Case Studies

December, 2011

FolioMed’s Provider Data as a Service expertise solves critical database challenges and creates a strategic asset for world class hospitals.

INTRODUCTION: Over the last few years FolioMed has been called upon to solve massive database challenges for several of the top health care organizations in the country. With unique database elements ranging from 50,000 to almost 100,000 records, these world class institutions required a high level of database management expertise, staff dedicated to the unique issues in the provider database industry and FolioMed’s custom developed database logic tools and  verified provider directories.

Growing Importance of Provider Databases: The wide range of important issues associated with provider directory databases are rapidly gaining greater attention through the efforts of Federal work groups designing interoperable medical record capabilities.

The Provider Directory Initiative under the work of the Office of the National Coordinator for Health Information Technology focus on identifying the requirements, core data set,standards, and certification criteria that will support querying of Provider Directories for health information exchange.

With this Federal work as a backdrop, leading medical institutions  are now viewing their provider directories and market area provider demographic files as key strategic assets in driving efficient transactions, physician communications, and the coordinated care of patients.

From the perspective of the health care Medical Information System executive, if the massive Electronic Medical Record, Electronic Health Record, or Health Information Exchange investments are going to prove effective, the challenges associated with creating and maintaining high quality, verified provider databases must be well understood and resolved. The demands associated with electronic medical record initiatives, HIPAA laws, and physicians’ demands for accurate real time data has increased the challenges for every health care MIS department.
Leading health care executives are viewing these new challenges as an opportunity to turn their provider directory into a true strategic asset.

“ The provider directory database was never a priority like maintaining the clinical systems. Yet, it quickly became a customer service nightmare given the new expectations of EMR and real time physician communications. The bad data challenge is what I call an iceberg problem; you can’t see the whole issue from inside the organization. We’re turning an ongoing headache into a strategic asset for MIS and the hospital.”

MIS Director, leading healthcare organization

FolioMed’s 35 years of expertise in the provider directory business and decade’s worth of technology innovation is being used to solve these significant industry challenges.

World Class Hospital and School of Medicine: This Medical Center includes a 1,200-bed, tertiary-care teaching facility acclaimed internationally for excellence in clinical care.

This world class hospital draws patients from a large US city, across the country, and around the world. The staff of more than 3,000 full-time and voluntary physicians treats almost 60,000 inpatients and over 530,000 outpatients each year.  The medical center also has over 3 dozen clinical affiliates including hospitals, long term care facilities, and physician practices. The hospital ranked top 20 in U.S. News & World Report’s “America’s Best Hospitals” issue.

World Class Hospital Provider Database:Given the size and complexity of the organization it is understandable that the institution’s initial provider database presented to FolioMed exceeded 19,000 unique records with more than 40 fields per record.

Major Metropolitan Health Care Organization: This major metropolitan based health care organization comprises three hospitals— a 700-bed acute-care tertiary facility; a rehabilitation hospital, with 200 beds and extensive outpatient rehabilitation programs; and the 200-bed Hospital for Specialized Diseases, one of only a handful of hospitals in the world dedicated  to these specialties—plus a major School of Medicine, one of the nation’s preeminent academic institutions. The organizations provide for 36,000 patient admissions, over 1 million physician visits, and 6500 medical students, trainers and faculty each year. Affiliations are worldwide. It is ranked in the top 10 nationwide in Specialty Disease for the 20th consecutive year by U.S. News & World Report.

Major metropolitan health care organization provider database: The initial provider database presented by this institution to FolioMed exceeded 10,000 unique records with more than 40 fields per record.

“ To be honest, I was becoming a huge pain in the rear to our hospital’s MIS team. The reality of poor provider databases affected our physician referral and communication efforts on a daily basis. The perception that the entire new EMR system was a failure because of this bad data was a serious complaint among all of our physicians. It was becoming a strategic problem. “
Hospitalist at leading health care organization

The two world class health care organizations being discussed have teams of highly talented and dedicated professionals dealing with all the complexities of their MIS and IT requirements. Both organizations are spending huge sums migrating their organizations to complete electronic medical record systems.

The point of this case study is to offer a view into FolioMed’s best practices that have helped these two clients achieve significant benefits.

For the purposes of presenting this case study to the broader community of health care executives and MIS practitioners we have blended the solution steps taken by FolioMed in solving the similar provider database problems found at both institutions.

