Module A: Using Metrics, Population Health Navigator and Disease Champion Toolkits to Build your Action Plan LCDR An

2. Understand relationship of Population Health Clinical Metrics, the BUMED Note & Business Plan Understand the significance of HEDIS� measures and benchmarking Understand how to leverage PHN tool for: Data Quality Demographics Clinical Preventive Services Disease/Condition Management

3. Demonstrate use of the PHN for your specific MTF population and how to compare your clinical performance. Introduce basic Excel skills and applications to leverage PHN data Introduce Toolkits to assist with disease management efforts

4. Medical Management Consists of Disease Management, Utilization (incl. Referral) Management, Case Mangement �a shift� to a proactive approach of continuous quality improvement and evidence-based practice.� ��not just about controlling costs. It is about developing more efficient approaches to providing high quality health care.�

5. Clinical Metrics

6. Disease Mgmt Evaluation Types of metrics civilian health plans use to evaluate DzMgmt programs Clinical Outcomes (94%) Quality Measures e.g. HEDIS (93%) Inpatient Utilization (92%) ED Utilization (90%) Patient Satisfaction (82%)

7. Qualities of Good Metrics 1. Relevance Meaningful Cost-Effective Important Clinically important Financially important Strategically important Controllable Potential for improvement Easily Interpretable

8. Qualities of Good Metrics 2. Scientific Validity Valid Accurate Reproducible Risk Adjustable Comparability of data sources Degree of professional agreement Acceptable to the patient

9. BUMED Metrics BUMED Business Plan and BUMED Note (6310) requires monitoring and reporting of: Diabetes patients (age 18-75) with hemoglobin A1c < 9.0% Diabetes patients (age 18-75) with LDL < 100mg/dl Asthma patients (age 5-56) on long term medications Female patients (age 52-69) with current mammogram Data from HEDIS� metrics in PHN BUMED Business Plan states that clinical goal is to perform greater than HEDIS� 90th percentile. Doesn�t prevent the tracking of other metrics or the use of other registries or databases, but only PHN data counts.

10. Other Relevant Metrics Numerous other sources for metrics and benchmarks� AHRQ NCQA/HEDIS JCAHO HP 2010 Disease-Specific Metrics Diabetes-- ADA, DQIP Asthma-- NHLBI

11. Metrics- Informatics Support Local Informatics Tools CHCS Registries SQL Servers M2 BUMED-Endorsed Tool Population Health Navigator- this will be the tool from which data is reported to the PHN dashboard and the BUMED Business Plan

12. Benchmarking & HEDIS Metrics

13. Performance Benchmarking Benchmarking is the continuous process of measuring processes, services, and practices against industry standards to compare performance and gauge where and whether efforts to improve might be indicated. Serves as a basis for action for improvements. Keys to successful benchmarking: 1) analysis at a level specific to what the user wants to measure 2) follow-up by appropriate personnel to research the reasons behind the undesirable results 3) formulation of alternate strategies for improvement One consideration in determining the appropriateness of benchmarking at any level is credibility, both in terms of reliability (i.e., accuracy and consistency) of the data used for the analysis and of having enough data to produce meaningful results.

14. Benchmarking and tracking selected clinical services leads to improvement in health care processes: Clinical processes (patient care and follow-up) Enrollment/Administrative processes Data quality and coding processes Patient and provider education process

15. HEDIS Metrics What is HEDIS? How are these metrics defined? How are the benchmarks derived? Why use HEDIS? Benefits?

16. Health Plan Employer Data and Information Set� Developed/maintained by the National Committee for Quality Assurance (NCQA) Most widely used set of performance measures in the managed care industry (61 measures/8 categories) Effectiveness of Care Set of standardized performance measures to compare the performance of health care plans. Very precise metric definitions based on: continuous enrollment, inclusion/exclusion criteria, age restrictions, etc.

