Removing Blind Spots: Seeing All the Data Supports High-Value,Patient-Centered Care

19 Dec 2012

“If we knew then what we know now...”

It’s the mantra of frustrated health professionals the world over who crave real-time, actionable data that leads to meaningful improvement in the delivery of patient care.
Determined to provide meaningful information and advance the quality and affordability of health care in its state, the Oregon Health Care Quality Corporation (Quality Corp) supported the implementation of the Oregon Health Leadership Council’s (OHLC) High-Value Patient-Centered Care Model (HVPCCM) demonstration. As part of a two-year demonstration, the organizations produced quarterly utilization reports for 3,600 patients served by eight health plans and 14 medical groups.
The interactive, user-friendly reports include information on emergency department (ED) use, hospitalizations, use of imaging services, pharmacy fill rates by therapeutic class, generic fill rates, visits over time to primary care, and visits over time to specialists. The reports are available through an online portal and released within four to six weeks of obtaining claims data.
OHLC’s overall model is designed to provide coordinated, high-quality care to patients with chronic and complex conditions and achieve shared savings for medical groups and payers. The model of care was based on the successful demonstration project launched by the Boeing Corporation. The evaluation of cost savings will occur at the end of the demonstration.
“We wanted to provide more timely and actionable information about the care enrolled patients are receiving,” said Denise Honzel, executive director of the OHLC. To accomplish this, the OHLC turned to Quality Corp to provide this information. “By providing claims based reports on utilization of services, we provide value added information about care that is happening outside clinic walls,” said Mylia Christensen, executive director, Quality Corp.
Building on an existing partnership and a shared commitment to improving the quality of care and reducing costs, the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality initiative provided support for the project. In fact, as a result of past work with RWJF and participating health plans, much of the necessary data for the utilization report project was already in place. Through this project, participating health plans and medical groups received their patient data more frequently.
“This is the first time that the medical groups are getting aggregate claims data for unique populations,” said Honzel. “They are seeing all the data from all of the players in one place.”
Each of the utilization topic areas contains multiple reports. For example, emergency departments use reports that include:
• Visit rates by quarter compared to benchmarks overtime
• Avoidable visits
• Visits broken down by each day of the week
• Visits by weekend versus weekday
• Visits by patient
The reports are examined primarily by nurse case managers, who are required to develop individualized care plans for identified patients. Medical groups also can track their enrolled patients’ progress in avoiding ED use over time. It’s usually difficult for medical groups to get timely information about their patients’ ED visits and hospitalizations. Even when a large health system has records of all ED visits to their hospitals in the patients’ EMRs, they don’t have records of visits to other hospitals.
Through the utilization reports, medical groups can see their patients’ activity regardless of their health plan. For example, one provider looked at the ED visits across the quarter and realized that a majority of hospital visits by people in their health system were not at affiliated hospitals. Data from the utilization reports were updated in the EMRs, providing a more complete picture of the care their patients were receiving.
“It turns out there is so much leakage of data when patients are going all over the place,” said Dr. Pranav Kothari, founder of Renaissance Health, a developer of innovative health care models that OHLC hired to support this work. “These utilization reports help identify when people receive care that we might not know about otherwise. It helps defragment care in a way that is useful for the patient.”
Dr. Kothari pointed to one example of conducting a similar review of data in one community. It uncovered a disproportionate number of ambulatory/ ED visits during certain times of day, particularly during the hours of 3 p.m. to 5 p.m.
“We found out that simultaneously the primary care practices were under pressure to contain costs,” Dr. Kothari said. “Situations that might result in overtime spending would often result in the patient being sent to an ED, even though they might be able to be seen in an outpatient setting if extended access was an option.”
The reports brought a new recognition of how frontline staff at primary care facilities respond in such situations. The utilization reports helped drive an effort to formally extend hours and rethink the implications of ED referrals to avoid overtime spending.
Lessons Learned
Medical groups, nurses, and staff are eager to know how they are doing with their patients, but ability varies greatly in evaluating and acting on data provided in utilization reports. Producing utilization reports from claims that are easily understood and actionable by clinical staff can be challenging. By soliciting feedback from users, organizers can institute modifications based on the first reports. Additionally, Quality Corp worked diligently to ensure the data are presented in a user-friendly way and
 provided training to maximize the use of the reports.
“The real fundamental value of reports is finding out about utilization opportunities you didn’t know about before,” said Dr. Kothari. “It’s not necessarily revealing a gap in care, but a missed opportunity to know something or to take action, like who had a hospitalization I didn’t know about? Who is not filling all of their prescriptions? A month could be missed. It’s important because you can talk to the patient about it or do something to improve.”
The added responsibility of tracking enrolled patients on a monthly basis has been tough for medical groups, project managers say. But there is now a unified understanding of its necessity and value for timely, accurate reports and per-member-per-month payments.
Promising Signs
When initiatives such as the HVPCCM have an evaluation component at the end of the project, too much time passes without feedback to the clinic staff and payers about care delivered. The OHLC/Quality Corp utilization reports provide timely snapshots of how patient care and services used are changing over time, both at the patient level and across settings of care.
While more detailed evaluation of the entire two-year demonstration project is under way, early indicators point to a positive impact on quality and efficiency. The organizations involved expect to see a reduction in ED visits and hospitalizations, and project managers say there is a strong foundation on which to achieve a broader impact.
In fact, the Pacific Business Group on Health in California is looking at the project as a way to better serve their intensive high-risk patients. And, there is a coalition of large employers in Washington State—including the state and two county governments—that are exploring ways to replicate the effort.
“Getting the health delivery system to change is a huge mountain to climb,” said Steve Hill, director of the Washington State Department of Retirement Systems. “I think there is great potential, and the state is one of the big players. This makes intuitive sense, and it has huge potential, particularly if we direct incentives toward systems integration and care coordination.”