As previously presented and discussed, health care in the United States is in deep trouble. Quality, information technology and accountability inadequacies, accompanied by “out of control” fiscal scenarios, permeate the health care landscape.
Critical health care dimensions like cost, quality, access, and population health are defined at the point of service. Cost and price points at the point of service translate into aggregate spending totals. The delivery of appropriate goods and services based on patient need feeds quality and, in the aggregate, is a major contributor to the improvement of the health of the entire population.
Virtually every American agrees that each of these dimensions requires major changes in order to build a proper health care continuum. So, why is it that costs and prices are out of control? Why is quality grossly inadequate? Why does health care in the United States lag behind a large number of other countries in a number of areas?
Our hypothetical Achievable Health Care Plan (AHCP), introduced two weeks ago here at the CACG Common Good Forum, has implemented a plan that addresses these “industry killing” issues. AHCP believes that it is imperative that any comprehensive health care information technology continuum should support timely performance and information management improvement. Thus, its IT facilitator, HIPE (Health Care Information and Performance Engine) is designed to pro-actively monitor, influence and improve service delivery performance and data completeness and integrity. Furthermore, HIPE both informs and influences clinical and care management decision-support functions. And last, but far from least, HIPE dramatically speeds up the process of information flow and service management. AHCP recognizes that data and treatment control functions are more timely and effective as they get closer to the point of service.
The purpose of this second installment is to briefly describe how HIPE goes about its daily mandate to:
• Inform and influence the timely delivery of recommended services and;
• Improve information accuracy, completeness and flow
HIPE springs into action at 12:01 AM when daily member/patient and provider information begin to arrive. Among the information elements included in these daily updates are:
• Plan member information
• Plan provider information
• Inpatient admission and discharge data
• Outpatient Service Data
• Pharmacy/Prescription data
Expected Service Buckets
To strive for total quality health care, AHCP knows that participation, coordination and cooperation are necessary ingredients among patients, providers and health plans. HIPE is commissioned to maintain the flow of information among these critical participants and both monitor and influence their involvement and participation.
HIPE kicks off the day by addressing member-expected service buckets and related delivery windows. Expected service buckets (ESBs) are, as the term suggests, services that are expected to be provided for each patient in order to fulfill the treatment and service guidelines adopted by AHCP. Invariably, ESBs have recommended delivery windows (time spans within which these services are expected to occur), and HIPE is designed to identify these buckets and related delivery windows, and to facilitate the timely delivery of the growing AHCP universe of service guidelines. To show how this process works, let’s take a look at a few examples.
In the member update for today, HIPE identifies Sarah, a 52-year old new member at AHCP. Following AHCP guidelines, HIPE immediately creates at least three ESBs for Sarah. The recommendations are that Sarah should have an annual physical by her personal care physician, that she have a mammogram every two years and a cervical cancer screening every three years. HIPE opens a bucket for each of these expected services, and begins a daily process of checking whether the services have occurred, and sets the preliminary intervention parameters that may later be needed to influence their timely delivery.
HIPE discovers that Laura, another AHCP member, is pregnant. A review of medical information suggests that Laura might have complications with her pregnancy. HIPE immediately alerts the Quality Assurance (QA) department which, in turn, implements AHCP’s special treatment management protocols for pregnancy complications. HIPE also alerts Laura’s physician that AHCP is aware of the potential problem, and that the QA department will be getting in touch to collaborate.
George is an AHCP member who is suffering from diabetes. He has recently been discharged from the hospital after a stay that was necessitated by uncontrolled diabetes --- George was not taking his diabetes medications. His pharmacy records suggest no recent prescriptions for diabetes control medications, so HIPE contacts the QA department, the patient and the primary care physician to address this issue so as to avoid any future hospitalizations that proper control medication would prevent.
Our last example is Lydia. It has been 20 months since Lydia has had a mammogram and HIPE knows that she has a history of weak compliance with treatment guidelines. HIPE sends her a letter reminding her that her mammography is due and alerts the primary care physician as well.
