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Closing the loop_on_referral_management_processes_circo
- 1. 1 1 Closing the Loop on the Referral Management Process September 8, 2016 Luke Sato, MD Senior Vice President & Chief Medical Officer, CRICO Assistant Clinical Professor of Medicine, Harvard Medical School Take Home Message • Missed and delayed diagnosis claims are the most expensive type of malpractice case to defend and closing the loop on referrals is one way to address these claims • These type of claims have two main contributing factors • Cognitive Contributing Factors • Systems Contributing Factors • Approaches to address cognitive contributing factors are multifactorial and therefore need a multipronged strategy, e.g., OpenNotes, CDS • Opportunities to close the loop of referrals and test results are the “low hanging fruit” opportunity to address these systems contributing factors • Technology solutions exist but gaps in applying these solutions still need to be further developed in partnership with EMR vendors, e.g., “referral black hole,” CRICO RMW Workgroup 2
- 2. 2 CRICO Controlled Risk Insurance Company (CRICO) Founded in 1976 Provides medical malpractice and professional liability coverage to the Harvard institutions 25 hospitals 13,000 physicians (3,700 residents/fellows), 120,000 employees $150 million annual premium $5 million coverage with a maximum of $10 million per year Risk Management Foundation of the Harvard Medical Institutions (RMF) Founded in 1979 Administrative arm of CRICO: claims management, patient safety, underwriting, finance services Employees located in RMF Medical Malpractice Claims Analytics Coding is the foundation of our data intelligence Clinical Coding Data Intelligence
- 3. 3 5 All coded attributes captured in a Case Summary Clinical Attributes Clinical Summary Contributing Factors Injury Severity Allegation Responsible Service Location Injury/Body Part Diagnosis Procedure Medication Claimant type Device Practice Site Physician Specialty Physician Status CCC Why Focus on Referral Management? 6
- 5. 5 • Blood in Stool – Patient never had the chance to answer the question because of interruptions • Patient misses several appointments • Blood Hematocrit and weight is slightly down • Patient recommended to get a colonoscopy but patient is test averse and misses several scheduled appointments • Patient overwhelmed with information and instructions from PCP Issues contributing to follow up failure 9 • 6 months later patient visits urgent care and provider notices 20lbs weight loss and follow up labs including colonoscopy • Tries to confirm with PCP but couldn’t send email that day due to technical issues with mail server, PCP never receives communication from urgent care provider • Continued episodic visits (3 our of 9) with her Primary Care Physician with no follow up or mention of colonoscopy • Eventually seen in ED for stomach pain and CT showed cecal mass with suspected liver metastases • Patient dies of colon cancer; family successfully files suit against Dr. Jones for delay in diagnosing the disease Issues contributing to follow up failure 10
- 6. 6 Themes from the case • Unable to recognize trends and patterns and act on ongoing symptoms and results that need follow up (due to interruptions, interactions with patient occurring episodically) • Closing the loop on referrals and test/procedures • Patient factors contributing to not following through on appointments 11 25% 25% 21% 7% 6% 83% 23% 37% 15% 6% 13% 93% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Surgical Tx Diagnosis Medical Tx Medication Obstetrics Subtotal PERCENTOFALLCRICOCASES % cases (2006-2016 YTD) % incurred losses (2006-2016 YTD) CRICO N=2,339 coded PL cases asserted 1/1/06–3/31/16. Total Incurred includes reserves on open and payments on closed cases Patient Safety targets the most significant loss areas. 2,339 cases | $1.1B total incurred 12
- 7. 7 CRICO N=2,339 PL cases asserted 1/1/06–3/31/16. CRICO N=1,938 PL cases asserted 1/1/06–3/31/16 with a major allegation of Diagnosis-related, Surgical Treatment, Medical Treatment, Obstetrics-related Treatment, or Medication. Trends in Target Areas - CRICO 1,938 cases | $1.0B total incurred 13 Assert Year 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 TYD 2016 PERCENTOFCASESASSERTED ASSERT YEAR Diagnosis-related Surgical Treatment Medical Treatment Obstetrics-related Treatment Medication-related 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 PERCENTOFCASESASSERTED ASSERT YEAR Diagnosis-related Medical Treatment Surgical Treatment Obstetrics-related Treatment Medication-related CBS N=47,166 PL cases asserted 1/1/05–12/31/14. CBS N=39,278 PL cases asserted 1/1/05–12/31/14 with a major allegation of Diagnosis, Surgical Treatment, Medical Treatment, Obstetrics, or Medication. Trends in Target Areas - National Landscape 39,278 cases | $7.4B total incurred 14 Assert Year
