PROJECTS

The Physician Advisor Team conducts peer-to-peer discussions with payors for hospital account claims that have been denied. Resolving medical necessity issues prior to a claim submission saves the organization time for claim rework and maintains cash flow since fighting a denied claim can be a lengthy process and involve significant claim rework. Previously, no reporting has been performed to analyze the volume of peer-to-peer referrals, successful vs. unsuccessful outcomes, and recuperation of denied dollars after successful outcomes. Therefore, the Director of ACO Revenue and Denial Management, Director of Central Utilization Management, and Lead Physician Advisor have requested development of a report to analyze the metrics previously stated. This report will greatly enhance the visibility of peer-to-peer volume and outcomes. Key report metrics include Total Payor Determination Requests, Successful Outcomes, Unsuccessful Outcomes, Total Outcomes, Percentage of Cases Worked, Total Inpatient&OBS Discharges, and Percentage of Discharges Worked.

A major factor impacting inpatient length of stay and inpatient discharge to a skilled nursing facility is prior authorization. Prior authorization (Prior Auth, or PA) is a management process used by health insurance companies to determine if a prescribed product or service will be covered. The prior authorization process for Franciscan Health inpatients starts when it is determined that a patient requires skilled nursing facility services after discharge. Previously, there was no centralized method to track and trend submitted prior authorization requests. In collaboration with the ACO Care Management team and Franciscan Alliance Information Services, a 'SNF Auth Form' inpatient flowsheet was created. Once a SNF Auth Form is submitted, a team of UM nurses takes the data from these forms and submits them in prior authorization forms found on health insurance portals. If the prior authorization is approved or denied, a UM nurse updates the Auth Status field. If the prior authorization is approved, a UM nurse enters a reference number from the health insurance provider in the Reference Number field found on the SNF Auth Form. The creation of the SNF Auth Form allows the leadership teams to assess the time from form submission to discharge and the time from prior authorization approval to discharge. Decreasing these times increases the efficiency of inpatient throughput and decreases average inpatient length of stay. Key dashboard metrics include AVG hours from form submission to discharge, AVG hours from form submission to prior auth approval, AVG hours from prior auth approval to discharge, and AVG basic mobility score.

Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what the documentation might be missing. Bridging the gap between clinical documentation and accurate coding drives CDI programs. “Clinical documentation” in the context of CDI generally refers to the entries made by a provider or clinical staff member who is responsible for the patient’s care during a face-to-face visit. CDI programs are organized so that a team of nurses can concurrently review the inpatient medical record documentation and query a provider concerning anything ambiguous or not complete prior to claim submission. This practice results in more accurate billing for the organization. The CDI Dashboard will assist in monitoring the volume of CDI queries and hospital accounts reviewed. This dashboard's development in Tableau, using staged data from the 3M CDI tool, automates previously manually-created CDI reports and dashboards, thus increasing efficiency for the Director of Revenue Management and Clinical Documentation Improvement. Key metrics include: Bedded Patient Discharges, Count of Accounts Reviewed, Percentage of Accounts Reviewed, Count of Queries, Percentage of Reviewed Accounts Queried, Count of Severity Queries, Severity Query Percentage, Count of Impacting Queries, Impacting Queries Percentage, Physician Agree/Disagree/No Response Rates, Overall CMI, Medical CMI, Surgical CMI, CC/MCC Capture Rate, and Financial Impact.

In January 2022, Ian was appointed as the project lead for Franciscan Alliance, Inc. Health Maintenance Organization (HMO) reporting automation. The HMO has never previously automated any reporting, and all reports were maintained in the form of Excel workbooks. Claims data was downloaded from MedVision QuickCaps, while utilization data was downloaded from Verscend Cotivity. The downloaded data was then used to build the various Excel reports. Through working with the Director of HMO Operations, we quickly identified a list of high-priority reports to be automated. The result is the HMO Reporting Dashboard, which contains fourteen individual reports in one Tableau dashboard. Each report on the dashboard contains data stored in SQL Server tables. These reports are: Eligibility Report, Capitation Summary Report, Hospital and FPN Capitation Report, Administrative Expenses from WorkDay, IBNR, Bedded Patient Report, Bed Days Report, Authorization Timeliness Report, Referral Authorization Report, ED Utilization Report, UC Utilization Report, Stop Loss Analysis Report, Stop Loss Accrual Report, and Readmission Report. This is an ongoing project with additional reports to be identified for automation.

Franciscan Health uses Care Management teams to assist patients in managing their health care, to provide quality health care, and to manage the cost of that health care. Tracking patients that have been care managed is accomplished through care coordination notes in Epic EHR. Patients that have been care managed have a non-deleted care coordination note created by a case manager within their Epic EHR chart. The Care Management Return on Investment Analysis Dashboard assists in monitoring the volume, utilization, and costs of the patients being managed. Key utilization metrics include: care managed patients by month, care managed patients by ACO payor registry, average CMS-HCC risk score, average HHS-HHC risk score, average SVI overall percentile ranking, ED visits per 1000 6-months and 1-year prior and post care management, IP visits per 1000 6-months and 1-year prior and post care management, and 30-day all-cause IP readmission rate 6-months and 1-year prior and post care management. Key ROI metrics include: cost per care managed patient per year, cost per care managed patient per month, risk-adjusted cost per care managed patient per month, estimated costs savings among care managed patients 6-months and 1-year prior and post care management, estimated cost of case managers for 6-months and 1-year, and return on investment ratio for 6-months and 1-year for care managed patients.

