3M™ Ambulatory Potentially Preventable Complications (AM-PPCs) Grouping Software

(DESCRIPTION) Slide presentation. Text, Welcome! We will start at 1:00 PM ET/10:00 AM PT. Advancing Outpatient Safety with Reliable and Actionable Insights. April 25, 2023. Click "Join Audio" and adjust your settings before we begin. MGMA logo. Daniel Williams' video feed appears in the upper right corner of the screen. He is seated and speaking to camera. (SPEECH) Hi, everyone. This is Daniel Williams, Senior Editor of Industry Content at MGMA. Welcome to today's webinar, Advancing Outpatient Safety with Reliable and Actionable Insights. Thanks so much for joining us. (DESCRIPTION) New slide. Text, Thank you! Logos: 3M, M asterisk Modal, 3 M dot com slash H-I-S. (SPEECH) We would like to thank 3M Health Information Systems for sponsoring today's webinar. You can visit their website at 3m.com/his to learn more about improving patient safety and all things capture to code. Please see the slide for available credits for the live and on-demand experiences. 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(DESCRIPTION) Logo: 3M, Science, Applied to Life. Text, Advancing Outpatient safety with reliable and actionable insights: Ambulatory Potentially Preventable Complications (AM-PPCs). MGMA. Sandeep Wadhwa, MD, MBA. Miki Patterson, PhD. 3M Health Information Systems. April 25, 2023. (SPEECH) In today's webinar, Dr. Sandeep Wadhwa, Global Chief Medical Officer 3M Health Information Systems, and Dr. Mickey Patterson, product owner of 3M's ambulatory potentially preventable complications grouping software will share actionable insights for advancing outpatient safety measures. Dr. Wadhwa, Dr. Patterson, I know you have a lot of great information. So I'm going to turn this over to you now. (DESCRIPTION) Sandeep's video feed replaces Daniel's. (SPEECH) Daniel, thank you for the kind introduction and for the little pop quiz. I was thinking about those questions too. We look forward to seeing folks' pre-post responses on that. Thank you so much for joining us today. We're excited to share with you some advances in how to look at post-procedure care, and particularly looking at related complications, and quality defects, and beginning to get more insight about 30-day outcomes post-procedure. We have a really rich infrastructure for looking at 30-day events on inpatient care and technologies advancing now to be able to look at procedures as well and add that lens to how we improve our ability to care for patients. So Mick, you can go to the next slide. (DESCRIPTION) New slide titled, Learning Objectives. Text, Review the current challenges and opportunities to track and improve patient safety with elective procedures. Recognize the broader implications of safety incidents on shared risk and value-based care (VBC) contracts. Identify a roadmap to identifying gaps in current outpatient safety practices. (SPEECH) I'll kick off these first few slides and then turn it over to Mickey. And then I'll come back to discuss the kind of close this out. It's nice to see folks from across the country. Texas and New Jersey representing so far. Just a couple of learning objectives. And again, I kind of teed up this conversation as beginning to advance our approaches for measuring post-acute events after elective procedures. And we'll take a really broad definition of procedures and kind of expand that definition from surgical procedures to also include procedures that occur in radiology settings or in all of the internal medicine subspecialties to which I belong. Though was a geriatrician, we don't do too many procedures in ambulatory surgical suites. And so the other part that we thought would be really interesting in this conversation was how looking at procedures could inform shared risk and value-based care contracts for a lot of our listeners today as being an area where there's almost a double, triple bottom line in terms of not only if we're able to reduce some complications, does that increase the patient experience? But it also reduces excess costs. And so as more relationships are being formed and interest is being formed, working directly with medical groups doing procedures. We think this is an area of getting more insight really can help improve performance on value-based care contracts. And then lastly is being able to drill down on where there's better than expected performance against benchmarks and where there's opportunities. By the different physicians, many of you may have several different sites where procedures are occurring. And being able to identify by procedure type, by site, and by practitioner starts to give insights on how to address for performance improvement and perhaps even opens up conversations around, are we getting the complexity of the procedure adequately and appropriately reflected in our coding? Next slide. (DESCRIPTION) A new slide shows a photo of a sign in front of a hospital that reads, Outpatient Services Drop Off, Outpatient parking. Text, Have you or a family member experienced a complication after an outpatient procedure. A, Yes. B, No. (SPEECH) So let's start off with a quick question. And part of this is we're just interested in whether you or a family member-- take a broad definition of family, whatever works for you on how you define a family, if it's spouses, kids, parents, grandparents-- have had a complication after an outpatient procedure, whether that's a surgical procedure, or an endoscopy, or any other procedure? We'll give you a second to feed that information back to us. Wowza. Boy, that is-- Mickey and I have spoken to a couple of audiences. That is a higher percentage, isn't it, Mickey, than I think we've been-- typically in our audience I think-- well, Mickey, what's your sense of just our informal feedback so far? Yeah, somewhere in the high 40s or 50s. Yeah. And so I think we're seeing it on the call here with over half the folks. (DESCRIPTION) New slide. Text, Safety Incident impact for elective procedures. Post procedure adverse events: Challenging to systematically analyze. Contribute to impaired patient recovery, excess paint and suffering, negative patient experience. Professional edict to "do no harm." Litigation costs. Reputation. Insurance premiums and inclusion in care networks. VBC opportunity: Excess emergency department (E-D) and inpatient admission for complication care. Staff time (MD, RN, ancillary services, consultants and supplies). Loss of reimbursement penalties. (SPEECH) And I think we can go to the next slide. I think part of the setup for this conversation is there a sense by patients that these procedures, if they're occurring in an outpatient setting, have a lower risk of complications. And we as providers don't