Driving Effective Patient-Provider Matching With Robust Provider Data

A healthcare organization’s ability to attract new patients and coordinate care depends on its capacity for effectively matching patients with providers.

Few of us today would book a trip, take a new job, or buy a product online without performing due diligence to determine that our choice would be a good match for our needs and preferences. So why do we settle for less when it comes to something as essential as finding the right healthcare provider? 

When patients search a health system’s website or when providers try to refer to a colleague, limited information too often handicaps their ability to accurately identify the right provider. In addition to the clear implications for clinical care, patient-provider mismatches have broad financial and operational ramifications. Health systems that can’t effectively match supply and demand will increasingly struggle to attract patients and then to coordinate care within the network. 

A health system’s provider directory is a foundation for effective care coordination. Too often, however, the information is outdated, inaccurate, or simply nonexistent. In 2014, a Kyruus nationwide survey of providers representing 11 specialties found that over 25 percent of referrals are misdirected. Respondents noted that about half of inappropriate referrals happened because patients were sent to the wrong specialist or subspecialist. 

Providers attribute referral misdirection most often to a lack of information about specialists. In the survey, 62 percent cited physicians’ lack of reliable information about specialists as a cause, and nearly one in three identified this as a similar issue for referring-provider offices (32 percent) and call centers (31 percent). In the face of a misdirected referral, three in five specialists say they would re-refer the patient to another provider—placing additional strain on patients and delaying their access to the right care.

A 2016 Kyruus research study focused on the referral processes of primary care providers, and uncovered similar challenges around visibility into provider networks. Forty percent of survey participants said they don’t even have access to a provider directory at their health system. And although the vast majority considered it important or very important to refer patients in-network, their referral patterns did not always reflect that belief. Three in five providers said they don’t always comply with in-network referral requirements—most commonly citing a perceived lack of clinical expertise within their network.

A High-Stakes Issue

New research shows that suboptimal matching can even be a matter of life or death when it comes to surgery. A BMJ analysis last year looked at procedures performed by more than 25,000 surgeons in the United States on almost 700,000 patients. The study found that a surgeon’s degree of specialization (i.e., the share of a provider’s total operations that the procedure comprised) was a significant predictor of operative mortality. This factor was independent of the total number of times the surgeon had performed a given procedure—so while other research has shown the importance of total experience and volume, this study underscores the importance of clinical focus.

As such, effective provider directories and referral behaviors must be based on more-detailed insight into what’s in-scope—and out of scope—for providers across the network. As networks grow and evolve, it is critical for providers to have access to this detailed information about their colleagues when making referral decisions.

This information is critical for patients as well. Patients access care at health systems through various entry points, including provider offices, call centers, and consumer-facing websites. An effective patient-provider matching strategy must address each of these channels. The approach must also account for nonclinical factors that influence the accuracy of a match, such as insurance accepted, location, and appointment availability (click on the exhibit below). 

As the exhibit shows, appointment availability is of great importance to patients. However, this information is often unavailable to providers, patients, and/or scheduling agents, in large part because of the wide range of practice management systems that are in use across networks. Primary care providers in a 2016 Kyruus survey cited the lack of information about availability as a top pain point in the referral process. The result is that an overreliance on “Dr. Famous” or “Dr. Familiar,” as opposed to “Dr. Right,” frequently leaves patients with excessively long waits for appointments while the health system contends with underutilized provider capacity—something we call the “patient access paradox.”

As highlighted in the exhibit below, meaningful improvements in patient wait times and system capacity utilization can be achieved when availability is used as a factor to drive the optimal routing of patients within the system.

Without visibility into the “digital inventory” of the health system, organizations struggle to manage their capacity and offer an acceptable patient experience. In a recent “secret shopper” study involving 40 hospitals and health systems, Kyruus found that only one in four call centers could find an available appointment with an appropriate provider within three weeks, and 82 percent could not book an appointment directly over the phone during the first call. These shortcomings lead patients to look outside the network for care—resulting in unconverted demand for the health system and potentially the loss of patient-consumers. 

Another issue: As more and more patients migrate away from phone-based appointments to online scheduling, they will look for the features that they have become accustomed to in other industries. Accenture predicts that 64 percent of patients will use self-scheduling, and almost two thirds of health systems will offer it, by 2019. 

Steps in the Right Direction

Health systems have taken note of the need to empower patients to find the right providers when they search on their own.

Mercy Health in Cincinnati is a prime example of a health system that has innovated around its digital presence to enable accurate patient-provider matching online. One of the largest health systems in Ohio, with service to patients in both Ohio and Kentucky, Mercy recently invested in new technology to unify its provider data across the enterprise and use the data to power a robust online provider-search solution for consumers. 

Patients can search for physicians by keyword and then filter results in a variety of ways, including by insurance accepted, distance from zip code, gender, age groups seen, and languages spoken. Patients can schedule appointments online with selected providers, and the health system is working on expanding this option for a broader group. 

Patient-provider matching is similarly important when coordinating care for patients who already receive care within a health system. Piedmont Healthcare, a seven-hospital, not-for-profit system in Atlanta, is a pioneer in this area. The organization recently implemented its “Seamless Transitions” initiative to enhance and link the patient experience throughout the continuum of care. 

An enterprise-wide patient access strategy plays a key role in this effort. The health system is in the process of implementing technology to enable precise patient-provider matching—powered by a comprehensive, accurate provider directory—regardless of whether patients find providers through the organization’s consumer-facing website, access center, or network of providers. 

The Time Is Now

As health systems continue to look for new ways to boost patient acquisition, prevent patient leakage, and deliver the best possible clinical outcomes, ensuring appropriate patient-provider matching should be a core focus. Without effective provider data management and a reliable and searchable provider directory, misdirected referrals, competitive vulnerabilities, and operational inefficiencies are inevitable. It’s time to enable and expect the same rigor in patient-provider matching as we now depend on in so many other aspects of our lives. 

Graham Gardner, MD, MBA, is CEO and co-founder, Kyruus Inc.