Franciscan Alliance, Inc. is preparing for mandatory Medicare bundled payments, which are estimated to begin in 2024. The Bundled Payment for Care Improvement Advanced (BPCI-A) Analysis Dashboard provides an interactive data platform to track clinical episodes, bundle performance, readily identify utilization trends, create episode-of-care timeliness and target price predictions, and analyze opportunities for care redesign / performance improvement. Key metrics include a count of anchor encounters, count of post-acute encounters, total episode claim spend, average episode claim spend, pre-anchor pay, anchor facility pay, anchor physician pay, ER pay, SNF pay, IRF/LTCH pay, post physician pay, outpatient pay, home health pay, DME pay, hospice pay, readmit spend, readmission rate, mortality rate, ER utilization rate, SNF utilization rate, IRF/LTC utilization rate, SNF ALOS, IRF/LTCH ALOS, estimated targets based on prior performance, estimated remaining spend for each bundle based on prior performance, net performance reconciliation amount (NPRA), average NPRA, NPRA as a percentage of program size, and patient case mix adjustment based on risk score and CMS guidelines. Bundled payment raw claim data from CMS was staged using SAS Enterprise Guide and SSMS, with Tableau providing the visual analytics.

The Franciscan Alliance, Inc. ACO launched the Remote Patient Monitoring (RPM) program in February 2021 with a goal of decreasing the 30-day all cause readmission rate of both the ACO and non-ACO patient populations. With percentage of premium arrangements included in four Medicare Advantage (MA) plan contracts as of January 1, 2021, the RPM program is a key area of focus as part of the larger system strategy to move to population health management (PHM). RPM is an innovative way for the whole care team to proactively manage high-risk patients across their care continuum on a single platform monitored daily by the care team to determine when a patient's condition starts to deteriorate. The goal of RPM is to engage the patients in managing their care and decrease the total cost of care by reducing unnecessary hospitalizations and ED visits. Data from the Clarity database for patients enrolled in the RPM program was transformed into a Tableau dashboard. Key metrics include count of patients enrolled in RPM, RPM enrollment by month, average CMS-HCC risk score, average HHS-HCC risk score, average LOS in days, patients enrolled by primary payor, average patient age by primary payor, total count (and average) of inpatient admissions and ED visits 30 and 90 days prior to enrollment, total count (and average) of inpatient admissions and ED visits 30 and 90 days post enrollment, estimated savings among enrolled patients (30 and 90-days pre and post enrollment), vendor full kit device cost for 30 and 90 days for enrolled patients, and return on investment (ROI) ratio for 30 and 90 days for enrolled patients.

The Medicare Hospital Readmission Reduction Program (HRRP) reduces Medicare payment rates, by up to 3.0%, to hospitals that readmit patients with certain specified conditions within thirty days. The financial penalty is applied only when the patient's initial hospital stay and subsequent hospital stay are both identified as inpatient. However, if a patient is classified as an outpatient in observation status for either the initial or subsequent hospital stay, the penalty is not imposed. Observation status has a significant negative effect on Medicare beneficiaries, especially those who need care in a skilled nursing facility after they leave the hospital and are required to pay for that care entirely out-of-pocket. Reducing rehospitalization of patients, as well as reducing observation rates, are policy goals that are viewed as reflecting a measure of organizational quality. The Bedded Patient Analysis Dashboard provides key metrics essential to understanding organizational use of observation and outpatient in a bed patient classes. Key metrics include count of patients with condition code 44, percent of obs patients evaluated with MCG Indicia observation discharge or inpatient admission criteria, average obs hours by hospital account admission diagnosis and by hospital account final diagnosis, count of obs patients receiving at least one obs charge from finance, total and average patient equivalent days based on obs hours charged, total and average obs hours charged, total and average charges and total and average payments for obs patients, average count of obs patients by admission hour of the day, average count of outpatients in a bed by admission hour of the day, etc.

Denied claims represent lost or delayed revenue to our organization. Preventable or avoidable denials are within the control of our organization and are caused by actions or inactions in the revenue cycle process. Before our organization can do anything to manage and prevent denials, we must first analyze the types and volumes of denials occurring within our organization. The Clinical Denials Analysis Dashboard transforms denial management reporting from previous Excel-formatted processes to automated, scheduled, and accurate Tableau reporting. This dashboard combines data from multiple SQL reports: Base Denials Report, Clinical Denials Report, Revenue Report, 468 CM Medicare Self-Audit Report, and Bedded Patient Discharge Report. The culmination of these report data into one automated dashboard heightens efficiency, visibility, accountability, and accuracy. The Denial Productivity Analysis Dashboard reviews denial management from a staff performance perspective. Addressing denials is always a large endeavor for an organization to undertake. However, with proper management, accountability, and analyses in-place, significant return-on-investment can be achieved.

