1 IBM Software Group, Information Management Healthcare Provider Registries: Reduce Health System Costs, Increase Efficiencies, Improve Care
2 2 Provider Registries: Reduce Health System Costs, Increase Efficiencies, Improve Care Contents 2 Delivering Value Through Managing Provider Data 3 Provider Registries Defined 4 Determining Which Type of Provider Registry is Needed 4 How Provider Registries Fit Within a HIE Architecture 6 Organizations Benefit From IBM Initiate Provider Software 6 IBM Initiate Provider Delivers Accurate Provider Data for Information Sharing Incorrect healthcare provider data is costly. In the U.S. alone, it costs the healthcare system $26B each year. The costs are a result of: Returned mail due to providers moving or changing affiliations Delayed payments from incomplete or inaccurate information Dissatisfied providers who no longer refer patients Incorrect and duplicate records that must be located and fixed manually Fines from regulatory agencies from lack of compliance Redundant testing resulting from limited data sharing across acute and ambulatory providers Several entities are impacted by incorrect provider data, including: Federal agencies that need to aggregate provider data across multiple agencies to detect and reduce fraud, and more efficiently manage benefits eligibility processes State and provincial governments that want to combine and provide access to data across integrated delivery networks (IDNs), states and provinces to reduce social services fraud, better coordinate benefits, support clinical results routing and payments, and reduce capital and operating costs IDNs or other health systems that need to make a comprehensive view of provider data available across various financial, electronic medical records (EMRs) and other internal systems to comply with regulatory credentialing requirements, support electronic referrals, and ensure that results are sent to the correct provider Some of these entities already understand the benefits of deploying provider registries to uniquely and consistently identify providers, and recognize why this need will increase in the future. The interest in providing easy access to accurate provider data is growing worldwide and includes many clinicians, health plans, public health agencies, standards bodies, states, provinces, regions and countries. This white paper provides an overview of the value of managing provider data, describes individual- and organizational-level provider registries, gives details about what to look for when implementing a provider registry, profiles some organizations already using provider registries, and presents an overview of the IBM Initiate Provider solution and how it can be used to create a master virtual repository of provider information by integrating trusted data sources from internal and third party systems. Delivering Value Through Managing Provider Data Provider registries enable better communication between everyone involved in the health delivery network, including physicians, nurses, hospitals, nursing homes and public and private payers. This communication helps improve health system efficiencies, enhance collaboration, reduce errors, increase referrals and lower costs. Managing provider data delivers value in the following areas: 1. Enhances data accuracy and administrative efficiencies. Out-of-date provider information is often stored within various systems throughout the healthcare ecosystem and results in processing errors, payment delays and other
3 Healthcare 3 administrative problems. For example, a claim is filed that includes an incorrect physician credential ID from an out-of-date record and Medicare rejects the claim. This results in increased administrative costs for researching and correcting the data and resubmitting the claim, and delayed payments to physicians, which can cause provider dissatisfaction. With a provider registry, healthcare organizations can access accurate provider information, resulting in fewer administrative errors, reduced costs, more timely payments and increased provider satisfaction. 2. Improves and personalizes provider communications. The rapid adoption of electronic technologies, including the use of personal communication devices, has resulted in the need to communicate with providers via multiple methods and locations. Instead of receiving all communications at one location, most providers want to receive information on different topics in different ways. For example, a physician may want to receive patient updates or lab results at their EMR account at the hospital, and referral requests from other physicians through their office account. On weekends or other days off, they may want to be reached by a third method. Provider registries improve interactions and enable provider communications to be personalized easily for how each individual works by including details about the locations of a provider, where and when they treat patients, and what types of information they want to receive for both clinical and business purposes. 3. Increases provider satisfaction and referrals. Health systems that deploy provider registries are easier for providers to work with, make them more productive and improve their ability to deliver patient care. Since providers are more satisfied with their interactions, they increase referrals, more patients return for treatment, and revenues increase for those health systems. Referring providers, which are a significant source of revenue for a health system, can contribute millions of dollars in referral business annually. Provider Registries Defined There are two different types of provider registries individual and organizational. An individual level registry includes information about physicians, nurses and other providers. An organizational-level registry contains entity-level information about clinics, hospitals, practices, etc., and technical information about consuming and contributing systems. These two registry types work together to give the best information about how to interact with individual providers by associating them with the practices, clinics and health systems where they are employed, affiliated or refer patients. Provider registries can be used in a number of ways including to exchange information between clinics or between hospitals or labs and clinics; to issue public health alerts; and to supply information about an individual provider s credentials. Individual provider registries allow queries across multiple levels: licensed caregivers, authorized state and public health resources and individuals involved in health information exchange transactions, including support and administrative staff. The main purpose of an individual provider registry is to support the exchange of clinical documents between providers. Organizational provider registries support the directed exchange of information between healthcare providers, health information organizations, health plans and public health agencies. The main purpose of an organizational registry is to make information about an entity s information exchange capabilities and security credentials available and easily discoverable by outside querying entities. Organizational registries may be deployed locally or regionally, but eventually most health systems will also want to support state level and federal level exchanges. Health systems should model their organizational provider registries to align with a national registry representation so that they can eventually present information and represent their organizations within registries maintained by certified registers.