17. Does NOT represent the standard of care, merely the standard of clinical quality for comparison to other facilities. Benchmarks are derived from population norms qYr Benefits of HEDIS� Concrete performance benchmarks for managed care and state/federal health plans allowing comparisons for healthcare delivery Consequently� allows the Navy to objectively compare itself against nationally-recognized civilian industry standards

18. Population Health Navigator

19. MHS Population Health Portal, web-based information and report application developed by the USAF, adapted for Tri-Service use, now used throughout the MHS. Selected by BUMED as the Medical Informatics Tool to be used by MTFs; new program implemented Jan 04. All Navy commands and most branch clinics have PHN users, with >200 users currently. Provides Action/Prevalence Lists for 14 Clinical Preventive Services and specific diseases/conditions. Patient-, provider-, clinic- and facility-specific action lists Updated monthly Provides HEDIS� measures to compare clinical quality of delivered healthcare. The PHN will give you lists of your patients who have diabetes, asthma, depression�..a total of 10 diseases and two clinical preventive services. They tell you the patients name, provider, some tests results, and contact informationThe PHN will give you lists of your patients who have diabetes, asthma, depression�..a total of 10 diseases and two clinical preventive services. They tell you the patients name, provider, some tests results, and contact information

20. M2 Standard Inpatient Data Record (SIDR) Standard Ambulatory Data Record (SADR) Health Care Service Reports (HCSR) Approximately 103 CHCS hosts Lab, radiology (mmgm), pathology (paps) Pharmacy Data (PDTS)- MTF, network, mail order Defense Eligibility Enrollment Registration System (DEERS) Because data is pulled from DEERS and all CHCS hosts, the system pulls patients passed on enrolled facility but will pull visits, lab and radiology tests regardless of where the test was performed. PTSD data is pulled for pharmacy encounters so MTF, Network, and Mail Order Pharmacy prescriptions will be reflected. Again, the Methods define what is considered a prescription refill. Importance of data accuracy. Data pulled is what�s entered�.only as good as your coding, end of day reports, etc. The data will be updated monthly but, because of where it is retrieved from, some of the data is 2-3 months old when it appears on the web. You will see that much of the data is from your CHCS host�.this data is the most current. Data coming from M2 for purchased care is usually behind several months because of delays in the billing process. Because data is pulled from DEERS and all CHCS hosts, the system pulls patients passed on enrolled facility but will pull visits, lab and radiology tests regardless of where the test was performed. PTSD data is pulled for pharmacy encounters so MTF, Network, and Mail Order Pharmacy prescriptions will be reflected. Again, the Methods define what is considered a prescription refill. Importance of data accuracy. Data pulled is what�s entered�.only as good as your coding, end of day reports, etc. The data will be updated monthly but, because of where it is retrieved from, some of the data is 2-3 months old when it appears on the web. You will see that much of the data is from your CHCS host�.this data is the most current. Data coming from M2 for purchased care is usually behind several months because of delays in the billing process.

21. Strengths Provides both corporate level (HEDIS�) metrics and drills to patient/provider/clinic level Provides data on patient care regardless of where care provided: throughout entire MHS inpatient & outpatient care network & MTF care Can be displayed in Excel� for easy use of data. FREE and readily available

22. Data Quality Issues Also a tool that provides the opportunity to assess data quality� Enrollment- AD, PCS�s Enrollment accuracy- PCM, pt contact info CHCS provider entry- ensuring providers, nurses, techs/corpstaff are entered correctly, haven�t PCS�d Coding entry/accuracy- ensuring certain clinics/providers are using the appropriate codes e.g. gestational diabetes vs. pregnant diabetic patient e.g. diabetes education (for family members) vs. actual diagnosis of diabetes

23. BUMED Note 6310 - Diabetes Requires the following: Standards: optimal diabetic management including general assessment, addressing control of HbA1c and LDL*, controlling BP, screening for retinopathy & nephropathy*, providing patient education and periodic follow up Identification of Cohort* Clinical Practice Guideline Disease Management Reengineering Identification of patients with A1C > 9.0%* Patient education Metrics: Diabetes patients (age 18-75) with hemoglobin A1c < 9.0%* Diabetes patients (age 18-75) with LDL < 100mg/dl*