These four AHCP members are but a few of the many members who must be reminded and encouraged to pursue proper health care including healthy living and compliance with preventive and treatment guidelines. This personal responsibility is an important factor, but shared responsibility by the provider and health plan are also valuable and necessary components, and it is up to HIPE to make sure that all three are well informed and influenced to be active participants in the pursuit of “just in time” quality health care.
Provider Performance and Information Flow
Providers have a stake in seeing to it that service guidelines are fulfilled in a timely manner for each of their patients. It is equally important that providers completely and accurately record and report all treatment and service interventions in a timely manner.
HIPE consistently updates provider profiles that are intended to inform, monitor and influence provider performance with respect to both service delivery and reporting. Among the provider information variables routinely tracked by HIPE are:
• Reporting Problems ---Time elapsed between service delivery and reporting
• Performance Issues --- Service delivery guidelines compliance and timeliness
• Unnecessary Services --- Questionable or unwarranted services
HIPE has targeted a number of providers for special attention today. A few examples will explain the need for and value of on-going provider monitoring.
Reporting Problem
At Lagtime Outpatient Clinic, the treatment-to-reporting time interval has been rapidly increasing, and is well above the norm for outpatient service providers. Today, HIPE discovers that Lagtime has crossed the threshold for intervention. HIPE alerts the provider that a review will be initiated, and proceeds to contact the AHCP provider relations department which is responsible for such reviews. Previous reviews of this sort with other providers have resulted in a number of reasons for slow reporting including but not limited to:
• Provider information submittal performance shortfalls
• Automated system processing or submittal problems on either the provider or health plan (AHCP) end
Reviews frequently lead to problem identification and viable solutions, and provide venues for collaboration and problem solving by the health plan and the provider.
Performance Issue
Doctor Low-Volume and Sparse Services Outpatient Clinic have also come to HIPE’s attention today. Both Doctor Low-Volume and Sparse have reached the threshold to trigger a review because their performance in meeting service guidelines for their patients is significantly lower than their peers. HIPE also alerts the doctor to expect a chart audit in the very near future and informs Sparse that a treatment services data extraction and/or a chart audit might be forthcoming. Chart audits are frequently requested, commissioned or performed by health plans to attempt to identify the extent to which quality measure services are being delivered and not reported.
Information control models like IPM and its critical component HIPE provide embedded information integrity and protection functions that control and protect data capture, flow, accuracy and completeness within and between systems and organizations. When goods and services are delivered in a health care setting, accurate coding is essential and each event must be successfully reported to multiple destinations. However, some medical interventions are never coded, and still others are coded improperly. Some properly coded events are never reported, and yet others get lost in the journey to one or more necessary destinations. When data and information are flawed, performance is not measurable, quality is not ascertainable, accountability is thwarted, and negative fiscal ramifications are spawned.
Moreover, without complete and accurate information, it is not possible to corroborate best practices, develop standards, and identify inappropriate treatment interventions. Accurate data is required to uncover fraud and abuse, to assist in maximizing “just-in-time” goods and services delivery, and to both evaluate and improve provider and health plan performance. Evidence-based medicine, evidence-informed treatment guidelines, and clinical decision support depend on timely data collection and dissemination. At the individual patient level, accurate health care data is essential to identify undelivered, duplicate or unnecessary services. Accurate data also plays an important role in the development of personal health care profiles that assist both providers and patients to make timely holistic treatment decisions and avoid medications and medical interventions that may prove harmful or ineffective. At the payer level, complete and accurate data provides a foundation for quality management, research, and cost controls.
Unnecessary Service
Dr. Scriptwriter has also made HIPEs list today. Dr. Scriptwriter has been inappropriately prescribing antibiotics for upper respiratory viral infections. This use of antibiotics is both unnecessary and costly, so HIPE alerts Dr. Scriptwriter to the problem, and informs the QA department to engage with Dr. Scriptwriter on AHCP guidelines and industry best practices on this particular issue.
Wasteful Thinking
No discussion of health care services delivery in America is complete without taking a look at the issue of waste.
On October 26, 2009, Thomson Reuters, a major supplier of information to business organizations and professionals, estimated that the U.S. Health Care System wastes between $600 billion and $850 billion annually. Among the categories of waste and related dollar estimates included in the Reuters White Paper were:
