Revidam Healthcare Technologies, S.C.

Welcome to Revidam Healthcare Technologies, S.C.

Founders: Dr. Bryan W. Rubach M.D. & Dr. Raj R. Iyer R.Ph., M.D.

Our Mission

To implement a goal directed protocol as a Patient Centered Medical Home (PCMH) allowing for more effective and personalized management of high impact diseases in the perioperative phase, thereby drastically reducing non-reimbursable hospital charges, increasing physician and other health care providers’ revenue and, most importantly, progressing towards Value-based care.

REVIDAM HEALTHCARE TECHNOLOGIES Have developed a Protocol to...(Non-Provisional Patent Pending, USPTO 1650-003 for Intellectual Property Rights and claims the benefit of priority to USPTO Provisional Patents 62/259,299 (11/24/2015) and 62/309,722 (03/2016).

Prevalence and Consequences of OSA

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Increase Safety with Vigilance, Monitoring and Collaboration + Preventing Gaps, & Creating Failsafes

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Demonstrate Safety with Reportable Measures: Hospitals/ACO's + Physicians'/Groups

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Demonstrate Economic Value: Reduced Healthcare Utilization + Reduced Liability

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Longitudinal Measures: Long term impact on Co-Morbid conditions

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WHAT DO WE BRING TO THE TABLE

CLINICAL EXPERTISE
- to audit current procedures

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FAILSAFES
- customized for each hospital system

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INTEGRATION
- of protocol to integrate with existing EHR

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DECREASED LIABILITY
- paving the way for increased safety

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MOBILE APP
- to assist with accurate reports & measures

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PROOFS OF CONCEPT - EVIDENCED BASED MEDICINE

  • Proof of Concept: The Medicare Shared Savings Plan and the ACO Measures and CMS focus on re-admissions.
  • Proof of Concept: From Federal Motor Carrier Safety Administration (F.M.C.S.A) Expert Panel Recommendations: Obstructive Sleep Apnea and Commercial Motor Vehicle (CMV) Driver Safety.
  • Proof of Concept: From the Society of Anesthesia and Sleep Medicine (SASM) with their “DEAD IN BED REGISTRY.”
  • Proof of Concept: From the Dartmouth Experience & Meta Analysis @ Toronto Western Hospital (October 2014; Abstract A4012: ASA Annual Meeting 2014).
  • Proof of Concept: From the ASA Closed Claims Analysis.
  • Proof of Concept: From The Medical Protective Data Claims Analysis and the Harvard and Princeton Claims Database.
  • Proof of Concept: From the Center for Medicare and Medicaid Services along with designated registries (PQRS, CMS directed QCDR or AQI directed NACOR).

PREVALENCE AND CONSEQUENCES

    OBSTRUCTIVE SLEEP APNEA (OSA): HIGH INCIDENCE AND PREVALENCE WITH READMITS FOR CARDIAC CAUSES LINKED TO UNTREATED OSA

  • 90% of OSA patients’ are not diagnosed; Highest incidence in the Obese; Solidly assoc., with Multiple Medical Problems. Untreated, they have 3 to 6 times increased mortality & Life Expectancy is only 58!
  • OSA patients’ have a high risk for Unplanned ICU Admits, Unplanned Admits and Re-admissions when not treated; They carry a high risk for Major Adverse Resp. & Cardiac events (MARE’s & MACE’s)and have 3 to 6 times increased risk for all cause morbidity & mortality.
  • Study in J Clin Sleep Medicine (10/2014) showed that while hospital readmission or ER visits occurred in 30% of cardiac patients with sleep apnea who only had partial positive airway pressure use and 29% of cardiac patients who suffer from sleep apnea who had no usage at all; not one of those who sufficiently used CPAP therapy was readmitted or visited emergency departments within 30 days from their hospital release… incredible!! Participants in the study included 104 patients who were currently being hospitalized for cardiac conditions such as heart failure, arrhythmia, or heart attack. They were tested for sleep apnea while in the hospital, with results showing that 78% of these patients had sleep apnea!  That is a very high percentage, and just one more reason why anyone who is dealing with heart issues should get tested for sleep apnea.
  • More than 20% of Medicare Part B Patients’ are Re-admitted (2 MIL); > 139,000 with 3 or more Re-admits; MEDICARE DOES NOT PAY FOR THESE RE-ADMITS!!; CMS reasons that if Re-admit rates were lowered to levels by top performing regions, they would save 1.9 BILLION DOLLARS annually.
  • CMS reasons that re-admission may result from poor quality care, inadequate co-ordination of care or lack of effective discharge planning and transitional care. Yale studies to CMS (Horowitz, et al., 2011 and 2014) via randomized controlled trials have shown improvement in health care can DIRECTLY REDUCE READMISSION RATES; RCT’s show reduction by 20-40%!!
  • CMS rationalizes that conditions typically cared for by the same team of clinicians are expected to experience similar added or reduced level of readmission risk.
  • PREVALENCE AND CONSEQUENCES OF O.S.A.

  • 82 to 93% of patients’ remain undiagnosed; 90% of Surgeons and 60% of Anesthesiologists still miss signs and symptoms of OSA;; 25% of patients’ presenting to surgery at risk for moderate to severe OSA!; 1.75 Million patients’ expected to present to Surgicenters and hospitals for surgical care.;
  • PREVALENCE AND RISKS: OSA occurs in >/=30% of the population. Obesity is the greatest risk factor with 80% of Men and 50% of Women with OSA being Obese!; Each 1 unit increase in BMI is associated with a 4 fold increased risk of Heart Disease; These patients’ have a greater incidence of sudden death, leading then to the DEAD IN BED REGISTRY formed by SASM (see further). More than 60% of our population is overweight (200 Million people), with 30% being Obese and 10% being Morbidly Obese. It’s common to be minimally symptomatic OR EVEN ASYMPTOMATIC and yet have an abnormal AHI score.
  • MULTIPLE MEDICAL PROBLEMS are solidly related to OSA: 40 to 50% of patients’ with OSA have High Blood Pressure; 35% to 45% have Heart disease and Failure; 3 times increased risk of A. Fib; Stroke risk doubles within 3 years of OSA onset; 65% have Diabetes; 50% have Chronic Kidney Disease in various stages; 80% have Fibromyalgia; 50% have ED and 11% have COPD. In some studies, 78% of cardiac patients’ had OSA!! Patients’ with untreated severe OSA have 3 to 6 fold increase in all cause mortality; Treatment is critical as Morbidly Obese patients’ with OSA have a life expectancy of 58 years of age!! MVA risk is tripled within 5 years of OSA onset and effective CPAP has been shown to decrease self reported crashes by 50 to 75%!!!
  • CPAP: Effective CPAP for OSA has been shown to markedly decrease the risk of readmissions within 30 days of discharge. CMS reasons that inadequate quality of care can be the root cause of increased readmissions within 30 days of the index admission. Recent study shows that 30% of cardiac patients’ with only partial CPAP usage and another 30% with no usage were increasingly readmitted while the other 40% with adequate usage had no readmissions!! As such, CMS asks hospitals’ and physician groups to report measures to demonstrate quality care or else face reduced reimbursement.
  • O.S.A. IN OUR VETERANS