To be clear, there are customized aspects in solving each client scenario. For example, technical variables include multiple EHRs and EMRs having been adopted across these organizations or even department level systems that do not integrate to a central directory system. The perception versus reality of the existing internal data quality is a conversation that has many components. Many times, the technical discussion can be less cumbersome than the political concerns that tend to creep into any initial discussions of who is ultimately responsible for the quality of provider data in these complex organizations. The range of challenges stemming from poor provider directories continues to grow. These challenges have been ratcheted up in intensity with accumulated customer service complaints from an array of stakeholders over the last few years.

These challenges include the following issues.
1. Critical delays due to the health care organization’s inability to facilitate “real time” medical referrals between physicians.
2. Critical delays allowing seamless and accurate transportation of medical records between providers.
3. Slower payment processing resulting in more severe cash flow problems for physician practices and health care organizations.
4. Media reports of million dollar litigation costs as a result of health records being stolen or sent to the wrong location.
5. Waste and avoidable costs due to multiple internal provider databases and associated effort in gathering new or changing provider information.
6. Enormously expensive EHR or EMR system upgrades viewed as “failing” by physician stakeholders due to the problem of bad data. The perception is the system is only as good as the data it holds.

It is a steady accumulation of these “regulatory and customer service” challenges or pain points that pushed these world class health care organizations to create a long term solution and take advantage of FolioMed’s Provider Data as a Service offering.

FolioMed’s Provider Data as a Service (PDaaS) solution consists of equal parts business process logic, staff expertise, the intellectual property developed within FolioMed’s database filtering and comparison technology tool kit and the various proprietary state by state provider databases.

The five phases of Provider Database as a Service interaction with clients like these two large health care organization will always be the same. They include data matching, data normalization, data comparisons, variance reporting, and ongoing move add change and summary reporting. These phases are not simply a linear process but are iterative steps taken in dealing with the entire database, subsets of the database and individual records or field elements. There is an art and science that make up the logic used to bring clients’ through these processes.

Phase 1: Data Matching
This first phase of the process provides a baseline of standardization between the client’s internal provider database and FolioMed’s multi-state databases. The granular level question asks whether the client’s physician record can be matched to a unique FolioMed physician record. FolioMed develops ‘crosswalk” tables that link the client’s data to FolioMed records.

With these clients their requirements for provider databases included New York, parts of New Jersey and Connecticut. National Provider Identifiers, Unique Physician Identifier Numbers, and State Board Licensure codes were run to complete the database match process. The final step in the match phase requires manual staff work to review false positives.

Completing the data matching phase provided these major clients a baseline database that can be worked against for quality improvements during the next phases.

The data matching phase typically shows off a high degree of missing or bad information depending on the data subsets that are being reviewed.
Referral databases of physicians in the clients’ own selected geographies tend to have only a 70% accuracy rate for even the most basic fields. While, credentialed provider databases typically are closer to 90% accurate with the most generic fields. Foliomed typically is able to add additional fields to each provider record including faxes or multiple addresses. Most major health care clients are also interested in adding providers to their database from a larger geography or catchment area.

In practice, a 1 in 10 failure rate matching basic information for a hospital’s credentialed physicians  or 3 out of 10 failure rate for referral matching is not good enough in organizations that are dealings with a range of 1000 to 2000 unique provider directory requests each day. A mistrust of the entire database becomes the standard perception by regular users.

Phase 2: Data Normalization
There are typically 15 unique data filters ( software code) that the matched database is run through to normalize the 40 or more fields that make up each of the physician records. Normalizing the many variable elements in the multiple address fields, phone numbers, faxes, and providing a medical specialty crossover match utilizes custom software tools developed by FolioMed technical staff.

This phase in the process is especially useful to organizations that have multiple and competing databases across institutions.  An organization with multiple hospitals for example can not effectively compare or even share data without normalizing it across every field in each record. Building, analyzing, and improving data filters for Provider Directories is a unique programming specialization that is not common in health care MIS departments.

Phase 3: Data Comparison
Client databases are run through automated comparison programs against the verified FolioMed databases. These automated comparison programs are created and run to reflect any and all the priority fields identified by the client.
State by state difference can come into play. Misspellings, name changes due to marriage, or americanization of first names can all be addressed through these comparison programs.

