# Presentation: 547865

## 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.**

**NCVHS Hearings on ****Data Quality, Accountability, and Integrity**

## PMRI uses, conceptual diagram

**PMRI uses, conceptual diagram**

***Lifetime***
***Medical***
***Record***

**Capturable**
**during a clinical **
**encounter**

## Critical Perspectives

***A***
***Lifetime***
***Record***

**Care **
**Management**

**Clinical**
**Performance**
**Measures**

**Process**
**Automation**

**Critical Perspectives**

- Leadership
- Incentives
- Tools

## Business and Clinical Problemdefinition  (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**
**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**** ****	**

**	****	****	****	****  ****# 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**

****** **1999, Cerner Corporation

## Going Beyond Current PMRI 

- Expected Cost        versus ‘Us,’
- (case mix adjusted)

**Drivers**:

-   Total Cost Summary

-   Drivers Summary

**Going Beyond Current PMRI **

****** **1999, Cerner Corporation

**Notes:**
This report shows macro-indicators that we are monitoring by day of stay for patients on the pathway.   One indicator highlighted by this report is pre-op antibiotics for the CABG Pathway.  The pathway recommended Ancef usage, but 4 patients were given Unasyn, an alternate antibiotic.  This is fine as long as the post-op outcome is still high.  However, comparing pre-op antibiotic to the “post-op day 2 temp” of the patients, we can easily see that every patient on Unasyn suffered a high temperature following surgery.

This leads us to the next question:  Why was formulary not followed?  

And, which patients did not meet the day of stay indicators for CABG?  
It is quite apparent that Alan Owens (patient) did not meet any of the 9 macro-indicators that we are monitoring, such as pre-op temp, neuro-stat, post-op function, etc.  Should Alan have been enrolled on the pathway in the first place? 

BENEFIT:  View clinical, operational and economic data surrounding care delivery through one viewer!

## PMRI needed to measureand improve quality and costs 

- 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

- Inadequate reasons
- 	Pleurisy
- Cough
- Fever

- PMRI needed to measureand improve quality and costs** **

- Record one time, in granular and codified form
- to support all measurement needs

## Time

- Drivers:

- Cost Summary

- Drivers Summary

**Value**

**Time**

**(Quality/Cost)**

- Value Improvement Initiativesenabled by adequate PMRI** **

****** **1999, Cerner Corporation

**Notes:**
This report shows macro-indicators that we are monitoring by day of stay for patients on the pathway.   One indicator highlighted by this report is pre-op antibiotics for the CABG Pathway.  The pathway recommended Ancef usage, but 4 patients were given Unasyn, an alternate antibiotic.  This is fine as long as the post-op outcome is still high.  However, comparing pre-op antibiotic to the “post-op day 2 temp” of the patients, we can easily see that every patient on Unasyn suffered a high temperature following surgery.

This leads us to the next question:  Why was formulary not followed?  

And, which patients did not meet the day of stay indicators for CABG?  
It is quite apparent that Alan Owens (patient) did not meet any of the 9 macro-indicators that we are monitoring, such as pre-op temp, neuro-stat, post-op function, etc.  Should Alan have been enrolled on the pathway in the first place? 

BENEFIT:  View clinical, operational and economic data surrounding care delivery through one viewer!

## 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**

**The Care World  **

- Acuity / Cost

- Time

****** **1999, Cerner Corporation

## Care

**Care**

- Acuity / Cost

- Time

****** **1999, Cerner Corporation

## Populations and Care

- Population

**Care**

****** **1999, Cerner Corporation

## Populations contracting for Care

- Medical Cost (Risk)

- Catastrophic							|
- 23%  30,000	          1 %					|

- Chronic
- 33%  7,920	          5 %					|

- Episodic
- 25% 2,143	        14 %

- Well
- 17%  255		        80 %

**Care**

- Population

- Catastrophic
- 23%  $ 30,000 PMPY          1 %

- Chronic
- 33%  7,920        5 %

- Episodic
- 25% 2,143     14 %

- Well
- 17%  255	        80 %

****** **1999, Cerner Corporation

## Medical Management Goals

- Population

**Care**

**Identify**

**Intervene**

**Inform**

## Medical Management Programs

**Care**

**Clinical Profiling**

**Case Management **

**Pathway Management **

**HEDIS Reporting**

**ORYX Reporting**

**Provider Profiling**

**Call Centers**

**Risk Management **

**Cost Profiling**

**Prospective**

**Concurrent**

**Retrospective**

**Global Health  Management **

**Credentialling / **
**Reappointment**

**Patient Education**

**Resource Planning**

**Risk Assessments**

****** **1999, Cerner Corporation

## Integration, Interrelationships and Management

**Integration, Interrelationships and Management**

- Population

**Care**

**Concurrent**

**Prospective**

**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