Provider profiling has a wide range of applications in the Healthcare Industry. Prior to developing a Provider Profile it is vital to understand how the profile will be utilized because a wide array of criteria can be included in the effort to build an accurate portrayal of the provider. Successful development and implementation are completely dependent upon the inclusion of correctly chosen statistical data sets which, when combined appropriately, provide the end user valid, concrete and useable information for decision making purposes. Groups which routinely utilize Provider Profiles include Health Plans, consumers (and consumer groups), employers, and Providers themselves (for benchmarking and competitive assessment purposes). Conceptually, we want to be comparing apples to apples and oranges to oranges.
In the effort to provide a compelling profile, there are ten specific principles which should be included and considered, as outlined in Essentials of Managed care authored by Doctor Peter Kongstvedt (Kongstvedt, 2013). The first principle to include is the identification of high cost and high utilization clinical centers, which are of particular interest because this is vital in understanding where money is being spent (Cost Centers) as well as primary centers of demand and income (Utilization and Revenue Centers, respectively). The second principle to include is relative derivative information obtained from internal and external customers. The information they provide is critical in providing the profile a real market perspective. The third principle is the inclusion of the subject provider in the process of building and deployment of the profile, which ensures organization investment in the process. The fourth principle is (once the profile is completed) to establish industry benchmarks which are used to compare and contrast internal vs. external performance. The fifth principle is that all performance reporting should utilize uniform clinical data sets. This principle streamlines information so that accurate and direct comparisons can be made. The sixth principle is to utilize an outside source of data for validation of information collected from the provider when possible. This factor is key in determination of anomalies and incongruences in data in comparison to benchmarks. The seventh principle is to scrutinize data obtained directly from the provider’s onsite data collection system, which ensures accuracy, validity and dependability of information. The eighth principle is to tender performance comparatives utilizing clinically relevant risk stratification. This provides vitally useful statistical information for the purposes evaluating and mitigating the possibility of negative outcomes. The ninth principle is to insist upon dimensions of statistical importance for evaluation and create thresholds for minimum sample size, which provides for enough criteria in order to extrapolate substantive and qualitative results. The tenth and final principle is to redraft measurements of performance utilizing standardized severity adjustment protocols. Severity Adjustment is a means of demographically studying groups of patients by the seriousness of their condition(s). This is important because facilities that score high in this category of measurement are typically seeing patients with more chronic and acute conditions and, thus, are spending more to treat these additionally complex cases.
Some common problems associated with profiling include; data warehousing challenges, validity and reliability of claims data (the source for most profiling information), information omission, lack of standardization of terminology and adherence to Health Insurance Portability and Accountability Act (HIPAA) regulations during data collection. “Developing methods that can reliably distinguish among physicians’ performance is challenging because of small sample sizes, incomplete data, and physician panel differences” (Pelletier, Johnson, Westrick, Edward, Fontaine & Krinsky, 2014). In order to obtain the most complete and effective Provider Profile it is important to have as much information as possible. With the advent of Electronic Health Records (EHR) it is now possible to collect massive amounts of data, or mega-data. As such, Mega-Data Warehouses (commonly known as “The Cloud”) have been built. These warehouses are extremely expensive to both develop and maintain, which is a challenge for provider profiling. Due to the sheer size and scope of information obtained, it is vital that the information be accurate in order to produce valid, reliable and (most important) actionable information for health care institutions. The omission of information is an ongoing challenge for provider profiling because many times a patient may be treated for more than one issue so the main diagnosis cannot always be relied upon to provide a complete picture of everything that was done to treat them. For example, a patient may be in the hospital as a result of a fall which resulted in a broken hip. However, while they were in the hospital they also developed a Urinary Tract Infection (UTI). Their primary diagnosis would be the reason for admission, in this case a broken hip but this was not the only medical issue that was addressed. The lack of standardization of terminology speaks to the problem of language and clinical interpretation of diagnosis. HIPAA regulations are quite stringent and great care should be taken when collecting, storing and using data to ensure the privacy of individuals is maintained throughout the process.
In conclusion, the creative development and implementation of a Provider Profile can be useful in a variety of applications and by different groups for decision making purposes. Giving clinicians well-articulated demographic information regarding the patient populations they serve will empower patients by those clinicians passing that information along, effectively educating patients so that they may make informed health care decisions. ”Ours is an era in which patients seek greater engagement in health care choices, increasing the demand for high-quality information about clinical options” (Woolf, Chan, Harris & Sheridan, 2005). Overcoming the challenges to building a reliable, accurate depiction of a provider is of paramount importance in this process because it is necessary in order to yield clear direction for the user. As the industry moves forward, with both clinicians and patients expecting more from the provider system as a whole, these issues will likely grow in importance, gravity and scope.
How do you see benchmarking, provider profiling and the management of big data affecting your organization? Do you see different and more innovative ways that provider profiling could be used to improve the way we go about providing healthcare? What steps do you see the industry taking to ensure that patient information remains confidential in light of data warehousing and the emergence of “The Cloud”?
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Kongstvedt, M.D., F.A.C.P., P. (2013). Essentials of managed care. (6th ed.). Burlingame, Massachusetts: Jones and Bartlett Learning.
Pelletier, L. R., PhD., Johnson, S. A., PhD., Westrick, E. R., M.D., Fontaine, E. R., Krinsky, A. D., PhD., Klugman, R. A., M.D., . . . Sax, Harry C, MD,F.A.C.H.E., F.A.C.S. (2014). Composite model for profiling physicians across domains of Care/PRACTITIONER APPLICATION. Journal of Healthcare Management, 59(3), 224-37.
Woolf, S., Chan, E., Harris, R., & Sheridan, S. (2005). Promoting informed choice: Transforming health care to dispense knowledge for decision making. (Master’s thesis).