PRACTITIONER DATABASE PROJECT

NYSAMSS 2014 Annual Educational Conference

Gerald M. Richmond, Jr. (Terry)Senior Associate/Deputy Director

HealtheConnections Health Planning (CNYHSA)

Thursday, April 25, 2014Albany Marriott Hotel, Albany, NY 12211

Overview Study Background Goals and Objectives Work Program/Stakeholder Involvement Work of Data Group Interaction with Vendors and Others Work of Advisory Committee Study Recommendations Questions/Discussion

The Problem The State did and still does not have a comprehensive

physician or mid-level practitioner database. The current process of gathering information is

arduous and complicated requiring users to examine multiple local, state, and national data sources, often followed by surveys and telephone contacts with offices, hospitals, and other entities.

This process has not really changed in 40+ years The need for a common, integrated database is

greater than ever, particularly as we deal with reforms that will increase the demand for primary care and other services.

Background Proposal made to New York Health

Foundation to create a regional database as a demonstration pilot

Response was request to propose a planning project for the whole state

Project was funded and kicked-off in July 2013.

Project Objective:Develop Plan for a database that:

covered physicians, physicians’ assistants, midwives, and nurse practitioners (100,000-120,000 individuals)

integrated information from multiple sources provided accurate, validated, geographically-based

information on number of practitioners, associated practice group(s) and office locations; specialization and sub-specialization; professional education and advanced training; age, major professional activities, and other practice characteristics

meets the needs of a wide range of users

Had Desired Capabilities would be searchable, queryable, and able

produce simple tables and tabulations. could be downloaded and readily incorporated

into user projects had geographic and other algorithmic fields that

support data analysis and file linking had internal validation and/or error correction

capabilities able to incorporate or receive user input (e.g.

updates and feedback on the status of practitioners)

We were challenged to find answers to the following questions

Which data elements should be included? Which data sources should be used? Are supplemental fields needed for analysis? How can related work be incorporated? What kind of platform should be used? How can we ensure that data is current and valid? How to handle difficult technical issues (multiple office

locations, hospital appointments, specializations, professional activities, conflicting information)

Where should the system be housed or operated (state government, collaborative, non-profit, private vendor)

How can data be shared with the widest range of users?

And to Address the Challengesthrough the Work Program,

Assess User Needs Catalog/Evaluate Potential Data

Sources Assess Platform Options and Other

Design Issues Recommend Strategy for

Implementation

Advisory Structures,Stakeholder Involvement,

Advisory Committee Data Workgroup Platform Options Group Subject Matter Advisors User feedback from survey and

other means

and Collaboration with Others

Coordinate with related DOH projects

Reach out to others who have done or are doing related projects

Make use of Center for Health Workforce Studies expertise

Consult with HRSA/National Center for Health Workforce Analysis

Stakeholder Involvement NYSDOH Offices (Primary Care, Health

Insurance, Quality and Patient Safety, Public Health Practice, Information Technology Transformation, Professional Conduct)

NYSED Office of the Professions, Board of Regents, and professional boards

Center for Health Workforce Studies Regional health planning agencies

and quality improvement collaboratives

Economic development councils, county & regional planning agencies and development organizations

County health departments Rural Health Networks/NYSARH

RHIOs/NYeC/HI-TECH/SHIN-NY Entities with IT expertise Area Health Education Centers Health Advocates and disease

associations (e.g. Cancer Society, Arthritis Foundation)

Hospitals, Health Centers, and other providers of health care

Provider and Insurer Associations Foundations which support health

related projects Consultants and private sources of

Information Schools of Public Health, Medical

Schools, and other institutions involved in provider training and research

Time Frame: July 2013 – April 2014

Data Work Group (4+ meetings)September 2013 – January 2014

Platform Options Group (Did not meet)January – February 2014

Advisory Committee (4 meetings)January – April 2014

Final Report: April 2014

Data Group Involved 12 “experts” experienced in working with

practitioner data plus 6 resource advisors Participating stakeholder organizations included:

NYSDOH (Primary Care and Health Systems Development, Health Insurance, Quality and Patient Safety, Professional Conduct)

NYSED Center for Health Workforce Studies Health Systems Agencies New York City Health Department Provider Organizations (HANYS, GNYHA, CHCANYS, MSSNY, and

NYS American College of Physicians) Treo Solutions

Data Group Accomplishments Completed data set documentation and

development of a comparative matrix Distributed and analyzed a stakeholder survey Make contacts with vendors, experts and

professionals working on other state projects (Profile redesign, APD, Medicaid MMIS RFP, NYeC effort to purchase physician data, Education Department processes and MIS needs)

Reviewed national standards and minimum data sets

Developed recommendations regarding data items, preferred sources, data validation, etc.

