From ‘who you know’ to ‘what you know’: The next evolution of patient-provider matching

Matching patients with the right providers is fundamental to clinical care. Individual physicians have always maintained a rich network of colleagues to call upon to diagnose and treat those conditions of patients that fall outside the scope of their own expertise.

Historically, this network was comprised of physicians with whom they trained and / or those recommended by other colleagues over the years. In many cases, providers lack objective data about their colleagues' actual case-load, quality, scope of expertise or even availability.

As medicine has become increasingly specialized, identifying the "right" provider for patients has never been more important or more challenging. Adding to the complexity is the requirement that care now be coordinated within defined provider networks as health systems look to optimize care for an entire population of patients. While clinical expertise must remain at the center of the match, consumer preferences and health system capacity utilization are factors that must also now be prioritized. Indeed, patient-provider matching is at the core of the modern-day health system's operational, financial, and clinical performance.

While health systems often have an abundance of well-trained and well-intentioned providers, they struggle with the ability to balance supply and demand at scale, in real time. As a result, patients are subject to long wait times and are too often referred to the "wrong" sub-specialist - whether defined as someone with insufficient or irrelevant clinical training or "leakage" out of the preferred network. It is vital that health systems give their providers the information and tools they need to more efficiently and accurately route patients to the "right" provider to help optimize care delivery for everyone.

The foundation for coordinating care within a defined provider network is an accurate and robust provider directory. An effective directory must include the following attributes:

  • Integration of all credentialing and privileging information across the network into a single database
  • Standardized library of medical conditions (and associated lay terminology) mapped to each provider within the network
  • Access to practice management systems with real-time availability and appointment inventory
  • Rules and governance to certify each provider's scope of practice and maintain updates to the data in real-time
  • Access to the information through applications across all sites of patient care (including call centers, referring provider offices, ER and in-patient discharge settings, and digital properties like the hospital website).

The collection of this information into a single, searchable database enables schedulers to find the "right" provider for patients in real-time regardless of whether the patient needs a flu shot (where "right" might be defined by access today, down-the-street, by a physician extender) or a cardiac bypass operation (where "right" might be defined by a completely different set of criteria). This ability to "match" patients to providers across the system in real time has profound clinical, operational, and financial benefits.

From a clinical perspective, there is mounting evidence that clinical scope of practice (defined both by volume and "focus") is correlated with better outcomes. In fact, in an analysis of procedures performed by 25,000 US surgeons recently published in the BMJ, researchers found that a surgeon's degree of specialization (i.e., the share of total operative volume the procedure comprised) was a significant predictor of operative mortality - independent of the sheer number of times the provider performed a given procedure. Thus, as relationships among providers in a network become increasingly virtual, it is imperative that they have access to detailed scope of practice information about their colleagues in order to facilitate an accurate referral.

From an operational perspective, a provider directory and scheduling platform can drive significant efficiencies for staff members looking to book appointments for patients within the network. Today, the workflows that agents must follow in many health systems frequently involve long calls, hold periods, and transfers - constituting a poor service experience for patients. In fact, in a 2013 study involving 28 hospital systems and more than 1,000 calls, Accenture found that it took over eight minutes on average to complete a scheduling call and more than 30% of that time was "unproductive time" (i.e., the caller was in a queue, on hold, or being transferred). Equally concerning, two in five calls did not result in a scheduled appointment on the first attempt, making organizations vulnerable to patient leakage as those callers potentially look elsewhere for care. A single directory with appropriate content (see above) can enable schedulers to meet the preferences of each individual patient, while simultaneously solving for even distribution of demand across the network.

The better balancing of supply and demand across a network can also deliver meaningful financial upside. Many organizations "leak" patients to outside facilities despite having available capacity for that exact service within the network. A robust directory helps expose capacity that might otherwise be overlooked - especially for new providers who may have recently joined a network but be unfamiliar with the "go-to" specialists for conditions that they might only see one or two times per year. Unlocking this capacity has enormous downstream revenue implications for systems that must find better ways of leveraging their fixed cost assets.

As healthcare delivery evolves, it is putting new demands on providers to identify and connect their patients with the "right" colleague. The growing specialization of medicine combined with the increasing complexity of network alignments, poses additional challenges for providers to coordinate care for their patients. The best health systems will aggregate their provider data, implement governance frameworks to ensure it stays accurate, and supply their providers with technology to make that data actionable, so that providers can find the right matches for their patients.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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