4 4 Provider Registries: Reduce Health System Costs, Increase Efficiencies, Improve Care For more information about the types of data contained in each type of provider registry, see the diagram below. Individual Provider Attributes Personal Information Locations Credentials & Identifiers Relationships Information Sharing Provider name Provider type Gender Languages spoken Emergency contact info Address for primary, billing & mailing locations Phone & fax Specializations National credentials State/regional credentials Internal system IDs Program reinbursement IDs Affiliated with Refers to Employed by Member of Information exchange capabilities & preferences by type and locations Organizational Provider Attributes Organizational Entity Information Locations Credentials & Identifiers Relationships Information Sharing Legal entity name Other known names Organization type Status Address for practice/ service, Billing & mailing locations Phone & fax Location contact person Specializations National credentials State/regional credentials Global Location Number (GLN) Program reinbursement IDs Affiliated with Referrals from Employees Information exchange capabilities & preferences by type and locations Web service & certificate URLs Determining Which Type of Provider Registry is Needed Most organizations will deploy an individual provider registry first before implementing an organizational-level registry. Individual registries are easier to construct and maintain than organizational registries because much of the data is already contained within various systems across the health system and just needs to be brought together. However, information about non-affiliated providers is more difficult to assemble and often requires manual collection. Nonetheless, individual registries can be deployed relatively quickly to deliver immediate benefits across the enterprise. If deployed alone, an individual registry will not provide as much value to a health system over time compared to the value realized when individual and organizational provider registries are deployed together. An organizational provider registry offers access to a single, high quality system that contains information critical to interact with other health systems. Fortunately, organizational registries are created by summarizing and linking together known information about individual provider locations and affiliations. Organizational registries can be expanded to include the types of clinical information requests that a location can fulfill, such as requests for patient care summaries or electronic referral capabilities. They can also be augmented with electronic communication information and locations of encryption certificates, and enhanced to analyze other types of information that are not yet part of the system or the health network. How Provider Registries Fit Within a HIE Architecture Provider registries supply comprehensive information about providers and the places where they deliver care to increase health system efficiencies, enhance collaboration, lower costs and establish a foundation for future physician quality reporting that is necessary for Accountable Care Organizations. What to Consider When Implementing a Provider Registry Health systems deploying provider registries need to ensure that the technologies they select meet their immediate and future requirements. Provider registry technologies should include the following capabilities. 1. Support for individual and organizational provider registries in a single platform. To enable efficient implementation and streamline ongoing maintenance, provider registry technologies should support the same architecture for both individual and organizational provider registries. Since most organizational provider registry data is generated from existing individual provider data, and changes and updates to provider data usually need to be applied to both registries, having them deployed on the same architecture improves efficiencies, and reduces maintenance errors and costs.
