IDC

February 2022

U.S. Provider Data Management for Payers 2022 Vendor Assessment

Jeff Rivkin

Jeff Rivkin

Research Director, Payer IT Strategies

Product Type:
IDC: MarketScape
This Excerpt Features: InterSystems

IDC MarketScape U.S Provider Data Management for Payers, 2022

Capabilities Strategies Participants Contenders Major Players Leaders

Major Players

Availity

InterSystemsFeatured Vendor

Quest Analytics

Santéch Software

symplr

Leaders

LexisNexis

Contenders

Virsys12

IDC MarketScape Methodology

IDC Opinion

This IDC study represents the vendor assessment model called IDC MarketScape. This research is a quantitative and qualitative assessment of the characteristics that explain a vendor’s current and future success. This study assesses the capability and business strategy of many of the most prominent provider data management (PDM) vendors found in payers that use that software to establish a “core provider system of record or truth” for the payer enterprise. This evaluation is based on a comprehensive framework and a set of parameters expected to be most conducive to success in providing provider data management software today and in the future. A significant and unique component of this evaluation is the inclusion of buyers’ perception of both the key characteristics and capabilities of these vendors. Interest in reengineering and automating payers’ “provider back office” is stimulated by the evolutionary change of value-based reimbursement provider contracts, the availability of enterprise workflow software, lightweight cloud models of operations proven by cooperatives and start-up health plans, and enhanced document management capabilities. A summary of findings of this study include:

  • Provider data is now its own core application. Provider data has moved from being a set of tangential reference data used to validate claims to become a core administrative asset that is being used for competitive advantage.
  • Provider data management has a crowded, dynamic field of vendors, and few do everything well. Vendors are being challenged by start-up and established companies that are creatively offering services, lightweight search, and modular approaches to function. Many “major players” were identified, each with its own value proposition. Traditional players are being challenged by an expanding problem set, and newer vendors are just beginning to appreciate the complexity of this space.
  • Provider data is a consumer differentiator. Consumers now want to search for providers not only by their location or network affiliation but also by increasingly more granular criteria including newly defined specialty types (e.g., adolescent-oriented psychiatrists, autism-inspired art therapists, naturopaths, and wellness specialties).
  • Provider data is a social differentiator. Recently, providers of “social determinants of health” like food banks, job placement, and government agencies are relevant to payers as “providers” as well. 
  • Network adequacy is equivalently important to directory accuracy, but vendors are slow to adopt this function. Legislatively, an adequate, diverse, and broad network is desired by consumers and required by ACA and state regulations.
  • Data stewardship remains a problem. Consumers expect payers to make available quality provider data. Unfortunately, providers do not always supply this information to the payer. The lack of a true “data steward” in this space is an ongoing problem, which drives the “data cleansing” function to have high weight when evaluating vendors.
  • Provider data management pricing will be more competitive, flexible, and on demand. Models of pricing that meld the “own the software” legacy mindset with the “buy as you need” incremental functionality will evolve.
  • Provider data management has significant scope and breadth and is enlarging. Up and coming requirements include tracking value-based provider and community affiliations and truly embedding the contract-to-claims loop into the provider management ecosystem.
  • Provider data management is back-office plumbing and is hard to justify enhancement, fundingwise. In the race for funding dollars in a cost-squeezed payer industry, back-office operational improvements rarely get high priority, competing against flashier or mandated initiatives for funding. Even though provider data is changing all of the time, with vendor stats indicating 33,000 weekly address changes, the back office is hard-pressed to get dollars.

