Brendan Iglehart: Welcome to Hard Problems, Smart Solutions, the
Newfire Podcast, where we explore the toughest challenges and the smartest
solutions with industry leaders.
I'm Brendan Iglehart, Staff Healthcare Architect at Newfire Global Partners
and your host for this episode.
In each episode, we bring you conversations with top innovators
and decision-makers tackling the biggest issues across industries.
Whether you're looking for insights to drive your own strategies or to learn
from the best, you're in the right place.
Let's get started.
Hello everyone, today we're discussing the transformative power of accurate
provider directories with Ron Urwongse, co-founder of Defacto Health.
Ron is a pioneer in healthcare data interoperability and transparency,
with a career dedicated to optimizing provider directories and creating scalable
solutions for the healthcare industry.
From leading the development of innovative data tools at Defacto Health,
to his prior work with CAQH, Ron has tackled some of the most critical
issues in provider data management.
If you're navigating the complexities of healthcare interoperability and regulatory
compliance, this episode is for you.
Ron, welcome to the podcast.
Ron Urwongse: Hi Brendan, it's great to be here.
Brendan Iglehart: Ron, getting started, your career spans critical milestones
in healthcare data innovation.
Can you walk us through your journey, particularly how your experiences
have shaped your approach to solving interoperability challenges?
Ron Urwongse: Certainly, Brendan.
So I started off in the early 2000s as a programmer.
I think it's important to call that out because I've had my share of
experiences with not the best data, sometimes inaccurate, sometimes always
messy data and well-documented APIs and not as well-documented APIs.
So I have firsthand experience as a developer having to interact with all
these developer tools and documentation.
I, uh, took the leap to go to business school and study at M. I. T. Sloan,
started my career as a product manager in a small healthtech company in
Boston called Vecna Technologies.
I had a chance to manage a variety of different products there from
infection surveillance solutions and patient check-in kiosk
for private hospitals, but also government-run hospitals within
the Department of Veterans Affairs.
I made the leap to CAQH soon after that, and I spent a good chunk
of time there managing shared utilities on the payer side.
Pretty much every aspect of provider data I had a chance to touch there:
credentialing, provider enrollment,
Provider Directory and I had the opportunity to interact directly
with payers and providers on both sides of the problem.
It was that at CAQH where I had a chance to see some of the new
government rules coming out and see how the payers were being required to
publish their Provider Directory data
via standards-based API.
And I looked at the data and it was incredibly valuable and voluminous.
And I I thought, well, I've got to do something about this.
So I needed to start Defacto Health with my co-founder, Tarun Theogaraj.
And, uh, that's where we are today.
We've been working on integrating with and querying these Payer-Provider
Directory APIs ever since.
Brendan Iglehart: That's really great.
So provider directories are often called the backbone of
healthcare interoperability.
And as a patient and as many listeners being patients, I think we can
all understand the importance of accuracy with those directories.
So, from your perspective, why are they so vital to operational
efficiency and patient care outcomes?
Ron Urwongse: Yeah, so we can start with the easy stuff.
I mean, the use case that pretty much all of us are familiar with,
which is looking up a provider in a Payer- Provider Directory.
And, I think most people, when they're searching for providers, they probably
start in a Google search googling "cardiologist near me," or asking a friend
"Hey, do you know a good PCP in the area? I just moved here." But the second
step after that is often, well, let me look up this provider in my payers'
directory just to make sure that they're in the network and they accept the plan.
Incredibly important for the patient engagement and for
the provider search use case.
But if, if you take a step back and look at how the Provider Directory is
the intersection between all sorts of different parties within healthcare,
so there's the payer and the provider.
There's also the payer and regulators.
Regulators are responsible for overseeing how robust or I guess what they say
adequate a provider of a payer's network is within a certain geography.
Regulators do look at information source from provider directories
to make that judgment call to see, okay, for this particular geography,
you've got this many members.
Do you have the right number of PCPs, cardiologists, et cetera,
to be able to service that type of population within that geography?
Moving from there, especially within this realm of interoperability, uh,
what we're seeing is that payers are very interested in finding the most
efficient ways to integrate with the providers within their network.
They need to collect clinical information for all sorts of use cases
for quality, for risk adjustment, for care coordination and value-based care.
And historically, it's been manual chart chases.
