September 28, 2021


Why Knowing John Doe From J. Doe Is So Important in Healthcare

Sumant Rao, Chief Product Officer and Justin Chang, Product Manager

The healthcare industry is in the midst of a transformative shift. Health plans are keeping pace with new reimbursement models, the growth of advanced analytics, the focus on the consumer and sweeping regulatory requirements.

Healthcare has the most complex data management issue of any industry. While health plans manage a bevy of detailed data about their members, that data is also extremely sensitive, siloed and highly subject to privacy and security restrictions. 

We cannot lose sight of the goal of data, which is to improve outcomes and support the member experience. The key is knowing whose data belongs to whom, or, on a more basic level, who is who. After all, John Doe and J. Doe are not always the same member, and sending the former’s healthcare data to the latter could result in a HIPAA fine — or worse. 

Most canned master data management (MDM) solutions do not take the nuances and complexities of healthcare data into account. This creates a bevy of barriers for healthcare CIOs, who are tasked with joining disparate data from legacy and emerging systems to create a single source of truth for every member. Healthcare data is nuanced, contextual, and constantly evolving — and the velocity of that data varies by system. While some systems run streaming protocols, legacy systems barely manage batch extract generation. 

Healthcare CIOs require more than technology to realize the true benefit of MDM. They need a partner with healthcare expertise — a partner that knows their data intimately, can provide a strategic touch in identifying key impactful data attributes, and can manage their data at scale going forward. At Abacus Insights, we approach MDM as a combination of entity resolution, workflow management, and data management.

Why MDM is mission-critical: Understanding the risks and leveraging the returns 

If the goal of healthcare data is to improve health outcomes and enhance the member experience, MDM should be the top priority of healthcare CIOs. The creation of MDM logic is an ongoing process; healthcare organizations should always be striving for better matches. Most health plans do not have the internal resources to maintain a resilient MDM program. 

As data changes and regulations shift, these organizations are left vulnerable. Poor execution of MDM can result in more than just a HIPAA fine; inaccurate entity resolution processes can lead to members receiving wrong or inappropriate messages about their plan benefits or the management of their care. In the worst-case scenarios, inaccurate entity resolution can deliver wrong information and impede member health outcomes.  

A well-executed program, on the other hand, integrates diverse data sets, powering advanced analytics, driving insights, and spurring innovation. Members are able to access and understand their data and use it to make more informed decisions about their care. Having a single source of truth and access to longitudinal member data enables higher quality care and better care coordination. Health plans equipped with this data can create better plan designs that offer more robust and varied options for members.  

In order to optimize MDM and fully leverage their data, health plans must overcome five major barriers: 

  • 1. Linking & tying data. Health plans are inundated every day with new transactional data like claims and lab data, as well as entity-related data like enrollment data. These data have inherent velocity and quality challenges that make linking and tying extraordinarily difficult.  
  • 2. Implementation time. MDM implementation typically takes up to six months. Most MDM vendors provide plans with the products and services needed to set up their systems without providing post-implementation support. This leaves health plans scrambling to onboard engineering and data operations teams to support their new MDM solution. MDM is more than an out-of-the-box solution; it’s an ongoing journey of continuous improvement. Relying solely on deploying an MDM solution unfairly shifts the burden back onto the health plan.   
  • 3. Patient matching. Healthcare data is constantly changing. Most MDM systems do not have the tooling to inform users how well their matches are performing or identify records that could potentially be mismatched because of new or changing data. This creates a nightmare scenario for health plans, which are subject to increasingly strenuous privacy and security regulations.  
  • 4. A workflow to deal with fallouts. Traditional MDM products expect payers to manually resolve fallouts. This is an unsustainable task. A proactive data partner combines industry expertise with fuzzy matching rule sets to train models that reduce the manual overhead.

5. Data quality. As the volume and complexity of data continues to increase, the difficulties of linking and tying data, implementing MDMs, and ensuring accurate entity resolution become exacerbated. While MDM solutions work to update records and cleanse redundant data, health plans still need robust data quality tools to fully optimize their MDM investments. These tools can help reduce rework and maintain accurate, connected data records while continuing to ingest data at scale.

Abacus Insights goes beyond MDM by providing an ongoing feedback loop 

By going beyond MDM, health plans can bolster trustworthy member and provider relationships, improve their data quality for analytical usage, and unlock the potential of their data. This requires more than just technology. Healthcare organizations need a trusted MDM partner that understands their data and its nuances and will work closely with them to leverage data to improve member experience.  

While most MDM vendors will hand off their solution and walk away, Abacus Insights works hand-in-hand with partners to implement, manage, and optimize MDM. Abacus Insights knows your data and will partner with you to set up MDM rules with high-quality matches within a matter of weeks. With Abacus Insights as your MDM partner, you can trust that your matches will be automatically improved as more matches are discovered over time, reducing the number of potential matches. This allows health plans to hone in on the development of new products for their members and reduces the risks of HIPAA non-compliance. 

Most importantly, Abacus Insights does not offer a one-size-fits-all solution. MDM is contextual by use case. For example, a broad marketing campaign has some innate tolerance for false positive matches, while a precision clinical use case, wherein data is much more sensitive, has none. Abacus Insights’ MDM implementers partner with business users to establish these thresholds in order to leverage MDM as the strategic asset that it is meant to be.