This page is part of the National Healthcare Query (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

General Guidance

Background

Healthcare directories play a critical role in enabling identification of individual providers and service organizations, as well as characteristics about them, their relationships, and the means by which to access and exchange patient information among them electronically. Healthcare directories support a variety of use cases, including:

• Electronic endpoint discovery
• Referrals and transitions of care
• Health plan enrollment
• Provider selection
• Service selection
• Provider credentialing/privileging

Today, many health and social care organizations maintain directories, including providers, payers, health information exchange organizations (HIEs/HIOs), health information service providers (HISPs), social services organizations, government agencies, and credentialing organizations. However, despite their importance, health and social care directory activities remain scattered, uncoordinated, and are often not interoperable. As a result, the industry collectively spends significant time and resources registering and validating demographic information for individual and organizational providers for purposes such as information exchange, referrals, licensure, credentialing, certification, and payment.

Providers and service organizations often have to submit and manage information about themselves and relationships to a variety of stakeholders. In the US healthcare sector, providers often contract with ten or more health plans, and are required to regularly submit similar information to each plan for inclusion in a provider network and directory. Likewise, provider credentialing and hospital privileging processes require similar documentation. The Council for Affordable Quality Healthcare estimated that just maintaining provider databases costs the US healthcare industry at least $2 billion annually.

Due to the high cost of acquiring and maintaining provider, organization and service information, existing healthcare directories often contain information that is inaccurate, out of date, or not validated.

National Directory Scope

This implementation guide uses the term ‘national directory’ because it encompasses all individuals and entities that provide services which may impact an individual’s health and well-being. We did not limit the definition of a directory to include only those individuals/entities that are licensed to practice medicine and/or bill for healthcare services. Rather, the directory is intended to include data about community/social service entities and non-licensed administrative/support staff, among others.

Patient/caregiver information, however, is considered out of scope.

Resource Relationships

Note: the following diagrams provide a high-level view of the relationships between resources used in this IG. They do not necessarily reflect all of the relationships/references between resources.

Practitioner

A practitioner is a person who is directly or indirectly involved in the provisioning of healthcare.

Practitioner Role

PractionerRole describes the relationship between a practitioner and an organization. A practitioner provides services to the organization at a location. Practitioners also participate in healthcare provider insurance networks through their role at an organization.

Figure 1: PractionerRole

Organization Affiliation

Similar to PractitionerRole, OrganizationAffiliation describes relationships between organizations. For example: 1) the relationship between an organization and an association it is a member of (e.g. hospitals in a hospital association), 2) an organization that provides services to another organization, such as an organization contracted to provide mental health care for another organization as part of a healthcare provider insurance network, and 3) distinct organizations forming a partnership to provide services (e.g. a cancer center).

Figure 2: OrganizationAffiliation

Network / Insurance Plan

A network is a group of practitioners and organizations that provide healthcare services for individuals enrolled in a health insurance product/plan (typically on behalf of a payer).

Figure 3: Network / Insurance Plan