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Standardized Provider Data a Must for Health Data Exchange

Limited health data exchange is a casualty of poor provider data and data governance.

By Kyle Murphy, PhD

A lack of high-quality provider data is not only costing the healthcare industry billions of dollars annually, but it also minimizes the effectiveness of organizations working to support health data exchange among other setbacks.

That and many observations come from a recent white paper published by the Council for Affordable Quality Healthcare (CAQH), which explores and opportunities associated with provider data as well as a call to action for the healthcare industry.

Ineffective health data exchange is among the several challenges facing industry stakeholders as a result of incomplete, inaccessible, or inconsistent provider data. Other challenges include patients seeking care out-of-network and burdensome billing and administration processes for both providers and payers, the latter of which expose themselves to violating state and federal regulation. Additionally, the digital age in healthcare makes the industry a target for cyberattacks.

A major pain point for those relying on this information is a lack healthcare data standards.

"Today, there is no industry-wide 'source of truth' for provider data. Each organization must decide how best to obtain and manage provider data, and identify ways to enhance data with alternative sources that must be extracted, translated and loaded into their systems to meet business needs," the authors explain.

"As a result," they later observe, "organizations across the industry have made redundant investments where a coordinated, collaborative approach could reduce effort and improve efficiency. Additionally, the quality of the resulting provider data is ultimately limited by the quality of the originating data sources, which can vary greatly depending on their level of quality assurance."

Estimates put the cost of annually maintain provider databases for commercial payers and providers north of $2.1 billion.

To resolve these numerous challenges, CAQH has issued a four-pronged call to action.

The first is the creation of multi-stakeholder collaborations to address the provide data quality:

All stakeholders have a vested interest in provider data, yet there are no clear organizing entities or processes leading the provider data dialogue. There is an opportunity for the industry to look within to identify or create an organizing framework and leadership that will work through provider data challenges. The industry may not come to clear consensus, but a coordinated dialogue that facilitates diverse stakeholder perspectives will be invaluable to identifying strategies that address challenges and improve provider data quality.

The second focuses on standardization:

Claims processing, network management, credentialing, licensing and other regulatory and business processes require a core set of data elements. By defining a minimum data set and establishing definitions, specifications and measures of quality through a collaborative, multi-stakeholder process, all stakeholders can share 16 in the solution and hold data producers and users accountable to agreed-upon standards.

Accepted industry-wide definitions, process, and standards for quality will enabled stakeholders to keep each accountable.

Third, CAQH is calling for provider data governance and accountability.

"All stakeholders that produce or use provider data must have a role in a data governance model," the group advises. "The path to data governance must be transparent, inclusive and not overlook the value that any one sector may bring to the provider data ecosystem and role they can play in solving the provider data problem."

Lastly, the organization is advocating for policymakers and industry groups to advance resolutions to provider data challenges.

"Coordination between policymakers and industry partners is critical to ensure policies are constructive, support broad industry needs, allow for ongoing improvement and promote innovation," CAQH states. "Any regulatory efforts should also be synchronized between federal and state governments and across states to avoid duplicative or conflicting efforts, and have the greatest impact across the entire healthcare system."

As the authors of the white paper note, the solution to the provider data dilemma hinges on the collaboration of consumers, providers, payers, health information exchange, and government.

"By addressing barriers, developing service level and quality standards and clearly defining accountability together, the industry has an opportunity to resolve inefficiencies that have plagued the healthcare system for decades," they conclude.




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