see the patients after the discharge that day. And so obviously, the inpatient setting we're watching folks for overnight or even longer. And also, there's literature that patients may underestimate the severity of symptoms or signs post-procedure, that they may not appreciate-- they may go into the procedure thinking that it's low risk. And so these are parts on the patient side what may be factors that end up manifesting themselves later when things arise to a level of involvement. But part of the other challenge is it's tricky to analyze post-procedure events that were kind of separated both in time and space that the post-procedure care may not be at the site where the care was rendered initially, where the procedure was given. Someone may end up at a different ER. And how you kind of link events together and have a view of a post-procedure window across different sites of care, whether it's an office, an ER, an inpatient setting, has been tricky to do. The other reason why we think this is an important topic is it is central to understanding this edict and extending the edict of doing no harm. There may be an initial focus at the day of the procedure and really focusing in on the best practices to ensure the procedure goes smoothly and kind of bringing some more light to the post-acute period to having that expanded definition of excellence on the day of and then also expanding and helping to support excellence for the next-- in our case, we're looking at 30-day windows here as a relevant range. And as previously mentioned, we think getting more insights for your groups and your practices on where you're doing better or not kind of just helps in so many domains in terms of improvement. And where we are particularly interested in is this intersection between the patient experience and also efficient use of healthcare resources. And that post-procedure events lead to kind of excess emergency room, office visits, supply, inpatient resources, which in an increasing environment of value-based care become areas where we can act upon that have that impact of both enhancing the patient experience, as well as being more efficient in how we use total cost of care and total resources. Next slide, Mickey. (DESCRIPTION) New slide titled, Outpatient procedure trends. Text, Orthopedic procedures have shifted to ambulatory centers (ASCs), with hip and knee replacements seeing the greatest percentage of shift. Technological advancements and Medicare coverage for these procedures being performed in ASCs have aided in these shifts. A bar graph titled, Percent of change in procedures performed at ASCs between 2019 and 2021. Spine arthroplasty, 36%. Shoulder replacement, 45%. Spinal fusion, 73%. Hip replacement, 150%. Knee replacement, 168%. (SPEECH) And so this kind of speaks to the trend that has been going on for 20 years. In a prior life a couple of Governors ago, I was the state's Medicaid director. And this line of outpatient spend was stunning to me in terms of just having to plan for a budget. Every year we were planning for 10%, 15% growth on outpatient services. And we saw a 2% decrease year over year in inpatient. And that was 15 years ago practically, right at the Great Recession. And that trend has just accelerated and continued. And we're finding that we're able to do more procedures in places that are convenient to patients, mainly in community settings, and are doing more procedures and more complex procedures in day settings. And what we're particularly interested at 3M is adding a lens of patient safety quality outcomes to that window. Next slide. And (DESCRIPTION) New slide. Text, Current opportunities and challenges. An aerial photo shows three men gathered together, a man in a white coat and stethoscope shaking the hand of a man wearing a tie, standing with a man in blue scrubs holding a tablet. Text, Greater than 70% procedures performed in outpatient setting. Limited outcomes/safety/quality measurement systems. Share results of a comprehensive quality outcomes system for ambulatory procedures. Trusted objective secure data methodologies. (SPEECH) oh, Mickey, here's the answer to our question. So just kind of more data to support that trend, where we're now more than 70% of procedures, surgical procedures are occurring in outpatient settings. And I did not train as a proceduralist. I probably trained as a talker and a diagnostician. But there was such a rich infrastructure around surgical morbidity and mortality in the inpatient setting. And Mickey is a leader in orthopedics. And and we have such a rich culture of learning from what we did well and where we could have done better on that inpatient setting. And we see this trend of bringing back culture of-- and it exists today. So I'm not trying to imply it doesn't exist today. I think that as data is able to be linked and we're able to apply technology and software, we're able now to get better views of this dominant side of care. And frankly, we have very limited tools for looking at post-acute care. I'll let Mickey kind of describe our work in this area. But we think that there's an opportunity to add to the measurement methodologies out there for outpatient safety. And this is work that 3M has been involved with for 40 years. There's a role for the private sector in maintaining, and updating, and innovating on quality, and safety, and payment. Great that we have government options. They serve a purpose. But we also think that having a private sector option allows for choice, and enhancement, and responsiveness. So Mickey, let me turn the floor over to you to kind of talk a little bit about what we've built here. Sure. (DESCRIPTION) Miki Patterson's video feed replaces Sandeep's. New slide. Text, 3M Ambulatory Potentially Preventable Complications (AM-PPCs) compared to A-S-C-Q-R. 3M AM-PPCs: 3M Ambulatory Potentially Preventable Complications, computerized grouper for billing or claims. A-S-C-Q-R: Ambulatory Surgical Center Quality Reporting, very manual process. A chart compares 3M AM-PPCs and A-S-CQ-R in the following categories: Measure scope, procedures included in measure, procedures excluded from measure, procedure definition, complication defined, and risk adjustment. (SPEECH) So we're going to talk a little bit about the differences between ambulatory potentially preventable complications. I'm going to call them AMPBCs because it's easier. And what kind of quality outcomes are we looking at now for these same complications. And as you look, you know that the ambulatory surgery centers, the quality is really looking at processes. There's the same biggies, wrong site, wrong side, wrong patient. But they also have is the cataracts, improve someone's vision, and did they have normothermia? We go