5 Healthcare 5 For example, if a group of clinics is acquired by a health system and there is a new owner and a new EMR system to communicate with, it is much more efficient to administer that change in the organizational record. When organizations and individuals exist within the same infrastructure, the change can be handled with one entry into the organizational registry that is automatically reflected in each individual provider s record. 2. Robust matching technologies and data stewardship tools. A reliable and sustainable provider registry must include powerful matching technologies and flexible data stewardship tools that enable health systems to create a unique set of providers by collecting and matching data across source systems. Provider registry technologies should support the following four steps to ensure that provider data is collected and maintained accurately and efficiently. Eliminate duplicate data with capabilities that locate dual entries for the same individual based on a number of characteristics. Automatically and manually link provider records together across source systems so that changes can be managed more efficiently. Leverage individual provider registry data, to create an organizational-level registry, including the ability to augment information not provided from source systems. Link individual and organizational provider registries together using as many relationships as are necessary to support all internal and external use cases, such as employment, referral or admitting relationship affiliations. 3. The ability to distinguish between internal and external data exchange needs. A comprehensive provider registry should be capable of supporting both internal and external needs while protecting the privacy of individual provider information such as their tax identification number, social security number or home address. Provider registry technologies should be able to maintain accurate contextual information about what information can be shared with internal systems and what information must be protected when sharing with outside entities. 4. A flexible architecture that enables data exchange and supports evolving standards. The types and nature of data required to support provider registries will continue to grow and change. Provider registry technologies need to have a flexible data model that can handle evolving priorities and standards including the movement toward patient-centric medicine, and the expansion of provider networks to support physician outreach and electronic referrals. This will require the ability to capture real world relationships between provider, organizations, and eventually, patients. Over time, organizational provider registries are expected to expand beyond physical and legal location data to include departments and floors, and levels of communication that take place with providers across health systems. The notion of an individual provider is also likely to become broader than someone who gives care to encompass virtual groupings of providers, who are connected by a patient to create care team groupings, which can be useful for Accountable Care Organizations and medical home care. It is important for registry technologies to have flexibility in terms of how different objects can be modeled, additional data is captured, and dynamic links are established between different levels, in order for provider registries to be able to easily adapt to changing data demands.
6 6 Provider Registries: Reduce Health System Costs, Increase Efficiencies, Improve Care 5. A secure location where provider data can be viewed, maintained and consumed. Provider data originates from many systems and processes and has traditionally been passed around an organization through phone calls and s. It is important for provider registries to give users an easy way to efficiently view, add and edit the provider data they need to support their specific business or clinical processes. For example, when a new provider is brought onboard in a health system, they typically go through a detailed credentialing process and are set up in the human resources system. A wealth of information is captured during that onboarding process, but that information is not automatically shared with, for example, the laboratory system administrator so that the new physician can view lab results. Provider registries should provide access to new or changed provider information to keep information flowing throughout the health system. 6. Electronic collaboration tools that easily identify new provider information and issue change notifications. Different personnel within the health system rely on varying pieces of provider data to do their jobs. It is important for provider registry technologies to include a mechanism that allows users to quickly identify new and changed information that is relevant to their specific job, and quickly disregard the information that does not matter to them, to support more efficient provider interactions. For example, users responsible for maintaining the electronic signature system only need to respond to new provider hirings or changes to electronic certificates, and those individuals responsible for the fax delivery system only need to take action when fax numbers change. Organizations Benefit From IBM Initiate Provider Software Several health systems are already using IBM Initiate Provider to create individual-level and organizational-level provider registries. Below are descriptions of how Baylor Health Care System, the Canadian province of Nova Scotia and New Zealand are benefiting from IBM Initiate Provider deployments. Baylor Health Care System wanted to create a single, enterprise-wide system for managing credentials that presents complete details about each provider in a centralized location, instead of continuing to store and manage credentials within silos at all 12 facilities. Baylor was already using IBM Initiate Patient master patient index software for patient identification and, after conducting a competitive review, selected IBM Initiate Provider to create a single source of truth for provider data, manage data centrally and communicate information out to all entities. IBM Initiate Provider has enabled Baylor to save time and reduce costs by eliminating manual methods for updating provider records, processing billing information and entering provider information during patient registration. In addition, with IBM Initiate Provider, Baylor is able to apply enterprise-wide data governance strategies to help ensure