  • Most recent data shows 20% of War Vets have sleep apnea; compare this to the general pop incidence, anywhere from 10% to upwards of 25% even.
  • The # of Vets receiving disability benefits for sleep apnea has increased to 61% over 2010 to 2012 showing they are at increased risk for sleep apnea (even PTSD places them at risk as this leads to sleep fragmentation and deprivation with decrease in REM sleep and thus REM rebound later with greater risk for apneic events). In response, the Brooklyn VA formally opened a sleep lab facility in 2010. and, as of April 2014, the Brooklyn VA estimated 90% of Veterans deal with some form of sleep apnea with 10 to 12 referrals to their sleep clinic per week.
  • As a result of the Increased # of Vets claiming disability benefits, the government started instituting rating systems for the severity of sleep apneas in veterans’ who claim their disability to stratify their need.
  • Studies as Proof of Concept:
    01/2012 STUDY (Otolaryngology, Head and Neck Sx): Perioperative Mgmt. of OSA in VA System
  • Studied 102 facilities for institutional guidelines on Perioperative Mgmt. of OSA & practice pattern for post-op disposition of OSA patients’. 80% of facilities responded (~82 facilities); only 25% (~20 facilities) had a policy for post-op disposition of known OSA patients’ while only 20% (~16 facilities) had a policy for post-op disposition of presumed OSA patients’. Compounding the problem, only 7 to 18% of OSA patients’ are ever diagnosed (thus 82% to 93% remaining undiagnosed!!).
  • Most importantly, of those facilities with a formal policy, 50% admitted patients’ to a monitored bed while 30% admitted patients’ to the ICU. With an avg. cost of regular admission of $15k and ICU admit of $76k, this shows staggeringly high health care utilization in these Vets.
  • 10% had major complications in the past yr.
    04/2014 STUDY (Ann Thoracic Med): OSA is associated with higher health care utilization in elderly VA pts
  • Retrospective study of inpatient and outpatient VHA data from 2003-2008 with ACTUAL DX OF OSA. Reviewed 1,867,876 elderly patients’. Only 4.4% had actual dx of OSA (lower than the general pop. Of 7 to 18%)!!. But, 37% of the new OSA dx patients’ needed at least one ED visit and 25% of the new OSA patients’ needed at least one hospitalization. So, earlier OSA dx can reduce healthcare utilization.

INCREASE SAFETY WITH VIGILANT MONITORING PLUS COLLABORATING TO PREVENT GAPS IN CARE AND CREATE FAIL SAFES

    WHY CREATE A PERIOPERATIVE SURGICAL HOME (PSH): A PHYSICIAN-LED MULTIDISCIPLINARY AND TEAM-BASED SYSTEM OF COORDINATED CARE FOR OSA PATIENTS’?

  • WHY FOR INSURANCE COMPANIES: A PSH for OSA would lead to reduced patient costs in hospitalizations due to decreased complications, decreased unplanned ICU admissions, decreased admissions/re-admissions and decreased lengths of stay. This would then lead to REDUCED PAYMENTS BY INSURANCE CARRIERS; By following this protocol, this would serve then to decrease health care utilization.
  • WHY FOR PHYSICIAN ANESTHESIOLOGISTS: A PSH can be critical based on the concepts of VABPM, the two tiered penalty system (2% vs. 4%), Quality Tiering component for quality of care and cost containment, Measure Applicability Validation, Cross-cutting measures and the Medicare Physician Fee for service.
  • WHY FOR HOSPITALS: This protocol would generate excellent and reproducible reporting measures to be reported to PQRS or QCDR or NACOR and thus lead to an AVOIDANCE OF NEGATIVE VALUE MODIFIERS for hospital/ACO owned groups; further, it would lead to lesser re-admissions, unplanned admissions and unplanned ICU admissions; & primarily an INCREASE IN PATIENT SAFETY; This would apply to the ACO’s and for EP’s in their reporting to registries. Hospitals’ could then have the opportunity to participate in the Medicare Shared Savings’ Program.
  • WHY FOR PATIENTS’: A PSH for OSA patients’ serves to INCREASE THEIR SAFETY by a synchronized collaborative care, leading to decreased complications & higher quality care.
  • THE VALUE IN IMPLEMENTING A PERIOPERATIVE SURGICAL HOME FOR OSA PATIENTS FOR EACH CARE GIVING ENTITY ENCOUNTERING THESE PATIENTS:

  • For the RISK-MANAGER: Reduction in risk by Pre-screening ALL patients’ with OSA, Educating medical and nursing staff & institution of a Post-operative Monitoring Regimen to detect apneas/hypopneas, especially in patients’ receiving opioids: Results in reduced Unplanned transfers to the ICU and Untoward Events which can lead to death and a new Hospital Claim.
  • For the PRIMARY CARE PHYSICIAN & THE PERIOP TEAM: A program that aims to make the Perioperative experience a safer journey for these high risk patients’; as 25% of surgical patients’ at high risk for OSA and heightened in Obesity, a proper diagnostic plan serves to appropriately treat these patients’ and reduces the risk of Myocardial Infarctions, Heart Failure, Respiratory failure, Pulmonary Embolism, Death, and MVA’s.
  • For the HOSPITAL ADMINISTRATION: Our protocol serves to increase patient safety, increase revenue by demonstrating high quality care (reportable measures for ACO’s and individual hospitals to CMS and participating in Medicare Shared Savings Program) and decrease unplanned cost of an admission/re-admission or ICU admission. If the Hospital solely owns or has a part interest in a Sleep Lab, the increased referrals to the Lab should result in increased revenue for that Hospital. Every year, 20% of Medicare patients’ are readmitted: 2 Million per year and 139,000 with 3 or more readmissions in 2012; CMS estimates cost to Medicare of $26 billion per year, $17 billion deemed avoidable. We will decrease the incidence thereby helping to preserve margin of safety for specific surgeries.
  • For the INSURER: An explosion of Narrow Networks and like products will continue. Hospitals who do not have Clinical Integration Models or Enhanced Recovery Protocols are likely to sign up for your network products but fail miserably due to an inability to first identify and mitigate risks of ballooning costs; one such risk is the OSA patient. Hospitals systems which participate in our programs will be Risk Mitigation Centers for decrease overall costs and enhanced patient safety.
  • SOCIETY OF ANESTHESIA AND SLEEP MEDICINE(SASM)