deeper. And what we're going to show you is 1,500 different complications put into groups. We're looking for 30 days, not just how many counts of the occurrences. We're also looking for, where did they show up and what procedures. So when we start to look, I'll give you a little bit more detail when I talk to you about the logic. But we think that the AMPBCs are a much richer way to start to look at our data. (DESCRIPTION) New slide. Text, USNWR evaluating inclusion of elective procedure safety in 2023 ranking. Outpatient outcome measurement: We recently began working with 3M Health Information Systems: Licensed 3M's Ambulatory Potentially Preventable Complications (AM-PCC) Grouping Software. Exploring potential use in specialty rankings and procedure rankings. Initial exploratory work will focus on: ear, nose and throat, gynecology, urology. The first two paragraphs of an article titled, Hospital Rankings Shift Emphasis to Objective Data Away from Expert Opinion. (SPEECH) I did want to say that US News World Reports has actually licensed our grouping software and are considering using it for the 2023 hospital rankings. They did say that they were starting with ENT, GYN, and urology. And expect to hear something from them in the June time frame to be used if they're using this for the July rankings. (DESCRIPTION) New slide. Text, Ambulatory potentially preventable complication. Harmful events (e.g., accidental laceration) or negative outcomes (e.g., sepsis) that develop after an elective procedure was performed in the ambulatory care setting and that may result from processes of care and treatment rather than from natural progression of an underlying illness and are therefore potentially preventable. (SPEECH) So I'm going to talk a little bit of details of, what is an ambulatory potentially preventable complication? It's a harmful event. So it's an accidental laceration, or a negative outcome such as an infection. It has to develop after an elective procedure. So there's no emergency room procedures here. And it had to be performed in an ambulatory care setting. These are key pieces so that we're only looking at scheduled elective procedures. And we're not really looking for a problem that had medical issues from an underlying illness. We're not looking for worse kidney because they're diabetics. We're really looking for a complication that was related to that particular procedure. (DESCRIPTION) New slide. Text, Identifying, locating and quantifying procedural complications. Procedure groups: 93 procedure groups which include more than 2,900 elective procedures. PSGs include similar procedures that also share the same relative risk. A classification hierarchy is applied to select a single and primary procedure group that best classifies outpatient encounters. For example: colonoscopies, upper GI endoscopy, biopsies, cataracts, arthroscopies. (SPEECH) So here's the logic. And there's about three or four little chains of this logic. So I'm going to just give you an overview of this. There were some almost 3,000 procedures. And what we did was we started anatomically looking at these procedures and then grouped them together by the complexity of the procedure. And to give you an example of this, if you had, say, a trigger finger release, that's not really complex. It's pretty routine. But if you were an outpatient and you had a total shoulder replacement done, much more complex. That's in a different procedure group. And we expect different complications. When we did this, we were able to do a hierarchy. So if you had more than one procedure done at the same day, one of those, the highest risk, would bubble to the top. And then we linked it for 30 days out looking for a complication. (DESCRIPTION) Complication groups (AM-PPCs): 35 total complication groups which include greater than 1,500 unique complications. Complications must meet defined timing requirements. (example: 48 hours for infection.) Complications plausibly related to the procedure. Sepsis, UTIs, bleeding, pneumonia, infections, hemorrhage. (SPEECH) The logic for the complication is such that we have some 1,500 different unique complications. And we also group them. So we group them in hematomas, and lung problems, and infection problems. We also had those complications needing to meet timing requirements. And they had to be plausibly related to the procedure. So you wouldn't have a problem with an eyeball related to a cardiac procedure. (DESCRIPTION) Complication setting: Emergency room visits, inpatient admission, outpatient encounters. Available on premise (CGS) or cloud (GPCS) with Medicare and national benchmarks. (SPEECH) And then the most important one is, where did that complication show up? So we are able to look at 100% claims and see that some of these complications showed up in the emergency department. Some were inpatient admissions. And that's not a readmission because they were done outpatient. So it wasn't a readmission. Or the complication showed up in an outpatient encounter. When we did look at these, we also started to think, what are we going to gear this on? So when we looked at benchmarks, we wanted to make sure it was a significant complication. So we excluded in our benchmarks those outpatient encounters. We only looked at the emergency room and inpatient as significant complications. And then this component is available on the grouping software that's either on-premise or in the cloud. When we did make those benchmarks, we started with the Medicare benchmarks. And then we added to national benchmarks. That includes pediatrics. (DESCRIPTION) 3M AM-PPC: Risk adjustment approach. Case adjustment: procedures with higher risk of complication grouped together. Plausible procedure and complication relationship: Clinically relevant focus on complication to procedure relationship limits effect of chronic conditions. Elective procedure focus: Less procedure complexity, care team informed by knowledge of chronic conditions (exclude ED procedures). Research: Chronic conditions reported on claim at time of procedure have few complications. Age, disability status, oncology adjustment: correlated with chronic conditions, frailty, ability to self manage. (SPEECH) And I want to talk a little bit about our risk adjustment approach. So the basic premises that we used was we wanted the procedure to be the risk adjustment because it was elective and because these patients were going to be done in outpatient and expected to go home. That's how we started to categorize. And we make sure the complication is plausibly related to that procedure, whether it was an anesthesia, or a puncture, or things like that. And then we put them into different complexities. So we put the less complex procedures in