In an intermediate stage, there's these bespoke integrations with a particular
health system hospital which I know you're quite familiar with, but in this
next phase payers are really looking to integrate with providers FHIR APIs
because they're more standards-based, they're more efficient and theoretically
they'll be able to get to the data a lot faster and a lot more efficiently.
And so a big part of that is knowing what providers are a network
and where their endpoints are.
You know, we've been thinking about all this time provider directories
answering questions about who is a provider, where are they located,
what kind of specialties do they have?
But on the other end of it, it's what is their digital contact information?
What EHR are they using?
What's the URL for the API that I need to ping?
So that's the other aspect of provider directories that is kind
of up and coming and becoming more important for the overall industry.
Brendan Iglehart: You mentioned earlier the term adequacy or adequate
in the context of directories.
What does that specifically mean?
I have a hunch that there's there's regulation and requirements around
how that's used, but I'm curious to get your perspective on that.
Ron Urwongse: Yeah, I'm going to overly simplify it and for those professionals
who are a little bit more involved in the adequacy use case, they'll be
able to provide a ton more detail.
But in the most basic form, payers are supposed to present a provider network
that can service their members' needs.
And at the very basic, you've got some type of member population.
And you need to have a certain number of providers to be able to service
that member of the population.
So a certain number of primary care physicians, cardiologists, behavioral
health, pulmonologists, etc. And depending on the line of business,
there's Medicare, Medicaid and Exchange.
They all have different rules, but
the regulator sets these types of ratios to dictate, okay, for your particular
population within this geography, you need to have this many providers.
So you can see how the directory plays a role in there because the directory has
information about providers, what their specialties are, and where they're located
from a geographic basis.
So you can certainly bump that data up against member data and where
the members are to be able to make some assessments on the adequacy
or the robustness of a network.
And what's interesting is that payers are looking to go
beyond just regular adequacy.
They want to know, how does my network compare relatively with other
payers' networks within the geography.
And so it's going beyond just compliance with regulatory requirements, but
it's how competitive am I in a market?
And can I can I make some type of claim that I've got the most robust
network for a particular type of member population within this geography?
Brendan Iglehart: Got it.
The CMS interoperability rule that came out, I believe last year put additional
focus on prioritizing Provider Directory API, so I'm curious to get your
perspective on this regulation and others and how they're shaping the industry's
focus on innovation in the space.
Ron Urwongse: Yeah, the original CMS Final R ule on interoperability came out
in 2020 and was effective in, uh, 2021.
I remember these dates because I, we timed the founding and the launch
of Defacto Health right around that time when the APIs were gonna be
available and when payers were going to be required to publish them.
So that, that was the first time the Provider Directory requirement came
into play in these standard-based APIs.
The most recent requirement it persists the the obligation for the
payers to publish their directory data via API which is good.
It's a signal to the industry that, hey, these APIs aren't going anywhere.
In fact, the the regulators are building on top of previous requirements.
The previous requirements don't go anywhere.
They remain.
And CMS is introducing new requirements for new APIs, like a prior authorization
API, and a, um, I think they call it a Provider Access API, where providers
can access information from payers on patients that they're seeing as well.
So what's interesting is, is if you go into the rule, they describe all sorts of
use cases where these APIs interact with each other and interplay with each other.
Within the prior authorization use case, a predecessor requirement is
knowing whether a provider is even in network before they can provide
care that needs to be authorized by a payer to, to a to a covered member.
You know, all that to say that the old requirements aren't going anywhere.
The regulators are imagining use new use cases and new APIs that
will be highly dependent on.
The older requirements.
And I guess most payers, all payers need to really consider that
where if they're not meeting the requirements from the previous rule,
they're they're playing catch up with these new requirements as well.
Brendan Iglehart: Like many problems in healthcare, there's a combination
here of kind of a technology problem as well as a kind of rights to
data or access to data problem.
So how do you view the interplay of those here, especially in light of,
again, some of those regulations that have come out recently?
How is, how is that relationship between the different parties
here evolved over time?
Ron Urwongse: It is an evolving mindset where if you rewind the clock back, five
years, if you ask any payer, you know, who owns the provider network information
and who should have access to it.