The Care Management team at Franciscan Alliance, Inc. consists of case managers and social workers. Every time one of these employees create a new note in a patient's EHR, a record is created in the Epic EHR Clarity database. To analyze employee performance and the management of patient care, an analyst in the Care Management team would download monthly Excel reports that provide the monthly employee note totals, note types, note authors, and patients for which notes were submitted. This information would be manually added to a YTD Excel report that would be emailed monthly to Care Management leadership. I was assigned as the project leader to transform this monthly task into an automated state. By working with the Clinical Analytics team, SQL was created to pull the same information as the previous reports into a SAS flow, which deposits the data into a SQL Server table and was scheduled to run on the first day of each month. Once the data flow was built and validated, I created a new Tableau dashboard to visualize the data. The FAIS Case Manager and Social Worker Notes Analysis Dashboard now displays this data through an 'Executive Summary' page and a 'Notes Analysis' page. The 'Executive Summary' page displays note goal ratios via tables and graphs. The 'Notes Analysis' page displays case manager and social worker staffing and notes by region, hospital location, and month, as well as average notes per month and note type. This dashboard has increased intradepartmental efficiency and has surpassed the expectations of the Care Management leadership team.

Skilled nursing facilities and home health agencies have partnered with Franciscan Alliance to create the Post-Acute Care Continuing Care Network (PAC-CCN). These facilities and agencies are dedicated to the same goals through higher standards: better quality care, reduced cost, and higher patient satisfaction. Franciscan Alliance's Accountable Care Organization and Care Management Team track bedded hospital patients that are discharged to partner facilities and agencies and non-partner facilities and agencies. This was traditionally done through downloading PDF reports from the Reporting Workbench section of the Epic EHR interface (Epic Systems Corporation). These reports were then distributed from an analyst to the Care Management team. In the new approach, custom SQL was created to pull the same PHI found on the PDF reports from the Epic Systems Clarity database. This SQL was placed into a SAS Enterprise Guide process flow, which deposited the columns and data into a SQL Server database table. The SAS process flow was then scheduled to run on the first day of each month. A Tableau dashboard was then created by connecting to the newly created SQL Server database table. The Tableau dashboard includes a 'front' page, 'executive summary' page, 'detailed analysis' page, and 'about' page. The 'executive summary' page shows PAC-CCN partner utilization rates by year, quarter, and month. The 'detailed analysis' page breaks down partner and non-partner bedded patient discharges by year, quarter, month, facility/agency type, and facility/agency name. Finally, the 'about' page provided metrics and measures definitions for end-users to reference. The automation and development of a Tableau dashboard has exceeded the Care Management leadership's expectations, added value to the organization, and improved cost savings and efficiency.

As of June 2020, Franciscan Alliance, Inc. emergency departments are utilizing Optum Lynx as a tool for charge capture of E/M services. As a competitor to Optum Lynx, the Epic EHR Facility Charge Calculator provides a weight point system to calculate E/M service charges. There are currently 17.5 FTEs employed system-wide utilizing Optum Lynx as a guide for documentation review. However, upon workflow review, it was found that once Optum Lynx interfaced with Epic EHR charge capture, there was no revenue denial queue being monitored. Implementing the EPIC Facility Charge Calculator has removed several steps in validating E/M charge capture by automating those processes into a summary calculator for submission. Additionally, this implementation has reduced administrative costs by eliminating Optum Lynx software and licenses. The Epic Facility Charge Calculator Dashboard trends charge volume by charger, trends average minutes per chart by charger, tracks the average daily DoNotBill Work-queue quantity, trends ED arrival time by hour of the day and week, trends frequency of infusion/hydrations and injections, trends the top ten diagnoses by E/M CDM code, trends volume of deferrals placed specific to nursing documentation, and trends volume of deferrals placed specific to provider documentation.

In their previous state, executive-level dashboards analyzing surgical services data were developed within the Optum Surgery Compass tool. The goal of this project was to provide an executive-level surgical services dashboard presenting monthly and quarterly data in an automated state utilizing the data that is available in the Epic EHR Clarity database. This project has allowed Franciscan Health to move surgical services analytics from the third-party Optum Surgery Compass tool to Tableau visual analytics, thus increasing costs savings and analytics standardization. Through collaborative working group meetings with project stakeholders, metrics were identified and defined. Key metrics of the Tableau Surgical Services Dashboard include First Case On-Time Start Rate, Avg Case Turnover Time, OR Capacity Utilization, Physician Block Utilization, Case Volume of Completed and Not-Completed Cases, Percentage of Day-of-Surgery Cancellations, Surgical Site Infection Rate, and Wrong-Site Surgery Count. Data for these metrics was found in the Epic EHR Clarity database through custom SQL query. This custom SQL query was input into the Tableau dashboard to regularly extract the necessary data on a weekly basis to populate the visual analytics of the Tableau dashboard.