The Edge of Healthcare: The Power of Interoperability in Healthcare Efficiency

Martin Cody: Welcome to The Edge of Healthcare, where the pulse of innovation meets the heartbeat of leadership. I’m Martin Cody, your guide through riveting conversations with the trailblazers of healthcare. Tune in to gain exclusive access to strategies, experiences, and groundbreaking solutions from influential payer and health system leaders. This isn’t just a podcast; it’s your VIP ticket to the minds shaping the future of healthcare right now. Buckle up, subscribe, and get ready to ride to the edge of healthcare, where lessons from leaders are ready for you to use today.

Martin Cody: Hello, everyone, and welcome to the Edge of Healthcare: Lessons from Leaders to Use right now. Today, I’m fortunate and pleased to bring a guest in, Ron Urwongse, who is from Defacto Health, founder of Defacto Health, but has a pretty well-established career in healthcare to share with us some of the wisdom and insight he’s gained along his journey in healthcare. Ron, welcome.

Ron Urwongse: It’s great to be on the show.

Martin Cody: Thank you so much for joining us. You know, I like to always start off with a little bit of background with regards to your journey and where you came from, kind of an educational aspect. And then, what was the first spark you had as it relates to getting into healthcare?

Ron Urwongse: Martin, thanks for asking the question. I have to say, I ended up in healthcare almost by accident. I started off my career as a software developer. I wanted to get more onto the business side, so I went to business school at MIT, and while in grad school, I had a chance to work with a lot of really interesting startups. I loved working in these small entrepreneurial environments, had also some experiences working with large software companies, and decided that, gosh, that’s not for me. And so, I looked for the most interesting startup that I could find in the Boston area after graduating from MIT. And I found a small company called Vecna Technologies, and that’s where I got started. I happened to have a focus on healthcare. They did patient check-in kiosks, infection surveillance software, and medication delivery robots. And I had an opportunity to play product management roles in a lot of those different areas. And that’s where I got started.

Martin Cody: So, you went to undergrad with a purpose to kind of be a software developer. And then in grad school, you got bit a little bit by the healthcare bug and it completely changed your path and trajectory.

Ron Urwongse: Yeah. You know, I’m attracted to big intractable problems that take years to solve and require collaboration. And I love exploring all the nooks and crannies of problem space. And that’s what I love about healthcare. You can work on a problem for years and, you know, make some continuous progress towards the solution.

Martin Cody: I was just going to say, if you want an industry with large intractable problems, you have found a home forever in healthcare. That is for sure.

Ron Urwongse: Yeah, I often hear that from fellow colleagues.

Martin Cody: I was going to say anecdotally, one problem in healthcare is the fax machine, but we’ll save that for another day. Tell me a little bit about Defacto Health and what problems you’re trying to solve there.

Ron Urwongse: Yeah. So, I guess to start on the story about Defacto Health, I actually have to go back to my previous employer. So, when I worked at CAQH, which was a not-for-profit alliance of health insurers, they focus on provider data and member data and interoperability. And when I was there, I had a chance to learn a lot about provider data and the provider directory problems that payers face. I also had the opportunity to launch an interoperability endpoint directory as the government started mandating API requirements for payers. That’s where I started to get a peek at all of the data that would be available soon enough via those APIs. And I decided, well, gosh, I really need to set off on my own and to start making that data operational, making that data useful. And so that’s when I founded Defacto Health with my partner Tarun Theogaraj. And we’ve been integrating with payer’s provider directory APIs, which are mandated by CMS. And what we’re hoping to accomplish is to assemble the nation’s largest data set of healthcare providers and the insurances they accept, and we make that data available to any company that needs to use it for a multitude of use cases across various verticals.

Martin Cody: So, you mentioned a couple of items there that I want to kind of expand on a little bit. So, you mentioned and maybe we get some definitions. So, you talked about CAQH. What is CAQH? What do the letters stand for, and what is the main purpose of CAQH?

Ron Urwongse: CAQH, it’s interesting. It’s almost like KFC, where everybody just uses the acronym now. But if I remember correctly, it’s the Council for Affordable Quality HealthCare, and they are a not-for-profit. And payers get together and they build solutions where collective action is required and no one payer can build it on their own. And so, things like the Pro View portal that allows providers to enter their credentialing data and submit it to any payer who needs to get it. That’s one thing that they’re very well known for.