a group. And when we did do the data-- and I'll show you a little bit about the data after that-- but it made sense. When we thought these were highly complex procedures, they did show that they had higher rates of complications. And we have looked at the chronic conditions. And actually when we started to look at it, if somebody had an oncology diagnosis in five of our procedure groups, they had a higher risk. So we built that adjustment in. We also had an age adjustment. So if you are over 75 or over 85, you had increasing risks. So we put those risk adjustments in. When we did the Medicare data, we also noted under 65 had a higher risk. And these would be the dual status. These would be patients that had disabilities. So it kind of made sense when we went through it. And again, we're always learning. We're doing research. But this is where all of the data has brought us. And I'll give you a little more explanation about that. (DESCRIPTION) A new slide shows a flow chart titled, Knee procedures and example of 3M AM-PPC exclusions. It begins with two branches: In gray, Text, Exclude: Knee procedures done as inpatient or observed for 23 hours and admitted. In Blue: Include: Knee procedures that are elective, performed in ambulatory setting. From the blue box is a row five other boxes: In gray: PSG 3 Knee Arthroscopy, PSG 14 Knee Arthroplasty Revision, PSG 28 Open Knee Fracture and Ligament Repair, PSG 29 Other Knee and Soft Tissue Procedures. In blue: PSG 13 Knee Arthroplasty. An arrow points below the blue box to another blue box: PSG Assigned: 13 Knee Arthroplasty. From that blue box is a row of four boxes. In gray: ED visit day 1 with fever, ED visit day 15 for burn on hand, ED visit day 32 with hematoma and hemorrhage. Each gray box has "excluded" written in red and the reason. The blue box reads: ED visit day 10 with deep vein thrombosis: Included, plausibly related to procedure and meets timing requirements. (SPEECH) But when we did the logic for this, we have this exclusion logic. So when we looked at all of the claims data, the first thing we did was eliminate anything that went inpatient. If they didn't make the 24 hours for observation, they're not considered an ambulatory procedure. So let's use knees for an example. You can see the five groups here. We have knee arthroscopy, which is a very less complex than a total knee, and a revision total knee, and fracture repairs. So if you particularly went into the group of having a total knee joint done, you would be in PSG 13. And we would start to look out from then on for any complications. And we would tie it. Now, we did talk a little bit about that 24-hour window for the fever, for infection of a wound. And we're going to keep that on our back burner. It's excluded at this time, so we can look at more data. But we think it takes more than 24 to 48 hours to develop a wound infection that can be seen post surgery. We also looked at DVTs. So if this patient came back to the ED with a deep venous thrombosis, that's plausibly related to that knee joint surgery. It makes sense. But if you came back and had a burn on your hand, that is not really plausibly related. So that would be excluded in our logic. However, if you did come back 32 days after and had a hematoma or a hemorrhage, we would flag it. It's outside the 30-day window. But it is an event. And that would be a flagged event. (DESCRIPTION) A new slide, titled Complication Groups, shows a long list of AM-PPCs with descriptions, each one with a different number code. (SPEECH) So here's a little bit more definition about what complication groups are. If you look on the left hand column, pneumonia, aspiration pneumonia, pulmonary embolism, these are very common complications. And they're used for inpatient potentially preventable complications. But (DESCRIPTION) A red box outlines two codes in the right-hand column: 101, Post-procedural infections of eye and adnexa. 102, post-procedural complications of eye and adnexa. (SPEECH) if you look on the right hand column, we have started to put in the complications directly tied to procedures, such as a post-procedure infection of the eye and adnexa. This would be correlated with eye procedures. And the same thing with muscle skeletal. So (DESCRIPTION) A new slide shows a chart titled Top procedure '19/'20 FFS Medicare HOPD 3M AM-PPC. It shows, PSG, Description, At-risk procedures, ED complications, IP complications and AM-PPC Rate. (SPEECH) here's a lot of data to show you. But I want to walk you through it so you understand what we came out with. When we looked at all of the Medicare fee-for-service hospital outpatient data, and we looked at the top 20 procedures, top 15 procedures, at the very top the number one procedure done for this group was an upper GI endoscopy procedure. There were over a million and a half of these done in '19 and '20. Of those, almost 7 and 1/2 thousand were seen in the emergency department for complications related to that upper GI procedure. And some 23,000 were unplanned admissions from complications from that upper GI procedure. Hence giving us that complication rate at the end. (DESCRIPTION) On the chart, the 103, Routine Cataract Procedures row is underlined in red. At-risk procedures, 487,922. ED complications, 114. IP complications, 938. AM-PPC rate, 0.2%. (SPEECH) If you look down a little further, you can see 103, the routine cataract procedures. Again, a half a million of these are being done. Very few are coming to the ED. Very few are being admitted. And the risk rate is 0.2%. So that made sense to us that a very low risk procedure would have low risk. Again, upper GI, almost 2%. And when we look at it, if you look down here at number 94, upper genitourinary stent and guidewire, now this is a very complex procedure. These are sick patients. We're putting stents in them. There's 174,000 done. But of those, 5,600 come to the ED. And 9,000 are being admitted. And because we know that's a high risk kind of a procedure, it made sense-- look at the risk of complications, 7.6. So it did pan out when we started to look at these procedures. (DESCRIPTION) New slide titled, Data by PSG 70 upper gastrointestinal edoscopy procedure. A bar chart shows AM-PPC for the procedure. At the top at 0 AM-PPC 70 is, Infection, Inflammation and Clotting Complications. At the bottom is Gastrointestinal and Peritoneal Complications or Significant, dot, dot, dot, at about 10,500 AM-PPC 70. (SPEECH) What we're also able to do is not only look at the complications what comes to the ED and gets admitted. But we know what the complication was. So if you look at this upper GI that we looked at that top layer, when we started to look at the data, the highest percentage were coming in for gastrointestinal