24. Hopefully everyone has seen this slide before�. The PHN can be used to identify your population. Identify the Population: Entire population can be listed, broken out by provider, provider groups, and clinical preventive services required for a specific age group Forecast Demand: Is dependant on accurate identification of your population, knowing the healthcare needs and disease prevalence of the population Manage Demand: Goal is to manage the health of individuals and populations with a focus on prevention of illness and injury. All stems from knowing your population and initiating the clinical preventive services to keep them well. If they already have diseases, managing the disease to prevent progression. Evidence-Based Primary, Secondary, and Tertiary Prevention: You may look at your diabetics and determine where your patients could benefit from a Clinical Practice Guideline. Community Outreach: You can use PHN to determine health promotion activities and target cohorts. Analyze Performance and Health Status: You�ve already seen the graphs that BUMED is using to evaluate clinical practice. This information is taken from the PHN and is one example of how the data can be utilized. Hopefully everyone has seen this slide before�. The PHN can be used to identify your population. Identify the Population: Entire population can be listed, broken out by provider, provider groups, and clinical preventive services required for a specific age group Forecast Demand: Is dependant on accurate identification of your population, knowing the healthcare needs and disease prevalence of the population Manage Demand: Goal is to manage the health of individuals and populations with a focus on prevention of illness and injury. All stems from knowing your population and initiating the clinical preventive services to keep them well. If they already have diseases, managing the disease to prevent progression. Evidence-Based Primary, Secondary, and Tertiary Prevention: You may look at your diabetics and determine where your patients could benefit from a Clinical Practice Guideline. Community Outreach: You can use PHN to determine health promotion activities and target cohorts. Analyze Performance and Health Status: You�ve already seen the graphs that BUMED is using to evaluate clinical practice. This information is taken from the PHN and is one example of how the data can be utilized.

25. Important links on the Navy Environmental Health Center (NEHC) web page in support of the Population Health Navigator program. Important links on the Navy Environmental Health Center (NEHC) web page in support of the Population Health Navigator program.

26. The PHN webpage also includes FAQs, which delineates how to get an account, addresses common questions with HEDIS metrics and methodology questions.The PHN webpage also includes FAQs, which delineates how to get an account, addresses common questions with HEDIS metrics and methodology questions.

27. This is the initial screen for the MHS Population Health Portal� the TriService Tool. The Navy has chosen to call its Portal the Population Health Navigator. The most important items on the home page are the �Request Access� tab and �Forgot Password� The �Request Access� tab is the starting point for getting a PHN account. When you submit a request, it will be sent to the Navy account administrator who will notify you of any additional requirements needed for an account. Once all requirements are met, an account will be established. When you submit the request, it is important to copy the page acknowledging the submission. This page contains your user name. �Preload Graphics� helps the initial webpages load faster. �Contact the Service Center� is for technical support with getting access to the Population Health NavigatorThis is the initial screen for the MHS Population Health Portal� the TriService Tool. The Navy has chosen to call its Portal the Population Health Navigator. The most important items on the home page are the �Request Access� tab and �Forgot Password� The �Request Access� tab is the starting point for getting a PHN account. When you submit a request, it will be sent to the Navy account administrator who will notify you of any additional requirements needed for an account. Once all requirements are met, an account will be established. When you submit the request, it is important to copy the page acknowledging the submission. This page contains your user name. �Preload Graphics� helps the initial webpages load faster. �Contact the Service Center� is for technical support with getting access to the Population Health Navigator

28. Population Health Navigator Major �Index Card� Sections : Demographic Information Preventive Services Disease and Condition Management Administration