Martin Cody: It’s an interesting point because when people think of healthcare, I think the first thought that pops into their head is the provider-patient interaction, you know, the methodology of care, the provision of care, the care location; is it at the doctor’s office? Is it at the, in the operating room, the hospital? That’s what they think of when they think of healthcare. But there’s a whole series of healthcare well, prior to that interaction: getting that, as you mentioned, that provider credential, making certain that he or she is licensed to perform medicine. And I think that’s a facet that not many people realize is fraught with intractable problems and challenges, as you mentioned earlier. And one of the key areas, another definition that I want to pull on, is the term interoperability. I’ve been in healthcare for 35 years. I think I’ve heard that term just about as long as I’ve been in healthcare. But I’m very curious for the listeners and viewers, you know, what does interoperability mean, and then what will it allow to happen once achieved?

Ron Urwongse: So, it’s interesting because oftentimes when people, at least nowadays think about interoperability, it’s all been about patient data. So, as a patient, can I have access to my data? Can I avoid filling out a paper form on a clipboard before every single appointment that I have with a doctor, even if it’s with the same doctor’s practice? So that’s often what people think about, you know, interoperability. Can all of my various healthcare providers have access to my data and make the best recommendations and diagnoses relative to that? But I’d love to broaden the scope of interoperability because, you know, as I mentioned, provider directory APIs also offer this data via interoperable methods, either Fire, standards-based APIs, hl7 DaVinci defines the implementation guide for these just like they do blue button and for some of these patient use cases. But you know you mentioned credentialing and licensing. I think you kind of hinted at payer enrollment. Gosh, you know, wouldn’t it be great if we could leverage these same interoperability standards to solve for those use cases as well? There’s significant overlap with some of the same data that I’m consuming for provider directory use cases. It’s something that, you know, as an industry, we should look into; every opportunity I have, I encourage companies who are tackling some piece of this problem to see how they can share data with others, avoid any type of keystroke by pre-populating data, I mean, I think that’s really the future. You know, there’s really no reason we need to enter and enter data when we can know it from a source, from a primary source.

Martin Cody: Amen. Completely agree with that. And I think it would befuddle, confuse, anger, frustrate most individuals if they recognized behind the scenes how much manual tasks and keystroke data entry that you referenced is occurring upstream from that provider-patient interaction, especially in the year of 2024. I mean, it’s amazing to think of that; like you said, physician offices are still handing out a clipboard with information that someone has to handwrite, and then that information has to be keyed into a system. I think they’re getting better on the clinical side of things, but we aren’t getting better at the speed with which society needs it on the administrative side of things. And it’s costing, as you know, to the tune of about $500 billion a year of just absolute waste from an administrative data standpoint. And that’s the key element there as it relates to interoperability. You know, this is administrative data. This isn’t PHI; this isn’t claims data; this isn’t sensitive HIPAA patient data or anything like that. It’s just administrative data, people’s names, addresses, phone numbers, NPI numbers. So, once interoperability can help that data flow, what are some of the downstream impacts you’d like to see?

Ron Urwongse: A great question. And it’s one that this is a little bit of a “I have a dream” kind of thought in my head. You know, we need some type of North Star that we can all, as an industry, agree on that this is where we want to be. This is, we’re both providers and payers would like to be like. Wouldn’t it be great where a provider just has all of their credential information in one place, and the credential is a credential. You don’t have to verify it. Wouldn’t it be great if it was pre-verified, and you could see it and you can just trust it? And wouldn’t it be great if a credentialing event could happen within minutes rather than days or weeks, or months? You know, it would have so many downstream impacts on mobility of the healthcare workforce. And mobility is important because we have such significant supply constraints. And if we can make the healthcare workforce more mobile and being able to move from one employer to another or, etc., or move from one payer to another, then they can migrate to the place where they are most needed. You know, it makes health insurer networks more dynamic. You know, you could create custom on-the-fly networks for an employer that meets the needs of their employees. I think there’s just so many ways this could have downstream impacts, and not even talking about all the administrative savings of saving all of those keystrokes that human beings have to take. And you could redeploy that human capital elsewhere on more significant problems like healthcare quality and outcome.

Martin Cody: I agree, and I hope it happens on an accelerated timeline. You mentioned workforce mobility as it relates to clinical staff or back office staff. And certainly, I think it would provide amazing boost for clinical provider fatigue, which is much needed because of everything that we’ve experienced. But for those listening and watching, let’s talk a little bit about workforce mobility in that, you know, over the last 3 to 4 years, we’ve had a global pandemic, and a lot of folks have now started to work from home and work more remotely. I was actually doing that for 25 to 30 years prior, so it was nothing foreign to me. But what wisdom and lessons from a disciplined standpoint and habitual daily routine standpoint would you give someone who, this may be their first time ever working remotely, and they aren’t going into the office five days a week? How can your background, and share some tips, if you will, on here are some things that you need to do on a daily basis to make certain that your happiness is where it needs to be, and your productivity is where it needs to be.

