Point-of-Care Clinical Data Support & Care management Integration

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Information technology and decision support web-based It tool in support of the Patient Centered Medical Home.

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Point-of-Care Clinical Data Support & Care management Integration

  1. 1. Point-of-Care Clinical Data Support & Care Management Integration.<br />David S. Hanekom, M.D., F.A.C.P., C.M.P.E.<br />October 6, 2009<br />
  2. 2. Outline<br />Claims data – accuracy and validity<br />Quality Measurement and claims data<br />Clinical data and quality measurement<br />Patient-Centered Medical Home<br />Benefits of clinical data<br />
  3. 3. Medical Management Activities at BCBSND<br />Uniform Participation Agreement <br />Near-universal participation<br />Specific Provider Performance standards in PAR Agreement<br />Performance Standards enforceable via Corrective Action Policy<br />Correction Action Policy transparent and available at www.bcbsnd.com<br />All member/provider complaints of fraud/quality-of-care issues are formally investigated.<br />Original source documentation is obtained.<br />Medical director and formal coding review of all source documents.<br />
  4. 4. Claims data<br />Claims data represent:<br />Billing practices of Provider<br />Medical and billing requirements of payers<br />Coding conventions and rules of organizations<br />Reimbursement strategies of various groups<br />Methodology for getting reimbursed to Providers and Patients.<br />
  5. 5. Lessons Learned<br />Claims data represent payment policy and reimbursement strategies and not clinically useful quality information.<br /> Claims data have huge gaps and is not useful for quality measurement or reporting.<br />
  6. 6. Paradigm Shift<br />Quality Measurement and Reporting will be:<br />Clinical data supported by claims data<br />Outcomes measures supported by process measures<br />Clinically meaningful measures to clinician/patient/payer<br />Comprehensive , multiple measures across multiple clinical conditions<br />Clinical quality benchmarking that is condition specific and regionally relevant to North Dakota<br />Clinical measures must be co-morbid condition risk-adjusted<br />Performance reporting must reflect patient preference and fairly reflect clinician controlled/influenced quality of care.<br />
  7. 7. Obtaining Clinical Data<br />No single, uniform information technology platform available that would meet PCMH need.<br />Contracted with vendor for custom-designed product that meets the following functionalities:<br />Technology platform/vendor agnostic<br />Allow for natural language processing<br />Patient-centric data gathering<br />Data gathering automated with option for manual entry modification<br />Rigorous quality assurance and complete transparency of data<br />Automatic risk-adjustment of metrics based on multiple clinical criteria<br />Intuitive ease of use for front-line clinical staff<br />Automated attribution process for clinical condition and personal physician<br />Near “real-time data” at point of care via web-portal<br />Complete transparency of all data, metrics, performance standards to all parties involved<br />
  8. 8. MediQHome Quality Project<br />Patient-Centered Medical Home <br />2 Large IHDS and 8 smaller clinical groups (Proof of Concept)<br />MDInsight PCMH information technology platform (Free to providers)<br />1,200 PCP’s enrolled and acting as Personal Physicians<br />9 Chronic Condition Clinical Suites, 4 Wellness Suites<br />82 metrics tracked and displayed to Providers<br />Metrics are risk-adjusted automatically<br />Comparative quality reporting with benchmarking<br />Quality reporting risk-adjusted for patient preferences and legitimate medical contra-indications to testing or treatment<br />Quality reporting contextually adjusted for patient and clinical factors <br />All data exportable by provider for additional data uses.<br />Sponsor Portal with powerful auditing and reporting capabilities.<br />www.thorconnect.org/nd/mediqhome<br />
  9. 9. Lessons Learned<br />Design of MDInsight Complex and challenging<br />Data acquisition much less complex than anticipated.<br />Clinical data resides in multiple places and originate from multiple sources (known and unknown to Provider)<br />Significant variability in IT resources in front-line offices<br />Resourcefulness of rural/smaller offices impressive<br />Urgent need for quality data and comparative quality reporting<br />Need and willingness to do practice transformation<br />Acceptance of quality data as basis for transformation<br />Recognition and embracement of prospective population management based on accurate data .<br />
  10. 10. Disease Burden<br />Disease burden much higher than that reflected by claims experience.<br />Member’s have higher burden of complex co-morbid conditions than reflected in claims data.<br />Claims data financial risk profiling e.g. ERG’sdo not reflect clinical risk as defined in clinical data.<br />Patient preferences play major role in clinical risk and future financial risk.<br />
  11. 11. Benefits of clinical data<br />Benefit Design<br />Disease burden more precisely defined<br />Gaps in benefit design identified.<br />Value-based design based <br />Underwriting<br />Disease burden and clinical risk well defined.<br />Case Management<br />Earlier and more targeted risk identification and intervention.<br />Intervention targeted and customized to Member’s needs<br />Disease management<br />FEP members targeted with various programs<br />Medical Policy<br />Clinical data informs and guides medical policy generation and adjustment to support PCMH and population management.<br />
  12. 12. Benefits of Clinical Data<br />Quality Reporting<br />Accurate, continuous, comparative and transparent<br />Clinically and contextually adjusted.<br />Locally , regionally, and nationally benchmarked.<br />Provider Relations<br />Cooperative, transparent Quality Initiative<br />Provides Six Sigma, lean principles process support via consultant<br />Employers<br />Better product and program design for Self-funded Groups<br />Customized wellness offerings based on clinical risk.<br />Other<br />External relations with other stakeholders<br />
  13. 13. Summary<br /> Contacts<br /> Petrice Balkan<br /> MediQhome program Director<br />petrice.balkan@bcbsnd.com<br /> David Hanekom, M.D., F.A.C.P., C.M.P.E.<br /> Medical Director<br />david.hanekom@bcbsnd.com<br />

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