Sources Reviewed by Data Work Group

New York State: DOH Profile, Center for Health Workforce Studies Registration Survey, NYSED Licensure Files, Medicaid Managed Care Directory, Medicaid Provider Enrollment Data

Federal: National Plan and Provider Enumeration System (NPI), Medicare Enrollment Files and PECOS, National Provider Data Bank, DEAA, TRICARE (Dept of Defense)

Association: CAQH, AMA Profile, Medical Society of the State of NY (MSSNY), Federation of State Medical Boards (FSMB), American Board of Medical Specialties (ABMS)

Commercial: SK&A, Treo Solutions, Maximus, ZocDoc, Health Market Science, FolioMed, Medical Marketing Services (AMA License), MEDICAlistings, Medical Mailing Services and similar services (USAData, Physicians Lists, DoctorListPro)

Made ongoing efforts to understand project relationship to other initiatives

Physician Profile Redesign Innovation Plan/Primary Care

Development All Payer Database Medicaid Information System RFP NYeC/HIT/Info Exchange Health Benefit Exhange

Other Recommendations Should incorporate/reflect national standards for

provider directories but not be inhibited by them Should use Profile or other system to collect

data that cannot be gathered from other sources Should have indices or other mechanisms to

permit user to understand the relationship between practice locations, corporate structures, hospital systems, IPAs, ACOs, and managed care networks

Should have robust validation, standardization, and error correction processes

Council for Affordable Quality Healthcare CAQH Universal Provider Datasource (UPD)

Demographics, Licenses and Other Identifiers (including NPI)

Education, Training and Specialties Practice Details – Sites of Service, Days and

Hours, Contact Information Billing Contact Information Hospital Affiliations Malpractice Liability Insurance Work History and References Disclosure Questions Images of Supporting Documents

Uncovered Interest in Credentialing

Tried to assess future of CAQH data use under New MMIS RFP. Set up meeting with OHIP/Medicaid representatives

Discovered DOH had interest in exploring potential for some form of uniform/streamlined state system

Saw this as opportunity to discuss potential role of CAQH UPD in the data base

Invited CAQH and DOH representatives to discuss issue at February Advisory Committee meeting

Also met with Greater Rochester IPA to assess their experience with UPD data

Advisory Committee Involved 22 representatives from a

broad set of governmental and non-governmental organizations

Chaired by Caleb Wistar, Associate Director, Division of Workforce Development, Office of Primary Care and Health Systems Management

NYS Association of Medical Staff Services represented by Dorothy Zelenik

Committee Charged to AddressSystem Development Issues

How should it be related or connected to other data systems and functions?

Where should the system be housed or operated? How should it be supported? How can data be shared with the widest range of

users? Should different classes of users or privilege

levels be established? Are legal and regulatory changes needed? What should the next steps be?

Expressed interest in Credentialing and what was happening in other States

Credentialing Systems Massachusetts (Non-profit, plan-created entity,

Uses Aperture as CVO, partners with CAQH) Washington State (Complex Structure, Uses

Medversant as CVO, partners with CAQH) Arkansas (State is its own CVO)

Common Credentialing Application Forms (19 States) Florida, North Carolina, Colorado, Illinois, Maine Minnesota, Oklahoma, Maryland, West Virginia

Heard more aboutCredentialing Verification Systems

Heard from Lori Burgiel, Executive Director, Health Care Administrative Services (HCAS)

HCAS was established by Mass Association of Health Plans as a non-profit entity to operate the program.

Program uses Aperture Credentialing as its CVO, partners with CAQH for data submission, serves non-public payers.

Also reviewed NYS interest in credentialing with representatives from the Office of Primary Care and Health System Management

Explored Potential Uses of CAQHUniversal Provider Datasource (UDP)

Committee met with Sorin Davis, UDP’s Managing Director. Understand that Christine Stroup from CAQH will be speaking tomorrow.