or peritoneal complications or significant bleeding. And this was after they had been discharged and gone home from a procedure. So this is not direct admits. So when we look at this, we are now able to see. We can focus on where we need to make improvements. We need to find out what's going on in these particular cases. (DESCRIPTION) New slide titled Complications by complication group. A pie charted titled Complication Frequency Medicare 2020. Septicemia and Severe infections, 20%. Urinary Tract infection, 18%, other pulmonary complications, 14%, Moderate infections, 5%, Hemorrhage and hematoma, 9%, pneumonia and other lung infections, 6%, Infection, inflammation and other complications of devices, implants or grafts except vascular infection, 5%, Major gastrointestinal complications or significant bleeding, 5%, post-hemorrhagic and other acute anemia, 5%. (SPEECH) And another surprising thing when we looked at all of that data for 2020, of all of the outpatient procedures, septicemia and severe infections came up number one. And that's 20% of all complications for all outpatient Medicare procedures for that year. So it does tell us we have a significant problem here. Urinary tract infections, what's happening post-procedure with those urinary retentions? Are they getting infections? Are they having to go to the emergency room or waiting too long and needing to be admitted? Pulmonary complications, hemorrhage hematoma. See this red one here, the mechanical complications? This (DESCRIPTION) The red wedge of the pie chart is labeled, 21,032, 7%. (SPEECH) is actually good to highlight that there may be problems with an implant or a device that we may not know of. So this information is really helpful for us to start to look and give your head a scratch and say, I wonder what's going on there? (DESCRIPTION) New slide. Text, AM-PPC surfaces contamination issue. Vignette: Previously healthy 65-year-old presented to the E-D with symptoms of sepsis two weeks after Upper Gastrointestinal Endoscopy Procedure. E-D doctor thought it odd that this was the fifth person in the past couple months with a similar story. Outcomes: AM-PPC reveals 2x as many complications than expected for Upper GI Endo resulting in sepsis. Root cause analysis: After new endoscopes were purchased for the GI group, Central Sterile never changed to the manufacturer's new sterilization method. What can we learn: High rates of procedure complications relative to a benchmark can serve as a trigger for review (or basis for performance improvement incentive). (SPEECH) And here's an analysis of what this could surface. If you have a 65-year-old presenting to the ED with symptoms of sepsis two weeks after that upper GI endoscopy and having an ED doc think, wow, this is kind of odd. This is like the fifth person that I've seen with this kind of scenario in the past couple of months. So when you looked at it, if you looked at those upper GIs and you saw that they had sepsis relating from that, you could start to do a root cause analysis. What did this find? And this actually happened nationwide a few years ago is that the GI groups were purchasing these new scopes. And they never alerted central sterile that they're new scopes. Central sterile never knew that there was a new manufacturer sterilization method. So this kind of data would help you do that root cause analysis and maybe change the way you attack something, look at something, or just trigger a review to look at the process. (DESCRIPTION) New slide. Text, National Medicare risk adjusted OP facility-based procedure complication variation (CY 2020). A bar graph titled, Distribution of hospital A/E Medicare FFS performance CY2020, showing HOPDs at A/E. The bars form a standard bell curve, the highest center bar going up to just over 250 at just before 1 A/E. (SPEECH) And this is what our rankings look like when we took all of the outpatient facilities and compared them. So this is 2020 data. And we have an expected kind of centrally. But you can see that some of the facilities were much better than expected. And some of the facilities were less, they were worse than expected. So these on the right hand side, these facilities that had more complications than you would expect would be the place that you would start to concentrate on. (DESCRIPTION) New slide. Text, Driving network performance on complications: site of service. A bar graph shows number of providers along the y-axis and percentage better than expected and worse than expected along the x-axis, with 0% in the center. The tallest bar is 12 providers at 0%. The shortest bars are 1 at negative 70%, negative 50%, and positive 60% and positive 70%. Text, The best performing provider was 70% better than the worst performer. 1 year, greater than 2,500 complications, costing $13.3 million, for providers performing below expected. (SPEECH) And this is just another example with a smaller data set. This is a statewide. And particularly, this had an orthopedic surgical center that was 70% better than expected. And it also had an orthopedic surgical center that was 70% worse than expected. And if you think about all of these complications that are happening greater than expected, these impact your margin. These impact your patient safety and outcomes. So it would be good to know where are the issues coming from. (DESCRIPTION) New slide. Text, Data by service line. A flow chart shows Procedure subgroup PSGs along with their total procedures, complication seen in E-D, complication inpatient admit, and risk IP and E-D. (SPEECH) And when we did this, we talked about doing it in anatomically. But we also did it by service line. So you could go and look in-- and I use spine because I'm orthopedics. And orthopedics and neurosurgery both do spines. But we took that all apart, that kind of division by utilizing cervical spine procedures or fusion procedure, which is a higher risk group. And same thing with lumbar. If it was a lumbar spine procedure versus the ones with fusion and higher complexity. And we could see by how many procedures which came to the ER and what was that risk of having a complication. Sandeep, I'm going to pass this on back to you. (DESCRIPTION) New slide. Text, AM-PPCs, documentation and coding quality, Top 10 procedure by volume: angiography and catheterizations. Coding Guideline: PSG 53, Coronary Angiography Procedures: at-risk cases, 564,725. Rate, 1.84%. PSG 52, Left and combined heart catheterization procedures: at-risk cases, waiting on data. Rate, 2.83%. Left Heart catheterization procedures have an expected AM-PPC rate that is 57% relatively greater than coronary angiography procedures. (SPEECH) Thank you, Mickey. Really appreciate you kind of reviewing all the insights