Tech Buyer Advice

When purchasing provider data management software, consider these recommendations:

  • Take an inventory of the number of possible data sources or origination points of provider reference data within your organization. Consider all the departmental/external responsibilities.
  • Take an inventory of the number of provider data “targets” or systems that need provider data. The typical payer may have more than a dozen provider targets. While normal, if not addressed comprehensively, there is a potential risk with duplicative ETL or overlapping SOA services executing.
  • Establish (buy or build) an independent flexible system of record for provider data. Use master data management principles.
  • Consider plug-and-play application architecture for the system of record/data mart.
  • Isolate workflow, document management, and other business capability applications from structured and unstructured data whenever possible.
  • Consider point solution, best-of-breed API, or microservices-oriented applications as the requirements are changing rapidly.
  • Educate providers as to the downstream value of having their data correct and incent them both negatively and positively to comply and communicate. Continue/implement the “carrot and stick” approach to partnering with your providers to enable quality provider data.
  • Recognize that payer data is probably very “dirty” and plan to spend significant time “cleaning” during the conversion.

Featured Vendor

This section explains IDC’s key observations resulting in a vendor’s position in the IDC MarketScape. While every vendor is evaluated against each of the criteria outlined in the Appendix, the description here provides a summary of each vendor’s strengths and challenges. 

IDC’s assessment includes seven vendors: Availity, InterSystems, LexisNexis Risk Solutions, Quest Analytics, Santéch Software, symplr, and Virsys12. Other vendors did not meet the inclusion criteria and they will be highlighted in an upcoming document featuring the vendors to watch for provider data management in 2022. Those vendors are NTT DATA, Ribbon Health, Salesforce, SKYGEN, and Simplify Healthcare.

InterSystems

According to IDC analysis and buyer perception, InterSystems is positioned in the Major Players category in this IDC MarketScape for provider data management for payers software in the U.S. market for 2022.

Product: HealthShare Provider Directory

InterSystems, a global player in information technology platforms for health, finance, and government applications, founded in 1978, and serving payers since 2005, is privately held and offers HealthShare as one of its product suites. InterSystems has been providing interoperability solutions for decades internationally for many industries. Its ability to atomize, aggregate, deduplicate, and normalize data clearly is and has been its focus.

HealthShare is a suite of connected health solutions, and Provider Directory is a standalone purchasable unit that has been in the suite since 2019. It alternatively can be used within HealthShare as a directory FHIR resource and to maintain a provider registry for notifications. For example, a HealthShare buyer could purchase the following individual products:

  • HealthShare Unified Care Record with FHIR Gateway. Provides an aggregated, deduplicated, and harmonized view of a member’s care record
  • HealthShare Health Insight. An analytics product, dependent upon HealthShare Unified Care Record, used for dashboards, data quality, as well as to aggregate and clean data to use with other analytics solutions 
  • HealthShare Patient Index. An enterprise master patient index (EMPI) solution that provides an automated and easily integrated solution for creating a “single source of truth” for patient identity and demographic information 
  • HealthShare CMS Solution Pack. A turnkey solution for CMS-9115-F Interoperability and Patient Access Final Rule
  • HealthShare Personal Community. A member self-management and engagement solution dependent on Unified Care Record
  • HealthShare Care Community. A solution for care givers, patients, and their families to improve communication, care transitions, and care coordination outside of the hospital setting
  • InterSystems IRIS for Health. An innovation and development platform to develop applications internally and used as the base of the HealthShare and other suites 
  • HealthShare Provider Directory. A master data management (MDM) solution for provider data to support member attribution and alerting (optional, standalone)

HealthShare Provider Directory, introduced in 2019-2020, on premises or hosted, focuses on master data management. Its data model and its understanding of the interoperability between payers and providers is its strength. Its core solution centers on the following key functionalities: data ingestion; data preparation and cleaning/normalizing; parsing data into the data model; matching and linking based on customizable rules; operational data management, such as validating matches, running queries, and updating records; and sharing and exporting data in multiple formats including FHIR.

HealthShare Provider Directory also offers a provider identity matching engine that combines deterministic matching, probabilistic algorithms, and defined rules to create, manage, and maintain the complex relationships that define the healthcare landscape, such as organization hierarchies, network participation, and multiple practice locations for provider information. Its Provider Directory is built on the HealthShare platform that includes interoperability tools combined with a push service that maintains a directory FHIR repository and can supply master data management records’ updates to downstream systems with accurate, up-to-date, reliable information. 

InterSystems offers an on-premises or cloud solution in a “per provider” pricing model. 

