Co-authored with Bill Wellman, adjunct faculty at Harvard University, where he teaches courses on innovation, entrepreneurship, and blockchain. This is part of a series examining how blockchain technology could be applied in the healthcare industry.
Healthcare professionals are the foundation of the healthcare delivery system and a vital resource in every healthcare delivery organization. Physicians are critical to the healthcare delivery system as they diagnose and treat their patients, healing the sick, managing chronic conditions, and work with their patients to promote health.
Provider credentialing is a core healthcare delivery system process that ensures the integrity of the healthcare workforce. Credentialing is the process by which organizations including hospitals, health plans, health networks and insurers verify the qualifications of licensed healthcare professionals, assess their backgrounds and validate their legitimacy. Unfortunately, the current provider credentialing systems are archaic, inefficient, and place a significant burden on one of the most important healthcare resources, the physician.
Despite the shortage of physicians, they are required to spend time navigating the arcane credentialing process and waiting for the results, which impedes their primary function of providing care to patients. The provider credentialing system needs to be transformed into a secure, efficient, and physician-friendly system that makes it easier for qualified physicians to gain access to provider networks, hospitals, and insurance plans.
A cornerstone of the physician credentialing system is verified provider data from primary sources. Despite an annual investment of $2B to maintain provider data bases1, accurate provider data remains elusive. Enclarity, a LexisNexis Company, estimates 30% to 40% of a payer’s provider records contain errors or missing records.2 Estimates suggest 12% of National Provider Identifier (NPI) numbers are inaccurate or missing,2 with approximately 2.5% of provider information changing each month and delays in timely updates to sanctions representing a significant cost burden for states, insurers, and hospitals that introduces additional risks for everyone.
While some centralized repositories exist like the AMA Physician Masterfile3 the HHS National Provider Data Bank, NPPES, PECOS, and ProView operated by CAQH4, the credentialing process can take in excess of 120 days to complete. Improving the physician credentialing system will eliminate burdensome overhead costs from the healthcare delivery system, reducing the cost of care while simultaneously improving workforce quality and reducing risk.
A possible solution to address this problem is blockchain.
Blockchain is a secure immutable distributed database that has demonstrated its ability to substantially reduce transaction costs. A critical step in the physician credentialing process is the validation of data from primary sources. Blockchain technologies provide secure encrypted mechanisms to authenticate primary source organizations. After authentication, the primary source organization would place physician information including degrees, certifications and licenses on the Blockchain in an encrypted format. Once accepted and integrated into the Blockchain, the information becomes immutable, making the Blockchain the single source of truth that can be trusted by all organizations and individuals needing validated physician information.
Utilizing secure cryptographic keys, the physician could control access to their information. Organizations needing access to physician information would request access from the physician. The physician would provide the organization with a one-time encrypted key to access the information from their credentials wallet, which resides on their computer or smart phone. Each piece of physician information would contain a digital certification code from the primary source, assuring the requesting organization the information is accurate and true.
The Physician Credentialing Blockchain would significantly improve the efficiency of the physician credentialing process that credentialing organizations could easily access by reading the Blockchain, eliminating thousands of hours of requests for information from original sources and substantially reducing credentialing costs. The timeframe for assembling physician information from original sources would only take minutes after the physician provides the access key. An added benefit, physicians would gain control over their information and its release.
The development of standards for participating organizations would ensure the timely update of physician information within the Blockchain. The standards could be incorporated into Smart Contracts, which would be contained in the Blockchain.
Smart Contracts are computer programs that automatically execute when specific conditions are met. Through Smart Contracts, the Blockchain would monitor participating organization performance to ensure compliance with standards. For example, the standard might require the Blockchain be updated within seven days after a physician’s license is renewed. The Smart Contract could monitor to ensure this standard is met and notify the Blockchain governance body as well as the physician of exceptions. Smart Contracts could also automatically follow-up on missing information or provide notifications of inconsistent information within the physician’s profile. The result would be increased transparency and improved efficiency throughout the physician credentialing process.
Blockchain technologies offer the potential to fundamentally transform the physician credentialing process and simultaneously improve information quality, information control, and information timeliness while dramatically reducing cost. This represents the type of breakthrough innovation needed as we design and build a healthcare delivery system for the 21st century.
- Issue Brief: Administrative Provider Data. CAQH [Analysis completed by Booz & Co., now Strategy&, Inc.] (December 2011).
- White Paper: A Business Case for Fixing Provider Data Issues. Enclarity, A LexisNexis Company.
- AMA. www.ama-assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile.page Accessed on 31 May 2017.
- HCPro. www.hcpro.com/CRD-33211-863/Verifying-overseas-medical-school-education.html. Accessed on 31 May 2017.
About the co-author
Bill Wellman is currently working on a startup focused on customer relationship management in the Healthcare Industry. Bill served as the Vice President for Global Support at Healthways International. He has also held executive positions at CSC and First Consulting Group where he played a senior leadership role in delivering technology and operations improvement solutions to clients and pioneering IT outsourcing to healthcare organizations. Bill has served as the Chief Information Officer in several healthcare provider organizations including the Dana-Farber Cancer Institute and Alexian Brothers Health System. He has also served as an executive in academic medical centers including Rush Medical Center and Henry Ford Hospital. Bill has taught courses in Informatics and Quantitative Methods at several colleges and universities including Rush University, Simmons College and Endicott College. He holds a B.A. in Social Science from Michigan State University and an M.S. in Industrial and Operations Engineering from the University of Michigan.
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