medical scientific resources: hospital care program.4.6.11
DESCRIPTION
Who can use this program?: Hospitals, TPAs, insurers, self-funded programs, PPOs, Managed Care organizations, Medicare, Medicaid, VA.TRANSCRIPT
Simplify and standardize Concurrent Inpatient Reviews
Efficiently adjudicate Per Diem payment arrangements
Reduce review times by up to 80%, with almost 100% inter-rater reliability
Objectively document the appropriateness of adult inpatient hospital admissions
Quickly and easily document Quality Improvement compliance
Maximize Hospital reimbursement under new Pay-For-Performance, DRG and Case Rate criteria
Better control hospital operating expenses and reduce staffing
Hospitals are being financially squeezed from all sides – Efficiency and Effectiveness have become critical for survival
Providing patient care occurs in “real-time”
BUT…Appropriateness of care is often measured “retrospectively” or after-the-fact
Simplifies and standardizes Concurrent Inpatient Reviews
Efficiently adjudicates Per Diem payment arrangements
Reduces review times by up to 80%, with almost 100% inter-rater reliability
Makes objective recommendations about the appropriateness of an admission, continued hospital stay, or a discharge
Quickly and easily documents Quality Improvement compliance
Maximizes hospital reimbursement under new Pay-For-Performance, DRG and Case Rate Criteria
Provides effective tool to better control hospital operating expenses and reduce staffing
Monitors the “real-time” status of hospital inpatients
Assists physicians in providing appropriate quality of care to patients, and documents compliance without need to pull and review medical charts / records
Cardiology Family Practice General Surgery Hospitalists Infectious
Disease Intensivists Internal Medicine Nephrology
Obstetrics/gynecology Ophthalmology Orthopaedic Surgery Pediatrics Psychiatry Psychology Pulmonology Urology
MSR Inpatient MAP – for Inpatient Concurrent Review
MSR Quality MAP – to prompt collection data and document compliance, for quality improvement studies
MSR Resource MAP – used for the daily monitoring of staff and hospital resources
Physicians provide patient care in real-time
However, other hospital functions (including administrative, regulatory, and compliance) are retrospective decision-making processes
Software that purports to assist physicians must operate in real-time
Ever-increasing costs in the 1970’s and 1980’s stimulated growth of organizations for managing costs (“financing”) and regulating patient safety
All currently available concurrent review tools were developed to meet the needs of these organizations – not the needs of real-time decision-makers in a hospital setting!
They developed tools to gather data and to meet their financial review and payment needs
The use of their ‘patient diagnosis algorithms’ became the norm for “managing” care
However, those algorithms do not readily translate to real-time hospital and clinical decision-making
These agencies (which now include quality-of-care monitoring) also function as retrospective review decision-makers
They adopted the diagnosis-based applications developed by the Financial Industry as their tools for monitoring safety and quality of patient care
The existing tools cause needless tension between the reviewer and the attending physicians by relying on diagnostic codes – codes which are frequently not accurate and cannot be determined at the time of hospitalization
BUT…
There are no “real-time” tools available to Health Plans to monitor and insure that diagnostic and/or treatment interventions recommended by national practice guidelines (and often sought by Payers and Hospitalist reviewers) are actually delivered.
Had to adopt them out of “self-defense” and to assure payment – and to understand how to appeal underpayments and denials based on those diagnosis-based algorhythms
These tools do not meet the hospital or medical staff needs associated with the practice of medicine.
Two significant studies have been conducted to evaluate the effectiveness and comparability of the MSR Inpatient MAP to existing concurrent review tools available to hospitals and health plans…
NevadaCare, Inc., (managed care insurance company with clients in Nevada, Iowa and Illinois) used both instruments for concurrent review of the same hospitalized patients in 2003 and 2004
NevadaCare, Inc. determined that 973 inpatient days met MSR Inpatient MAP continued stay criteria, 20 fewer than the 993 inpatient days that met InterQual/McKesson.
NevadaCare, Inc. concluded that the MSR Inpatient MAP was easier to administer and took less time to complete
A national Trust Employer Welfare Association (TEWA), in 2005, used the MSR Inpatient MAP to audit appealed denial-of-coverage determinations previously made using InterQual/McKesson
The audit of 123 admissions, 507 days, identified the same number of denied days. However, case specific days differed slightly
the TEWA found that reviewer’s inter-rater reliability was close to 100% when using the MSR Inpatient MAP.
Concurrent Review today requires diagnostic codes – which are frequently not accurate nor can be readily determined at the time of admission – doctors make decisions based on organ system instability, not diagnoses
Quality of Care is difficult to improve and measure because there are no real-time tools to monitor and insure that recommended interventions (per national practice guidelines) are delivered to patients
Hospital Resources are difficult to audit and optimally allocate
COMPUTER SYSTEM REQUIREMENTS:
NEW SOFTWARE IS DESIGNED TO OPERATE ON MICROSOFT WINDOWS 7, VISTA, XP, OR 2000 (WITH SERVICE PACK 4)
PRINCIPAL DATA EXCHNAGE PROTOCOL:HL7; BOTH ROUTING AND LISTENING IS SUPPORTED.
ENCRYPTION TYPE: AES- 256
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EXPORT/IMPORT VIA SQL