Concept: Group use cases for provider registry

From Demand-Driven Open Data for HHS
Jump to: navigation, search

Background: The concept for this article has been taken from

As I've been reviewing Use Cases for DDOD (Demand-Driven Open Data), I'm realizing how much the industry depends on an up-to-date, reliable source of healthcare providers (aka, physicians, groups, hospitals, etc.).  Although some people may also call such an effort "NPI registry", the actual need identified encompasses much more than even the fields and capabilities of the existing NPPES database.

Here are just the Use Cases that directly mention NPPES and other existing registries.

And besides these, there are at least a dozen more that would benefit from this repository, since they rely on the "provider" dimension for their analytics.  For example, most analysis on provider quality, utilization, and fraud depend on this dimension.

The most obvious improvements needed are around:

  1. More realistic association between provider, group, and location, recognizing that these are many-to-many relationships that change with time
  2. More accurate specialty taxonomy
  3. More up to date information (since NPPES entries are rarely updated)
  4. Easier method to query this information (rather than relying on zip file downloads)

These's also a provider network aspect that's been growing in importance as more people sign up for or change health insurance plans, due to the ACA (Affordable Care Act). In other words, enrollees need to know which provider takes which health insurance plans and whether they're accepting new patients. Without having up-to-date network information on hand, consumers are likely to make poor choices when selecting insurance coverage, especially if they have preexisting conditions that must be treated by specialists.

But there are challenges on the "input" side of the equation as well.  There also seems to be some confusion in terms of assigning rights for modifying registries.  For example, it's not easy for a provider group to figure out how to delegate update rights for all of its physicians to third party administrator.

There's a growing list of companies and non-profits (including the American Medical Association) that have been trying to capitalize on the opportunities for a better solution.  As we go about working on the use cases mentioned here, I'd be looking to build a body of knowledge that would contribute to solving the core problems identified.