I think they would say I, as a payer on this information and I give access to
it on specifically to members and to,
you know, folks who are, uh, who I have business with, and so that they can
get the care that they need, or they can do other jobs that are required.
You're getting to a point where, regulators are asserting that
actually this information, while it's collected by the payer, and
perhaps owned by the payer, but it is still made available to the public.
And they've asserted that it is public data.
And that mind shift is happening.
And I think that the payers are evolving with it, too, whether complying with the
rules, just to comply with the rules.
But now they're also realizing all the different jobs this data can
do, especially when payers have access to each other's data via
their Provider Directory APIs.
You're also seeing that with patient data, too.
Payers are obligated to make data available via Patient Access APIs.
Now, the, uh, the initial use case around that and the mandatory use
cases that I, as a patient I can access information either from a provider or a
payer, but I authorize how it gets used.
Now, if payers, there's a, a use case within uh, the CMS rule called
Payer-to-Payer Data Exchange, where perhaps there are payers with
overlapping coverage on a particular member or a patient, or there's an
old payer and there's a new payer.
They've got the right to exchange that data
between themselves, and they can use a lot of the same infrastructure that was
created for the Patient Access API to be able to enable that data exchange.
I think all that to say there's a shifting mindset.
There's more willingness to share this data and also more interest in
using, uh, various types of data that are being published via these APIs.
Brendan Iglehart: You mentioned it earlier on the evolution of FHIR, and so I want
to touch on the evolution of different data standards here and how that affects
us as well, because as we both know, just because you make available an API for a
certain type of data doesn't necessarily mean that that can be useful if the data
is structured in different ways across organizations and other source systems.
So what are some of the kind of inputs here, such as FHIR and others that are
impacting and how data is structured as you're able to increasingly retrieve
this from payers and other parties?
Ron Urwongse: Back in 2020, when I was first looking at these APIs that the
payers were publishing and then, into the early part of 2021, I got really spoiled.
So I took a look at and I remember them, it was United Healthcare, it was
Humana and Cigna, big national payers, they probably have a huge IT bucket.
They can put the right investment in place to be able to publish amazing APIs.
I remember in particular Humana documentation.
I think United too was really good.
I was talking before about as a developer, having the experience
of interacting with well-documented APIs versus not well-documented APIs.
These first ones were really good.
And, started querying them and all the data that I was expecting to
come back with coming back when I passed in the right query parameters.
And I, uh, mistakenly thought that, well, gosh, if these first three APIs
are going to be good, then probably the next 150 are going to be good as well.
That was absolutely not the case.
A fter that, I think the ratio was maybe 9 out of 10 of the APIs that we
encountered first were broken in some way, shape or form, and that was, everything
from, uh, not publishing any data at all, the query parameters were broken,
not performance, not well documented, authorization requirements and approval
channels were not being monitored.
But, it's evolved and matured over time.
You know, most of the Payers-Provider Directory APIs are now working.
There's still a tail of smaller payers where it's not.
The FHIR standard for, uh, the Directory APIs in particular, the the
Da Vinci Plan Net implementation guide was really good too, to get started.
And without the existence of that implementation guide, I wouldn't have
a common ground to be able to interact and communicate with the payer saying,
Hey, I'm expecting this data, this data is supposed to do this job.
The IG not only talks about what data needs to be available and the logical
model and how different entities relate to each other, but also this is,
these are the jobs that patients are trying to do with the data.
Now, what it doesn't do, though, and I think there are opportunities
either through a Da Vinci workgroup, broader HL7, or perhaps some, you
know, USCDI plus venue where we can talk about the quality of the data.
There's no standardization on the quality of the data, how accurate it needs to be,
how do you even test that?
I mean, particular CMS program offices have put a stake in the ground and
said, "Hey, Provider Directory needs to look this way. We're auditing it
this way. And this is how you should measure it." But, you know, other lines
of business aren't that prescriptive and it's not, there's no requirements
on that on the commercial side that
I've seen beyond, you know, some no-surprises act and, um, update timeline.
So I think that's a huge opportunity.
HL7, FHIR, some of these IGs, really great about describing logical models
and what data formats should be, but data quality, I, I think is, uh, an opportunity
for the industry to mature even more.
Brendan Iglehart: So, as we both know, technology really plays a
transformative role in terms of how healthcare data gets better and
more useful to drive innovation.
