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MHMC - PTE Objectives Objective: To get providers and patients/consumers
(and secondarily purchasers, policy makers, etc. and others) the information they need when they need it to assume the accountabilities and responsibilities we are asking them to.
Rationale: With the onset of healthcare and payment reform, and initiatives like Patient Centered Medical Homes and Accountable Care Organizations, providers are assuming responsibility for the cost, quality, and patient experience (i.e. Triple Aim) of some sort of people/populations in their areas. However, we almost universally hear from providers they don’t have the information they need when they need it to assume this responsibility.
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Proposed Core Measures - I
Cancer Screening• Breast• Cervix
Diabetes• Annual A1c test• Annual LDL test
Heart Disease• Annual LDL test• Persistence of BB use
Safety• Monitoring of pts with
persistent medications
Asthma• Appropriate use of meds
Overuse• Imaging for LBP• Approp. Testing for
pharyngitis• Antibiotics for bronchitis• Appropriate tx for
children with URI Readmissions Utilization of services
Could be computed through claims only
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Proposed Core Measures - II
Diabetes• BP value (e.g. 130/80)• A1c value (e.g., < 8.0)• LDL value (e.g., < 100)• Annual eye exam• Nephropathy screen• Foot exam
Heart Disease• LDL value (e.g., < 100)• Persistence of BB use
Hypertension• BP value (e.g. 140/00)
Prenatal/Postpartum Care• Visits
Population Health• Flu shots (chronic dx
patients, older adults)• Childhood immunization• Pneumovax• Colorectal cancer screen• BMI (adult, child)• Tobacco Use (ID, Advice,
Medication)
Could be computed through claims + some clinical data
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Proposed Core Measures - III Measures of care experience Key themes
• Quality of MD-Patient Interaction• Health Promotion• Helpful Office Staff• Access to needed Care• Care Coordination/Chronic Care
Functional Health Status Risk Assessment
Could be computed through patient survey
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Function & Risk
• Health Care Delivery• Perceived Health Benefit
Disease
Costs
• Direct Medical
• Indirect Social
To Measure Health Status & Outcomes …Need Patient Reported Data
• Physical• Mental• Social/Role• Behaviors
Experience
• Mortality
• Morbidity
• Symptoms
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Risk Assessment
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Implications for Measurement: to improve health care value we need patient-focused feed forward information
Need to measure changes in health status, quality & costs using feed forward and feedback principles
Need to include patient-reported data to measure health outcomes and value
Need to design and implement new HIT systems to accomplish this -- good news technology is (almost) ready
Demonstrations have shown the utility and feasibility of this approach
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Touch Pad or Web Technology
Patient provides self-report data when visiting provider or at home using web-enabled system
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Patient Summary Report: Dartmouth Spine Center
Used to develop/revise care plan & monitor impact of care for individual patients
Function
DiseaseExperience
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Managing Patients & Providers (HDA)
How do we do things differently?Start with creating data-based population management tools (necessary, but not sufficient)
1. Data management/aggregation –infrastructure and capability to integrate and aggregate data across various sources (EMR, HRA, Rx, lab, administrative, etc.)
2. Analytics – sophisticated modeling capabilities (predictive, risk adjustment, attribution, measurement, etc.)
3. Reporting/Tools –pre-set reports, or inter-active, web-based flexible tools, ability to present actionable information
4. Strategy/Consulting – challenge is in the combination and integration of the above with clear direction and the realization that the hardest part of all of this is the execution
1. Interventions for patients 2. Interventions for clinicians
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