Getting ahead of the reform storm

Nov. 1, 2010

Three steps to supercharging provider information management.

The universe of provider information is rapidly expanding and changing across the healthcare ecosystem. Whether you are a payer introducing innovative benefit designs, or a hospital implementing a pay-for-performance (P4P) program, you are counting on reliable provider information. Provider information is the undervalued currency fueling your successful response to reform.

Payers are responding to the Patient Protection and Affordable Care Act (PPACA) and other market pressures through innovation and by revamping cost structures on multiple fronts. Their products are being redesigned to incorporate value-based benefits and are being tailored to meet the specific demands of their customers. Payers are preparing to differentiate their products and services in the homogenizing world of health insurance exchanges. New provider networks are being designed to deliver the promise of these new products while new reimbursement models are being introduced to align the performance of providers with the value expected by employers and customers. Additionally, experimentation with collaborative care models, such as the patient-centered medical home, is in full swing. Provider information that spans access, quality and cost dimensions is critical to each of these initiatives.
Reliable provider information is a cornerstone of the payer focus on administrative simplification and accuracy. For example, an accurate electronic claims payment process requires identification of the service provider, attribution of the appropriate contract governing the services delivered, as well as the corresponding payment methodology. This, in turn, requires accurate provider demographic information and codified information on the payer's multiple relationships with the provider. Streamlining other core processes, such as marketing, medical management, provider relations and customer service, is also contingent on reliable provider information.

The capability to manage accurate provider information is increasingly becoming a key differentiator and an asset for provider organizations, as well. Hospitals, along with other provider organizations (such as accountable care organizations, or ACOs), are under growing pressure to show evidence of the consistent application of medical best practices and guidelines as their reimbursement rates may soon be predicated on such evidence. In addition, patients and employers are demanding greater transparency about provider credentials, experience, quality, costs, convenience factors, language skills and site details. All of this is in an effort to help members/patients make more informed health and wellness decisions.
While provider information is becoming increasingly critical to both payers and provider organizations, ensuring its accuracy and integrity can be very challenging. Provider information is typically distributed amongst disparate systems with varying levels of data quality and duplication. Furthermore, provider information is usually accessed, utilized and modified within multiple process silos leading to fractured and partial data sets. The manual handoffs between these process silos contribute not only to inefficiencies but also to data errors and latency. Data integrity rules are either manually or inconsistently enforced. The expansion of the information set to accommodate growing business needs represents another key challenge. Meeting this challenge demands high levels of flexibility in the systems storing provider information. By its nature, provider information is highly dynamic, both inside and outside the walls of the organization. For example, in any given year, approximately 15 percent of providers change locations, retire or pass away yearly. Additionally, 90 percent of all physicians are affiliated with one or more hospitals and 30 percent change their affiliations.

The importance of provider information and the extent of challenges governing it necessitate a holistic and a systematic approach. It consists of three key steps:
Step 1: Identification and attribution. In most payer and provider settings there are multiple, internal and external sources for provider information. A first step in a management approach is to identify the universe of unique providers and link the records across all the data sources to their matching unique provider. This linking can be accomplished by the deployment of an identity management solution called a master provider index (MPI). An MPI will use both deterministic and probabilistic algorithms to identify, match and link provider data records to create a “Golden Provider” ID index. The resulting index is leveraged for duplicate management and piecing together the complete information on a given provider across all the data sources. For example, it could enable the assembly of a provider's clinical performance profile from claims, HEDIS survey and EMR data streams.

Step 2: Provider system of record (PSOR). In this next step, a common, core enterprise repository is established to consolidate, store and maintain all provider information. The unique provider identity created in Step 1 is utilized by the PSOR to compose a 360-degree view of providers from all the different data sources. This composite view (the “Golden Provider” record) created in the PSOR is then stored and maintained over the lifecycle of the provider within the payer or provider environment. In order for the PSOR to properly function as described above, it must have the following core capabilities:

1. Highly flexible provider information model — The information model must be able to store demographics, credentialing, contract, reimbursement, quality and other service information. Current analysis points to a 20 to 30 percent expansion in the information set over the next two to three years.

2. Configurable business rules — The use of configurable business rules enforces data integrity. Centralization of these rules ensures consistent enforcement across all methods for provider data changes, including user data entry and electronic interchange. Such enforcement can result in a 15 to 25 percent improvement in provider data quality.  

3. Work-flow automation — This is needed to connect all the key provider maintenance processes. It decreases administrative costs while increasing accuracy. Best practice implementations of work-flow automation have resulted in a 25 to 35 percent increase in productivity as well as 55 percent decrease in new staff training.

4. Real-time and batch integration capabilities — The interoperability of the PSOR is a critical capability due to the fact that a large number of downstream systems and other departments need a portion of the provider record to carry out their day-to-day activities. Support for service oriented architecture (SOA) is necessary for PSOR to be a true enterprise asset.

5. Granular security — As is the case for much of the information in a healthcare setting, the PSOR also needs strict security and privacy rules that constrain the access and visibility of certain data elements based on the user's role in the organization.

6. End-to-end audit and history tracking — Another critical capability of a PSOR is not only to understand what data is within the system but also how has that data changed over time and who changed that data.   

The deployment of a PSOR is the most essential and fundamental step to reliable provider information. Without a properly designed PSOR, it is very difficult for a payer or provider organization to make the information operational throughout the enterprise. The PSOR is the enterprise information bank that understands, manages and distributes the provider information that the rest of the organization needs to carry out its day-to-day business.  

Step 3: External data augmentation. This step incorporates the periodic comparison of your provider information (demographic and credentialing data) with external provider master reference files to ensure its currency and completeness. The comparison process leverages trust-based rules to accept any differences with the master provider reference files. Resolution work flows are required to alleviate the impact of any change. For example, a new provider location may require an authorization to do business before being accepted as a part of that provider's record. Ensuring the ongoing accuracy of provider information takes on an even greater importance as state-based exchanges begin to come online and both providers and members begin to demand enhanced customer service capabilities.

Provider information management has evolved into a critical core competency for both payer and provider organizations in the post-reform world. Gone are the days when siloed databases and manually maintained spreadsheets could sufficiently support provider information operations. How payers and provider organizations approach provider information management initiatives could mean the difference in how successfully these entities compete in their markets..

Sam Muppalla is executive VP and chief strategy and marketing officer at Portico Systems.
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