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 IndustryQuadruple Aim*
*adapted from the Military Health System
Evolving IndustryQuadruple Aim*
*adapted from the Military Health System
Evolving IndustryQuadruple Aim*
*adapted from the Military Health System
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
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call • Visits
• Non-visit encounters
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call • Visits
• Non-visit encounters
Primary Focus
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call • Visits
• Non-visit encounters
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Third party contacts
• Visits
• Non-visit encounters
• Non-visit encounters
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
Third party contacts
• Visits
• Non-visit encounters
• Non-visit encounters
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
Third party contacts
Care management contacts to patient
• Visits
• Non-visit encounters
• Non-visit encounters
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Third party contacts
Care management contacts to patient
• Visits
• Non-visit encounters
• Non-visit encounters
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Third party contacts
Care management contacts to patient
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Non-visit encounters
• Non-visit encounters
• Not counted
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Non-visit encounters
• Non-visit encounters
• Not counted
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Non-visit encounters
• Non-visit encounters
• Not counted
Routine Reports
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Non-visit encounters
• Non-visit encounters
• Not counted
Routine Reports
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Non-visit encounters
• Non-visit encounters
• Not counted
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Other Clinical Encounters
Interactions between patients and providers outside of visits
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Other Clinical Encounters
Interactions between patients and providers outside of visits
• Collateral CareInteraction between providers; the provider and the record; or the provider and concerned others
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Other Clinical Encounters
Interactions between patients and providers outside of visits
• Collateral CareInteraction between providers; the provider and the record; or the provider and concerned others
Primary Focus
Re-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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• Visits
• Other Clinical Encounters
Interactions between patients and providers outside of visits
• Collateral CareInteraction between providers; the provider and the record; or the provider and concerned others
Routine Reports
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
• 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
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Chart/Record review (e.g., test results)
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Chart/Record review (e.g., test results)
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)
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Chart/Record review (e.g., test results)
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)
System Changes / Training
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Secure messages to
patients/clients/students
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Secure messages to
patients/clients/students
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
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Secure messages to
patients/clients/students
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
System Changes / Training
System Changes / Training
Secure messages to
patients/clients/students
Secure messages to
patients/clients/students
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
System Changes / Training
Secure messages to
patients/clients/students
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
System Changes / Training
System Changes / Training
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
Nurse face to face triage with referral
Nurse face to face triage without
referral
Nurse on-call
Nurse telephone triage
All other phone encounters with patients/clients/
students
Rounds
No-show chart reviews with
patient contact
Third party contacts
Care management contacts to patient
Secure messages to
patients/clients/students
Health History review
Chart/Record review (e.g., test results)
No show chart reviews without patient contact
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%
Other Clinical Encounters (VE) 829 1065 28%
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%
Other Clinical Encounters (VE) 3837 4467 16%
Collateral Care (not included in total) (VE) 1001 934 -7%
Year to Date
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)
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)
• 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
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