CAQH’s Universal Provider Datasource (UDP) is used to support credentialing processes across the nation including those of the NYS Medicaid program, major insurers, hospital systems and provider organizations such as IPAs.

CAQH expressed interest in exploring broader uses of its database.

Reviewed other forms of State Involvement in Practitioner Databases

Health Care Exchange Directories (Colorado) All Payer Databases (Most States) Consumer Oriented Physician Profile Systems

Many states have these systems. Most are modeled after New York State’s System.

Virginia is one of few states that posts a downloadable file Most states do not allow for data downloading. North

Carolina, for example, has a profile system, but it is not part of state’s workforce analysis system which relies on licensure and survey data, much like NYS at the present

Self grown database with Quality Measures (Maine)

Reviewed data collected forNYS Physician Profile (Art 2995-A) criminal convictions actions taken against the licensee and current license limitations loss or involuntary restriction of hospital privileges or failure to renew medical malpractice court judgments, awards, and settlements medical schools attended and date of graduations; graduate medical

education; current specialty board certification and date of certification; dates admitted to practice in New York state; names of hospitals where the licensee has practice privileges; appointments to medical school faculties; responsibility for GME publications in peer reviewed medical literature professional or community service activities or awards location of practice setting and names of other practitioners at setting translating services that may be available at the location participation in Medicaid, Medicare, other state or federal insurance

programs participation in other health care plans

Made Effort to UnderstandVendor Capabilities Data Validation

Mark Biddle (Enclarity, a LexisNexis Company) Josh Schoeller, VP, Chief Solutions Architect

Master Data Management Services Joe Kelly (Treo Solutions)

Other Services Special Datasets (eg. SK&A, Health Market

Science) Taxonomies Unique Applications (e.g. ZocDoc)

ExporedPotential Hosting Options creation of a state sponsored system such as SPARCS used for

hospital discharge data. Such a system could be run by NYSDOH which oversees the provision and quality of health care, NYSED which is responsible for licensing or joint venture of both departments

component of an existing or yet to be developed system such as the All Payer Database, an HIE structure such as NYeC, NYS Health Insurance Marketplace, or a statewide credentialing system

creation of a new statewide collaborative that involves governmental and non-governmental stakeholders

use of an existing independent non-profit entity with workforce expertise such as the Center for Heath Workforce Studies (CHWS)

contract with a proprietary entity that specializes in practitioner databases and provider directories

A combination of one or more of the above approaches

Project Recommendations Should meet the needs of a broad set of stakeholders Users with different skill sets and interests should be readily able

to access information Its development should build on other initiatives Will need to incorporate data from multiple sources of information Should have robust mechanisms for data validation and

standardization Should be operated as a state sponsored system Existing fiscal resources should be used, in part, to support it Legal and regulatory changes will be needed A process to create the database should be initiated ASAP Should be expanded to include dental and behavioral providers

Meet Needs of Multiple Stakeholders

Data Elements Should Include: Personal Information (Name,

Birthdate, Sex) Professional ID Numbers Professional Education GME/Advanced Training and

Certification Specialization and Sub-

specialization NPI Taxonomy Code Group/Practice/Corporate

Information ACO/IPA Associations Practice Location(s) and

geographic identifiers

Practice Characteristics (Primary Professional Activity, Work Hours/Days, FTE, Accept New Patients, PCMH status)

Practice Volume & Productivity Language/Translation Capability Insurances Accepted Accept Medicaid/Medicare Hospital Appointments Work History Malpractice Insurance Teaching Activities Memberships/Publications Sanctions/Actions/Convictions/

Restrictions

Users with different skill sets and interests should be readily able to access information

The database should be searchable, able to produce simple tables and tabulations, have standard reports and analyses, downloadable, and readily incorporated into user projects

It should be fully documented, able to receive user input, and employ administrative procedures that do not inhibit access to data.

It may be necessary to limit access to some items. This issue could be addressed by creating different classes of users;

access tools, data screens, and downloadable datasets. Responsibility for making determination should be given to an

advisory committee rather than defined precisely in law or regulation. The ultimate goal of the database, however, should be to

promote access to as many fields as possible.