- 8. 8 Diagnosis-related Cases 278 CRICO MPL cases asserted 2009–2013, $231M total incurred losses* *Total incurred losses include reserves on open cases and payments on closed cases. $0 $10,000,000 $20,000,000 $30,000,000 $40,000,000 $50,000,000 $60,000,000 0 10 20 30 40 50 60 GeneralMedicine Radiology Emergency Neurology Pathology Gastroenterology Orthopedic Gynecology GeneralSurgery Otolaryngology(No Plastic) TOTALINCURRED NUMBEROFCASES number of cases total incurred N=278 MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation. General Medicine is top responsible service named in diagnostic allegations and most expensive per case 278 cases | $231M total incurred
- 9. 9 PERCENT OF CASES BY SEVERITY* PERCENT OF TOTAL INCURRED N=278 MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation. Total Incurred includes reserves on open and payments on closed cases. *NAIC Severity Scale: High = death, permanent grave, permanent major, or permanent significant Medium = permanent minor, temporary major, or temporary minor Low = temporary insignificant, emotional only, or legal issue only The majority of diagnosis-related cases result in high-severity injuries and drive over 80% of the total incurred losses. Low 5% Medium 32% High 63% Low 1% Medium 14% High 85% 278 cases | $231M total incurred 0% 10% 20% 30% 40% 50% 60% 70% 80% 2009 2010 2011 2012 2013 PERCENTOFCASES Ambulatory Emergency Inpatient N=278 MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation. The majority of diagnosis-related cases originate in an ambulatory setting 278 cases | $231M total incurred ASSERT YEAR 12% 70% 18% Ambulatory Inpatient ED
- 10. 10 $0 $10,000,000 $20,000,000 $30,000,000 $40,000,000 $50,000,000 $60,000,000 0 10 20 30 40 50 60 GeneralMedicine Radiology Gastroenterology Neurology Pathology Gynecology Orthopedic Otolaryngology (NoPlastic) Oncology(Medical) UrologySurgery TOTALINCURRED NUMBEROFCASES number of cases total incurred N=194 MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation and involving an ambulatory care patient. Together, General Medicine and Radiology account for 48% of the cases and 47% of the dollars associated with diagnostic allegations in ambulatory settings. 194 cases | $164M total incurred PERCENT OF CASES BY SEVERITY* PERCENT OF TOTAL INCURRED N=194 MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation and involving an ambulatory care patient. Total Incurred includes reserves on open and payments on closed cases. *NAIC Severity Scale: High = death, permanent grave, permanent major, or permanent significant Medium = permanent minor, temporary major, or temporary minor Low = temporary insignificant, emotional only, or legal issue only The majority of ambulatory diagnosis-related cases result in high-severity injuries and drive over 80% of the total incurred losses. Low 5% Medium 29% High 66% Low 1% Medium 14% High 85% 194 cases | $164M total incurred
- 11. 11 PERCENT OF CASES BY CANCER DX 13% 5% 6% 4% 32% 40% PERCENTAGE OF TOTAL INCURRED 11% 6% 8% 3% 37% 35% National Landscape: Top Cancers vs. Other Final Diagnosis *Includes benign neoplasms. N=194 coded MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation and involving an ambulatory care patient. Total Incurred includes reserves on open and payments on closed cases. 60% of the ambulatory diagnosis-related cases involved missed or delayed in diagnosing cancers Breast cancer Lung cancer Colorectal cancer Prostate cancer Other cancers* Non-cancer diagnoses 194 cases | $164M total incurred *A case will often have multiple factors identified. N=194 coded MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation and involving an ambulatory care patient. Failure to establish a differential diagnosis (step 4) and its influence on test ordering (step 5) has the most impact on diagnostic failure. STEP # CASES* % CASES TOTAL INCURRED 1. Patient notes problem and seeks care 3 2% $800,915 2. History and physical 15 8% $14,802,055 3. Patient assessment/evaluation of symptoms 75 39% $74,555,674 4. Diagnostic processing 88 45% $84,239,268 5. Order of diagnostic/lab test 84 43% $75,378,803 6. Performance of tests 12 6% $7,679,297 7. Interpretation of tests 63 32% $50,850192 8. Receipt/transmittal of test results to provider 5 3% $3,540,000 9. Physician follow up with patient 50 26% $37,792,257 10. Referral management 21 11% $17,956,434 11. Post discharge follow up (inc. pending test results) 26 13% $24,699,837 12. Patient compliance with follow-up plan 16 8% $10,928,239 194 cases | $164M total incurred