And so I'm curious, um, are there other innovations such as like public data sets
or other APIs that we haven't touched on that you're really optimistic about growth
and kind of on silo in some of this data?
Ron Urwongse: Certainly.
We've been talking a lot about Provider Directory.
We touched a little bit upon Patient Access API.
So the patient data I think the next data set that I haven't touched upon,
but that is probably on everybody's mind right now is the price transparency data.
Both hospitals, as well as health insurers, have been
required to publish their negotiated rate within these huge
massive machine-readable file.
All with the idea that patients, consumers, employers, uh, even
regulators can see the rates, they can make better decisions on purchasing or
finding high quality, low-cost care.
And maybe bending the cost curve.
I think there's probably more of a convergence in the cost curve
than necessarily bending it down.
But predictability, predictability can be good too.
I think there's a whole lot of opportunity there.
I think the price transparency data is, uh, suffering from some of the same
challenges as Provider Directory data in terms of data quality and consistency
and data format and standardization.
But I see a lot of work going on there between public sector and private
sector to converge on what this data could look like and what it should do.
So, I, I see a lot of opportunity to.
Leverage interplay between Provider Directory and the price
transparency data over time.
Brendan Iglehart: And I guess on that front, like, I'm personally the kind of
kind of guy who likes to email the mayor and, you know, my elected officials and
help to, in my mind, move things along.
What what can people who are listening to our innovators in
this space do to kind of contribute and advance some of these causes?
Obviously, there's things like public comments on different regulations that are
coming out, but do you have any thoughts on on that and how people can pitch in?
Ron Urwongse: Yeah.
So, as you said, public comments on any number of emergent rules, I'm
sure with the new administration taking place, there will be a whole
slew of new proposed rules that the public can review and comment upon.
There's an interesting experiment going on within the state of Oklahoma
in the early part of this year, in the National Directory of Health.
So CMS released an RFI around this notion of a national directory a couple of years
ago, and the whole idea of it is to create a common utility that collects data one
time from a bunch of healthcare providers and makes it available to any number of
other organizations, including government agencies, payers, other providers.
The whole idea is to reduce and rationalize the administrative
burden around that.
What's neat is that CMS is doing this out in the open and that as
they establish it, they will be releasing public data sets from it.
It's going to benefit from more eyeballs.
If you're in this space and you're taking a look at directory data or data sets
that are adjacent to directory data,
it might be interesting to take a look at what's going on there and see if
this centralized national directory approach is going to move the needle.
Brendan Iglehart: So, as we both know, collaboration is, is
vital to success in health care.
Some, can you speak on a little bit of the collaboration and work that
you've done specifically with perhaps different payers to help kind of
advance this cause and especially related to your, your current company?
Ron Urwongse: Sure.
A big part of what we do, I would venture to say, perhaps the majority of what we
do, is review payers' APIs and provide them with constructive feedback around it.
You know, I mentioned that early on 9 out of 10 payers API, particularly Provider
Directory APIs, had some type of issue that blocked us from being able to use it.
And so what we've done, we've actually tried to streamline this process where
we have test cases that we make available to the payer so that we tell them, Hey,
this is how we're going to test the API.
And then we create a, um, nice little scorecard that shows we've done
these tests, here are the results for these tests, here are the specific
reproduction steps that you can take
if you want to reproduce the results that we made feel free to bring that back
to your technical team or your vendor.
Uh, we've had an opportunity to interact with many technical teams across many
payers and their vendors and provide this constructive feedback and working
in collaboration to get these APIs working, not just for us, but for
anybody else who wants to query them.
So and we're doing that at no cost to the payer.
We want the APIs to work so that we can get it.
But the side benefit is that they're available to the
rest of the industry as well.
The other thing that we are doing is, uh, we are using the APIs to assess
the the accuracy of the data.
What we've noticed is that if a critical mass of payers agree that
a provider is at an address and has a particular phone number, that it's
very likely that provider is actually there and has that phone number.
It's like the, uh, like the jelly bean exercise at the carnival where you've got
thousands of jelly beans within a jar, and you ask a hundred people,
how many jelly beans are in that jar?
Everybody's wrong.
Actually, everybody's wrong.
Maybe one person's right.
But if you average everybody's guesses together, then it's very
close to the actual number of jelly beans, like one or two off.