that one can get from this approach. And listeners on the call, we welcome your thoughts and your thinking about how kind of a 30-day insight for the procedures that are going on with your groups could be useful. And I think the piece that we're really excited about is being able to show some of those benchmarks, that how are you doing against folks that look like you? And we're getting more and more data into our database. But the other part that we've been looking at is how important coding may be on capturing and making sure that the case is in the right risk group. And so in this case, if the procedure was a coronary angiography, we kind of expect a 1.8% revisit rate. But if they did also go into the left heart and do an EF, an ejection fraction, and you go through the aorta, that becomes a more complex procedure. And you're increasing the complication rate by a third, almost to 3%. And so we're talking to some of our coding experts. And the professional [? may ?] not look that different. But often times, this may be an example where if this isn't coded with the left heart cath procedure and just got coded as coronary angiography, we'd be putting that patient into a different risk group, just as Mickey was describing. And so we think as folks look at their outcomes that there's both a chance to do a check on the coding accuracy, as well as starting to look at the quality procedure. So Mickey, we can take a look at the next slide too. (DESCRIPTION) New slide. Text, AM-PPCs, documentation and coding quality. Top 10 procedure: cataracts. Coding guideline: complex cataract removal: CPT 66982 is defined as "extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (i.e., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage. Routine: PSG 103, Routine Cataract Procedures: at-risk procedures, 487,922. Rate, 0.19%. Complex: PSG 104, Complex Cataract Procedures: At-risk procedures, waiting on data. Rate, 0.31%. Complex cataract procedures have an expected AM-PPC rate that is 63% relatively greater than Routine Cataract procedures. (SPEECH) I also just wanted to pull an example of a low risk procedure, cataracts. That's something in geriatrics we're very keen to address just as a leading cause of blindness that is reversible and treatable. But you can see exactly what we expect, which is a pretty low complication rate, 2 in 1,000. But if it's a complex procedure, that increases, again, by a third. And this can be very tricky on the coding side in terms of getting the-- it's complex coding rules. But I think that this would be another area kind of in addition to the quality improvement areas that we would expect folks, depending on your procedure suite, to now have more of a quality lens for why coding is really important to kind of complement the traditional being made sure you're being paid in full for the service being rendered for the complexity of the procedure. We think having this quality safety lens will further contribute to kind of accurate, complete coding. (DESCRIPTION) New slide. Text, AM-PPC mechanical failures. Vignette: AM-PPCs reveal higher than expected mechanical complications from the new joint center. Patients were being admitted for joint revisions less than 30 days following a joint placement for one facility. Outcomes: This rate was noticeably high and points to the device or application. What can we learn: High rates of procedure complications relative to a benchmark can serve as a trigger for review (or basis for performance improvement incentive). (SPEECH) And so this is another kind of vignette of where we think there will be insights. And I invite you to think about in your own settings for the common procedures that are being done by either by the doctors on the call or by the practice sites that, in this case, this example of being able to look and see if the rates of mechanical complications are higher than expected, and then drill down and say, OK, let's apply a lot of the root cause analysis and all of the total quality management tools that we have at hand to improving that post-acute experience, and identifying root causes, and building on the practices that I think are in place, but now being able to extend them to perhaps more procedures, and have benchmarks, so that you're able to get a richer sense of relative performance. Next slide. (DESCRIPTION) New slide. Text, Establish baseline for elective procedure complications. 1, Integrate into your BI environment. 2, Input your billing, EDW or claims into grouper which feeds your analytics engine. 3, Conduct system-wide analysis by site, service line and provider for assistance. 4, Benchmark to Medicare or national norms. 5, Assess, aggregate, site, service line actual to expected. 6, Create actionable data for clinicians, HOPD, service lines. (SPEECH) And we're kind of wrapping up here. We are interested if there's folks on the call who would like to learn more. We see this system as informing your business intelligence environment. And we are coming to the table with some Medicare and national benchmarks, but can complement that with information from your own system and start to build out more recent data. Always the drag with these payer databases is that there's a lot of latency. And and we're able to bring them more current with your information, and then invite that analysis by procedure, by physician, by site, how are we doing on post-acute care events, and where are we doing really well, and let's learn from those sites, and expand that out, and then ultimately kind of driving towards actionable results that are kind of aligned around patient safety. Next slide. (DESCRIPTION) Next slide. Text, Summary: Promote member safety in outpatient settings. Growing need for ambulatory standards of care and safety is great. Identify actual versus expected variations. Source comprehensive, trustable, actionable outpatient methodology and data. Foundation to VBC in rapidly expanding ambulatory care. (SPEECH) And so in closing, we're looking forward to spending a little bit of time discussing your questions and kind of advancing the safety lens both from the procedure to that 30-day window. And as Mickey had mentioned, US News is evaluating this system on the outpatient facility side. But we built the system so that it also can look at events at ACs and even office events. And so we're able to look at procedures in a wide range of where they occur. And part of what we think is really important is recognizing that there are risks with every procedure. And that that's why that slide that showed the different rates, we don't have a strong opinion yet on what's the right rate. For us, this reminds us of what re-admissions looked like 20 years ago, where that slide that Mickey showed you was