  • Formed in 2010 with Anesthesiologists, Sleep Physicians, Surgeons and Basic Scientists
  • 2011 Meeting discussed several ongoing CATASTROPHIC EVENTS occurring in OSA Patients’ following Surgery
  • Over 90% of Surgeons and 60% of Anesthesiologists still are NOT AWARE of OSA signs and symptoms
  • 82 to 93% of Patients’ with OSA remain UNDIAGNOSED!! APPROXIMATELY 30% OF THE GENERAL POPULATION SUFFERS FROM OSA, WHILE A SIMILAR FRACTION OF SURGICAL PATIENTS’ ARE AT HIGH RISK FOR OSA, WITH MOST OF THEM LACKING A FORMAL DIAGNOSIS: Peppard PE, et al., Increased prevalence of sleep-disordered breathing in adults, Am J Epidemiol 2013; 177: 1006-14 AND Singh M., et al., Proportion of surgical patients with undiagnosed OSA, Br J Anaesth 2013; 110: 629-36.
  • OSA Patients’ have higher rates of Post-operative complications (Major Adverse Respiratory and Cardiac Events’), higher rates of unplanned ICU admissions/re-admissions’/unanticipated admissions’, and prolonged hospital lengths of stay; Untreated, they have a 3 to 6 fold increase in all cause morbidity & mortality; Also, a higher odds ratio exists in smokers where they are 3 times more likely to have OSA!!
  • Source: Chest: 129; 198-205 (2006) & 138: 1489-1498 (2010)
    Anesthesiology: 108, 812-821 (2008)
  • DEAD IN BED REGISTRY CLINICAL TRIALS

  • Formed in 2011-2012 by the SASM, Anesthesia Quality Institute and Experts in the Anesthesia Closed Claims project and its Registries
  • Found a large # of cases where patients’ didn’t die BUT were left with a DEVASTATING NEUROLOGIC INJURY; Found a LARGE # OF CASES where patients’ were in Cardio-Pulmonary Arrest and were resuscitated; ABUNDANT “NEAR MISSES” were noted; & Registry began accepting cases in May, 2014
  • UP TO DATE CLINICAL TRIALS: ClinicalTrials.gov
  • Sleep Apnea Intervention for Cardiovascular Disease Reduction: Brigham and Women’s Hospital; This is a randomized, double-blind safety/efficacy study; The trial’s primary endpoint uses mean 24 hour SBP over a time frame of 3 years; The purpose is to test the hypothesis that active treatment for OSA with CPAP reduces CVD Morbidity and Mortality; Study results have not been posted; Study is ongoing but not recruiting participants. Final data collection date was March, 2014.
  • Unrecognized Obstructive Sleep Apnea Study (OSA): University Health Network, Toronto; Dr. Frances Chung; The primary outcome of this study is postoperative vascular events within 30 days after surgery. This is an observational, cohort study. This study is currently recruiting participants with estimated primary completion date of December, 2015.
  • Mild Cognitive Impairment and Obstructive Sleep Apnea (MEMORIES); George Mason University collaborating with NIH and U. Penn., The goal of the research is to determine the power and feasibility of the study design to inform a full-scale trial that will determine whether treatment of OSA in older adults with mild cognitive impairment delays cognitive decline and preserves everyday function. The study has been completed (2011 to 2015) but no results have been posted.
  • OBSTRUCTIVE SLEEP APNEA DEATH AND NEAR-MISS REGISTRY COLLECTING CASES BUT SASM SAYS MORE NEEDED JANUARY, 2016

  • The Dead in Bed Registry: Cases reported to investigate unanticipated peri-operative deaths and near-misses in patients with OSA, with the latter leaving the patient with severe injury such as anoxic brain injury. By assembling a series of detailed case reports, researchers hope to identify recurring patterns associated with OSA-related adverse peri-operative events, with the ultimate goal of risk prevention and improved patient safety.
  • SASM’s annual meeting in 2015: Critical cases continue to occur in the peri-operative period but the negative effects extend into the future, with serious financial penalty seen. One case paid out $1.5 MILLION involving a patient with peri-operative death while another paid out $4 MILLION for anoxic brain injury.
  • The majority of these malpractice cases involving peri-operative complications in OSA patients are being found to be from early extubation, failed re-intubation and the administration of Opioids in an unmonitored setting.
  • University of Washington Medicine (Dr. Laura Cheney, MD & Dr. Karen L. Posner, PhD): Early case insights have already been made: the majority of injuries occurred within 24 hours of surgery and almost all were judged to be preventable by appropriate monitoring, both in quality and quantity.
  • The American Academy of Sleep Medicine and The American Society of Anesthesiologists have both recommended, due to these adverse outcomes, that hospitals develop their own protocols to manage patients with OSA; HOWEVER, MOST HAVE NOT COMPLIED.
  • By having appropriate protocols in place, one can establish patterns in the real time-series data that precede these adverse events. 46 cases have been reported so far with under-reporting being a problem.

DEMONSTRATE SAFETY WITH REPORTABLE MEASURES TO CMS REGISTRIES

    WHAT WOULD BE THE BENEFITS FOR PHYSICIAN GROUPS’ TO PARTICIPATE IN A PERIOPERATIVE SURGICAL HOME FOR OSA PATIENTS?