It's it's a similar approach around Provider Directory, where, you know,
every Payers' Directory is wrong, but where they agree and where they disagree
is incredibly informative to figure out what's right and what's wrong.
And so we're sharing some of these results with payers right now just
to help them improve the accuracy of their data as upstream as possible.
Yeah.
Brendan Iglehart: I've
seen similar technology in place on kind of patient level data so the concept of
a master master patient index and mapping your specific data your organization owns
with kind of public and other data sets.
So that's that's really cool to hear that that could be applicable here as well.
So external providers like Newfire often play a crucial role in scaling
solutions like this effectively.
So I'm curious if you can tell us a little bit about how you view partnerships in
fostering innovation and then ensuring success with with complex projects.
Ron Urwongse: Yeah, so,
just thinking back to my own experience with payers at Defacto Health.
We can only go so far into the payer organization.
Actually, sometimes we've been on so many phone calls with these payers that they
forget that we're an external party and they think they're contracted with us
and we have to remind them that actually, no, you're not paying us anything, we're
just doing this as a service to you guys, but also to get your APIs to work.
But still, we, we can only go so far into the organization.
We can provide evidence of incorrect data.
We can provide evidence of maybe upstream issues where processes
are are not implemented correctly.
But it really takes an organization like Newfire that has direct engagements
with these payers to be able to assess.
Actually, these are the upstream issues, both from a technology perspective, but
perhaps from a governance perspective.
And, and I think with Newfire's abilities, both from a technical and
a management consulting perspective, there, there is an opportunity to
establish better governance and to clean the data as upstream as possible.
Brendan Iglehart: And looking forward, what what are some of the
trends or technologies do you think will further transform innovation
in this space, whether it be Provider Directories, usability or
accuracy, what are some things that you're kind of keeping an eye on?
Or if you had your to rub your magic crystal ball that you
expect to see in the coming years?
Ron Urwongse: The magic wand that I've been I've been craving
for years is this idea of an appointment API on the provider side.
So for a practice or a health system and their EHR or, and, or their
appointment system, could they surface up some type of standards-based API
to answer a couple of questions?
One is for a given provider, this is for available appointments
within the next 30 to 90 days.
And also, here's an ability to actually book an appointment.
There are a couple of IGs that were published years ago from the Argonaut
Project that address these particular use cases; I believe they've only
been implemented a handful of time.
I'm seeing some renewed interests in it.
Some interesting interests on the payer side.
I've heard through the grapevine that some payers are incorporating
direct appointment capabilities within their directories.
If you think about it for a second, if you can get information about
actual appointment availability,
the particular practice locations that providers are accepting
patients and providing appointments.
That goes a very long way to clean up these directories.
Because if a provider is not actually providing appointments at a particular
address, maybe as a payer, you don't want to publish it in your directory.
Or maybe you want to only surface up the providers who have the most the
most immediate availability within your search results so that members
or consumers will have an easier time getting appointment because getting
appointment right now, you might call 5, 6, 10 doctors until you find one with
a near term appointment availability.
So that's one.
I wish there were a magic wand to make that happen faster.
I am optimistic that some of this renewed interest is going to move the needle some.
Brendan Iglehart: And I think that brings up a good point.
This, this aligns with my thinking on the kind of phases of the rollout of EHRs is
the first phase is just to get the kind of base technology or systems in place and
get data flowing between organizations.
But then what's really cool from there is, is the use cases and the problems
you can solve once you can take that for granted, which, as we both know,
and healthcare can take a bit of time.
But once it's there, unlocks some, some great possibilities.
Ron Urwongse: You know, I think that's why people stay within this field for
so long for decades at a time, because: A, it takes that long for change to
happen and B, I think for those of us who want to see the end of the story,
who want to see the next or want to see all of the pre-work in place really
pay off by 5, 10 years down the road.
There will be an opportunity to do that.
I do think it's iterative, we shouldn't view the the 1st generation
of these APIs or machine-readable files as a failure by any means.
It's just the 1st version and the 2nd version of the 3rd version.
Are you get are going to get better as the public provides
more constructive feedback.
And as their expectations increase on what that data should be able to do.
Brendan Iglehart: I'm going to link this back to something that we were talking
about earlier is really the patient perspective and the fact that we are
all ultimately consumers of a lot of the technology that we are creating.
