Isn’t there already a National Provider Directory?

 

By Justin Sims

Yesterday, careMESH announced the launch our National Provider Directory, completely built on the HL7® FHIR® standard. Are you curious why? 

First, a little background. The very definition of a “provider directory” varies by audience. Healthcare organizations need directories in their EHRs to communicate during the patient care process. Health Plans require accurate lists of providers in their networks. Patients/Consumers often research who accepts their insurance. Others require directories to support licensing, credentialing, management of affiliates and a myriad of other uses. So how does the collective industry move forward with an authoritative source?

Until now, the most common directories were built and used by providers—some are integrated into EHRs, others are maintained on spreadsheets by administrators, and then there are the lists pinned to notice boards that you see in just about every doctor’s office. But there are also a number of official sources that could be called Directories. Let’s take a look at the main ones:

  • A National Provider Identifier (NPI) is nearly universally issued to physicians and other clinicians, because getting paid by health plans without one is very difficult. Approximately 5 million NPIs have been issued through the NPPES systems since 1996 but once issued they do not need to be renewed and therefore can become outdated. 

  • The Provider Enrollment, Chain, and Ownership System (PECOS) is used by CMS to enroll both organizations and providers in the Medicare program. Because PECOS is used by CMS to pay practitioners for services, individuals and healthcare organizations have an incentive to maintain accurate information. 

  • State Medical Boards are used for licensing and credentialing medical professionals.  Licensing varies from state-to-state and must be updated as often as annually. State Medical Board data typically does not capture NPI so is more difficult to cross reference but when a match is identified this increases the level of trust in the other information.

  • DirectTrust (website) is an association formed around the Direct protocol secure messaging system. They maintain a directory of over 800,000 providers with Direct addresses. This information is well-maintained since Direct addresses are assigned to EHR users, and  when a practitioner leaves an organization their direct address is removed—at least in theory.

  • Finally, Health Plan Provider Directories capture specialty and contact information, and whether the provider is accepting new patients. Most of these are available only to members and can’t be downloaded as databases. However, CMS issued a proposed rule that would require Medicare Advantage plans and Medicaid Managed Care Organizations to publish them through open APIs by January 2020 and July 2020, respectively.  

Each of these has valuable data and serves an important role, and only careMESH has converted every one of these (and more!) into a common format: FHIR. We combined them into a single system, and perform constant updates using a proprietary algorithm to create a “record of truth”. We invite you to learn how the Directory helps solve your provider-to-provider communications problem so you can banish inefficiency (and fax machines) to the dark ages.

Justin

HL7 and FHIR are the registered trademarks of Health Level Seven International.