Medical Scientific Resources: Hospital Care Program.4.6.11


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Hospitals, TPAs, insurers, self-funded programs, PPOs, Managed Care organizations, Medicare, Medicaid, VA.

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Medical Scientific Resources: Hospital Care Program.4.6.11

  1. 2. <ul><li>Simplify and standardize Concurrent Inpatient Reviews </li></ul><ul><li>Efficiently adjudicate Per Diem payment arrangements </li></ul><ul><li>Reduce review times by up to 80%, with almost 100% inter-rater reliability </li></ul><ul><li>Objectively document the appropriateness of adult inpatient hospital admissions </li></ul><ul><li>Quickly and easily document Quality Improvement compliance </li></ul><ul><li>Maximize Hospital reimbursement under new Pay-For-Performance, DRG and Case Rate criteria </li></ul><ul><li>Better control hospital operating expenses and reduce staffing </li></ul>
  2. 3. <ul><li>Hospitals are being financially squeezed from all sides – Efficiency and Effectiveness have become critical for survival </li></ul><ul><li>Providing patient care occurs in “real-time” </li></ul><ul><li>BUT… </li></ul><ul><li>Appropriateness of care is often measured “retrospectively” or after-the-fact </li></ul>
  3. 4. <ul><li>Simplifies and standardizes Concurrent Inpatient Reviews </li></ul><ul><li>Efficiently adjudicates Per Diem payment arrangements </li></ul><ul><li>Reduces review times by up to 80%, with almost 100% inter-rater reliability </li></ul><ul><li>Makes objective recommendations about the appropriateness of an admission, continued hospital stay, or a discharge </li></ul>
  4. 5. <ul><li>Quickly and easily documents Quality Improvement compliance </li></ul><ul><li>Maximizes hospital reimbursement under new Pay-For-Performance, DRG and Case Rate Criteria </li></ul><ul><li>Provides effective tool to better control hospital operating expenses and reduce staffing </li></ul>
  5. 6. <ul><li>Monitors the “real-time” status of hospital inpatients </li></ul><ul><li>Assists physicians in providing appropriate quality of care to patients, and documents compliance without need to pull and review medical charts / records </li></ul>
  6. 7. <ul><li>Cardiology </li></ul><ul><li>Family Practice </li></ul><ul><li>General Surgery </li></ul><ul><li>Hospitalists </li></ul><ul><li>Infectious Disease </li></ul><ul><li>Intensivists </li></ul><ul><li>Internal Medicine </li></ul><ul><li>Nephrology </li></ul><ul><li>Obstetrics/gynecology </li></ul><ul><li>Ophthalmology </li></ul><ul><li>Orthopaedic Surgery </li></ul><ul><li>Pediatrics </li></ul><ul><li>Psychiatry </li></ul><ul><li>Psychology </li></ul><ul><li>Pulmonology </li></ul><ul><li>Urology </li></ul>
  7. 8. <ul><li>MSR Inpatient MAP – for Inpatient Concurrent Review </li></ul><ul><li>MSR Quality MAP – to prompt collection data and document compliance, for quality improvement studies </li></ul><ul><li>MSR Resource MAP – used for the daily monitoring of staff and hospital resources </li></ul>
  8. 9. <ul><li>Physicians provide patient care in real-time </li></ul><ul><li>However, other hospital functions (including administrative, regulatory, and compliance) are retrospective decision-making processes </li></ul><ul><li>Software that purports to assist physicians must operate in real-time </li></ul>
  9. 10. <ul><li>Ever-increasing costs in the 1970’s and 1980’s stimulated growth of organizations for managing costs (“financing”) and regulating patient safety </li></ul><ul><li>All currently available concurrent review tools were developed to meet the needs of these organizations – not the needs of real-time decision-makers in a hospital setting! </li></ul>