So from that lens of a patient, what are some of the things that you're most
excited about in terms of what these advances will will bring to the floor?
Ron Urwongse: We'll go back to some of the the future innovations
and trends that I was predicting.
But I think there will come a time, you know, and you can call me out on
this, we can have another podcast in 5 years to see if I'm right or I'm wrong,
but I think there will come a time when these directories are going to be
more accurate, where we can search for providers by appointment availability,
where it's going to be a whole lot easier to get your data as a patient.
And where you can use that data to help inform provider search
plan selection, cost estimation.
These are rules that are on the book.
These are data that are available, but they need to get refined and the
quality of the data needs to improve.
And innovators out there need to bring these data sets together.
But I'm optimistic that it's going to happen just because it's more public and
there are so many eyeballs on, not only the data, but also these API capabilities.
I do think it's gonna happen.
Brendan Iglehart: Yeah, I think it's really exciting to me just kind of
seeing the trends and healthcare moving toward a more consumer centric
perspective but in current state, not giving people the the data and the
resources to necessarily be consumers.
So, the closer that we get to that, I think, is really, really
a cool future to look forward to.
Ron, for organizations that are looking to be tech-forward and kind of get
ahead of some of these regulations, what are things that you recommend
that they look at and take steps to do around the directories and other
interoperability topics as those advance?
Ron Urwongse: If I had to recommend one thing, it would be listen
to the people who are trying to use your data and your API.
They have they have a lot of feedback and constructive feedback and take that into
consideration as you're working with your tech team or your vendor and improving
them and making decisions on roadmaps and backlog with in particular for directory.
What I would recommend for health insurers is that they take a look at all the places
the data surfacing, the web directory, the Provider Directory, API, any CRM
systems that they have, any data sets that they're obligated to submit to the
government, price transparency files.
And ask the question, how aligned are these data?
And it could be very simple.
It could be, okay, the number of practitioners in each of these data sets.
Is it about right?
Are they within the ballpark?
And, what is the overlap between all of them?
That would be incredibly informative.
And the reason I bring it up is because folks like me and
others are doing that on our end.
If you guys did that on your end, it would make sure that the data was
aligned and it could also identify some upstream data governance issues.
I think around Provider Directory as well, it's having a repeatable, reproducible
accuracy measure that is aligned with how the industry is measuring.
I think we're, I mentioned it before, but we still don't have an
industry-wide definition about how how Provider Directories should be
measured from an accuracy perspective.
And then I think the final thing that I would mention for health insurers is
clean the data as upstream as possible.
Don't just clean it up at the API side or the, if you've got a dock finder
there, if you clean it further upstream within your PDM system, then you've got
a number of other downstream systems that are going to benefit from it.
And by the way, if you clean it upstream all the way on the provider side, giving
that critical constructive feedback to the providers, it's going to help out
not only you, but other payers as well.
And then recommendations on the provider side, because right now they
don't have a whole lot of regulatory requirements around this directory data.
But if they did want to get ahead of it, it's take a look at what the payers are
saying about your providers and where they're at and what their specialties are.
That's informative.
There are probably all sorts of differences between what you're
submitting and what they're publishing.
And having that second pair of eyeballs from that part of the
industry would also be helpful.
And it's going to be easier to do that with these APIs and with
these machine-readable files.
Brendan Iglehart: This conversation, like most in healthcare technology, bring to
light a lot of complex challenges, but also makes me feel really optimistic
about the advancements and the and the things that are coming down the pipe.
So really appreciate your time, Ron, and bringing clarity and actionable
strategies to some of the most complex challenges of our day.
Ron Urwongse: Thanks Brandon.
It's been a pleasure.
Brendan Iglehart: Ron, thanks for bringing clarity and actionable strategies to one
of healthcare's most complex challenges.
Your work here in improving Provider Directories underscores the
importance of data-driven solutions in creating more efficient and
transparent healthcare systems.
To our listeners, today's conversation highlighted the vital role of
accurate provider directories in transforming healthcare.
As we navigate the evolving landscape of interoperability and compliance,
the insights shared here offer valuable guidance for driving meaningful change.
Thanks for joining us on Hard Problems, Smart Solutions, the Newfire podcast.
See you next time.