MBSC Meeting

1. MBSC Meeting June 11, 2010

2. Welcome/Introductions John Birkmeyer, MD

3. Changes to BCBSM Payment for CQI Participation Ellen Ward

4. Changes to BCBSM Payment Methodology for CQI Participation

5. Payment for CQI Administration Costs Payment to reflect BCBSM, government and uninsured cases (approximately 80% of total) Phased in beginning October 2010 Payments made prospectively (annual) via EFT Notification sent to CEO and other stakeholders.

6. CQI Payment Transition Schedule (tentative)

7. CQI Performance Index Maximum of 10 CQIs included in index No limit on reimbursement eligibility for administration costs Initial (2010) measurement period: July - December Subsequent measurement periods: January � December Index performance scores submitted to BCBSM by coordinating center

8. Approximate dollar value of the performance index for each CQI within the Hospital P4P program

9. Sample CQI Performance Index

10. Accuracy in completeness of complications ascertainment John Birkmeyer, MD

11. Amanda O�Reilly, RN Clinical Nurse Project Manager

12. Orientation to the meeting binder and site specific packet

13. Progress with rates of follow-up Strategies attempted so far Obtaining weights and complications from the sites when the patient does not return the follow-up questionnaire to the DCC We have worked with 10 sites Completed process with 5 sites Started process with 5 sites Calling patients who have not followed up with the hospital or returned the survey to the DCC

14. Progress with rates of follow-up 1-year follow-up Increased from 49.3% (4109/8332) to 57.0% (4745/8332) 2-year follow-up Increased from 42.8% (1348/3148) to 44.8% (1410/3148) The cut-off dates for operations are 4/30/09 and 4/30/08, respectively.

15. Ideas to continue to improve follow-up rates??? Each site will ask the patient to complete the annual follow-up questionnaire when the patient returns for a yearly appointment Sites will mail these to the DCC monthly when they send the paper forms Other ideas?

16. Progress with error proofing data entry system We have been working with a data programmer to improve our data entry system Goals: Create more validation less missing answers, less time spent on looking up queries Data will be more complete and accurate at all times On-line program will become more user friendly

17. Examples of error proofing If the patient is recorded for treated hypertension, you will not be able to submit the page without recording the number of meds. Every question will have to have an answer before the page can be submitted Discharge date will not be able to be recorded prior to the admit date

18. Blinded National Death Index Service (BliNDS) Vic Kheterpal, MD Prinicpal Care Evolution, Inc. vik.kheterpal@careevolution.comApril 2010

19. Agenda Problem Statement NTIS/SSA Death Master File Background Privacy Protecting Lookup � Hashing Overview How to Subscribe Discussion Facts about chronic disease in the U.S.Facts about chronic disease in the U.S.

20. Problem Statement How to manage 30+ day mortality information for �your� clinical intervention? Individual contact � very expensive operationally and dubious results Other approaches like death database lookups can be more efficient National Databases SSA publishes the Death Master File NTIS distributes a variety of methods of looking up information How to subscribe and use this lookup without disclosing PHI Most of patients you will lookup will still be alive (hopefully ? ) How to do it minimal IT headache

21. DMF Background

22. Two Basic Approaches For Lookup Lookup using various websites Individual lookup Submit files Web based queries All suffer from 1 basic issue You must share your PHI with an external entity to perform the lookup Download the file and build a tool internally No disclosure of your PHI to external entities Issue : IT effort + approx $5K in master file license fees annually

23. USE ADVANCEDCRYPTOGRAPHIC TECHNIQUES The Use of Hashing Can Obfuscate the PHI � The�SHA hash functions�are a set of�cryptographic hash functions�designed by the�National Security Agency�(NSA) and published by the�NIST�as a U.S.�Federal Information Processing Standard. SHA stands for�Secure Hash Algorithm.� (wikipedia) �The four hash algorithms specified in this standard are called secure because, for a given algorithm, it is computationally infeasible to: find a message that corresponds to a given message digest, or find two different messages that produce the same message digest�

24. Privacy Protecting Lookup Death database lookup Application to convert PHI to one-way hashed code Updated to use SHA-256 hashing algorithm Pings central server for lookup Match or no-match + date of death returned

25. Self Service Tool To Invoke Lookup

26. Sample Text File Within Your Facility

27. Sample Results File

28. Getting Started Get URL from Dr. B Download Hashing Widget from web site Prepare Text File Submit File Get Answer Back

29. Technical quality focus groups Technical Skill Stan Hamstra, PhD/ Jon Finks, MD

30. Technical quality focus groups Technique Randy Baker, MD/John Birkmeyer ,MD

31. Technical quality focus groups OR environment Paul Kemmeter, MD/Caprice Greenberg MD, MPH/Nancy Birkmeyer, PhD

32. Highlights from ReportsNancy Birkmeyer, PhD

33. Highlights from Reports

34. Highlights from Reports

35. Highlights from Reports

36. Highlights from Reports

37. Highlights from Reports

38. Highlights from Reports

39. Highlights from Reports

40. Highlights from Reports

41. Highlights from Reports

42. Highlights from Reports

43. Highlights from Reports

44. Risk Factors for Serious Complications

45. Risk and reliability adjusted rates of serious complications by site

46. Accepted at JAMA

48. Rates of serious complications by hospital volume category and COE status

49. Surgical Technique and complication ratesJon Finks, MD

50. VTE Prophylaxis Guidelines Jonathan Finks, MD

51. Risk Factors for VTE

52. Rates of VTE According to VTE Risk Category

53. VTE Pocket Card Example: Risk Factor Points Sleeve 4 Age 50 4 BMI 50 3 Female 0 Smoker 2 Total 14

54. VTE Pocket Card

55. Variation in the proportion of patients receiving pre-operative heparin by site

56. Variation in the proportion of patients receiving post-operative heparin by site

57. Variation in the proportion of patients receiving pre/post-operative heparin by site

58. Trends in use of peri-operative heparin

59. Trends in use of LMW heparin for peri-operative prophylaxis

60. Trends in the use of post-discharge heparin by VTE risk category

61. Variation in proportion of low risk patients receiving post-discharge heparin by site

62. Variation in proportion of medium or high risk patients receiving post-discharge heparin by site

63. Trends in the Proportion of Patients Receiving Prophylactic IVC Filters by VTE Risk Category

64. Variation in proportion of patients receiving pre-op IVC filters by site (2009 or later)

65. Trends in VTE Rates

66. RevisionsJohn Birkmeyer

69. Relationship between serious complications and weight loss Patient level Hospital level

70. EBWL(%) by Procedure

71. Risk Factors for Weight Loss Failure

72. Relationship between rates of serious complications and weight loss failure at the patient level

73. 1-Year Weight Loss Failure Rates by Site

74. Relationship between rates of serious complications and weight loss failure at the hospital level

75. Meeting Adjourned Thanks for coming! Next meeting is October 1, 2010