 OUTPATIENT PATHWAYS
BY JOHN W. LACEY, III, MD
SENIOR VICE PRESIDENT AND
CHIEF MEDICAL OFFICER
THE UNIVERSITY
OF
UPA . 9000 Executive Park Drive . C 200 . Knoxville, TN 37923
ISSUE 2
SUMMER 2013
TENNESSEE MEDICAL CENTER
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Publishers Trey La Charité, MD Jerry B. Willis, MBA Contributors Blaine L. Enderson, MD Jill Mar nez Design & Edi ng Donna Mowery  GOT HEDIS?
TREY LA CHARITÉ, MD
MEDICAL DIRECTOR OF CLINICAL INTEGRATION
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 LENGTH OF STAY
JILL MARTINEZ,
CI DATA ANALYST
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CIimpact
YOUR INSIGHT TO LIGHT THE WAY.
A physician led system of care dedicated to improving patient outcomes
through the real time coordination of an individual patient’s care delivery
amongst all of their providers regardless of service setting or life stage.
HEDIS
Healthcare
Effectiveness
Data and
Information
Set
by Jerry B. Willis, MBA The National Committee of
Quality Assurance (NCQA)
defines HEDIS as “a set of
standardized performance
measures designed to ensure
that purchasers and consumers
have the information they need to
reliably compare the
performance of health care
plans.” HEDIS is one component
of NCQA's Accreditation. HEDIS
is the most used performance
measure in the managed care
industry. NCQA uses these
measures for commercial,
Medicare and Medicaid. In turn,
these measures are utilized by
the health care plans to measure
the quality of the providers that
format their panels. HEDIS
metrics are designed to evaluate
the effectiveness of the health
plans and a provider’s ability to
demonstrate an improvement in
IF IT’S HEALTHCARE
its preventive care and quality
measures to the health plans’
members. The majority of
HEDIS include measurements
from administrative result claims;
thus the data is extracted from
the claims submitted by
providers. The importance of
documentation on the claim is
critical and equally important as it
is within the record for score
improvement. Another portion of
data is captured through physical
review of the patient record.
With HEDIS reviews, the auditor
is actually looking at the prior
year’s information. Data is
reported to NCQA in June of the
reporting year by the health plan.
Data reflects events that
occurred during the
measurement year (calendar
year). The 2013 HEDIS data is
reported in June; however, it
reflects data from January to
December 2012.
WHY HEDIS IS
IMPORTANT
Health care reform has
heightened the significance of
HEDIS scores. In a few years,
Medicare reimbursement will be
tied to HEDIS scores, along with
several other performance
indicators. Transparency and
sharing of data has grown
exponentially over the last 3-4
years. In the coming years,
patients will have access to this
data at the time they select
healthcare providers; whether
inpatient or in a physician
practice. Revealing this data to
patients emphasizes the
importance that we strive toward
improvement of our HEDIS
scores now.
WE’LL BE THERE.
Don’t Use “High-Risk”
Medications!
by Trey La Charité, MD, Medical Director of Clinical Integration
The American Geriatrics Society recently updated the Beers
Criteria for Potentially Inappropriate Medication (PIM) usage in
patients aged 65 years or older. Initially published in 1991, this list
of medications is intended to guide the practicing clinician towards
the use of safer medications in the elderly. These “high risk”
medications are known to have a high incidence of unintended and
undesired effects in our elderly patient population. Numerous
studies have documented the association between the use of the
medications found on this list with subsequent poor patient
outcomes. Specifically, mental status changes, gastrointestinal
bleeding, falls, and fractures are the most frequent medication
related problems seen. Furthermore, the clinical effectiveness of
many of these medications has been shown to be questionable at
best.
As an additional consideration, avoiding the use of these
medications in the elderly has become a focus of many physicianattributed quality metrics. CMS, the private carriers, and the
National Committee for Quality Assurance (NCQA) closely monitor
the percentage of elderly beneficiaries in your practice who have
received at least one prescription found on this high risk list.
Providers should be aware that this particular metric is also a
component of the Health Effectiveness and Data Information Set
(HEDIS) which the private payers use to report the quality of care
they provide to CMS. Recently, the UPA has witnessed a growing
number of private payers link physician reimbursement to the
successful attainment of the HEDIS measures.
Therefore, before starting a medication found on the high-risk list, a
non-pharmacologic treatment modality or a safer pharmacologic
alternative should be utilized whenever possible. If you already
have elderly patients (aged 65 or older) taking one or more of these
medications, steps to transition them to a safer regimen should be
considered. As our elderly patients are the most vulnerable to
medication effects, current clinical standards dictate not prescribing
those drugs that clearly have a higher probability of causing them
harm.
