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providers change locations, retire or pass away yearly. Additionally, 90 percent of all physicians are affi liated with one or more hospitals and 30 percent change their affi liations.


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


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The importance of pro- vider information and the extent of challenges govern- ing it necessitate a holistic and a systematic approach. It consists of three key steps:


Step 1: Identifi cation and attribution. In most payer and provider settings there are multiple, internal and external sources for provider information. A fi rst 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 proba- bilistic algorithms to identify, match and link provider data records to create a “Golden Provider” ID index. The resulting index is leveraged for duplicate manage- ment 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 per- formance profi le 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 es- tablished 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 func- tion as described above, it must have the following core capabilities: 1. Highly fl exible 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. Confi gurable business rules – The use of confi gu- rable 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-fl ow automation – This is needed to connect


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all the key provider maintenance processes. It decreases administrative costs while increasing accuracy. Best practice implementations of work-fl ow 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 diffi cult for a payer or provider organization to make the informa- tion 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 in- corporates the periodic comparison of your provider information (demographic and credentialing data) with external provider master reference fi les to ensure its currency and completeness. The comparison process leverages trust-based rules to accept any differences with the master provider reference fi les. Resolution work fl ows 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 ac- curacy of provider information takes on an even greater importance as state-based exchanges begin to come on- line 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 suffi ciently support provider informa- tion operations. How payers and provider organizations approach provider information management initiatives could mean the difference in how successfully these enti- ties compete in their markets.


HMT HEALTH MANAGEMENT TECHNOLOGY November 2010 25


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