29. In the Administration tab there are several items: Generated reports: This is where you will find reports you have requested while using the program Personalization: For changing password, etc. Passwords should be changed ever 90 days Documents: Contains User Guide, Methods, and other helpful documents. Discussed on next slide Links Logout: It is always recommended that you logout of the program. There are logout buttons throughout In the Administration tab there are several items: Generated reports: This is where you will find reports you have requested while using the program Personalization: For changing password, etc. Passwords should be changed ever 90 days Documents: Contains User Guide, Methods, and other helpful documents. Discussed on next slide Links Logout: It is always recommended that you logout of the program. There are logout buttons throughout

30. This section contains a User Guide and Methods for the metrics. It is recommended that these documents be printed and used to guide you through the program. Frequently asked questions are extremely useful as you navigate through the program. This section contains a User Guide and Methods for the metrics. It is recommended that these documents be printed and used to guide you through the program. Frequently asked questions are extremely useful as you navigate through the program.

31. Demographics are available in aggregate report and patient lists. Demographics are available in aggregate report and patient lists.

32. If you are a user from a Parent DMIS, you will have an option of selecting fields for either parent or child DMIS. You can also have the data pulled for later use� this is particularly helpful for large files. By selecting the �File� Report Feedback button, a report will be queued and saved for you to retrieve. This report can be found under �Generated Reports� in the Administration section.If you are a user from a Parent DMIS, you will have an option of selecting fields for either parent or child DMIS. You can also have the data pulled for later use� this is particularly helpful for large files. By selecting the �File� Report Feedback button, a report will be queued and saved for you to retrieve. This report can be found under �Generated Reports� in the Administration section.

33. The demographic groups are broken out by age group for specific clinical preventive services (breast cancer screening, cervical cancer screening, colo-rectal screening, etc). The demographic groups are broken out by age group for specific clinical preventive services (breast cancer screening, cervical cancer screening, colo-rectal screening, etc).

34. You may also select to display a clinic�s panel via a specific provider.You may also select to display a clinic�s panel via a specific provider.

35. Information found in report for all enrolled patients for the provider selected. Highlighted are the # of records found, the link to open the report in Excel and the link to return to the main page. Would discourage using the navigator bar to return to the previous view since this often causes problems.Information found in report for all enrolled patients for the provider selected. Highlighted are the # of records found, the link to open the report in Excel and the link to return to the main page. Would discourage using the navigator bar to return to the previous view since this often causes problems.

37. There are two modules for Diabetes� The Diabetes HEDIS metrics which include the LDL and HbA1c metrics that are in the BUMED Business Plan are available in the first module. The data for the nephropathy screening is in a separate module.There are two modules for Diabetes� The Diabetes HEDIS metrics which include the LDL and HbA1c metrics that are in the BUMED Business Plan are available in the first module. The data for the nephropathy screening is in a separate module.

39. HEDIS Metric Definition: Percentage of patients continuously enrolled to an MTF with Type 1 or Type 2 diabetes (18-75yo) with: At least one HbA1c in the last year With HbA1c < 9.0% With LDL < 100 mg/dl With retinal or dilated eye exam in last 1-2yrs (depending) If on insulin, if A1c > 8, if dx of diabetic retinopathy then qYr Includes: Patients diagnosed with Diabetes (250.xx, 357.2, 362.0, 366.41, 648.0) 1 Inpatient Admission OR 1 ER visit OR 2 outpatient visits Patients with Diabetic Meds in last 24 months (MTF, network, mail order) Both MTF & network care Action List contains all diabetics > 1yo Excludes: Polycystic Ovarian Syndrome, Steroid-Induced Diabetes, Gestational Diabetes Metformin as a diabetic medication Benchmark: A1C = 79% LDL = 43% (HEDIS 90th percentile) Navy Average: A1C = 75.4% LDL = 47.56%

40. There are two modules for Diabetes� the data for the nephropathy screening is in a separate module.There are two modules for Diabetes� the data for the nephropathy screening is in a separate module.

41. This is the HEDIS page and contains 4 different measures.This is the HEDIS page and contains 4 different measures.

42. There are two modules for Diabetes� the data for the nephropathy screening is in a separate module.There are two modules for Diabetes� the data for the nephropathy screening is in a separate module.