Ron Urwongse: Yeah, I think, like you, I worked remotely even before the pandemic. I mentioned I was working at Vecna Technologies up in Boston. I actually moved down to the D.C. area to be closer to my wife’s family. And, you know, there was an office there in the D.C. area, but my team was up in Boston. And, you know, it’s incredibly difficult to manage a remote team. Every other week, you can fly up there, and it’s not a long flight from D.C. to Boston, and you can go in for a day or two, and it’s not awful. But, you know, it’s interesting because, like, if a company is all remote and everybody is on the same playing field and they can communicate with each other on that same platform of playing field, and if everybody’s in the office, then it’s easy. But if some people are in the office and some people are remote, then it’s incredibly difficult for the remote people to know all of the hallway conversations going on. I think my suggestion for folks who are getting started in their careers, or maybe working remotely for the first time, is you have to kind of harmonize with the rest of the company. Like if they’re mostly in person, you’ve got to have some face time with them because you’re not going to know everything that’s going on. Being a remote worker. You know, if you’re an individual contributor and you want to continue to be an individual, maybe it’s fine as long as you have a great relationship with your manager. But if you’re managing and you’ve got to interact across departments like, you’ve got to have some face.

Martin Cody: Yeah. And I think you’re seeing a lot of businesses now recognize that whether it’s going to be a quarterly meeting or 1 to 2 days in the office for those people within a certain proximity, they believe that there needs to be some face time. There needs to be some in-person socialization at an office in a work environment just to augment some of the remote work. I agree with you. I think there’s going to be, you’re going to see that play out. You know, there’s no rule book or guidebook or instruction manual to navigate this right now, but I definitely think you’re going to see that play out. Before we go into our next segment, I want to go into, you know, you mentioned CMS as it relates to kind of some of the mandates that have come down as associated with provider data. If you could wave a magic wand and get one wish granted by CMS, what would that wish be?

Ron Urwongse: It’s just one. It would be to enforce the rules already on the book. There are some good ones on there. It’s been almost three years now since the effective date of the final rule for provider directory APIs, and unfortunately, there are still some payers not complying. You know, I’m not going to name any names. And the good news is that most payers are complying. They have functional APIs and are able to query them. But there’s still like a tail of payers that either don’t have an API yet or they have an API, but it’s not functional enough to answer the most basic question of does this provider accept my plan? That is the main question members and patients want to answer when they go visit a provider directory, and that those APIs aren’t able to answer that question is unfortunate, and it’s something that needs to be resolved.

Martin Cody: And it’s interesting, too, because we actually don’t tolerate that in our personal lives. And I’ll give you an example. If you went to a restaurant’s website because you were planning a special celebration, and on the website that restaurant had listed ten different locations, and you found a location near you, and you planned a big evening, and then you went to that location, and that location physically didn’t exist, or that location was closed, no longer open for business, you would never frequent that restaurant, or it would be a very, very long time before you gave that restaurant your business. But in healthcare, these directories, on the payers’ websites or on the provider websites, members are supposed to navigate them on their own, they’re supposed to rely on that information, and oftentimes, you know, the percentages are alarming on how often that information is incorrect. And that also then has downstream negative impact, because then the member, the patient, if you will, all of us consumers and payers of insurance, they end up calling the payer. And then the call center gets clogged down with very, very mundane questions about is this provider in network or out of network? So why do you think payers are resistant to wanting to improve the member experience as it relates to Member Directory?

Ron Urwongse: Oh, I think there’s plenty, I was going to say the word blame, but I think responsibility is probably the better word to go around across the payers and providers. And I think this is still going on. You know, when these regs started coming out, there was a lot of finger-pointing of, well, gosh, the payers aren’t updating their directories, and I submit my roster to them. And you know, if only they updated my, the directory based on my information in a timely fashion, then this wouldn’t be an issue. And that is certainly an issue that is certainly a problem. It’s not happening as quickly as it should. However, you know the payers will come and say, well, gosh, the providers aren’t sending the right information, and only the providers would send the right information, and there wouldn’t be any problem. How can I, as a payer, know where the provider is? The provider has to tell me. And so, debate. This conversation has been going on for years, ever since 2015, when the first wave of regulations started rolling out. And so, there’s plenty of responsibility to go around. I think the payers are mostly being held accountable for this because CMS has purview and oversight over the payers. They’re encouraging the payers to put requirements in their contracts with the providers to update their directories appropriately and incentivize them appropriately. But we just discussed there is a provider workforce supply problem, so the payers can’t enforce all that much like they need the providers and network. So, they can only go so far as to coerce the providers to submit the right information. I think there’s a couple of solutions that we could consider as an industry, and I think one is on the provider side, being able to find the right repository of information to submit to the payer. And oftentimes, they’re going into their credentialing database, which is fine; you know, it’s a place to get it. But, you know, some of these hospital systems and health systems, they’ve got 16 complete data for their own directory that they’re paying good money to clean up and that patients are using to find doctors. And that data is complete and accurate, at least relative to some of these payers’ directories. Wouldn’t it be great to tap into that nice source of information to submit to the payer side? I think that would solve for a lot of these problems, and I think being able to introduce the right incentives for that to happen would help solve a lot of these problems.