*Note: A complete list of the high-risk medications, including the drug-specific reasons
not to prescribe them, was recently mailed to your office and is also available at
http://www.americangeriatrics.org/files/documents/
beers/2012BeersCriteria_JAGS.pdf
If you are unable to secure a copy of this list, please contact the UPA’s Division of
Clinical Integration at 865-670-6146.
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got HEDIS? CCR:
Crimson Care Registry
by Trey La Charité, MD
reviously, the medicine we practiced changed faster than any other aspect of
healthcare. Now, the environment in which we practice that medicine is changing
more rapidly than all other factors. The pendulum in healthcare is swinging from a
quantity-driven system fueled by fee-for-service to a quality-driven system propelled by
three goals: better population health, better patient outcomes, and reduced costs. While we
are most familiar with the initiatives recently set forth in the Patient Portability and
Affordable Care Act (aka “Obamacare” or “PPACA”), these are actually global efforts
actively being pursued by all industrialized nations.
P
For outpatient physicians, the thrust for quality improvement is obtaining the care directives
listed in the Health Effectiveness and Data Information Set, also known as the HEDIS
measures. Most are routine health maintenance tests or procedures we already check
such as annual mammograms, appropriate periodic colorectal cancer screenings, or routine
HbA1c measurements. While no clinician intends to forget to perform these things, office
mistakes occasionally prevent full HEDIS measure compliance. We also frequently fail to
appropriately document their completion again leading the carriers to believe they were
never done. Unfortunately, credit will not be given to the clinician for a particular HEDIS
“Therefore, regardless of which political party is in control of our
government, quality-based healthcare reform is here to stay.”
measure if the patient refuses to comply with that suggested test or procedure. Patient
accountability for your quality metric obtainment will likely become an additional focus of
your future clinical practice.
Currently, the UPA has one payer contract that rewards providers for obtaining a specified
percentage of some of the HEDIS measures. Several other large payers have recently
approached the UPA expressing strong interest in similar programs. As our
reimbursements will only continue to be whittled away, our survival will depend on all extra
reimbursement incentives such as these being actively pursued. It has also become clear
that the regulatory and watch-dog agencies, including CMS, strongly believe the HEDIS
measures make a substantial difference in patient outcomes. Therefore, regardless of
which political party is in control of our government, quality-based healthcare reform is here
to stay .
*Note: A complete list of the targeted HEDIS measures for 2013 was recently mailed to your office.
If you have not received a copy of this “Measures of Excellence” card, please contact the UPA’s
Division of Clinical Integration at 865-670-6146.
by Jerry B. Willis, MBA
UPA is pleased to announce the purchase of Crimson
Care Registry (CCR). CCR is designed to help UPA
improve population health through proactive care
management. CCR tracks and documents all patient
problems and is not specific to any particular
condition or disease. CCR examines information
garnered from the EMR that includes patient
demographics, diagnoses, service values, absence of
services and other criteria to deliver prompts and
reminders for needed prevention, screening and
disease management services. At the point-of-care,
CCR uses patient-specific encounter forms to
document a patient’s needed services, current
problems, and vitals. These reports will assist the
UPA in meeting and exceeding the HEDIS portion of
the Humana and other pay-for-performance contracts.
Patient Health Summaries can be printed for each
patient, charting a patient’s history on key clinical
indicators and can be provided to the patient to
engage them in managing their own care.
Finally, CCR helps in the submission and
management of Medicare’s Physician Quality
Reporting System (PQRS), by gathering and
reporting individual provider and group attainment on
specific PQRS metrics. This will assist UPA members
to avoid the future reductions in Medicare payments,
like the 1.5% reduction in 2015 for providers that fail
to report PQRS in 2013.
Transitional Care Team
Nicole Simmons, MSN, APRN, ANP-BC
Laura Bullock, Pharm.D., BCPS
In the coming weeks and months, your office will be
contacted to first, get a data connection between your
EMR and CCR. Secondly, once the data is
connected, providers will be trained on how to access
this information and assist in improving individual
HEDIS and other quality metrics. We encourage all
members, especially primary care to utilize this tool.
In the interim, all PCP’s in the UPA will receive a
HEDIS/HCC sheet for each Humana Medicare
Advantage patients assigned to that PCP. Review
that information and encourage your patients to
schedule the needed exams or studies to fill the gaps.