- 12. 12 Themes from the case • Unable to recognize trends and patterns and act on ongoing symptoms and results that need follow up (due to interruptions, interactions with patient occurring episodically) • Closing the loop on referrals and test/procedures • Patient factors contributing to not following through on appointments 23 Overall Top Contributing Factors 24 N=60 cases asserted 1/1/09–12/31/13 involving outpatients (excl. ED location), with a diagnosis-related major allegation and naming a general medicine physician (excl. Hospitalist). A case may have multiple factors identified. 87% 42% 35% 23% 15% 8% 5% 3% 3% 0% 20% 40% 60% 80% 100% Clinical Judgment (CJ) Clinical Systems (CS) Communication (CO) Behavior-related (BR) Documentation (DO) Administrative (AD) Supervision (SU) Clinical Environment (CE) Technical Skill (TS) Percent of cases
- 13. 13 Overall Top Contributing Factors 25 TOP CONTRIBUTING FACTORS % CASES CJ Fail/delay ordering diagnostic test 52% CJ Fail to establish differential diagnosis 30% CJ Lack/inadequate assess—note of clinical info 18% CO Communication among providers— patient’s condition 18% CJ Narrow dx focus—chronic/previous diagnosis assumed 15% CJ Fail to respond to patient’s concerns 15% CJ Fail/delay in consultation/ referral 15% CS Failure in follow-up system—new findings 13% CJ Lack/inadequate assessment—history & physical 12% CS Patient did not receive result 12% BR Pt not comply with follow-up call/appointment 10% CJ Misinterpretation of diagnostic studies 10% CJ Fail to rule out abnormal finding 8% CJ Lack/inadequate assessment—other 8% CJ Rely on negative finding with continued symptoms 8% CJ Select/mgt of therapy—medical 8% CS Fail in follow-up system—routine screening 8% N=60 cases asserted 1/1/09–12/31/13 involving outpatients (excl. ED location), with a diagnosis-related major allegation and naming a primary care physician A case may have multiple factors identified. *A case will often have multiple factors identified. N=194 coded MPL cases asserted 1/1/09–12/31/13 with a diagnosis-related major allegation and involving an ambulatory care patient. Steps 8, 9, 10, 11 related to closing the loop on test results and referrals STEP # CASES* % CASES TOTAL INCURRED 1. Patient notes problem and seeks care 3 2% $800,915 2. History and physical 15 8% $14,802,055 3. Patient assessment/evaluation of symptoms 75 39% $74,555,674 4. Diagnostic processing 88 45% $84,239,268 5. Order of diagnostic/lab test 84 43% $75,378,803 6. Performance of tests 12 6% $7,679,297 7. Interpretation of tests 63 32% $50,850192 8. Receipt/transmittal of test results to provider 5 3% $3,540,000 9. Physician follow up with patient 50 26% $37,792,257 10. Referral management 21 11% $17,956,434 11. Post discharge follow up (inc. pending test results) 26 13% $24,699,837 12. Patient compliance with follow-up plan 16 8% $10,928,239 194 cases | $164M total incurred
- 14. 14 • Established by the CRICO Technology Task Force • Members-IT leadership at each participating shareholder • BIDMC • Partners • Atrius • BCH • Meets Quarterly to inform, exchange, and govern the projects • Plan for expansion (Phase II, III, etc.) • Additional practices and specialists • Leverage work to other similar workflows (critical results) • Commenced by developing RM grant proposal Formed Referral Management Workgroup 27 Referral ordered Appt scheduled ID missed appt Req MD reviews missed appt Appt rescheduled Document missed/cancel appt Consult note sent to req MD Consult note reviewed by req MD Consult note & MD ackn. entered in MR Pt told of report & tx options 1 3 4 5 6 7 8 9 11 Life Cycle Tracking • Discrete data elements • Messaging • HIPAA logs • HITSP C32 Report: Statistics by Institution and/or by Provider Number of Referrals •Open •Closed •Total •Out of network •Aggregate views CRICO Guidelines for Referrals Optional Curbside Consult 2 10 a. % referral appointments completed b. % consult notes acknowledged by PCP c. % consult notes communicated to patient a. b. c.