43. Action List contains: Patient Info: name, SSN, DOB, age, BenCat Provider Info: PCM name, group Patient Contact Info: address, phone Lab Test/Date: A1c, LDL, Tchol, HDL, Chol/HDL Pharm Data: # Rx, Insulin Utilization data: # Inpt, ED, Outpatient Visits Retinopathy screening: date Nephropathy screening: separate module Those w/o A1c are highlighted, then sorted by date of last A1c

44. This is the diabetic action list. Again, the numbers will be greater than the HEDIS because the action list does not add a qualifier for designated enrollment period. Also, There are age constraints in HEDIS. The action list includes all ages. It is very important to read the methods when reviewing this data. The Utilization data can help to risk stratifying your population, to assist in prioritize one�s efforts/resources. Focusing on the individuals who may be poorly controlled, or inappropriately utilizing the ER would likely benefit most from patient education or more intensive disease management. Additionally, patients who have inpatient or ER visits, but no/minimal outpatient follow-up would be targets for intervention. Patients who have no PCM and high utilization are further opportunities for improvement. Data quality may be a concern, since enrollment data is not populated. Continuity of care may be an issue if the patient is seeing more than one physician. If this patient is in the network, the MTF is still responsible for all expenses given revised financing environment, so referral (and/or case) management may be of some assistance. Using a multi-disciplinary team approach, pharmacists could be consulted to see if medical regimens could be simplified, particularly for elderly individuals.This is the diabetic action list. Again, the numbers will be greater than the HEDIS because the action list does not add a qualifier for designated enrollment period. Also, There are age constraints in HEDIS. The action list includes all ages. It is very important to read the methods when reviewing this data. The Utilization data can help to risk stratifying your population, to assist in prioritize one�s efforts/resources. Focusing on the individuals who may be poorly controlled, or inappropriately utilizing the ER would likely benefit most from patient education or more intensive disease management. Additionally, patients who have inpatient or ER visits, but no/minimal outpatient follow-up would be targets for intervention. Patients who have no PCM and high utilization are further opportunities for improvement. Data quality may be a concern, since enrollment data is not populated. Continuity of care may be an issue if the patient is seeing more than one physician. If this patient is in the network, the MTF is still responsible for all expenses given revised financing environment, so referral (and/or case) management may be of some assistance. Using a multi-disciplinary team approach, pharmacists could be consulted to see if medical regimens could be simplified, particularly for elderly individuals.

45. Action list�.continued Opportunity for improvement include: Patients w/o Labs Patients w/ outdated labs Patients w/ labs that are out of standards Patients who have no data entry can occur for numerous reasons-- can either reflect that patients are not truly diabetic patients (e.g. gestational diabetic miscoded), patients that are enrolled to your facility but are no longer seeking care, patients who are enrolled to your facility but are seeking care out in the network (PHN wouldn�t get lab results b/c input based on claims data)Action list�.continued Opportunity for improvement include: Patients w/o Labs Patients w/ outdated labs Patients w/ labs that are out of standards Patients who have no data entry can occur for numerous reasons-- can either reflect that patients are not truly diabetic patients (e.g. gestational diabetic miscoded), patients that are enrolled to your facility but are no longer seeking care, patients who are enrolled to your facility but are seeking care out in the network (PHN wouldn�t get lab results b/c input based on claims data)

46. Annotations can be added by clicking the box to the left of the patients nameAnnotations can be added by clicking the box to the left of the patients name

48. Leveraging PHN Data Actions that might be considered Risk Stratify Patients Find patients haven�t had appropriate visits, studies Consider referral to Nutritionist, Pharmacist Contact patients using demographic information Assess utilization behavior for intervention Lots of ER visits ER/inpatient visits without outpatient care or studies Consider case management for designated patients

49. Leveraging PHN Data Actions that might be considered (cont�d) Demand forecast for services E.g. Ophthalmology exams Compare quality of care via HEDIS measures Download into Excel or Access for further eval�n Sort by age, PCM clinic, PCM provider Create A1C �profile� for population (avg, distribution)

50. Leveraging PHN data Use your Health Care Team!!! WHO is going to identify/contact patients? HOW are you going to contact patients? WHO is going to pull data and HOW often? WHO is going to analyze/distribute the data? HOW will data be used for feedback? WHAT is your current performance? WHAT are your goals/benchmarks? WHAT will you do when you reach your goals?