Each UPA member should have also received a
laminated card titled “Measures of Excellence”. It
highlights the HEDIS and other metrics that the UPA
is focusing on in 2013. It also indicates how to report
these measures to get credit for them. Most are
claims based reporting. Remind your patients to
follow up with ordered tests and if possible, complete
outreach calls to noncompliant members.
If there are any questions, or you would like more
detailed information on how to meet these metrics,
please contact the UPA Clinical Integration team at
865-670-6725.
Multidisciplinary Transitional Care Team
Transitional Care refers to the safe and timely transfer of a patient between healthcare settings or health care practitioners. The American Geriatric Society
defines transitional care as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or
different levels of care within the same location.” With the recent focus on providing enhanced quality of care and reducing hospital readmissions, streamlining
care transitions has become a hot topic and led to the development of a multidisciplinary Transitional Care team at The University of Tennessee Medical
Center. The team consists of Nicole Simmons MSN, APRN, ANP-BC and Laura Bullock, Pharm.D., BCPS.
Components that can hinder effective care transitions and lead to potential readmissions include: medication reconciliation; patient education concerning selfcare, diet, and medications; financial barriers; communication between providers; timely follow-up post hospital discharge; and patients’ inability to recognize
and appropriately respond to the warning signs of a worsening condition or acute exacerbation.
Above are some of the areas the Transitional Care team is focused on in order to improve the quality of care, improve the use of evidence based treatment
guidelines, and reduce avoidable readmissions. The Transitional Care team currently focuses on Heart Failure and COPD hospitalized patients. 2
CI impact
IF IT’S HEALTHCARE
WE’LL BE THERE.
Outpatient Pathways
by John W. Lacey, III, MD
Senior Vice President and Chief Medical Officer, The University of Tennessee Medical Center
T
he impact of the Affordable Care Act, changing reimbursement, UPA’s march toward
Clinical Integration, and the growing number of Tennesseans with chronic conditions such
as Congestive Heart Failure, Diabetes Mellitus, and COPD are creating an environment
where “business as usual” is not a viable option. It is increasingly clear that we must create and
take ownership of multidisciplinary and interdisciplinary patient-centered/evidence-based clinical
pathways which are supported with various outpatient services are connected to companion
inpatient pathways as well. The goal of such pathways will be to more effectively and efficiently
manage chronic conditions while keeping our patients’ needs and their personal goals at the center
of this effort.
Recently, a multidisciplinary and interdisciplinary group which included UPA representation met for
two days to outline the present state of management of chronic conditions at UTMC, define what
we believe the future state should include, and then to understand the key elements in the gap.
Several challenges were immediately clear beginning with the fact that all
too often our patients have limited understanding of their chronic condition
diagnosis and the opportunities, if not obligations to participate in their own
care. The group also encountered the challenges of the health care team
that we must create and take ownership of
communicating important and timely patient information across the
multidisciplinary and interdisciplinary patientcontinuum of care (especially at handoffs) and a lack of real time two-way
centered/evidence-based clinical pathways…”
communication between patient and the care team. In addition, there was a
realization that our patients with chronic conditions spend only a small
fraction of their time in a physician’s office or in a hospital setting with most of their day-to-day care activities taking place where they
live. Currently there are at best limited tools to bring health care support to patients in a “just in time” manner much less provides
continuous monitoring with feedback wherever the patient needs it. These challenges were made even more evident when the work
group rode with Meals on Wheels to deliver food to patients with chronic conditions. Additional issues were encountered including a
lack of understanding by the patients of their medications, transportation deficits, and general health illiteracy.
“IT’S INCREASINGLY CLEAR
If we are to be able to make the investments required to create a robust chronic disease management system, we must ultimately be
able to define and target high-risk patients and provide our care team with data from numerous sources including our electronic
medical records, patient registries, claims data, pharmacy data, and from the patients themselves. We must develop algorithms that
identify current and future high cost and high risk patients and create care management systems which match high risk patients
(those that have poor control of their chronic disease and/or barriers to effective care such as health illiteracy) with the resources
that the patients need to succeed including self-care participation.
These systems will likely involve new members to the health care team
such as care managers, chronic condition coaches, and others.
“THE GAME IS ON!
The UPA, along with UHS, is already making significant investments in
systems that can help identify patients in need of this advanced care
Seize the day for our patients and our physicians.” management system and support effective documentation and coding to
create the required financial underpinning. At the same time, the
construction of consistent chronic disease management pathways is underway by a team of primary care physicians in collaboration
with specialists in COPD, Congestive Heart Failure, and Diabetes Mellitus. The challenges inherent to building such pathways
include recognition of the fact that few of our chronic condition patients have only one chronic disease.