- 15. 15 Application name WebOMR CRMS LMR Epic Cerner Step # CRICO Best Practices for Referral Management Deployed/ in use Deployed/ in use Deployed/ in use Deployed/ in use Deployed/ in use 1 A referral is ordered by the provider sometimes Y Y Y Y1 2 The practice/patient schedules the referral appointment Y Y N Y Y 3 The referring provider's office reconciles the referral against the consult report to identify missed appointment N Y N Y N 4 Missed appointments are reviewed with the ordering provider for appropriate follow up N Y N Y N 5 The office contacts the patient to reschedule if necessary N Y N Y N 6 A note is placed in the medical record about missed/canceled/not rescheduled appointments N Y Y Y N 7 The consult note is transmitted to the requesting provider (electronic/paper) Y Y Y Y Y 8 The consult note is reviewed by the responsible provider and acknowledged N N N Y N 9 The consult note is filed in the medical record and includes the provider's acknowledgement N N N Y Y 10 The patient is notified of the consult report and any new treatment recommendations (and knows who is responsible for coordination of care) N N N N N 11 Auditing and reporting system compliance and success with the 10 step process ? ? ? ? ? 1 - Available, but not widely used. 2 - Missed appointments are communicated (faxed) to ordering provider. 3 - No confirmation that the note that we sent was in fact reviewed by the ordering provider. 4 - The consult note is stored in our EMR, but there is no acknowledgement that the ordering provider acknowledged the note. KEY: Available in system and in use, Available in system and not in use, Not available in system and not in use 29 Evaluation of Existing RM Systems Themes from the case • Unable to recognize trends and patterns and act on ongoing symptoms and results that need follow up (due to interruptions, interactions with patient occurring episodically) • Closing the loop on referrals and test/procedures • Patient factors contributing to not following through on appointments 30
- 16. 16 31 Case # Contributing factors to RM Process Failures 3delay in sending referral 17delay in sending referral 68delay in sending referral 119delay between steps 159delay between steps 30patient refused referral 36patient missed 8 out of 14 follow up appointments 56patient refused referral 64Patient cancelled 152patient did not keep appointments 157 patient refused referral, no communication for 3 years in spite of multiple attempts 28patient related reasons led to delay in referral 44patient related reasons led to delay in referral (chose to delay) 135patient related reasons led to delay in referral (cancellation) 38need more information, states pt did not f/u but unclear why 165need more info ‐ abstract does not list reason for referral code 16referral made to wrong provider type (diagnostic anchoring) 29referral made to wrong provider type (diagnostic anchoring) Lucier, D et al (CRICO Publication Pending) Referral ordered Appt scheduled ID missed appt Req MD reviews missed appt Appt rescheduled Document missed/cancel appt Consult note sent to req MD Consult note reviewed by req MD Consult note & MD ackn. entered in MR Pt told of report & tx options 1 3 4 5 6 7 8 9 11 Life Cycle Tracking • Discrete data elements • Messaging • HIPAA logs • HITSP C32 Report: Statistics by Institution and/or by Provider Number of Referrals •Open •Closed •Total •Out of network •Aggregate views CRICO Guidelines for Referrals Optional Curbside Consult 2 10 a. % referral appointments completed b. % consult notes acknowledged by PCP c. % consult notes communicated to patient a. b. c.
- 17. 17 Take Home Message • Missed and delayed diagnosis claims are the most expensive type of malpractice case to defend and closing the loop on referrals is one way to address these claims • These type of claims have two main contributing factors • Cognitive Contributing Factors • Systems Contributing Factors • Approaches to address cognitive contributing factors are multifactorial and therefore need a multipronged strategy, e.g., OpenNotes, CDS • Opportunities to close the loop of referrals and test results are the “low hanging fruit” opportunity to address these systems contributing factors • Technology solutions exist but gaps in applying these solutions still need to be further developed in partnership with EMR vendors, e.g., “referral black hole,” CRICO RMW Workgroup 33 We Welcome Your Questions… Please use the microphone so others may hear you.