NCVHS Hearings on Data Quality, Accountability, and Integrity

NCVHS Hearings on Data Quality, Accountability, and Integrity • Patient Medical Record Information • Functions served and value of comparability • how precise, • how accurate, • consequences of inaccuracy • Joe Bormel, M.D.,M.P.H.

Care Management Clinical Performance Measures Descriptive Documentation Process Automation Still in someone’s head, only PMRI uses, conceptual diagram Lifetime Medical Record Capturable during a clinical encounter

Critical Perspectives Data capture- a byproduct of the care process Standard definitions of data elements Descriptive Documentation Process flow is the integration glue A Lifetime Record Care Management • Leadership • Incentives • Tools Clinical Performance Measures Process Automation

Business and Clinical Problemdefinition (I.e. Bed/days per thousand, Inappropriate variation, …)

Extent of Variation Explainable From Current PMRI (ICD-9,CPT-4, groupers) # of Average Range RDRG Cases $K/Case $K__ s.d. Pneumonia 0890 110 11.54 0.7 - 56.0 8.1 # of Average Range RDRG Cases $K/Case $K__ s.d. Pneumonia 0890 110 11.54 0.7 - 56.0 8.1 Congestive 1270 168 12.70 3.7 - 174.0 14.1 Heart Failure 1271 774 16.70 1.6 - 121.5 13.1 1272 73 36.86 2.0 - 182.6 32.6 8050 20 8.14 0.461 - 23.9 5.8 # of Average Range RDRG Cases $K/Case $K__ s.d. Pneumonia 0890 110 11.54 0.7 - 56.0 8.1 Congestive 1270 168 12.70 3.7 - 174.0 14.1 Heart Failure 1271 774 16.70 1.6 - 121.5 13.1 1272 73 36.86 2.0 - 182.6 32.6 8050 20 8.14 0.461 - 23.9 5.8 Hip Surgery 2090 499 30.0 0 - 64.8 5.7 2091 225 33.7 14.2 - 146.8 11.3 2092 157 37.3 0 - 153.5 15.7 2093 22 62.0 25.2 - 257.9 50.3 1999, Cerner Corporation

Going Beyond Current PMRI Drivers: Total Cost Summary Drivers Summary Expected Cost versus ‘Us,’ (case mix adjusted) 1999, Cerner Corporation

PMRI needed to measureand improve quality and costs Cases with significant variation in costs not explained by independent drivers/triggers (age, comorbidities, event sets) Clinical Low Risk Expected performance Clinically Higher Risk Information construct: Event Set Pneumonia • Adequate reasons for higher costs • Hemodynamic instability • Extensive involvement with hypoxemia • Inability to clear respiratory secretions • Failure of outpatient treatment • Severe neutropenia under 1000/cu.mm. • Altered mental status Record one time, in granular and codified form to support all measurement needs • Inadequate reasons • Pleurisy • Cough • Fever

Value Improvement Initiativesenabled by adequate PMRI “New” Comfort Level Value Improvement Initiatives aka Medical Management “Old” Comfort Level Value Drivers: (Quality/Cost) Cost Summary Drivers Summary Time 1999, Cerner Corporation

Medical Management Programs undertaken by the Administrative, Clinical and Financial management of a provider organization to: Improve quality Lower the cost of care Reduce inappropriate variation Meet reporting requirements 1999, Cerner Corporation

The Care World Care Acuity / Cost Time 1999, Cerner Corporation

Acute / Urgent / Emergent Chronic / Disease Demand Health, Wellness, Alternative Self-Care Care Acuity / Cost Time 1999, Cerner Corporation

Populations and Care Acuity / Cost Time Population Care 1999, Cerner Corporation

Populations contracting for Care Medical Cost (Risk) Population Catastrophic | 23% 30,000 1 % | Catastrophic 23% $ 30,000 PMPY 1 % Care Chronic 33% 7,920 5 % | Chronic 33% 7,920 5 % Episodic 25% 2,143 14 % Episodic 25% 2,143 14 % Well 17% 255 80 % Well 17% 255 80 % 1999, Cerner Corporation

Medical Management Goals • PMRI: • Functions served and • value of comparability • how precise, • how accurate, • consequences of • inaccuracy Acuity / Cost Time Population Care Identify Intervene Inform

Medical Management Programs Global Health Management Pathway Management ORYX Reporting Care Case Management Cost Profiling Risk Assessments Clinical Profiling Call Centers Provider Profiling Resource Planning HEDIS Reporting Risk Management Patient Education Credentialling / Reappointment Prospective Concurrent Retrospective 1999, Cerner Corporation

Integration, Interrelationships and Management Case Management Cost Profiling Risk Assessments Clinical Profiling Population Care Prospective Concurrent Retrospective Continuity 1999, Cerner Corporation

Summary Billing data lets you evaluates patterns of resource consumption: The what, where, when, and who, but not the why or the clinical context. Without common, situation-specific, granular, codified PMRI, the consequence will be lower cost effectiveness of medical management initiatives. This current state was illustrated in the first several slides. Our greatest opportunity is PMRI, captured as a by-product of routine care, that is common and codified. This is the critical first step to quicken the pace of health care improvement. 1999, Cerner Corporation

NCVHS Hearings on Data Quality, Accountability, and Integrity