In addition, new ground will need to be broken in regards to inculcating these standardized pathways into the office workload so that
as we build a better future for our patients and our physicians, we do not diminish the productivity that is required for viability today.
Ultimately, if we are to seize the day for our patients and our physicians, the UPA in partnership with UHS must build-out inpatient
and outpatient pathways and develop new systems of care which can focus the right resources on the right patient, in the right
setting, at the right time. The game is on!
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How to Read a Crimson Measure Dial
Make It For #90
Doc!
Perhaps mistakenly, I left my residency
training with the belief that new prescriptions
should only be written for 30 days. The prevailing
wisdom at that time was the patient leaving a
hospitalist’s care would then have no choice but to
follow up sooner rather than later in their primary
care physician’s office. This represented one of
many strategies hospitalists thought would force
the patient back into their family doctor’s care as
soon as possible. However, new evidence
regarding the efficacy of provider prescription
habits has challenged this bit of dogma I have so
religiously followed for the last decade.
In a recent pilot program carried out by Walgreens
Pharmacies in Wisconsin, switching patients from
a 30 day supply of a prescription to a 90 day
supply improved patient medication compliance by
15%. Additionally, studies of claims data by
Humana carried out in their Medicare beneficiaries
revealed that prescription medication compliance
with 90 day supplies averaged 82% compared to
just 68% for 30 day supplies. This difference was
even more dramatic in Humana’s commercial
programs where patient compliance jumped from
58% with 30 day supplies to 79% with 90 day
supplies. In other work, the National Community
Pharmacists Association (NCPA) has recently
shown that moving to 90 day supplies lowered
overall medication costs to both the patient and
the pharmacy filling those prescriptions.
This new data is obviously compelling given that
improved medication compliance for chronic
conditions reduces the frequency and severity of
disease progression. Additionally, increased
prescription compliance has been shown to
reduce the incidence of acute care
hospitalizations. If our goal is to do the best we
possibly can for our patients, it seems that our
practice patterns should collectively migrate to
giving 90 day supplies for all of our chronic
medications instead of 30 day supplies. Given the
clear benefit, this represents a worthy change in
our inpatient and outpatient practice patterns.
by Trey La Charité, MD
*Color Dial – The dial
changes color according to
the amount of deviation from
the standard. Green: less
than ½ a standard deviation
from the mean. Yellow: more
than ½ a standard deviation
from the mean. Red: more
than 1 standard deviation from the mean. Gray: measures that the physician
cannot impact such as the patient age, severity level; or when there are less than
5 cases to compare. In the example above, this physician is
performing significantly better than the average for the entire
University Health System, Inc. (UHS) (green dial that is greater
than one standard deviation below the mean).
Jill Martinez **Comparison Group – The Crimson product gives the ability to
compare your performance to different hospital cohorts. When
first logging into Crimson, the data is being compared to like
cases in the UHS system for the past 27 months. You have the
ability to change this to different cohorts in the focus setting.
Possible choices include the top decile of hospitals nationally,
teaching hospitals, all Crimson hospitals, etc.
Length of Stay: What is
Your Contribution?
Hospital’s Length of Stay for May 2012 –
April 2013
by Jill Martinez
To evaluate your contribution to the Hospital’s
Length of Stay, simply log into Crimson and check your LOS under the “Utilization”
tab of your profile. This will show your length of stay compared to like cases in the
hospital for the past 27 months. To further evaluate your LOS, click the “Details”
button in the “Average LOS” metric. This will bring you to a screen that breaks out
your cases by MS-DRG. Your average LOS for each MS-DRG will be shown, and
it allows you to see which MS-DRGs have a higher length of stay than others.
There is an additional option to break down those cases by admission day,
discharge day, ICD-9 diagnoses, severity level, etc. These options will allow you
to see if there are any noticeable trends in your performance data. You also have
an option to see the details for each case enabling further investigation. To
access the details, click on the blue hyperlink entitled “cases” in the middle of the
page. Another way to examine your length of stay is to compare yourself to your
peers in your specialty or practice group. This will allow you to see if your length
of stay is aligned with your colleagues or to evaluate best practices. For more
information on how to evaluate your length of stay, contact the Clinical Integration
Office at 670-6726.
P: 865.670.6146
F: 865.670.6779
www.upasolutions.com
9000 Executive Park Drive . C 200 . Knoxville, TN 37923
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