  10. 11. <ul><li>They developed tools to gather data and to meet their financial review and payment needs </li></ul><ul><li>The use of their ‘patient diagnosis algorithms’ became the norm for “managing” care </li></ul><ul><li>However, those algorithms do not readily translate to real-time hospital and clinical decision-making </li></ul>
  11. 12. <ul><li>These agencies (which now include quality-of-care monitoring) also function as retrospective review decision-makers </li></ul><ul><li>They adopted the diagnosis-based applications developed by the Financial Industry as their tools for monitoring safety and quality of patient care </li></ul>
  12. 13. <ul><li>The existing tools cause needless tension between the reviewer and the attending physicians by relying on diagnostic codes – codes which are frequently not accurate and cannot be determined at the time of hospitalization </li></ul><ul><li>BUT… </li></ul>
  13. 14. <ul><li>There are no “real-time” tools available to Health Plans to monitor and insure that diagnostic and/or treatment interventions recommended by national practice guidelines (and often sought by Payers and Hospitalist reviewers) are actually delivered. </li></ul>
  14. 15. <ul><li>Had to adopt them out of “self-defense” and to assure payment – and to understand how to appeal underpayments and denials based on those diagnosis-based algorhythms </li></ul><ul><li>These tools do not meet the hospital or medical staff needs associated with the practice of medicine. </li></ul>
  15. 16. <ul><li>Two significant studies have been conducted to evaluate the effectiveness and comparability of the MSR Inpatient MAP to existing concurrent review tools available to hospitals and health plans… </li></ul>
  16. 17. <ul><li>NevadaCare, Inc., (managed care insurance company with clients in Nevada, Iowa and Illinois) used both instruments for concurrent review of the same hospitalized patients in 2003 and 2004 </li></ul><ul><li>NevadaCare, Inc. determined that 973 inpatient days met MSR Inpatient MAP continued stay criteria, 20 fewer than the 993 inpatient days that met InterQual/McKesson. </li></ul><ul><li>NevadaCare, Inc. concluded that the MSR Inpatient MAP was easier to administer and took less time to complete </li></ul>
  17. 18. <ul><li>A national Trust Employer Welfare Association (TEWA), in 2005, used the MSR Inpatient MAP to audit appealed denial-of-coverage determinations previously made using InterQual/McKesson </li></ul><ul><li>The audit of 123 admissions, 507 days, identified the same number of denied days.  However, case specific days differed slightly </li></ul><ul><li>the TEWA found that reviewer’s inter-rater reliability was close to 100% when using the MSR Inpatient MAP . </li></ul>
  18. 19. <ul><li>Concurrent Review today requires diagnostic codes – which are frequently not accurate nor can be readily determined at the time of admission – doctors make decisions based on organ system instability, not diagnoses </li></ul><ul><li>Quality of Care is difficult to improve and measure because there are no real-time tools to monitor and insure that recommended interventions (per national practice guidelines) are delivered to patients </li></ul><ul><li>Hospital Resources are difficult to audit and optimally allocate </li></ul>
  19. 20. <ul><li>COMPUTER SYSTEM REQUIREMENTS : </li></ul><ul><li>NEW SOFTWARE IS DESIGNED TO OPERATE ON MICROSOFT WINDOWS 7, VISTA, XP, OR 2000 (WITH SERVICE PACK 4) </li></ul><ul><li>PRINCIPAL DATA EXCHNAGE PROTOCOL:HL7; BOTH ROUTING AND LISTENING IS SUPPORTED. </li></ul><ul><li>ENCRYPTION TYPE : </li></ul><ul><li>AES- 256 </li></ul><ul><li>FILES COMPATIBLE WITH : </li></ul><ul><li>CSV FILE IMPORT </li></ul><ul><li>SPREAD SHEET FILE IMPORT </li></ul><ul><li>ACCESS IMPORT </li></ul><ul><li>EXCEL IMPORT </li></ul><ul><li>  </li></ul><ul><li>DATA EXPORT FORMAT : </li></ul><ul><li>MSSQL IMPORT / EXPORT </li></ul><ul><li>SPREAD SHEET FILE IMPORT </li></ul><ul><li>TEXT (CSV) – </li></ul><ul><li>BATCH DATA EXPORT/IMPORT VIA SQL </li></ul>