  • Consistent Data Tracking, Collecting and Reporting of Measures to registries as PQRS, or CMS developed QCDR or AQI developed and CMS authorized Anesthesia QCDR called NACOR. This becomes critical as Physician groups’ are induced to report 9 measures’ across 3 NQS Domains with at least 3 Outcome Measures. These are to be reported on at least 50% of the EPs patients’ participating in Medicare Part B PFS and during the reporting period. If they fail to participate in the PQRS et al.: First a 2% payment penalty for total Medicare Billing in 2017 will be instituted for 2015 reporting period; then an additional Two Tiered Penalty System will be imposed: 2% reduction in total annual Medicare billing for groups of 10 or less vs. 4% reduction in total annual Medicare billing for groups of greater than 10. This becomes extremely significant for larger groups of Physicians’! The ASA estimates that groups may risk losing ~$1,500 per physician not participating in the PQRS
  • There is also a Quality Tiering (QT) component to this program that allows a provider to potentially earn a bonus, or receive a penalty, based on: (a) quality of care, and (b) cost containment. Solo practitioners and physicians in groups of less than 10 EPs are not subject to a downward QT adjustment in 2017 (based on 2015 performance), but physicians in groups of 10 or more EPs will be subject to a potential QT penalty, as well as a bonus.
  • The software will reproducibly capture specific PQRS O.S.A Measures as: #276: Sleep Apnea Assessment of symptoms/NQS domain (effective clinical care); #277: Sleep Apnea Severity/NQS domain (effective clinical care); #278: Sleep Apnea Therapy/NQS domain (effective clinical care); #279: Sleep Apnea: Assessment of adherence to positive airway pressure therapy/NQS domain (effective clinical care); and #374: Closing the referral loop with the receipt of specialists’ reports/% of patients’ referred for which the referring provider receives a report from the referred provider/NQS domain (communication and coordination).
  • These and others’ will serve to satisfy the Measured Application Validation and Cross Cutting Measures. CMS is moving towards EHR/EMR based reporting rather than claims based.
  • THE PERIOPERATIVE SURGICAL HOME: ASA NEWSLETTER JULY 2015, VOL. 79, NO. 1 PSH FOR OSA PATIENTS’

  • THE PASSAGE OF MACRA: On 04/15/2015, Congress passed H.R. 2 Medicare Access and CHIP Reauthorization (MACRA) which successfully repealed the SGR formulas limitation on physician payments (An outdated and unfair formula). It imposes a new set of rules and regulations yet to be developed by Medicare/CMS to shape the Fee-For-Service (FFS) payment system into one that encourages participation and reporting in both a Value-Based Payment Model (VBPM) and in an Alternate Payment Model (APM). All these regulations, rules, payments and penalties are focused upon reporting of quality and to the contribution of savings in health care costs.
  • For services paid under the Physician Fee Schedule (PFS) of CMS during 2016 to 2019, Medicare’s conversion factor rates are to increase by 0.5% a year; then the conversion factor update is to be 0% from 2019 to 2025. Starting in 2019, the amounts paid to individual EPs will be subject to two mechanisms, depending on whether these EPs choose to participate in the APM or the Merit-Based Incentive Payment System (MIPS).
  • The MIPS: EPs are to receive payments that will be subject to positive or negative performance adjustments. The MIPS annually measures Medicare Part B EPs in FOUR PERFORMANCE CATEGORIES to derive a “MIPS Score” of 0 to 100, which can significantly change a EPs Medicare Payment in each payment year. These performance categories are:
    • The Physician Quality System (PQRS) measured quality: up to 30 points
    • VBPM measured resource use: 30 points
    • Meaningful Use (MU); 25 points
    • Clinical Practice Improvement Activities: 15 points (A new category).
  • MIPS Score’s max negative impact increases from Negative 4% (2019) to Negative 9% (2022 & later).

THE PERIOPERATIVE SURGICAL HOME: ASA NEWSLETTER JULY 2015, VOL. 79, NO. 1 PSH FOR OSA PATIENTS’

  • The MIPS Score: The amount EPs will receive will depend on their composite score above a threshold & the adjustment will be made by a scaling factor to a max of three to maintain CMS’s budget neutrality. The performance adjustment then depends on the EPs performance compared to that threshold (TBD). HR 2 provides $500 Million each year from 2019 to 2024 as an additional performance adjustment for EPs in this program that achieve exceptional performance. However, the positive adjustments depend upon how many negative adjustments are made: The max payment adjustment is to be multiplied by a scaling factor such that the total of all the positive and negative payment adjustments across all MIPS EPs results in either reduced or neutral impacts on Medicare budgetary spending. In other words, CMS will “feed the winners and starve the losers.”
  • What does this mean to Physician Anesthesiologists and other Physicians? Physicians using FFS will have to successfully report on quality, meaningful use, the VBPM and yet undefined “clinical practice improvement activities” to maintain their current levels of payment.
  • This PSH for OSA Patients’ can successfully report quality measures within the CMS defined PQRS (Physician Quality Reporting System) registry as meaningful use measures in regard to Anesthesiology (measures with valid numerator and denominator domains: PQRS Measures #276, #277, #278, #279 and #374). By doing so, this PSH for OSA Patients’ will demonstrate that our comprehensive care results in high quality and lower costs by our “contribution to savings.”
  • As an option over PQRS registry, AQI (Anesthesia Quality Institute) developed NACOR (National Anesthesia Clinical Outcomes Registry: a valid registry approved by CMS as a QCDR (a Qualified Clinical Data Registry) and as a new option to achieve satisfactory PQRS participation). QCDR’s can be then used for PQRS reporting for 2015 to 2018, and based on the new MACRA, is going to be important moving forward.
  • THE PERIOPERATIVE SURGICAL HOME: ASA NEWSLETTER JULY 2015, VOL. 79, NO. 1 PSH FOR OSA PATIENTS’

  • As NACOR is a CMS approved QCDR, by definition it is a CMS-approved entity that “collects medical and clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care delivered to patients’.”
  • Data submitted to CMS via a QCDR cover quality measures across MULTIPLE PAYORS and are not limited to Medicare Beneficiaries only!
  • NACOR as a qualified CMS endorsed registry is not limited to the current measures within the PQRS; however, this PSH for OSA Patients’ can collect PQRS Measures #276, #277, #278, #279 and #374 during the creation of a Vertically Integrated Protocol in the Perioperative care of these patients’.
  • In 2015, a QCDR can include a max # of 30 “non-PQRS “ measures.
  • The important issue is that Physicians must be prepared to report quality measures to registries demonstrating high quality care while reducing costs in the delivery of health care with the reporting of these quality measures to a endorsed registry, with the reporting of VBPM measured resource use, with the reporting of Meaningful use measures, and with the reporting of “yet to be defined” Clinical Practice Improvement Activities
  • DEMONSTRATE ECONOMIC VALUE

    Click here to view the PITCH

      WHAT WOULD BE THE BENEFITS FOR A HOSPITAL TO INCORPORTATE A PROTOCOL FOR A PERIOPERATIVE SURGICAL HOME (PSH) FOR THE OSA PATIENTS?