51. Other PHN Features that may be of interest� Quick Look Sheet High Utilizer File

52. A new feature of the PHN is the Quick Look sheet. This patient-centric view allows one to determine at a glance whether a patient falls into any of the noted disease states, summarizes the number of high-utilizer visits, and annotates when their last pap smear and mammogram were completed.A new feature of the PHN is the Quick Look sheet. This patient-centric view allows one to determine at a glance whether a patient falls into any of the noted disease states, summarizes the number of high-utilizer visits, and annotates when their last pap smear and mammogram were completed.

53. The quick look sheet has many of the same fields as the other modules: Patient name, SSN, FMP, DOB, PCM Name/Group, etc�.The quick look sheet has many of the same fields as the other modules: Patient name, SSN, FMP, DOB, PCM Name/Group, etc�.

55. High utilizers is a very useful tool for case managers. This field lists every visit for each patient with over 10 visits to certain clinics (full list in Methods). It is a large file so the �full report� can be selected in Zip format. You can also pull the report by provider� High utilizers is a very useful tool for case managers. This field lists every visit for each patient with over 10 visits to certain clinics (full list in Methods). It is a large file so the �full report� can be selected in Zip format. You can also pull the report by provider�

56. Or by parent or child DMIS, and you can have the report sent to your account (Administration tab under Generated Reports) but it still takes a long time to open when you get it so recommend using the Zip version, depending on the size of your facility.Or by parent or child DMIS, and you can have the report sent to your account (Administration tab under Generated Reports) but it still takes a long time to open when you get it so recommend using the Zip version, depending on the size of your facility.

57. This report pulls from all MTFs and purchased care. The DMIS is shown for the clinic where the visit occurred. ICD-9 Code and Description for each visit is shown. This report pulls from all MTFs and purchased care. The DMIS is shown for the clinic where the visit occurred. ICD-9 Code and Description for each visit is shown.

58. To obtain a PHN account: Need command endorsement Waived as a special benefit of this class! Need to request acct via PHN website POC: CDR Peggy Sleichter (BUMED) E-mail: phn.admin@us.med.navy.mil Phone: #(202) 762-3125

59. Population Health Navigator Dashboard

60. PHN Dashboard Now that you know: What is being measured� How it is being measured� How do you know you�re doing a good job? How are you doing compared to everyone else in the Navy?

61. BUMED Metric Tracking BUMED Business Plan states that clinical goal is to perform greater than HEDIS� 90th percentile. Population Health Navigator Dashboard Presents 4 BUMED Clinical Quality metrics Displayed by command, drill down to clinics Compares to other clinics/MTFs, Navy averages, HEDIS� 50th and 90th percentiles Provides denominators, values Updated monthly https://dataquality.med.navy.mil/reconcile/pophealth Also available via NEHC webpage, and NMO as a resource kit

62. This is a total enrollment slide. You can go to the lower left and select a metricThis is a total enrollment slide. You can go to the lower left and select a metric

63. This is HbA1c across Navy Medicine. The HEDIS goals and Navy Medicine average are shown. This is HbA1c across Navy Medicine. The HEDIS goals and Navy Medicine average are shown.

64. This is HbA1c across Navy Medicine. The HEDIS goals and Navy Medicine average are shown. This is HbA1c across Navy Medicine. The HEDIS goals and Navy Medicine average are shown.