Martin Cody: Yeah, I agree, and it’s amazing how many things are impacted by accurate or inaccurate provider data. And it has so many downstream ramifications when the data is wrong and it just continues to build, it just snowballs. So, we need to figure out that provider data accuracy. And I’m going to move on to a very fun round. And this is our word association lightning round. So now, in the famous phrase of every doctor, this is only going to hurt for a bit. I’m just teasing; it won’t hurt at all. So, I’m going to say a couple of words or a phrase. And this is speed association. So, when I say the word, you tell me the first thing that pops into your mind. Well, we’ll do a test. This is a test. Harvard.

Ron Urwongse: Oh. Zuckerberg.

Martin Cody: Yes. Okay, good. And I just did that one as a softball because I know you went to MIT, so I knew there would be something coming out, which is perfect. All right, so that’s how it’s going to go. I’m going to say a word or phrase, and you tell me the first thing that pops into your head. Ready? Prior authorization.

Ron Urwongse: API. There’s a new required API for prior authorization.

Martin Cody: PBM.

Ron Urwongse: High costs.

Martin Cody: No Surprises Act.

Ron Urwongse: No Surprises Act. Fiduciary responsible party.

Martin Cody: Interesting. All right. Now I know you’re also an avid reader. So, the final question relates to both either reading, food, or dining; completely unrelated. But if you could sit down with a person living or deceased in healthcare and have a meal with them or a drink with them, who is that person and what are you eating and drinking?

Ron Urwongse: Yeah. So, I don’t know if you know the name Eric Bricker. He’s part of AHealthcareZ, and he has this series of YouTube videos. I think there are literally hundreds of YouTube videos. He goes down the rabbit hole of these nuanced and esoteric healthcare topics, and he’s such a great explainer and educator. I’ve learned so much by watching those videos. I almost feel like I’m giving away a competitive secret by mentioning his name, but I’d love to have a meal with him. Cabernet Sauvignon is fine. That would be great. And I would just love to learn as much as possible within an hour’s mealtime with him.

Martin Cody: Well, I think that’s a great compliment because when you fear that you’re giving away potentially competitive information and it’s about another individual, that’s pretty high praise. And I think it’s also interesting because as we talk about lessons from leaders, is that we never forget that we should be sponges to knowledge and certainly expose ourselves to as much knowledge as we can on this journey of healthcare and our personal and professional life. Any other thoughts, Ron, as we depart on some advice to someone starting out in healthcare and how to make it easier on them and how they could achieve their goals?

Ron Urwongse: Yeah. You know, I just piggybacking off of that, there’s just a wealth of resources out there to tap into if either you’re trying to get into the industry or if you want to reinforce some of the knowledge that you already have. The Out of Pocket blog is great by Nikil Krishnan. The Health Tech Nerds Slack is an amazing resource. And I’m an open book. If you ever want to reach out to me, I’m happy to talk healthcare tech provider directory interoperability. You know, I’d love to engage with others in the industry.

Martin Cody: Awesome! I totally agree; there’s a lot of great resources out there. And if you love intractable long-term problems, healthcare has a home for you, I assure you. And if you need to get a hold of Ron, just look up Defacto Health, and you can contact him through there. Ron, thank you. I can’t say thank you enough. I appreciate your time this afternoon, helping other folks learn about healthcare and a little bit more about what you do, and wishing you a very successful and pleasant rest of your day. Thanks so much. We’ll talk soon.

Martin Cody: Thanks for diving into the edge of healthcare with us today. I hope these insights will fuel your journey in healthcare leadership. For more details, show notes, and ways to stay plugged into the conversation, head over to MadaketHealth.com. Until next time, stay ahead of the curve with the Edge of Healthcare, where lessons from leaders are always within reach. Take care of yourselves and keep pushing the boundaries of healthcare innovation.