    • Screen all patients’ for OSA, Actively Co-ordinate their care by PCP & Sleep Specialist, Actively Educate
    • Reduce Post-op Complications by improving vigilance and monitoring, Increase Patient Safety by mitigating risks and liabilities and decrease Unplanned ICU Admits, Unplanned Admits and Re-admits
    • Reduce Risk of Post Discharge Complications and Follow them Longitudinally.
    • Actively Collect Quality Measures for Hospitals, collected and reported to CMS; As of 2012, 33 quality measures; As of 08/2014, Hospitals’ and A.C.O.’s can report these O.S.A. related measures:
      • ACO 5: Health Promotion and Education to CMS via the C.A.H.P.S. Survey
      • ACO 6: Shared Decision Making to CMS via C.A.H.P.S. Survey
      • ACO 7: Health and Functional Status education to CMS via C.A.H.P.S Survey
      • ACO 8: Risk Standardized all condition re-admission
      • ACO 16: Preventive care and screening: BMI screening and follow-up
    • Actively Collect Quality Measures for Physician groups in coordinated practices: to decrease Medicare Penalties.
    • Participation in the Medicare Shared Savings’ Program and thus demonstrate: a) quality care during the index admission; b) improvement in communication with patients’, caregivers’ and clinicians’; c) pre-discharge assessment and d) co-ordination of care after discharge.
    • Decreased re-admission rates (U Penn study et al.,), decreased unplanned admissions and unplanned ICU admissions/transfers; This directly leads to tremendous cost savings & Decrease in Medicare penalties.
    • WHAT ARE THE ECONOMICS OF LOST DOLLARS DUE TO READMISSIONS AT A TYPICAL HOSPITAL MEDICARE PATIENTS & READMITS FOR CARDIAC CAUSES & OSA

    • In 2014: 750 to 800 OR cases/month on average; 25% of patients’ at risk for mod. to severe OSA.
    • % of Patients’ who are Medicare Part B PFS enrollees: 28% of Inpatients and 18% of Outpatients were enrollees; An average of both these statistics leads us to estimate ~23 to 25% of all patients’ to be enrolled in Medicare Part B PFS in the hospital.
    • For ~800 cases per month, if 25% are Medicare Part B enrollees, then ~200 cases per month would account for these Medicare Part B enrollees. Of these ~200 MED B pts., 10% are at high risk for OSA
    • National statistics tell us that nearly 1 in 5 fee-for-service Medicare patients’ return to the hospital within 30 days of the index admission; this then is “Re-admission:” after 48 hours of the index admit but within 30 days of that admit. Therefore, 1 in 5 (20%) of Medicare Part B PFS get readmitted; 20% of 200 Medicare cases per month yields ~40 cases per month being re-admitted. However, at RCMC, 5% of 200 Medicare cases (10 cases/month) were thought to be re-admitted.
    • A SINGLE ADMISSION for CHF/ASCAD costs ~$15,000 ($13,000 to $18,000: DARTMOUTH):
    • FOR 20% RE-ADMIT (40 cases): $600,000 PER MONTH of hospital utilization could be foreseen;
    • FOR 5% RE-ADMIT (10 cases): $150,000 PER MONTH of hospital utilization is foreseen;
    • ICU admissions cost much more: $76,000 per DARTMOUTH.
    • It is not clear what % of these Re-admits of Medicare Part B patients also have OSA; But in light of the U. Penn study, where 78% of “Cardiac Patients’” have OSA, if patients’ are re-admitted commonly due to cardiac causes (Medicare or not), then the culprit is OSA and its associated diseases.
    • Readmissions, Unplanned Admissions and Unplanned ICU admissions are effectively dollars lost from lack of re-imbursement from CMS & inability to recoup $$ from the Shared Savings.
    • OBSTRUCTIVE SLEEP APNEA DEATH AND NEAR-MISS REGISTRY COLLECTING CASES BUT SASM SAYS MORE NEEDED JANUARY, 2016

    • The Dead in Bed Registry: Cases reported to investigate unanticipated peri-operative deaths and near-misses in patients with OSA, with the latter leaving the patient with severe injury such as anoxic brain injury. By assembling a series of detailed case reports, researchers hope to identify recurring patterns associated with OSA-related adverse peri-operative events, with the ultimate goal of risk prevention and improved patient safety.
    • SASM’s annual meeting in 2015: Critical cases continue to occur in the peri-operative period but the negative effects extend into the future, with serious financial penalty seen. One case paid out $1.5 MILLION involving a patient with peri-operative death while another paid out $4 MILLION for anoxic brain injury.
    • The majority of these malpractice cases involving peri-operative complications in OSA patients are being found to be from early extubation, failed re-intubation and the administration of Opioids in an unmonitored setting.
    • University of Washington Medicine (Dr. Laura Cheney, MD & Dr. Karen L. Posner, PhD): Early case insights have already been made: the majority of injuries occurred within 24 hours of surgery and almost all were judged to be preventable by appropriate monitoring, both in quality and quantity.
    • The American Academy of Sleep Medicine and The American Society of Anesthesiologists have both recommended, due to these adverse outcomes, that hospitals develop their own protocols to manage patients with OSA; HOWEVER, MOST HAVE NOT COMPLIED.
    • By having appropriate protocols in place, one can establish patterns in the real time-series data that precede these adverse events. 46 cases have been reported so far with under-reporting being a problem.
    • THE ASA CLOSED CLAIMS ANALYSIS: MARCH 2015