not a normal distribution. It had more of this tent approach. And there's a lot of variation. And on that second slide, you saw a lot of what we call fat tails, where you have outliers. And so we expect with more of this focus on 30-day results to see that curve kind of take on more of an upside down U and the extremes get pulled in. And we see more concentration around the center. And we start to see that move to the left. And so we would love to invite a follow up if partnership or collaboration on that would be of interest. And our team works very closely with many payers on value-based care contracts. And so as your thinking about commercial or Medicare or even seeing more Medicaid procedures going into value-based care contracts, we'd welcome partnership. And one thing I forgot to mention earlier was we did build the system to also include pediatric cases. And so we have been showing you a lot of Medicare data. The Medicare data tends to be a little bit more available. As a former Medicaid guy, I think a lot about kids and moms. And so we have built this out to also look at patient safety event for those adolescents and kids that are getting inguinal hernias, or getting tubes placed in their ears, or the whole range of procedures that kids get to are also included. Final slide. This is the slide that always makes me nervous, Mickey. Let's go there. (DESCRIPTION) A new slide shows phots of Miki and Sandeep. Text, Thank you. Miki Patterson, PhD, NP. miki dot patterson @ m m m dot com. Miki is spelled M-I-K-I. Sandeep Wadhwa, MD, MBA, swadhwa @ m m m dot com. (SPEECH) I feel like there's truth in advertising. Are we matched up here? I feel like the hair is getting whiter. And the Vision's getting a little worse. But we wanted to leave you with our contact information and invite follow up directly. And Daniel, if there's questions, we can spend a few minutes going through. That sounds great. Thank you, Sandeep and Mickey. Great presentation. We do have some questions that have come through. And just as a reminder to everyone, just go to that Q&A button down there. You'll see that icon at the bottom of the screen. Click on that and drop your question in there. So first question up, how much of these growing inpatient numbers to have procedures at ASCs are contributed to COVID worries and not wanting to be at major hospitals, do you think? This attendee says, I hear this a lot in my surgical practice, not as much recently, but absolutely heard it a lot in '21 and 2022. Lauren, thank you for that question. I think it's a very perceptive question. And your hypothesis, it follows our sense of the trend too, that we see institutional settings as being increasingly reserved for higher risk and complex procedures. Particularly during COVID, I think we were getting our hands on more ASC data and saw that trend with more procedures going on with ASCs, as you did too. I'll make one side comment, which was Lauren, we saw lower infection rates at the height of COVID. And I hesitate to say this. And I think we'll probably prepare a paper on this. But we're seeing those infection rates begin to climb up. But it looked like in 2020 and 2021, this nationwide focus on sterility everywhere sort of played out in our data. So Mickey, I think we're super eager to run the most recent data set we have to see that trend. So Laura, I think your point is well made that COVID accelerates this trend. And we just think there's this broader trend around convenience. And that's kind of favoring these less institutional sites of care. Mickey, anything to add on that? No. Well, I just think that that's right. It did sort of force the hand of people who wanted or needed procedures done to go outpatient. But I think it was starting to happen. That sort of gave it a giant boost. And I don't think it's going to go back. I think that's just the way it is. But the data didn't show that we had many less infections and complications from the 20s, 2020, during the COVID time. OK, thank you all for that answer. Next question up, how do you anticipate this could or will in the future be used from the consumer side? Knowing that the ASC I'm headed to is 70% better or worse than the benchmark would influence my decision. Anonymous attendee, excellent question. This was somewhat of the exact motivation on why we were investing on building on this system, was to give the public, to give the whole system visibility on performance and to do so in a way that was thoughtful, that's risk adjusted, that's clinically related. And this is, I think, where US News kind of jumped on this, which was to give consumers more visibility on patient safety in outpatient settings. But their work tends to focus on hospital outpatient facilities. So I think the ASC visibility is still something to come. And as we talk to all payer claims databases, or public reporting efforts, or people who have complete-- I think particularly, Mickey, within different states is my guess where we'll see the ASC sites being included. Now, on the other hand, anonymous, I think that there's an opportunity for the groups themselves to tell a safety story within their market. I think so much of the-- you guys tell me. I'll see you at some event in person at some date. And we'll have a drink of your choice. But I think that people are making choices oftentimes on reputation or name, Daniel, and that there's an opportunity to start for folks to say, hey, our patient safety rate is half the regional or norm in their area. So I think folks will start to distinguish themselves independently to the consumers as part of their efforts and how they describe themselves. And this can help tell a broader story. And I think we're seeing that, just to answer your question, I think this is kind of where I think US News is going on the facility side. And I think we'll start to see, Mickey and Daniel, more folks looking at bigger databases and wanting to have more informed decision making for consumers. And I think the other piece of that is we compare apples to apples. So no matter where you did this procedure, on the C spine, or the knee joint, or whatever, everybody's in the same pile. They're all grouped together because of the procedure, not necessarily where they go. But when we did do a little glimpse into the 2021 data from CMS, the ASC had much less complex procedures being done. You would agree that that's where they go. However, there really isn't a lot out there to say how well is this particular ASC. And I think this is a tool that will help. OK, just a reminder to everyone, we do have some time left. So please drop those questions into the Q&A. Got a couple more here for you all. What are some examples then of action plans after these insights are