Building a Comprehensive Practitioner Database for New York State's Healthcare System

1. Practitioner Database ProjectNYSAMSS 2014 Annual Educational Conference Gerald M. Richmond, Jr. (Terry) Senior Associate/Deputy Director HealtheConnections Health Planning (CNYHSA) Thursday, April 25, 2014 Albany Marriott Hotel, Albany, NY 12211

2. 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

3. 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.

4. 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.

5. 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

6. 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)

7. 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?

8. 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

9. Advisory Structures,Stakeholder Involvement, • Advisory Committee • Data Workgroup • Platform Options Group • Subject Matter Advisors • User feedback from survey and other means

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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)

16. 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

17. 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

18. Council for Affordable Quality HealthcareCAQH 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

19. 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

20. 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

21. 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?

22. 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

23. 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

24. 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.

25. 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)

26. 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

27. 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)

28. 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

29. 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

30. Meet Needs of Multiple Stakeholders

31. 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

32. 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.

33. Build On/Relate to Other Initiatives Should leverage state acquisition/investment in internal/external sources and systems • Licensure/Registration • Physician Profile Redesign/Workforce Surveys • Professional Conduct • All Payer Database • Medicaid Information Systems • NYeC/HIT/Info Exchange • Health Benefit Exchange Should anticipate potential future uses (e.g. State Health Innovation Plan, DSRIP, health plan directory requirements, credentialing)

34. 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

35. Could help with database financing and ensuring completeness and accuracy Illustrative Example • Research 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 State • If 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.

36. 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

37. Data Validation/ Master Data Management Services Credential Verification Process

38. 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)

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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?

45. Thank you HealtheConnections Health Planning (CNYHSA) 109 South Warren Street, State Tower Building Suite 500 Syracuse, NY 13202 (315) 472-8099 Terry Richmond, Deputy Director/Senior Associate Project Director, Practitioner Database Project gmrichmond@healtheconnections.org