"Welcome to our company blog. Within these blog posts, we hope to share our insights on clinical quality management, the patient-centered medical home, chronic disease management in primary care, evidence-based medicine, and the use of technology in ambulatory care settings."

- David Morin, CEO and Donald Nease Jr., MD, Chief Medical Officer

It seems as if the interest level has risen rapidly on our argument that there are many shortcomings when using billing data and ICD9 for a quality improvement program. I've been involved in numerous discussions about this over the last month and they are, in general, in-line with our thoughts at Cielo; billing data and ICD9 are plain insufficient! Usually, the discussion is with a person that has already undertaken a quality improvement program and found this out after trying to work with their billing data.

To study this further, we are working with a few providers and comparing their billing files to their Cielo Clinic database to look at how a patient's diagnoses align in these two datasets. While I can't release our findings just yet, suffice to say the results of this work are eye-opening. Look for more to come from us on this topic.

FYI - I'd also recommend reading a very good article in the February 2009 article of Healthcare Informatics that discusses this topic.-


Dave Morin
CEO
Cielo MedSolutions LLC

Type "personal health record" into your favorite search engine and you will be overwhelmed with the number of vendors offering such a solution.

I'm intrigued with the variety of stakeholders offering such solutions; software start-ups, employers, payors, EMR vendors and portal and search engine providers all have a PHR that they think you should be using. I'll bet there 100s of PHR solutions now available.


When evaluating these solutions, a few characteristics are key for adoption:


From the patient's perspective:

• Ubiquity and Patient Ownership - the PHR record is ultimately the property of the patient. It must be transportable into every situation in which a patient needs it and it must be accessible by the patient at any time.
• Adds Value - a record on it's own has value, but a PHR solution that can add value around the record is of great value. Care reminders, links to literature are all examples.
• Is Correct - those that populate from claims data will be populated with data that was never intended for clinical documentation, only for reimbursement. If you diagnose that wheezing patient with asthma and that patient, who is ultimately found to NOT have asthma, sees he's asthmatic in his personal health record, might 1) decide this PHR can't be trusted and not use it or 2) call your practice in a panic asking why you never told him he was asthmatic (and have trust issues with you as a provider).

From the provider's perspective:

• Easily accessed - and I mean "easy"! When the average visit is 16.5 minutes, even one minute to fumble through access of this record will make this a no -deal.
• Complete Picture - a PHR that only tells a part of the story isn't of much value if the provider still has to go back and verify and document everything.
• Is Correct- if it doesn't provide accurate clinical data, there's no reason to use it.

Any PHR vendor that would find any of the bullets above to not be in their best interest is probably one that won't survive. That leads me to think right now that vendors such as Google, Microsoft and Revolution Health probably represent the best strategies, IF they can provide the features above.



Dave Morin
CEO
Cielo MedSolutions

Data is data, right? Facts and figures presented in some manner. More data is always better than less? Larger reports must always tell you more? Many a job has been justified on generating data. There are many to which generating data is the end-goal.

Each of us is drowning in data. And much of it really doesn't help you do what you do better. Shouldn't that be the point of getting data?

Actionable data is data that you can do something with. It answers not just "what" but "why".

An example: your clinical system generates a report that says your compliance rate with a guideline for measuring A1C levels every six months for diabetics is 50%. That tells you, for half your diabetic patients, you are meeting the goals of the guideline.

Cool! Now, you want to get that compliance rate to 60%.

What do you do? All the report tells you is that 50% are in compliance. You have no idea what's going on with the other 50%, you don't even know who they are. Good luck getting your compliance rate higher.

Here comes the need for actionable data! The data you need to get your compliance rate higher includes:

1. A list of the patients not in compliance.
Yep, this certainly is where you'd start, but this alone doesn't tell you why they are not in compliance. And, it needs to be all the patients not in compliance, even those you haven't seen in years.

2. Details as to why they are not complaint (like: have never been seen, have a lab req but never completed it, refused to do it, have not been asked to do it).
Cool. Now we know what to do for each patient. How do we take action to move forward?

3. Contact information for each of these patients.
Use this info for telephone calls, custom letters, emails, text messages, smoke signals, whatever it takes to reach these non-compliant patients and move them to compliance (Note: Cielo Clinic can generate letters and create call lists but cannot yet generate smoke signals). And, because you know the exact reason each patient is not in compliance, you can have directed communication with them to get to their exact needs.

4. Details on the actions you take.
Track the fact you made calls, sent letters, got more lab reqs out, etc… So, as you continue to work with these patients, you know exactly what you've done to be smarter about it next time around.

Got actionable data?

Dave Morin
CEO
Cielo MedSolutions

As you know if you've spoken with us or spent much time browsing our website, we're big on the fact that Cielo Clinic contains a coded, all-problem registry. Here's a brief description of why that is so important.

Your registry is only as good as its accuracy.

Many registries are built off of billing data. Not a bad place to start you may say. Just take all those people with asthma or depression codes and dump 'em in! Not so fast... Billing data sits at one end of a long process that begins with a clinician thinking, "This patient is wheezing, but I don't have enough yet to make an asthma diagnosis." So the clinician either writes down "wheezing" which gets changed to a billable diagnosis of asthma, or they realize from the start that wheezing won't get paid for and they just write asthma. When that billing data gets dumped into the registry, the patient with wheezing is now part of the asthma registry, and becomes part of the reporting for which one is responsible. Whoops!

If you have a system that allows you to accurately represent with a coded problem what that clinician is thinking, "wheezing" doesn't become "asthma", and your quality improvement efforts are focused with precision on the patients that truly have asthma.

Cielo Clinic contains a rich set of clinical terminology that was built by having primary care physicians record problems using words that make sense to them. These terms are coded, and mapped to a classification system that allows accurate aggregation of the problems into disease categories for quality management. If your quality management system can't do this, you'll spin your wheels focusing on patients that don't have the diseases you're trying to impact.

If you build it they will come - Field of Dreams

OK, maybe it's a bit corny, but that's our reason for having an "all-problem" registry. Clinicians build it by recording the problems they are working with every day. Not just on a select set of patients, but all patients. A lot of work? Not if you are getting something in return. What Cielo Clinic gives you in return is an accurate problem list on every patient, using terms you understand, not up-coded to meet billing standards. Additionally, Cielo Clinic gives you back reminders based on those problems and the ability to "on-the-fly" respond when new guidelines emerge for conditions. Because you've been accurately recording the problems, you have already built the registry for any given clinical disease category.

You're building it, because those new guidelines will come!

Don Nease, MD
Chief Medical Officer
Cielo MedSolutions