[MCOH-EH] Metrics for externally facing occ med clinics

[Philip Harber]

Ron,


This is a very important and challenging question, for which overly simple
measures may be misleading. Here are some thoughts based upon my (somewhat
limited) experience in this area.



1. CASE MIX: A single metric applied to all providers may be misleading.
Some providers or clinics deal largely with the first visit for acute
trauma, whereas others have longer term chronic patients; this may affect
appropriateness of opioids. My case mortality rate when I was running in
ICU would certainly be unacceptable for my current clinical practice. In
several projects, we employed adjustment methods analogous to ascertaining
such as how many prior visits to other providers involved an opioid
prescription.



2. DO NOT AUTOMATICALLY APPLY TREATMENT GUIDELINES TO QUALITY MONITORING: Many
treatment recommendations are “strong suggestions” and not easy to apply
without understanding the individual case features (e.g., the clinician may
have good reasons to feel it does not apply to the instant case). Some
guideline recommendations depend upon data difficult to automatically
ascertain (e.g., do not continue PT unless there has been a response to
prior PT). Others, however, may be automatically and electronically
ascertained for monitoring. (E.g., beta blockers after MI, follow-up visit
after CTS surgery are easily identified from electronic records). See 2
articles below that describe this in more detail from the work we did with
Rand Corporation.



3. DECIDE WHETHER TO FOCUS ON THE PRACTICE OR ON THE INDIVIDUAL: Sometimes
it is advisable to avoid the temptation to focus on identifying the “single
outlier clinician”. Rather, in a widely dispersed system such as Banner,
more stable and precise estimates should be obtainable for a clinic rather
than for each individual. Improving the Average may sometimes be better
than trying to find the severe outlier.



4. FOCUS ON MEANINGFUL SAMPLE: Rather than obtaining limited quality data
on every case, it is sometimes better to systematically select appropriate
sample cases for more in-depth analysis of guidelines compliance. We
continue to use this approach in quality improvement work in workers
compensation.



5. SIMPLE BUT SPECIFIC RULES: NIOSH sponsored work with both ATS and ACOEM
to develop extremely simple decision support system rules that are very
easily based upon automated review of EHR records. (Summaries of Bob
McClellan and my committees’ recommendations are shown below).



6. PARTNERING WITH INSURERS OR EMPLOYERS: In the past, had the pleasure of
working with two projects directly relevant to the employment setting. Both
used uniquely occupationally relevant outcomes such as worker return and
persistence at work or insurer reserve fund allocation. For externally
facing clinics, it is necessary to establish strong but protected
collaborations with a corporate employer or with a large insurer to obtain
the data since the treating clinic rarely has this type of information.
Accomplishing this in an ethical fashion requires extremely careful
consideration about who will see the data; the “honest broker” approach
used in many research studies may be particularly applicable.



7. SO WHAT? Ultimately, the monitoring process should depend on what you
will do with the information obtained.



8. THE FUTURE?? ChatGPT



9.(Sorry for being so wordy! This is an extremely important & interesting
but challenging problem). The references below are not necessarily the
best, but are easy for me to find since they sit on my computer.



Phil Harber

Dictated to Dragon voice dictation system. I apologize for any overlooked
errors.

🌵🌵🌵🌵🌵🌵🌟

1. Quality measures for the diagnosis and non-operative management of
carpal tunnel syndrome in occupational settings.Nuckols T, Harber P, Sandin
K, Benner D, Weng H, Shaw R, Griffin A, Asch S; Carpal Tunnel Quality
Group. J Occup Rehabil. 2011 Mar;21(1):100-19. doi:
10.1007/s10926-010-9260-6. PMID: 20737200

2. Selection of workers' compensation treatment guidelines: California
experience. Harber P, Wynn BO, Lim YW, Mattke S, Asch SM, Nuckols TK. J
Occup Environ Med. 2008 Nov;50(11):1282-92. doi:
10.1097/JOM.0b013e3181841fb4. Https://pubmed.ncbi.nlm.nih.gov/19001954/

3. Recommendations for a Clinical Decision Support System for Work-Related
Asthma in Primary Care Settings. Harber P, Redlich CA, Hines S, Filios MS,
Storey E. J Occup Environ Med. 2017 Nov;59(11):e231-e235. doi:
10.1097/JOM.0000000000001182.

4.Using Electronic Health Records and Clinical Decision Support to Provide
Return-to-Work Guidance for Primary Care Practitioners for Patients With
Low Back Pain. McLellan RK, Haas NS, Kownacki RP, Pransky GS, Talmage JB,
Dreger M. J Occup Environ Med. 2017 Nov;59(11):e240-e244. doi:
10.1097/JOM.0000000000001180..

*Philip Harber *

email:  philharber at gmail.com or pharber at arizona.edu
<pharber at email.arizona.edu>

Office Phone: 520-626-1263

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On Thu, Feb 9, 2023 at 9:55 AM Teichman, Ron F via MCOH-EH <
mcoh-eh at mylist.net> wrote:

> Hello everyone,
>
>
>
> We have started tracking non-traditional quality metrics for our occ med
> providers across our clinic system. I consider things like volumes, RVUs,
> patients per hour, etc., as traditional metrics. The metrics I am now
> looking at include:
>
>    - % of visits with a prescribed narcotic
>    - % of visits with a prescribed non-narcotic medication
>    - % of LBP visits with a prescribed narcotic
>    - % of initial visits taken out of work
>    - % of visits with restrictions seen again within 5 business days
>    - % of patients with an emergency room referral
>    - % of patients with a specialty referral (excluding imaging)
>    - % of patients with a physical therapy referral
>
>
>    -
>
> Currently, we are tracking each provider versus the group averages, but
> would like to have external benchmarks. Is anyone else tracking these or
> similar metrics and would you be willing to share your benchmarks if you
> have them. You can email me directly and I can compile them and return the
> composite to the group. Conversely, if anyone knows where I can find
> benchmarks or relevant national data I would be greatly appreciative.
>
>
>
> Stay safe, Stay healthy,
>
> Ron
>
> Ron Teichman, M.D., M.P.H., FACOEM, FACP
>
> Division Medical Director
>
> Banner Occupational Health and Wellness
>
> 1300 N. 12th Street, Suite 610
>
> Phoenix, AZ 85006
>
> Ron.teichman at bannerhealth.com <Ronald.teichman at bannerhealth.com>
>
>
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