Build On/Relate to Other Initiatives

Should leverage state acquisition/investment in internal/external sources and systemsLicensure/RegistrationPhysician Profile Redesign/Workforce SurveysProfessional ConductAll Payer DatabaseMedicaid Information SystemsNYeC/HIT/Info ExchangeHealth Benefit Exchange

Should anticipate potential future uses (e.g. State Health Innovation Plan, DSRIP, health plan directory requirements, credentialing)

Should consider role it might play in supporting credentialing

Some Options include: Uniform/Common Form Common/Shared Database (e.g. CAQH UPD) Global or Uniform Credentialing Process

States which have uniform processes include: Massachusetts, Washington, and Arkansas

Is a complicated issue, more work is needed

Could help with database financing and ensuring completeness and accuracy

Illustrative ExampleResearch suggests that physicians have an average of 12 credentialed relationships and in the future will need to be re-credentialed every three years.There are approximately 90,000 active physicians in New York StateIf one third need to be re-credentialed each year, a charge of $30 per verified credentialed data set, for example, could raise as much as $10 million per year.

Should Use Multiple Sourcesof Information

NYSDOH Redesigned Profile Sources NYSED Licensure/Registration files Specialty/Training Information (FMSB, ABMS, or alternative) CHWS Survey questions Self Reported items which cannot be obtained elsewhere National Provider Data Bank

CAQH UPD (Credentialing related data source) Proprietary Sources (e.g. SK&A, Health Market Science)

which have indices showing relationship between practitioners, service locations, practice/corporate structures, hospitals, IPAs, etc.

National Plan and Provider Enumeration System (NPI) Other: All Payer Database, Medicaid Information Systems

Data Validation/

Master Data Management

Services

Credential Verification

Process

Should have robust mechanisms for validation and standardization

Master Data Management (MDM) services Data governance/intake/integration Master indexing/coding Remediation/enhancement Data storage/warehousing/analytics

Data validation and error collection mechanisms Validated sources vs. validation services Capability to address issue from a national perspective

Credentials Verification Organization services (CVO)

Should be hosted by New York State

creation of a state sponsored system such as SPARCS used for hospital discharge data. Such a system could be run by:

NYSDOH which oversees the provision and quality of health care

NYSED which is responsible for licensing, a joint venture or cooperative program of both departments a joint venture or cooperative program that also includes the

Department of Financial Services. Should have advisory committees representing key non-

governmental stakeholders to guide: system development policies and practices regarding data access the selection of vendors the overall design of the system.

Should use existing fiscal resources, in part, to support the database

Current resources used to collect and analyse provider data include: Medicaid, Professional Conduct, DOH physician profile, NYeC, All Payer Database, NYSED

Other potential sources include: Assessments and user fees (e.g. for credentialing) State and federal budget appropriations Funds related to implementation of the Accountable

Care Act including the Health Benefits Exchange Demonstration program funds from Federal, State,

and/or foundation sources Licensing and registration fees

Legal and Regulatory Changeswill be needed - Examples

NYS Profile Law Eliminate provisions which make reporting of certain

items optional (e.g. practice location) Mandate collection of more items or cover reporting

requirement through regulation or policy Broaden purposes of system to include other

professionals Allow workforce survey questions to be shared Create framework for support for credentialing Empower or permit data access provisions to be

developed by advisory structure, not through precise definition in law or regulation

Should initiate process to create the database as soon as possible

Promote Plan/Expand Stakeholder Buy-in Create Informal Leadership Team to work on general

approach for implementation Recommend/Request that a formal state supported

process/structure be established to refine and carry out the plan. Issues to be addressed:

Establishment of advisory structures Regulatory Requirements plan Information Sharing, data acquisition, technology plan

Establish special task force on credentialing to explore interest of Medicaid, insurers, hospitals and other providers

Goal: Have a formal plan in place by the end of the year

Project shows that collaboration with others, although not easy, is important

Coordinated with related DOH projects Reached out to others who have done

or are doing related projects Consulted with Vendors and Other

Experts Made use of Center for Health

Workforce Studies expertise Consulted with HRSA/National Center

for Health Workforce Analysis

Questions/Discussion How much interest in a database

or some kind of broader system that would support credentialing?

Who should be involved? Provide Leadership?

What functions should it perform? How might it be supported?

Thank you

HealtheConnections Health Planning

(CNYHSA)109 South Warren Street, State Tower Building Suite 500Syracuse, NY 13202(315) 472-8099

Terry Richmond, Deputy Director/Senior AssociateProject Director, Practitioner Database Projectgmrichmond@healtheconnections.org