For data ingestion, HealthShare uses a suite of tools to enable interoperability among and onboarding of healthcare systems. Key tools in the ingestion process are: 

  • Out-of-the-box adapters for working with healthcare standard formats, custom formats, and standard protocols with prebuilt mappings for common healthcare standards
  • Intuitive visual data mapping and process orchestration tools

HealthShare processes inbound records as data events, allowing rules-based action triggers based on transactions flowing through the system. As data is ingested, it is also made available in a relational data model for operational reporting and analysis.

Regarding curation of data, HealthShare ensures the consistency of data in several ways:

  • Message validation
  • Matching records across data sources, which can match deterministically or probabilistically using matching algorithms (Matching rules and linkage models can be customized, and customers can tune weightings and thresholds.) 
  • Normalizing various formats into a single comprehensive data model and applying code system mappings to normalize codes to a chosen target code system
  • Role-based access for data stewards who maintain the directory 

Strengths

InterSystems is extremely experienced in health data and its management. Its preexisting adapters for mapping standard data formats that facilitate data onboard show its commitment to (international) standards, and it serves on standards bodies (DaVinci, DEQM, Carin, INTEROPen, FHIR, HL7, and IHE). Tangentially, it is notable that EPIC relies on InterSystems development technology for its EHR software and expertise in infusing data into the EHR workflow. It also serves as the engine for 12 state health information exchanges (HIE) and the eHealth Exchange. The eHealth Exchange is active in all 50 states, is the oldest and largest national health information network in the United States, and is the principal network that connects federal agencies and nonfederal organizations, including over 75% of U.S. hospitals and tens of thousands of clinics, to share patient records to better treat patients and coordinate care. This shows its expertise in scalable bidirectional data exchange and an understanding of standards, certifications, and state regulation.

Challenges

InterSystems does not support campaigns for recruiting, onboarding, search (although it has REST and FHIR API implementation guides), outreach, attestation, self-service, CAQH/SAM/PECOS/LexisNexis validations, network adequacy, provider ratings, or sanctions, but these are on its road map and the data model is extensible. 

InterSystems’ focus is on cleansing and identity so that the company’s core HealthShare applications and external interfaces have good provider data to execute with, including adherence to DaVinci methodology. InterSystems has an expertise in claims, enrollment, clinical, and SDoH data integration. Its slant on its provider data focus shows that lineage. 

Consider InterSystems When

Consider InterSystems when you want a very health-oriented, international, experienced, data-centric, professional software vendor that understands the importance of clean data, governance, and the role of provider data integration in the interoperable health ecosystem. Its experience in HIE, payers, providers, finance, and government show its dedication to data engines providing accurate data as the commerce for better health. 

Methodology

IDC MarketScape Vendor Inclusion Criteria

This research includes analysis of seven software providers that offer both on-premises and cloud-based provider data management solutions to payers for their purpose of contracting with providers. IDC believes that the vendors in this study generate most of the revenue in this market.

The increasing depth and breadth of the data that consumers require from their provider directories, the explosion of new provider types under wellness or specialty care themes, the maturation of value-based reimbursement, and the strategic payer advantage of establishing narrow networks cause a rethink of the provider data management software market. Vendors were polled and were included based on meeting the majority of following criteria:

  • Enable provider outreach and enrollment. (The vendors should have the ability to find, vet, and enroll providers to a health plan for future contracting.)
  • Establish the provider “source of truth” for demographics for a payer enterprise.
  • Cleanse provider data. (Match with external data sources, identify duplicate or deceased providers, validate various demographics and specialties, and identify sanctions against providers.)
  • Maintain provider directories. (Upload new [valid] data, extract print and web and electronic directories in various formats, and support audits when external organizations challenge the completeness, accuracy, and adequacy of the network and directory.)
  • Configure and interface to provide provider data inside and outside the payer organization.
  • Maintain provider data via mass update, self-service portals, sanctions monitoring, and integration with hospital systems.
  • Define and prove network adequacy to customers, regulators, and other parties.