The overall accuracy rates across all needed fields between these client databases and the FolioMed database was around 50%-70%. As mentioned  during the Matching phase of the clean up process generic record level accuracy was much higher but a 50% error rate across the required fields within a record was common.
With the help of the Foliomed created crosswalk tables, internal customer records can be flagged to deliver special reports for change reporting or for special groups of doctors.

Phase 4: Variance Reporting
These first three phases in the process lead to the creation of a variance report on all the records that show some ongoing discrepancies. This report is then sent to FolioMed’s data research team.

This is a manual process that relies on trained staff to efficiently and quickly go through each individual report variance and resolve the problem. On average, FolioMed staff can review and correct variances at a pace of approximately 5 minutes per record. The research staff also are able to recognize and add entirely new physician records at this step in the process.

Phase 5: Database enhancements,data change processing, reporting
This ongoing phase in the process is vital for healthcare organizations intent on using a provider directory as a way to differentiate themselves competitively.

Provider databases by the definition of who they track are snap shots in time. So, the ongoing update of the provider database is vital.

On average monthly update work required for both of these clients is 5% of the entire verified database. Much of the daily, weekly and monthly work required to keep the quality level of the clients’ database well above 95%  is then automated with back and forth routinely scheduled checks between FolioMed and the client’s databases. FolioMed exchange public and private data encryption keys and agree upon FTP sites for secure data exchange. FolioMed customizes the file structure and formats for easy mapping to the clients’ files.

If the client’s internal systems allow FolioMed will enhance their legacy databases by adding information for future reference such as board numbers, taxonomies, additional medical specialties, hospital affiliations, medical schools, and multiple practice addresses.

Often clients want to add the general population of Providers who are actively practicing in the  traditional catchment area or targeted marketing region.

Most EMRs are able to provide general flags of modified or changed provider data. They are not able to provide detailed reasons for the flags. These flagged changes tend to be the file sample used for regular maintenance updates. Changed or edited data will be regularly sent to FolioMed. Alternately FolioMed will identify more complete files against prior files to identify changes in records.

Customer change records are then compared to FolioMed’s master files and any variances reconciled. FolioMed continues to update records in the clients’ catchment areas as well as previous records based upon “cross walk” identifiers between the client and FolioMed.

FolioMed identifies any records to be marked Inactive including deceased, retired, not licensed, moved. All changed records both the verified client records and the edits are electronically returned to the client.

This completes the cycles and insures that  both FolioMed and Client files are synchronized and current.

Given the typical staffing of health care MIS departments and the nature of their EHR/EMR vendor relationships provider directory reporting tools are not common or rigorous. Vendors typically view provider database reporting as custom and out of their normal project scope. Off the shelf database reporting tools do not provide the custom techniques required for optimizing provider directory reviews.  Thus, FolioMed can provide custom summary reporting as part of the regular cycle of database enhancements and data change processing.

With complex health care organizations, the scale and speed of their provider directory utilization continues to escalate. Even a 15 percent failure rate in physician referrals may mean that 200 mistakes have to be discovered and corrected on a weekly basis. Those mistakes may be combined with similar error rates in billing processing or medical record transfers. Problems are compounded each time another business process utilizes the provider directory.

With the evolution towards electronic medical records, provider directories become the key data set across the most vital and common business processes in any health care organization. Furthermore, hospitals must view themselves as part of a broader competitive health care environment where physician communication becomes one of the primary differentiators.

With these two hospital clients, the combination of real errors and avoided errors due to staff oversight led to seriously escalated customer service complaints being generated by physician groups towards the MIS department.  The physician referral process was perceived as being a problem casting even more concerns on the ongoing EMR projects. Any business process that required a physician directory look up was perceived as being critically flawed.

The benefits of FolioMed’s Provider Data as a Service relationship with clients such as these two world class health care institutions can be measured in multiple ways.

Hard data quality measurements show ongoing improvement in these clients’ provider directories of more than 30%.The financial impact due to more efficient use of staff resources and improved business processes approaches a million dollars a year.

Yet, a most important impact tends to be on the morale within the hospital’s MIS team and their improved relationship with the physician groups.

“ Initially, we viewed our own internal provider directory data as being good enough. We then saw the excessive error rate in our broader catchment area directory and were willing to look at the reality of our internal directory. Once we had the “AHA moment” that provider directories had become a strategic asset for the hospital, it opened up process improvement discussions across the organization.”
Hospital database manager


Sincerely, The FolioMed Team

December, 2011



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