compliance with provider certification requirements, and rapidly deliver test results to providers. In 2008, the Canadian province of Nova Scotia selected IBM Initiate Provider and IBM Initiate Patient software to provide the foundation for its province-wide patient and provider registry systems that link provider identity data, from multiple sources, to EHR systems and patient records. IBM Initiate Provider serves as the source of identity validation, links provider data from Nova Scotia s College of Physicians and Surgeons, College of Registered Nurses and College of Pharmacists, and helps coordinate EHR source system identifiers and changes across receiving patient and provider systems. Nova Scotia also uses IBM Initiate Provider along with IBM Initiate Patient to establish relationships between patients and providers, and enable authorized users to access and exchange clinical records. A new national health identity solution, to be deployed throughout New Zealand by 2012, is using IBM Initiate Patient and IBM Initiate Provider software to help meet its
7 Healthcare 7 goals of ensuring that shared or exchanged health information is accurate, protected and trusted. IBM Initiate solutions will provide the New Zealand Health Identity Program, with a secure, robust Health Identity platform for patients and providers as part of the interoperable infrastructure that supports its person-centered care goals. In the future, the country plans to enable New Zealanders to access their own electronic health records. IBM Initiate Provider Delivers Accurate Provider Data for Information Sharing IBM Initiate Provider enhances communications across the health delivery network to improve efficiencies, reduce errors, increase revenue and lower costs. With IBM Initiate Provider, health systems can deploy both individual and organizational provider data within a single platform. The platform models, matches and links across individual and organizational providers, while enabling both registries to be managed independently. IBM Initiate Provider utilizes highly accurate probabilistic matching capabilities, optimized for data about both people and legal entities, to identify providers even when information about them is sparse. Industry-leading data stewardship capabilities allow health systems to improve the data quality of the provider registry through automatic or manual remediation. IBM Initiate Provider protects the privacy of provider information while enabling flexible information sharing. Health systems can define and authorize which attributes or levels of information can be shared with each specific internal and external entity by leveraging key data relationships to identify the true ownership of each data element. Even more value can be gained from further insights into provider referral patterns and care team structures that can be obtained when IBM Initiate Provider is extended to identify and use relationships with patient data that resides in IBM Initiate Patient. With its flexible data model, IBM Initiate Provider enables health systems to add data elements or relationships between individuals and organizations to registries. As new data standards, internal requirements or data sharing objectives arise, new data types can be added within a registry, instead of incurring the costs and disruptions of extending closed source systems. IBM Initiate Provider improves collaboration and information sharing between administrative and clinical system owners by offering authorized users a single location to find, create and maintain provider data. The solution enables users to quickly locate providers, add physician communication preferences and use that information to route patient updates directly to new providers. When provider data is updated or added, the software makes it easy for teams to identify which changes are relevant to the processes they support and more easily collaborate with their team members. IBM Initiate Provider summary pages profile change histories about specific providers and highlight data elements that have been modified, to save time and improve workflows. Health systems that deploy IBM Initiate Provider to create individual and organization provider registries will increase data accuracy and administrative efficiencies, improve provider communications and increase provider satisfaction and referrals, while laying the foundation for the broader information sharing and quality care initiatives of the future.
8 1 Provider Registries: Reduce Health System Costs, Increase Efficiencies, Improve Care About IBM Initiate Provider IBM Initiate Provider enables healthcare organizations to create a single trusted view of care providers and provider organizations to improve data quality and access for targeted and consistent information delivery. The solution establishes a master provider index by linking provider records across disparate systems and incorporating third party data from marketing, insurance and licensing sources. In tandem with IBM Initiate Patient, IBM Initiate Provider offers the ability to visualize and leverage data relationships between patients and providers. About IBM Information Management solutions for healthcare The journey to sustainable healthcare systems starts with a smarter approach to information sharing. IBM Information Management solutions for healthcare deliver master data management (MDM) capabilities that help stakeholders to connect and share clinical information accurately, securely and cost-effectively. IBM Initiate Patient and IBM Initiate Provider are a trusted foundation for information sharing around the globe; they help healthcare organizations improve collaboration to increase quality of care, streamline compliance and increase patient and provider satisfaction. For more information Contact your IBM sales representative or IBM Business Partner, or visit us at: www-01.ibm.com/software/data/ infosphere/provider/ Copyright IBM Corporation 2012 IBM Global Services Route 100 Somers, NY U.S.A. Produced in the United States of America January 2012 All Rights Reserved IBM, the IBM logo, ibm.com and Initiate are trademarks or registered trademarks of International Business Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with a trademark symbol ( or ), these symbols indicate U.S. registered or common law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on the Web at Copyright and trademark information at ibm.com/legal/copytrade.shtml Other product and service names may be trademarks of others. Please Recycle IMW14574-USEN-04