67. Leveraging PHN Data with Excel

69. Basic Excel Skills Basic Excel Skills can serve you well in analyzing PopHealth Navigator data. Sort e.g. sorting/ranking Filter** e.g. isolate clinic, doc Sum =SUM(range) e.g. utilization metrics Average =AVERAGE(range) e.g. average A1C Count If =COUNTIF(range,"<7") e.g. A1C <7

70. Additional Excel Skills Intermediate Excel Skills Add-In �Analysis ToolPak� (under �Tools�) allows Data Analysis capability Descriptive Statistics (e.g. min, max, mean, SE, SD) Rank and Percentile Histogram Advanced Excel Skills Pivot Tables

71. SG�s Performance Dashboard&Disease/Condition Management Report Card

75. Disease Champion Toolkits

80. Parting Pearls� Don�t reinvent the wheel Leverage technology as much as possible Utilize your Healthcare team wisely Determine who/what/where/when etc. as you re-engineer and fine-tune your processes Feedback & communication of results is impt. o/w how do you know you�re doing a good job? Advertise/share/celebrate your successes Start simple, start small, start SMART �SMART� objectives: Specific, Measurable, Achievable, Realistic, Time bound

82. To obtain a PHN account: CDR Peggy Sleichter E-mail: phn.admin@us.med.navy.mil Phone: (202) 762-3125 To submit items for Toolbox inclusion: LCDR Ron Gimbel E-mail: rwgimbel@us.med.navy.mil Phone: (202) 762-3105

83. Complete the following� Review Dashboard & PHN www-nehc.med.navy.mil https://pophealth.afms.mil/tsphp/login/login.cfm https://dataquality.med.navy.mil/reconcile/pophealth/ Review Toolkits https://dataquality.med.navy.mil/community/ Work on Action Plan

84. References/Resources Navy Resources: BUMED Note 6310 (3 Dec 04). Navy Medicine Disease State and Condition Management Program https://navymedicine.med.navy.mil/files/media/directives/Note%206310%20(3%20Dec%202004).pdf Disease/Condition Management Toolboxes https://dataquality.med.navy.mil/community/Clinical/Disease+Management/default.aspx Evidenced-Based Healthcare Advisory Board resources https://dataquality.med.navy.mil/community/Clinical/Evidence/default.aspx Population Health Navigator resources www-nehc.med.navy.mil/hp/ph_navigator/index.htm

85. References/Resources Medical Management: MHS Population Health and Medical Management Support Center www.mhsophsc.org TMA Policy Guidance for Implementation of Medical Management Programs http://www.ha.osd.mil/policies/2004/04-008.pdf DoD Medical Management Guide www.mhsophsc.org/public/spd.cfm?spi=mmguide Healthcare Support Offices: Info on HSO activities, success stories and best practices https://nhso.med.navy.mil/newimage/index.aspx

86. References/Resources Population Health: DoD Population Health Improvement Plan and Guide. Tricare Management Activity, Dec 2001. www.tricare.osd.mil/mhsophsc/DoD_PHI_Plan_Guide.html McAlearney, A. S. (2003). Population health management: Strategies to improve outcomes. Chicago: Health Administration Press.

87. References/Resources Clinical Practice Guidelines: Clinical Practice Guidelines resources www-nehc.med.navy.mil/hp/ClinPract_guide.htm DoD/VA Clinical Practice Guidelines. www.cs.amedd.army.mil/qmo/pguide.htm Group Health Cooperative Guidelines. https://bumed.med.navy.mil/med03/ebm/Guidelines/glines.html

88. References/Resources Metrics/Benchmarking: Health Plan Employer Data and Information Set (HEDIS) http://www.ncqa.org/Programs/HEDIS/ National Quality Measures Clearinghouse (AHRQ) http://www.qualitymeasures.ahrq.gov/ U.S. Department of Health and Human Services (2000). Healthy People 2010: Understanding and improving health. www.healthypeople.gov/

89. References/Resources Other Organizations: Disease Management Association of America http://www.dmaa.org/ National Committee for Quality Assurance http://www.ncqa.org/ Agency for Healthcare Research & Quality http://www.ahcpr.gov/ http://www.qualitytools.ahrq.gov/