    • 03/2015 REPORT: From Insurers Insuring >33% of Practicing Anesthesiologists’
    • Joint Commission Sentinel Event Alert Issue 49 from the Sentinel Events Database (2004-11) was issued 08/2012 re: safe use of opioids in hospitals; Analysis showed IMPROPER MONITORING in 30% of the events, WRONG DOSE MEDICATION ERRORS in 50% of the events, OTHER FACTORS related to MEDICATION DOSING AND INTERACTIONS in 11% of the events , AND FOR THE HIGHLY SUSCEPTIBLE in 60% of Post-op Respiratory Depression (RD) events
    • Data Analyzed As of 03/2015 from Claims’ Database of 9,799 claims, occurring between 1990 to 2009
    • Reviewers assessed 357 Acute Pain Claims for the likelihood of RD; 26% were assumed as having Respiratory Depression (R.D.) (n=92).
    • 77% of the RD events resulted in HIGH SEVERITY INJURIES as severe brain damage or death (n=71);
    • The vast majority of RD events (88%) occurred within 24 hours of surgery (especially after transfer from the highly stimulating PACU to a “QUIETER” room on the floor)
    • 97% were judged as preventable with better monitoring and response.
    • 70% of the R.D. claims: HIGHEST PROPORTION IN THE OBESE
    • IN 62% OF PATIENTS BEFORE THE EVENT, SOMNOLENCE WAS NOTED : THIS IS THE HERALDING SIGN IN OSA PATIENTS!!!!
    • CONTRIBUTING FACTORS:
      • Multiple prescribers (33%), Concurrent Administration of non-opioid sedating medications (34%) and showing a high % of Physicians’ and Nurses’ don’t fully appreciate the synergistic effects of these other Meds and Opioids
      • Reviewers noted that the AHI values on the first Post-op night may have been artificially lowered by the high utilization of O2 therapy at that time
      • Under reporting of contributing factors (AS RISK FACTORS FOR OSA) was noted as a significant limitation of the study as it was not prospectively designed to collect all relevant info related to RD events in a std.
    • MEDICAL PROTECTIVE DATA ANALYSIS

    • In the Risk Management Foundation (RMF-HARVARD) and Princeton Claims Database: Over 11 years of data collection (2003-2013): OSA was identified in 8% of the Claims where it was already pre-operatively diagnosed; however, in 82% to 93% of the cases, OSA is not diagnosed (thus, only 7 to 18% are diagnosed on presentation). With the significant % of patients’ with OSA expected to present for surgery (25%), it was surmised that A LARGE # OF PATIENTS’ COULD BE MISSED!!
    • With an estimate of 25% of patients’ presenting routinely for Surgery considered to be at high risk for OSA, this points to maybe more future OSA claims or allegations there of than shown in the RMF-Harvard and Princeton Database; In addition, APPROXIMATELY 30% OF THE GENERAL POPULATION SUFFERS FROM OSA, WHILE A SIMILAR FRACTION OF SURGICAL PATIENTS’ ARE AT HIGH RISK FOR OSA, WITH MOST OF THEM LACKING A FORMAL DIAGNOSIS: Peppard PE, et al., Increased prevalence of sleep-disordered breathing in adults, Am J Epidemiol 2013; 177: 1006-14 AND Singh M., et al., Proportion of surgical patients with undiagnosed OSA, Br J Anaesth 2013; 110: 629-36.
    • Considering ~30 cases/day, ~150 cases/WK, ~600 cases/month and ~2400 cases/ QTR & ONE ICU ADMISSION COSTING (PER DARTMOUTH DATA) ~$58,400, THIS TRANSALATES TO TREMENDOUS COST SAVING FOR ~600 PATIENTS’ PER MONTH!!
    • There’s also a need for a Validated Pediatric-Specific Risk Assessment Scoring System to identify children at risk for OSA and who are not appropriate to be cared for as an Outpatient: Anesth Analg, 2014 Jun: 118 (6), 1276-83: Death or Neurologic injury after a Tonsillectomy in children with a focus on OSA: Houston we have a problem! Cote, C. et al.

    DEMONSTRATE ECONOMIC VALUE WITH REDUCTION IN HEALTH CARE UTILIZATION

    • Decreased utilization by a demonstrable decrease in readmission rates in high risk patients with OSA: For cardiac patients’, 30% with partial CPAP use and 30% with no use had hospital readmissions and ER visits; 40% sufficiently using CPAP DID NOT!!
    • Decreased utilization by a demonstrable decrease in unplanned ICU admissions, unplanned admissions and postoperative complications by increasing quality of care, increased coordination of care and effective discharge planning/transitional care
    • Decreased utilization by the coordination of care amongst clinicians who typically take care of conditions on a repeated basis and therefore expected to have similar reduced or added level of readmission risk
    • Enforcing and enhancing effective therapy during hospitalization and after discharge to directly decrease the risk of readmission by evidence based medicine and proof of concept
    • Demonstrable decrease in hospital admission and readmission rates to equate to “real time” dollar cost savings more than overcoming any cost in implementation of protocol
    • Effective participation for Hospitals in Medicare Shared Savings Program and effective decrease in Medicare penalties for groups of physicians reporting to CMS endorsed registries linking high quality care to Quality Tiering and Negative Value Modifiers.

    LONGITUDINAL MEASURES

    • COLLECTING METRICS: Based on compliance with CPAP therapy (from wireless data procurement which is routine by Sleep Labs), we would measure longitudinally in these patients the extent of progression or lack thereof of their comorbid conditions. Evidence based data shows a direct link between compliance with CPAP and the correction of sleep disordered breathing and mitigation of their connected disease states.
    • SHARE THE METRICS: With Hospital Systems enabling their demonstration of high quality care beyond their initial encounter with the patient.
    • SHARE THE METRICS: With Primary Care Physicians most directly responsible for the ongoing care of these Patients’
    • SHARE THE METRICS: With Insurers, demonstrating quality care linked to keep ballooning costs down and then secondarily decrease insurance premiums hopefully in a tiered manner from those hospital systems who don’t demonstrate this to those who do.
    • SHARE THE METRICS: With Risk Managers who could use the data with a multitude of Insurers to enable a “drive” to better contract negotiations based on high quality care and with demonstrable metrics earn bonuses from Medicare Shared Savings Plan.
    • THE MEDICARE SHARED SAVINGS’ PROGRAM AND THE A.C.O’s: From cms.gov

    • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
    • Quality data REPORTING & COLLECTION supporting quality patient care is an important part of the Medicare Shared Savings’ program. Before an ACO can share in any savings generated, it must DEMONSTRATE that it met the quality performance standard(s) for that year. From 2012, CMS established 33 quality measures spanning 4 quality domains’: 7 for patient-caregiver experience collected via the Consumer Assessment of Healthcare Providers’ and Systems’ (CAHPS) survey, 3 calculated via claims, 1 calculated via Medicare/Medicaid EHR incentive programs’ data and 22 collected via ACO Group Practice Reporting Option (GPRO) Web Interface (WI).
    • As of 08/15/2014, the ACO Program Analysis Quality Performance Standards were published. Specific to the care of OSA patients’, they span the domains’ of care coordination/patient safety, at risk population and preventive care. Our protocol focus:
      • ACO-8: Risk Standardized all condition Re-admission/NQF# 1789
      • ACO-16: Preventive Care and Screening: BMI Screening and Follow up/NQF# 0421
      • ACO-6: Shared Decision Making/Reported to CMS via the CAHPS Survey
      • ACO-5: Health Promotion and Education/To CMS via CAHPS Survey
      • ACO-7: Health Status or Functional Status/To CMS via CAHPS Survey
    • RATIONALE FOR THE ACO-8 MEASURE FROM cms.gov
      http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-8.pdf

