Www.mhmc.info & 1 MHMC - PTE Objectives Objective: To get providers and patients/consumers (and secondarily purchasers, policy makers,

1www.mhmc.info & www.mehmc.org

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.


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


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


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

7www.mhmc.info & www.mehmc.org7

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


Risk Assessment


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


Touch Pad or Web Technology

Patient provides self-report data when visiting provider or at home using web-enabled system


Patient Summary Report: Dartmouth Spine Center

Used to develop/revise care plan & monitor impact of care for individual patients

Function

DiseaseExperience


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

Documents

Www.mhmc.info & 1 MHMC - PTE Objectives Objective: To get providers and patients/consumers (and secondarily purchasers, policy makers,