PRACTITIONER DATABASE PROJECT
NYSAMSS
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
Overview
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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
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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
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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:
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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
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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
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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 Challenges
through the Work Program,
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Assess User Needs
Catalog/Evaluate Potential Data Sources
Assess Platform Options and Other
Design Issues
Recommend Strategy for
Implementation
Advisory Structures,
Stakeholder Involvement,
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Advisory Committee
Data Workgroup
Platform Options Group
Subject Matter Advisors
User feedback from survey and other
means
and Collaboration with Others
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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
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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
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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
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Data Work Group (4+ meetings)
September 2013 – January 2014
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Platform Options Group (Did not meet)
January – February 2014
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Advisory Committee (4 meetings)
January – April 2014
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Final Report: April 2014
Data Group
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Involved 12 “experts” experienced in working with
practitioner data plus 6 resource advisors
Participating stakeholder organizations included:
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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
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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
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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
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Physician Profile Redesign
Innovation Plan/Primary Care
Development
All Payer Database
Medicaid Information System RFP
NYeC/HIT/Info Exchange
Health Benefit Exhange
Other Recommendations
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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)
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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
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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
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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 Address
System Development Issues
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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
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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 about
Credentialing Verification Systems
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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 nonpublic payers.
Also reviewed NYS interest in credentialing with
representatives from the Office of Primary Care and
Health System Management
Explored Potential Uses of CAQH
Universal Provider Datasource (UDP)
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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
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Health Care Exchange Directories (Colorado)
All Payer Databases (Most States)
Consumer Oriented Physician Profile Systems
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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 for
NYS Physician Profile (Art 2995-A)
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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 Understand
Vendor Capabilities
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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)
Expored
Potential Hosting Options
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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
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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:
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Personal Information (Name,
Birthdate, Sex)
Professional ID Numbers
Professional Education
GME/Advanced Training and
Certification
Specialization and Subspecialization
NPI Taxonomy Code
Group/Practice/Corporate
Information
ACO/IPA Associations
Practice Location(s) and
geographic identifiers
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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
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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.
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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 systems
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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)
Should consider role it might play in
supporting credentialing
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Some Options include:
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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 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.
Should Use Multiple Sources
of Information
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NYSDOH Redesigned Profile Sources
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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
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Master Data Management (MDM) services
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Data validation and error collection mechanisms
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Data governance/intake/integration
Master indexing/coding
Remediation/enhancement
Data storage/warehousing/analytics
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
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creation of a state sponsored system such as SPARCS used for
hospital discharge data. Such a system could be run by:
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NYSDOH which oversees the provision and quality of health care
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NYSED which is responsible for licensing,
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a joint venture or cooperative program of both departments
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a joint venture or cooperative program that also includes the
Department of Financial Services.
Should have advisory committees representing key nongovernmental stakeholders to guide:
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system development
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policies and practices regarding data access
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the selection of vendors
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the overall design of the system.
Should use existing fiscal resources, in
part, to support the database
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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:
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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 Changes
will be needed - Examples
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NYS Profile Law
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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
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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
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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
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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 500
Syracuse, NY 13202
(315) 472-8099
Terry Richmond, Deputy Director/Senior Associate
Project Director, Practitioner Database Project
gmrichmond@healtheconnections.org