    • Re-admission following acute care hospitalization is costly: From 2003 to 2004, 20% of Medicare beneficiaries (> 2.3 Million patients’) were re-admitted within 30 days of discharge (Jenks, et al., 2009). A commonwealth fund report estimated if national re-admission rates were lowered to levels achieved by the top performing regions’, Medicare would have saved $1.9 BILLION DOLLARS ANNUALLY!!
    • CMS reasons that re-admission may result from poor quality care, inadequate co-ordination of care or lack of effective discharge planning and transitional care. Yale studies to CMS (Horowitz, et al., 2011 and 2014) via randomized controlled trials have shown improvement in health care can DIRECTLY REDUCE RE-ADMISSION RATES by: a) Quality of care during the initial admission; b) Improvement in communication with patients’, caregivers’ and clinicians’; c) Pre-discharge assessment; and d) Co-ordination of care after discharge. Our PROTOCOL DOES PRECISELY THIS!!; RCT’s show reduction by 20-40%!!
    • This measure data is from Medicare Inpatient Claims and beneficiary enrollment data; The NQF ID #1789 is its associate; Measurement duration/period is a calendar year; It’s an outcome measure and the payer source is the Medicare Part B PFS; Lower Risk Standardized all condition Re-admission (RSSR) scores are better; the measure steward is CMS; the measure describes the risk-adjusted percentage of assigned beneficiaries who were re-admitted within 30 days of the index admission. The target population is assigned or aligned Medicare beneficiaries. CMS rationalizes that conditions typically cared for by the same team of clinicians are expected to experience similar added or reduced level of readmission risk. The Perioperative setting is then perfect climate to affect changes.
    • META ANALYSIS ASA ANNUAL MEETING 2014: ABSTRACT A4012

    • Researchers from the Toronto Western Hospital found that CPAP reduces the Perioperative AHI (Apnea/Hypopnea Index; Score of the Sleep Test) and the Hospital LOS in this at risk population. They recognized the high prevalence of OSA in the general population and is NOT ONLY HIGHER in the surgical population in comparison but that most are NOT DIAGNOSED, NOT TREATED & HAVE MANY COEXISISTING DISEASES. All they foresaw would lead to increased perioperative adverse events.
    • They conducted a Meta Analysis English-language literature search for OSA studies in the adult surgical population who were OR were not using perioperative CPAP and who reported on AHI and hospital LOS. They reviewed a total of FIVE manuscripts.
    • Two studies tracked Preoperative (n=100) and Postoperative AHI in PATIENTS’ TREATED WITH CPAP. These studies revealed that CPAP significantly reduced perioperative AHI: The preoperative AHI of 37 +/- 19 events per hour fell to 12 +/- 16 events per hour (P<0.001 validating significance). Therefore, they saw a 30% decrease in the postoperative AHI (a decrease of about 25 events per hour when using CPAP). Certainly, this was significant but not completely effective; Three studies provided data on hospital LOS, revealing that CPAP patients’ (n=264) had a significantly shorter LOS than their counterparts who did not receive CPAP (3.9+/-4.0 vs. 4.3+/-4 days; P<0.05); In addition they found postoperative compliance still very poor (only 42%): So there’s a definite room for improvement.
    • Therefore, Education was deemed critical in educating patients’ and other health professionals’ regarding the importance of using CPAP in the preoperative and postoperative period: decreased postoperative AHI and significantly shortened hospital LOS.
    • Our VERTICAL INTEGRATION MODEL will do precisely this; it will further enhance by inducing multi level education, multiple checks and balances catching interactions and definitive treatment when is sorely lacking. The decrease in LOS means large cost savings and a demonstrable metric to CMS.
    • Why CMS is Focused on Readmissions: 10/02/2014 Real-Time Reporting of Medicare Readmissions Data

    • Nearly one in five fee-for-service Medicare patients returns to the hospital within 30 days of being discharged
    • 2 million readmissions each year
    • 139,000 beneficiaries had 3 or more readmissions in 2012
    • High readmission rate can be an indicator of poor quality care; Index Admission = Inpatient Admission where patient did not die in the hospital; Re-admission = Inpatient Admission within 30 days of discharge from index stay; Re-admission rates decreased from 19% (2007 to 2011) to 18.5% in 2012 and 17.9% in 2013; But Post-discharge ED visits began to increase along with Post-discharge Observation stays (23 hour admits).
    • Readmissions estimated to cost Medicare $26 billion per-year, $17 billion of which is potentially avoidable
    • Study in J Clin Sleep Medicine (10/2014) showed that while hospital readmission or ER visits occurred in 30% of cardiac patients with sleep apnea who only had partial positive airway pressure use and 29% of cardiac patients who suffer from sleep apnea who had no usage at all; not one of those who sufficiently used CPAP therapy was readmitted or visited emergency departments within 30 days from their hospital release… incredible!
    • Clearly, CPAP usage benefits the health of those suffering from cardiac issues. However, it also benefits their wallets, since the Centers for Medicare and Medicaid Services (CMS) does not reimburse hospital charges for the care of patients readmitted within 30 days after discharge. Therefore, proper CPAP usage for those suffering from heart conditions – especially those who are, or had been hospitalized – is a win across the board!
    • Why CMS is Focused on Readmissions: 10/02/2014 Real-Time Reporting of Medicare Readmissions Data

