyond the standard codes.

Considering the complexity and variation in clinical terminologies and coding systems, and the fact that specific terms or codes may not fully reflect the clinical nuances of desired groups, it can be a challenge to build value sets that correctly identify the right patients.


For a brief and informative look at value sets – how they work and why they often don’t – download Accurate value sets: The basis for clinical initiatives and targeted analysis.

SNOMED and SNOMED CT® are registered trademarks of SNOMED International.

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