There are a variety of vendors around the broader “provider relationship management” space. The focus of this research is around the core administrative system that provides a “source of provider truth” for the enterprise. Therefore, this scope specifically excludes contract management, product assignment, credentialing, fee schedule management, network modeling, contact management, provider relations, provider quality management, contract monitoring, and visits management.

Reading an IDC MarketScape Graph

For the purposes of this analysis, IDC divided potential key measures for success into two primary categories: capabilities and strategies.

Positioning on the y-axis reflects the vendor’s current capabilities and menu of services and how well aligned the vendor is to customer needs. The capabilities category focuses on the capabilities of the company and product today, here and now. Under this category, IDC analysts will look at how well a vendor is building/delivering capabilities that enable it to execute its chosen strategy in the market.

Positioning on the x-axis, or strategies axis, indicates how well the vendor’s future strategy aligns with what customers will require in three to five years. The strategies category focuses on high-level decisions and underlying assumptions about offerings, customer segments, and business and go-to-market plans for the next three to five years.

The size of the individual vendor markers in the IDC MarketScape represents the market share of each individual vendor within the specific market segment being assessed. Critical to a successful vendor selection is the articulation of the priorities and strategy of the purchasing organization.

Recognize that a vendor’s market share as represented in this document is a snapshot in time and may not reflect its near-term growth or consider its experience and success with related legacy products. A vendor’s market share should be considered when evaluating the relative risk of a relationship with a vendor. For example, if a vendor’s product has been active in the market for 10 years and has fewer than 20 clients further, due diligence is required.

The IDC MarketScape is a valuable representation by a neutral third party of a vendor’s current capabilities and future strategy. The IDC MarketScape should not be used in a vacuum but rather be one of several inputs to short listing vendors.

IDC MarketScape Methodology

IDC MarketScape criteria selection, weightings, and vendor scores represent well-researched IDC judgment about the market and specific vendors. IDC analysts tailor the range of standard characteristics by which vendors are measured through structured discussions, surveys, and interviews with market leaders, participants, and end users. Market weightings are based on user interviews, buyer surveys, and the input of IDC experts in each market. IDC analysts base individual vendor scores, and ultimately vendor positions on the IDC MarketScape, on detailed surveys and interviews with the vendors, publicly available information, and end-user experiences in an effort to provide an accurate and consistent assessment of each vendor’s characteristics, behavior, and capability.

Market Definition

Provider data management in the payers’ back office involves creating a “system of truth” for provider data in a payer organization. Concerns include demographic data capture, facilitating provider relations, enabling network formulation, establishing a provider relationship, credentialing, contracting, and directory publication as well as enabling the rest of the organization to refer to the system of truth for reference.

Related Research

  • IDC PeerScape: Lessons Learned for Payers in Provider Data Management (IDC #US48405121, December 2021)
  • IDC Market Glance: Payer, 3Q20 (IDC #US46848117, September 2020)
  • IDC PlanScape: Payer Data Platforms for Member-360 and Provider-360 Views (IDC #US46015320, February 2020)
  • IDC MarketScape: U.S. Contract Management Tools for Payers 2018 Vendor Assessment (IDC #US43511218, February 2018)
  • IDC PlanScape: Payer/Provider Contract Management 2.0 for Payers (IDC #US43259117, December 2017)
  • Perspective: For Payers, It’s Time to Get a New Claims and Billing Engine — Decoupling and Change Have Atomized Your Legacy System (IDC #US41552216, July 2016)
  • IDC PlanScape: Directory Accuracy and Network Adequacy — For Payers, the Time Has Come (IDC #US41242516, May 2016)
  • Vendor Assessment: Provider Data and Network Management Solutions Refactor, Expand, Deepen, and Broaden Markets and Function (IDC #US40702515, December 2015)
  • Perspective: Why a Comprehensive Provider System of Record Is Fundamental for Payers (IDC Health Insights #HI259664, October 2015)

IDC MarketScape: U.S. Provider Data Management for Payers 2022 Vendor Assessment