    • This new study shows then that using continuous positive airway pressure to treat sleep apnea in cardiac patients reduces these patients’ 30- day emergency department visits and hospital readmission rates.
    • As noted, this was published by the American Academy of Sleep Medicine in the Oct. 15 issue of the Journal of Clinical Sleep Medicine; they studied hospitalized cardiac patients, which involved a collaboration between the Center for Sleep and Circadian Neurobiology and the Department of Cardiology at the University of Pennsylvania in Philadelphia and it showed the positive effects that CPAP treatment brings for those suffering from both heart disease and sleep apnea.  Being effectively treated with positive airway pressure therapy showed to reduce 30-day hospital readmission rates and emergency department visits for patients, with 30-day rates being defined as a hospitalization or visit to the ER for a cardiac issue more than 48 hours after initial discharge.
    • Dr. Timothy Morgenthaler, President of the American Academy of Sleep Medicine, and a national spokesperson for the Healthy Sleep Project, points out that “severe sleep apnea is solidly associated with serious cardiovascular outcomes, such as heart failure, heart attacks, and heart-related deaths.”  Previously, thought to be in 35%; Per this study, as high as 78%!!; Therefore, this study proves just how important it is to diagnose and treat sleep apnea in patients hospitalized for heart problems. Treating and diagnosing such patients, Dr. Morgenthaler says, “is a win-win-win move; it improves the patient’s quality of life, improves health outcomes, and reduces the resources used to manage heart diseases.”
    • Participants in the study included 104 patients who were currently being hospitalized for cardiac conditions such as heart failure, arrhythmia, or heart attack. They were tested for sleep apnea while in the hospital, with results showing that 78% of these patients had sleep apnea!  That is a very high percentage, and just one more reason why anyone who is dealing with heart issues should get tested for sleep apnea. Each of those 78% was then treated with positive airway pressure, using CPAP for at least four or more hours per night on at least 70% of nights.
    • Why CMS is Focused on Readmissions: 10/02/2014 Real-Time Reporting of Medicare Readmissions Data

    • Review of CPAP data in this study in the Journal Clinical Sleep Medicine revealed 45.2 percent of patients were full users and averaged better than minimum adequacy. These patients had no readmissions during the 30-day period.
    • These findings also support the cost of in-hospital sleep studies and CPAP use. These researchers’ from the University of Pennsylvania (Departments’ of Neurobiology and Cardiology) noted the average cost per heart failure hospitalization was between $13,000 and $18,000, with readmissions potentially costing hospitals more as well as in Medicare penalties. They estimated the cost of sleep studies to be around $40,000 to $50,000, annually. Considering ~30 cases/day, ~150 cases/WK, ~600 cases/month and ~1800 cases/ QTR & ONE ICU ADMISSION COSTING (PER DARTMOUTH DATA) ~$76,000, THIS TRANSALATES TO TREMENDOUS COST SAVING FOR ~600 PATIENTS’ PER MONTH!! Of these 600 patients’, ~30% comprise Medicare beneficiaries (180 to 200); With 20% of these Medicare beneficiaries being readmitted (here ~36 to 40; & 2 MIL in 2012 and 139,000 beneficiaries re-admitted 2 or 3 times in the year), even with each hospitalization costing on the avg., $20,000, this could result in $720,000 to $800,000 in readmission health utilization costs per month. Importantly, Medicare will not pay for any of these readmits!!
    • “Based on these numbers, decreasing 30-day hospital readmission rates by JUST three to five patients per year would offset the cost of funding an inpatient sleep consult service,” per the researchers’ in this study. Big city hospitals in the United States have been severely penalized for readmission of patients with heart attacks, heart failure and pneumonia, according to research presented at the American Heart Association’s Scientific Sessions 2014. In 2013, 2,200 hospitals forfeited more than $280 million in Medicare funds due to readmission penalties!!

    WHAT DO WE BRING TO THE TABLE

    CLINICAL EXPERTISE: By auditing current procedures and preventing “GAPS” with the creation of proper “HANDOFFS.”

    FAIL SAFES: These will be customized to each Hospital system by working closely with various departments as Pre-op Holding, Risk Management Team, Intra-op team, PACU staff, Respiratory Staff, Pharmacy Staff and Nursing Care. Close communication between Engineers and IT staff with various departments would ensure a smooth transition into this system.

    INTEGRATION: The skill set in integrating a Software merging with the existing EMR which would then communicate via a cloud base network to Mobile App. This would enable compiling of reporting measures for both the Hospital to CMS and Individual Physician groups to specific practice based registries. Additionally, integration into the physician billing system.

    DECREASED LIABILITY: Meticulous but easy to follow/apply ORDER SETS created at EACH LEVEL to continually increase the safety in this high risk Pop. By successive handoffs and fail safes, documentation would demonstrate clarity to potential examiners/reviewers of high quality care.

    A SOFTWARE: That would sequentially capture individual measures at various stages of care therein enable Anesthesia groups to report these to CMS registries demonstrating quality care. This in turn would prevent decrease in Medicare reimbursement by 2% to 4%.

    THE SOLUTION PERI-OPERATIVE SURGICAL HOME (PSH) FOR OSA PATIENTS A PHYSICIAN-LED MULTIDISCIPLINARY AND TEAM-BASED SYSTEM OF COORDINATED CARE FOR OSA PATIENTS’

    A PATIENT CENTRIC PLATFORM THAT WILL HEIGHTEN PATIENT SAFETY!

    A platform that will enable SCREENING of ALL surgical patients. Will endeavor to set Screening hospital wide (i.e.: add-on surgical cases, VCU patients, GI suite patients, ER patients and Pain Management patients).

    A platform that would send NOTICE TO different systems ensuring vigilance at every level of care at present and in the future.

    A platform that would send an NOTICE TO Surgery Scheduling to enable advance identification of the patient inducing vigilance!

    A Platform that WOULD NOT CALL FOR CANCELLATION OF ANY SURGERIES!!

    A platform that would ENABLE ADVANCED preventive measures, enable ASSESSMENT and enable TIMELY TREATMENT.

    A platform that would DECREASE HEALTH CARE UTILIZATION, would CO-ORDINATE care & that would enable ADHERENCE to CPAP by continual education. It would enable FOLLOW-UP by DATA ACQUISITION from various systems by pulling data and pushing alerts and thus reduce risk of post discharge complications by following them longitudinally.

    A platform that would COLLECT REPORTING MEASURES for multiple physician groups to demonstrate quality care and cost containment and, for the hospital, ACO MEASURES in the advent of the hospital joining one.

    A platform that would MINE THE DATA key in deciding Value Based Payment Models, Merit Based Incentive Payment System (MIPPS: stressing meaningful use and clinical practice improvement activities) & efficient participation in Medicare Shared Savings Program.

    A platform that would define the hospital as a RISK MITIGATION CENTER with an enhanced recovery protocol and a TOP PERFORMING CENTER enhancing a greater share in revenue and decreasing costs at multiple levels. In other words, CMS will "feed the winners and starve the losers".