90. Extra Slides- ExerciseDiabetes

91. Exercise Part 1 Look up your clinic�s data for the Clinical Metrics being used in the BUMED Business Plan (HEDIS) via the PHN Dashboard HbA1c < 9.0 Diabetic LDL < 100 https://dataquality.med.navy.mil/reconcile/pophealth

92. Exercise Part 2a Look up your clinic�s data for the Clinical Metrics being using the Population Health Navigator HbA1c < 9.0 Diabetic LDL < 100 Make a note of total HEDIS eligible diabetics https://pophealth.afms.mil

93. Exercise Part 2b Pull up Diabetes �Action List� How many diabetics are on the action list? How does this compare with the number of HEDIS�-eligible diabetics? What�s the difference between these 2 groups? The number of diabetics on the Action List should be higher than the HEDIS eligible because the Action List is for all diabetics regardless of age or continuous enrollment status. The HEDIS diabetics must meet enrollment criteria for one year and be 18-75yrs old. The number of diabetics on the Action List should be higher than the HEDIS eligible because the Action List is for all diabetics regardless of age or continuous enrollment status. The HEDIS diabetics must meet enrollment criteria for one year and be 18-75yrs old.

94. Exercise Part 3 What % of diabetics on the action list have: No HbA1c? HbA1c greater than 1 year? HbA1c greater than 9.0? Need retinopathy screening exams? (Hint: Use Excel and/or the calculator on the computer when trying to figure out data) Extra Credit: What is your average HbA1c and what percentage of diabetic patients have a HbA1c <7.0? You will need to use Excel to sort the data in each category. You will need to use Excel to sort the data in each category.

95. Exercise Lessons What questions arise during this exercise related to: Coding Enrollment Process Some items to review: Coding�are there coding errors that make patients appear as diabetics when they aren�t? Gestational diabetes, spouse attending class and getting coded for diabetes, improper coding of eye exams or provider doing exam Enrollment�do you have enrollees who get most of their healthcare through another health system? If so, results won�t show up in the PHN. Maybe nothing you can do but be aware of it. Enrollees who move and never transfer their enrollment to new location? Enrollment to PCM-- PCM group. Is it accurate? Are there a lot of patients with a PCM? Process�.how does your clinic manage their patients? Is it random when the patient decides to come in for a appt or do you have a plan for patient management? Would Clinical Practice Guidelines help? What about nurse managed clinics? Is the entire healthcare team involved in the care of the patient?Some items to review: Coding�are there coding errors that make patients appear as diabetics when they aren�t? Gestational diabetes, spouse attending class and getting coded for diabetes, improper coding of eye exams or provider doing exam Enrollment�do you have enrollees who get most of their healthcare through another health system? If so, results won�t show up in the PHN. Maybe nothing you can do but be aware of it. Enrollees who move and never transfer their enrollment to new location? Enrollment to PCM-- PCM group. Is it accurate? Are there a lot of patients with a PCM? Process�.how does your clinic manage their patients? Is it random when the patient decides to come in for a appt or do you have a plan for patient management? Would Clinical Practice Guidelines help? What about nurse managed clinics? Is the entire healthcare team involved in the care of the patient?

96. Additional Slides

97. Disease-Specific MetricsDiabetes Diabetes Quality Improvement Project Performance and outcomes measures with which plans, physicians, clinics and healthcare providers could be compared for the purposes of accountability Measures to be well-grounded in evidence, comprehensive w/ respect to the complexity of the disease and as parsimonious as possible in terms of the financial and logistic burden of data collection Coalition of private & public entities ADA, HCFA, NCQA, AAFP, ACP, VHA, AHRQ, FDA, CDC 6 of the 8 measures were incorporated into HEDIS in 2000

98. Disease-Specific MetricsDiabetes Accountability Set (process measures) Quality Improvement Set (outcome measures)