raised? And how quickly might you expect to be able to close these care gaps? I'll take that. So one of the things that-- we looked at total joints. So I love to do this because it makes sense to me. But when total knees, when we looked at the complications for them, the number one complication was anemia and acute anemia. So as a clinician, as somebody that's going to go look at this, did they have an adequate crit before they started? Did we do a lot of cauterization? Did we use trans anemic acid? Was the tourniquet up? There is a lot of things that you can start looking at in that realm. So I think once you start to understand what your complications are, you can start to do something about it. People just don't know. I just think a procedure was done. And then they went home. And unless they came back in a couple of weeks to get their stitches out, you don't really know what happened. You think they did great or somebody called them. But if they did go to an urgent access clinic or they went to the ED, you may get notified. But it's a while from now. But not everybody knows those outcomes. And now getting this data group that we can start looking at national benchmarks, I think that's going to be really helpful for the future. That's great. Let's go to the next question. We've got time for that. Are there any ways to leverage these insights proactively when considering incremental risk contracts? Mickey, I can start on that one. I think that if groups are equipped with their performance, it really can help inform your negotiations with the payers. That you're able to start to have a story that expands beyond access and price. And often, I wanted to say this earlier too, sometimes people will focus on mortality as a measure, Daniel. And it's great. It's just those are very rare events. And so when you are able to look at ER visits and inpatient, you start to be able to distinguish performance a lot more readily. And so I would say that the piece I'm excited about is the groups being able to showcase their strengths in a way to the payers that I don't know if the payers appreciate. And I think it just starts to influence the negotiations. And then the other piece is kind of this opportunity within a contract to say, OK, are there opportunities here, where a simple change or a focused effort with a particular provider or site can not only give better patient experience and safety, but also reduce some costs that kind of fit into this movement towards bundled payment? I mean, there's a lot of talk-- the action-- I mean, you guys are closer to it. We hear that a lot with orthopedics and oncology. But as we start to get interested in that, I think getting the experience on performance, Daniel, starts to build up the expertise and experience with insights. OK. Got one more question here. And again, everybody, we do have time for probably one or two more. So if you do have something, drop it in that Q&A section. So we've talked a lot about the data. So where are the blind spots? Where are the blind spots in that data? Mickey, you want me to start? Sure. I can do-- I think the-- I think some of the blind spots on the data are the payer data for our benchmark tends to be complete but not recent. And so one blind spot is when we're pulling data from our partner sites that they may not have access to the emergency room or inpatient experiences. And so that can be a blind spot if there's not a relationship with kind of regional ERs or inpatient. We can catch that, but dated from the payer. But I think that's one blind spot that we're trying to get a sense of systemness on when we're pulling data out of the group's databases. Mickey, your thoughts? Yeah, I think one of the things that we thought of when a large hospital system, if they're running their data through it, there will be a little bit of leakage because they might go to a local ED near their house if they came to a big center to have their procedure done. So there is that in the mind. But when we looked at this particular 100% Medicare to start with, we did have all comers. But it is years old now. And as we do every year, we'll catch it up. But I think that is the blind spot that we have. OK. I think we've got time for one more. So why are inpatient PPCs so much easier to identify than the outpatient ones? They're a captive audience. So if you're inpatient and you have a complication, you're already still inpatient. It's in your chart. It can be captured. The problem is when you have your procedure done at the ASC and you go home and it closes at 5:00, you're not actually going to go back there with your problem. So they can't necessarily catch it. And I think that is the ease or not ease. But the fact that we now can do this through 30-day either billing or claims is worlds ahead of what we-- we were not even able to find out what all these complications were. All right, well, Sandeep, anything you wanted to add to that? You feel good about Mickey's answer there? I do. Daniel, there's no amount of time I can't fill with my own voice. So I'm trying not to do that, Daniel. So I thought Mickey's answer was great. OK, perfect. Well, I want to thank you both for a great presentation. And I want to thank everyone in attendance for attending, first of all, and then also helping drive that conversation during the Q&A. That was great. Thank you all for doing that. (DESCRIPTION) New slide. Text, Thank you! Logos: 3M, M, asterisk, Modal. Text, 3 M dot com slash H-I-S. (SPEECH) The education for this session is now ended. We would like to thank 3M Health Information Systems for sponsoring today's webinar. You can visit their website at 3m.com/his to learn more about improving patient safety and all things capture to code. (DESCRIPTION) New slide. Text, Thank you for attending! Additional content questions? ask 3 M H I S @ m m m dot com. [REQUIRED], Fill out the evaluation to be able to claim CE credits. A screenshot from the MGMA page shows a green arrow pointing to a link that reads, Evaluation: Zoom Webinar. Text, Webinar questions? Contact E D at mgma dot com or www.mgma.com/events. (SPEECH) And if you do have content questions, email ask3mhis@mmm.com. And if you have a webinar question, contact ed@mgma.com. And if you haven't already, please be sure and click on the evaluation link. It's located in the learning management system. After completing this evaluation, which is required to claim credit, please allow 24 hours for system communications to process credit for this session. For more information on all of our conferences and webinars, please see the MGMA events page. Thanks, everyone. Look forward to seeing you at another online event soon. Sandeep, Mickey, thank you again. That was awesome. Thank you, Daniel.