Central Medical is a group practice consisting of 4 physicians’ offices. Central’s committee is trying to find a way to predict high risk patient groups. They want to take patients from these groups and apply intensive treatments. This paper will discuss process that Central used, additional processes that could be used, how data can be used to guide clinical practice, and the application of this case to another clinical environment.
Central’s Process The committee first makes a determination of what disease process they want to focus on. After this has been determined patients and families should be included in discussions. The patients that have the disease and their families can give firsthand knowledge as to if they would participate in different measures that are proposed. They may also have further ideas of the resources that they need to manage their specific disease process.
Health First is an insurance company that many patients within Central’s system use. Health First is focused on profit and Central is focused on quality. More …show more content…
However, they are often not in the correct format to be measured. Four challenges of using insurance claims for data reviews are: (1) conversion of claims into unique visits, (2) identification of incomplete claims data, (3) categorization of providers and locations of service, and (4) selecting the most useful measures of utilization and expenditures ("Quality of care," 2014). There is also a question of reliability and validity of the data. One study found only a 78.2% agreement between the principal diagnosis in a billing dataset and the principal diagnosis in the medical record ("Quality of care," 2014). Another study found that there was bias noted in coding comorbid condition on patients that died in the hospital, showing conditions that would be expected to increase the risk of death actually decreasing it ("Quality of care,"
Central’s Process The committee first makes a determination of what disease process they want to focus on. After this has been determined patients and families should be included in discussions. The patients that have the disease and their families can give firsthand knowledge as to if they would participate in different measures that are proposed. They may also have further ideas of the resources that they need to manage their specific disease process.
Health First is an insurance company that many patients within Central’s system use. Health First is focused on profit and Central is focused on quality. More …show more content…
However, they are often not in the correct format to be measured. Four challenges of using insurance claims for data reviews are: (1) conversion of claims into unique visits, (2) identification of incomplete claims data, (3) categorization of providers and locations of service, and (4) selecting the most useful measures of utilization and expenditures ("Quality of care," 2014). There is also a question of reliability and validity of the data. One study found only a 78.2% agreement between the principal diagnosis in a billing dataset and the principal diagnosis in the medical record ("Quality of care," 2014). Another study found that there was bias noted in coding comorbid condition on patients that died in the hospital, showing conditions that would be expected to increase the risk of death actually decreasing it ("Quality of care,"