As part of the ongoing road to value-based care, there is now a greater need for health systems to manage information about health plan participation and network affiliations for their providers. Indeed, provider data management is critical to running a profitable and efficient business.
In North Carolina, the Chapel Hill-based UNC Health Care—a state-run health system comprised of UNC Hospitals and its provider network, the clinical programs of the UNC School of Medicine, and nine affiliate hospitals and hospital systems in the region—has quite an interesting history. From 2011 to today, UNC Health Care has been defined by its owned and employed framework, which has doubled in its size of providers, licensed beds, and employees, says Robb Malone, Pharm.D., system vice president of practice quality, innovation, and population health services, UNC Health Care.
In recent years, Malone recalls, the system’s leaders began looking at how healthcare was evolving forward, including how population health management was becoming a critical component of care management. They then realized that partners and partnerships—specifically how to support independent providers and work with the community—were needed. “We don’t have to be all and own all. We just have to be good partners that deliver good services to our partners and patients, to make sure patients get high-quality care,” says Malone.
That is how UNC Health Alliance, which is the health system’s clinically integrated network, was developed. It’s physician-led, notes Malone, adding that it includes independent providers meshed with UNC Health Care providers. “In order to deliver cost-effective, high-quality care , what do you need to do?” asks Malone. “We do what we’re good at, which is bringing healthcare services and high-quality providers to payers, and then you develop plans and products that leverage that network to manage the total cost of care, access to care, and to deliver high-quality care,” he says.
Of course, when talking about a system that doubled in size over a six-year period on its own, and when adding a focus on independent providers, the net outcome is a complicated system to work in and to coordinate care across, Malone attests. “In setting up that IT infrastructure, you need lots of solutions—from care coordination and care management platforms to reporting and predictive analytics. So we started investing in many different solutions, from people—business intelligence people, analysts, and data scientists—to solutions.”
Robb Malone, Pharm.D.
To this end, one of those solutions was Phynd Technologies, a Dallas-based company whose unified provider management (UPM) platform aims to help systems such as UNC Health Care manage all of their providers. The work the North Carolina organization is doing with Phynd—internally referred to as “provider data integrity”— involved tackling provider data management in three different areas: location management, health plan roster management, and then ultimately network management, explains Malone. “Like all clinically integrated networks, our network is built on the [elements of] the Triple Aim, but you cannot accomplish that unless you have the underlying structure and partnership with payers that gets you out of the fee-for-service environment into the value-based care world,” he says.
But for UNC Health Care to operate in this new payer-based framework, changes would be needed. “Like most systems, we have several contracts across different payers, and they arrange in complexity from narrow networks to open networks to [disallowing] out-of-network, to plans with different kinds of benefits.”
And as Malone notes, the UNC Health Alliance must manage their roster of providers who participate in the network, as well as their statuses in the network, and which contracts those providers are participating in. “Just because you are in the alliance doesn’t mean each provider participates in all the contract segments. And there’s no way that a referring provider and a patient can wrap their heads completely around their benefit limitations and what their network is. So we have to help patients and providers navigate that through decision support,” he says.
According to Malone, Phynd specifically helps the alliance maintain the roster at the provider level that would associate each provider with a given plan, and then allow operational leaders to deliver decision support at the point of care so that the provider knows how to connect patients with a provider in the network. “And more importantly, they will be connected with the preferred providers within our network who are operating at the highest level of expertise for delivering high-quality care and have accessibility to see patients,” he says.
The Phynd platform is a cloud-based solution, hosted by Amazon, with two main elements to its provider data management equation. One is that it enables clients to consolidate, synthesize and integrate their existing data—so taking information from their EHRs (electronic health records) and credentialing systems—because that information is often redundant, conflicting and not complete, explains Peter White, chairman and chief product officer at Phynd Technologies. The vendor also maintains an independent database of more than 4 million provider records that it aggregates internally. And then, notes White, there is a blending of these two worlds—external and internal data—that is pulled into a single-source-of-truth record. Health systems can then share that back out with their internal systems, their EHRs, and their credentialing systems, White says.
Previously at UNC Health Care, Malone recalls, there were a myriad of different technology platforms with very little provider data organization. “What you would see most commonly was operational leaders like me who would be using anything from Excel spreadsheets to a variety of vendor-based solutions. There was no single cohesive approach to provider data management or location management,” Malone says.
Most healthcare systems, he notes, even without an integrated network, are made up of a series of hospitals that have their own associated practices. “That gets complicated over a wide geography. Who would maintain the list of locations, the manager of those locations, phone numbers, services they deliver, and key contacts? [Previously], we would maintain it as best we could on our own within that given entity and that geography. But we had no complete look at our location and our resource management,” Malone admits.
What’s more, within the UNC Health Care ecosystem exists advanced medical homes, with the core belief that its primary care providers partnering with its specialists will deliver the best care for patients, says Malone. “We put a focus on developing medical neighborhoods that can deliver those services: keeping the patients at home or close to their home within a provider network, and conveniently geographically located,” he says.
For Malone, that means that one of the health system’s advanced medical homes can transparently see who the providers and what the services are located around the patient. Then, the patient will be easier to manage. “To be able to quickly retrieve the results, the feedback, the consults, and close the loop on the services that I am seeking for my patient, is quite valuable,” he says. “So basically, if I make a referral, I want to know that it happens in a timely manner and I want the results back to me in a way that’s convenient to me, so I can manage the patient and close the loop, from front to end.”
But if the data infrastructure is in a fragmented and redundant state, managing that patient becomes much more challenging. “If I don’t have those point-of-care decision supports in place to help me manage that patient flow, then how will I ever get it done? How do I know who is down the street or that there are services conveniently located to the patient? How do I manage and know that network? I need a system in place to support me and making the right decision easy: getting the patient to the highest-valued provider. That’s at risk here if you can’t solve that fundamental problem.”