acha 2014 administration section hot topics utilization reporting: cornell’s response to evolving...

ACHA 2014

Administration Section Hot Topics

Utilization Reporting:

Cornell’s Response to Evolving Health Care Delivery

Christopher Payne, PT, MHAAssociate Director, Planning and Analysis

Janet Corson-Rikert, MDAssociate Vice President for Campus Health

Evolving IndustryPatient Care Outside of Office Visits: A Primary Care Physician Time Study - J Gen Intern Med. Jan 2011; 26(1): 58–63.

• 20% of workday spent delivering care outside of visits

• These efforts mostly go unnoticed/unreimbursed

• “Policies supporting physician and staff time spent on [clinical activities outside of visits] may reduce health care costs, save time for patients and physicians, and improve care coordination.”

Evolving IndustryQuadruple Aim*

*adapted from the Military Health System

Evolving IndustryExamples of Quadruple Aim strategies

• Nurse-delivered programs

• Secure messages in lieu of follow-up visits

• Medical and mental health brief assessments

Student population

Process1. Inventory and categorization of existing ‘visit

types’ or ‘note types’ or ‘encounter types’

2. Re-categorization

3. System changes and training

4. Reporting changes

Inventory and CategorizationKey Questions

1. What do we call a ‘visit’?

2. What else do we count, and what labels do we use?

3. Are the encounters we call visits face-to-face and unduplicated in the same day?

Inventory and Categorization

Face to face encounters without same day referral in the same division for

the same condition/service

Face to face encounters with

same day referral in same division

for the same condition/service

CAPS Brief Assessment (telephone)

Psychiatry Phone Visit • Visits








Psychiatry Phone Visit

Nurse face to face triage with referral

Nurse face to face triage without

referral

Nurse on-call • Visits

• Non-visit encounters











referral



Primary Focus











referral



Routine Reports











referral

Nurse on-call

Third party contacts

• Visits



Routine Reports











referral

Nurse on-call

Nurse telephone triage


• Visits



Routine Reports











referral

Nurse on-call



Care management contacts to patient

• Visits



Routine Reports











referral

Nurse on-call


All other phone encounters with patients/clients/

students



• Visits



Routine Reports











referral

Nurse on-call



students



Chart/Record review (e.g., test results)

No show chart reviews without patient contact

• Visits



• Not counted

Routine Reports











referral

Nurse on-call



students

No-show chart reviews with

patient contact





• Visits



• Not counted

Routine Reports











referral

Nurse on-call



students

Rounds


patient contact



Health History review



• Visits



• Not counted

Routine Reports











referral

Nurse on-call



students

Rounds


patient contact



Secure messages to

patients/clients/students




• Visits



• Not counted

Routine Reports

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits



• Not counted

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits

• Other Clinical Encounters

Interactions between patients and providers outside of visits

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits



• Collateral CareInteraction between providers; the provider and the record; or the provider and concerned others

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits




Primary Focus

Re-categorization










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Visits




Routine Reports

System Changes / Training










referral

Nurse on-call



students

Rounds


patient contact



Secure messages to















referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





• Category of service was clearly defined by encounter/note type

• Standard durations already existed within the system OR staff felt comfortable with applying a standard duration

• No information other than a raw count is needed

No system changes necessary









referral

Nurse on-call



students


patient contact



Secure messages to










referral

Nurse on-call



students


patient contact



Secure messages to



Duration varied widely and wasn’t recorded

System Changes:

Added reportable ‘duration’ field to templates

Instructed providers to estimate (do not want them to spend time tracking time)










referral

Secure messages to









referral

Secure messages to


Needed to know if a referral occurs within the same division for a similar service, e.g.:

• Triage nurse referring to nurse treatment or clinician

• Brief assessment counselor referring to a same-day counseling appointment

• Nurse treatment referring to physician

System Changes:

Added reportable field to all appropriate templates



Secure messages to


Secure messages to


Tricky. Can get a raw count of secure messages sent…but needed to know:

• Was the secure message THE encounter? If so, we want to count it.

• Was it part of another encounter (e.g., sent in the course of a visit or a miscellaneous note)? If so, we don’t want to double count.

System Changes:

Added reportable field to all appropriate templates












referral

Nurse on-call



students

Rounds


patient contact



Secure messages to





Reporting Changes

• A work in progress

• Major challenges:

• Combining visit counts and time-based counts

• Summarizing data in an accessible way

• Initial concept: ‘Visit equivalents’

(e.g. 20 minutes of phone calls = 1 visit equivalent)

Cornell University Health Services

Utilization ReportDecember

VE = Visit Equivalent 12/12 12/13 Variance

Core Clinical ServicesTotal Clinician Clinical Encounters 14666 14337 -2%

Face to Face Visits 12766 12231 -4%

Other Clinical Encounters (VE) 1900 2106 11%

Collateral Care (not included in total) (VE) 2401 2746 14%

Total Physician Clinical Encounters 7521 8271 10%

Face to Face Visits 6692 7206 8%


Collateral Care (not included in total) (VE) 1600 1521 -5%

Total NP/PA Clinical Encounters 7145 6066 -15%

Face to Face Visits 6074 5025 -17%

Other Clinical Encounters (VE) 1071 1041 -3%

Collateral Care (not included in total) (VE) 801 1225 53%

Total Nurse Clinical Encounters 19227 20190 5%

Face to Face Visits 15390 15723 2%


Collateral Care (not included in total) (VE) 1001 934 -7%

Year to Date

Reporting Changes







Reporting Changes







• Leaning toward time-based, graphic displays

Student population

Other Clinical Encounters (OCE):Interaction between patients/clients and providers outside of the visite.g., secure messages via EHR

Collateral Care (CC):Interaction between providers; the provider and the record; or the provider and concerned otherse.g., no-show chart reviews, case meetings, calls with parents

Important exclusion:Cornell’s data do not yet reflect phone callsStay tuned for ‘lessons learned’!

Key Lessons Learned

When categorizing visits, test what you learnProviders often use visit/encounter notes in unanticipated ways; chart reviews are helpful

Stay connected with your EHR template developers:

Template design is very influentialTemplate designers are very influential

Be aware of your visit type volume:More visit types = more complexity for set-up and reporting

Focus on the ‘story-telling’ value with providers

Key Next Steps

• Graphic summaries of data (volume can overwhelm)

• Explore CPT coding for services that can be coded

• Re-examine key metric: Percent of student population reached

• Re-examine other key breakouts, including by:• Insurance type• Financial aid status• Ethnicity• Gender

Discussion

Contact information:

Chris [email protected]

Janet [email protected]

mailto:[email protected]

mailto:[email protected]

acha 2014 administration section hot topics utilization reporting: cornell’s response to evolving...

Documents

college health

military health system

health care costs

health system performance

population health outcomes

experience of care

highquality care

care coordination