Managed care is data management.
Managed Care Is Data Management
Accountability, the crux of the managed care movement, is the fundamental principle by which we will formulate new ways to manage patients and doctors better in response to demands for value. We must recognize, however, that as managed care decentralizes and delegates more care, and as patients' prerogatives increase, control and accountability will diminish. There are essentially two ways to restore some control:
* Data management, coupled with an advisory role for physicians.
* Restricting payment for services rendered.
The latter is called the adjudication The legal process of resolving a dispute. The formal giving or pronouncing of a judgment or decree in a court proceeding; also the judgment or decision given. The entry of a decree by a court in respect to the parties in a case. process; it may cause difficulty at or near the point of service. The former recommends an accessible, organized medical database, one that actually recapitulates the medical logic used in comprehensive care. These vital data, however, have been unavailable, and making them available may create new problems for providers. The power of the medical database and concurrent monitoring/tracking systems can create new demands and threaten confidentiality. Thus, to manage care optimally, we must not only organize the care so that less work is required, but also be mindful of our primary purpose: to improve the health of our patients. This all requires expertise in patient communication, the careful handling of sensitive information, and active support of the advocacy role.
We have or should have the ability to supply service-based information about medical claims and clinical processes. We know how to take care of patients comprehensively, and we are expert at managing care. But we do not have the data we need. A more accessible medical database is needed at every point of patient contact. Nice, but not required, is the assistance of a computer in making this relevant information available.
Is there a better way to obtain valid and accurate medical data than by mandating it? There is, if we pay physicians only for what is appropriate (i.e., gaming is kept out of the system), all financial incentives that conflict with the advocacy role of physicians are removed, and the utility of the data is increased. The data will be more useful if they are available 24 hours a day; if physicians are taught to represent their logic in a summary list of medical problems, concerns, or preliminary assessments; and if effectiveness and efficiency are regularly evaluated from the data.
The data can be made more accessible by having well-organized, up-to-date lists of vital medical information, such as the problem list (an index and table of contents of the medical record) and a chronology of recent medical interactions, on-line and available from a centralized cen·tral·ize
v. cen·tral·ized, cen·tral·iz·ing, cen·tral·iz·es
1. To draw into or toward a center; consolidate.
2. location. The confidentiality of this medical information is essential. It can be protected by making the managing entity responsible for the security of the data.
Finally, how will such a system be paid for? Insurers and others who have a vested interest Vested Interest
A financial or personal stake one entity has in an asset, security, or transaction.
For example, if you have a mortgage, your bank has a vested interest on the sale of your house.
See also: Right in the "appropriateness decision" will be more than happy to pay for the opportunity to work with physicians to improve care. What better way to establish protocols and standards of diagnosis and treatment and influence the appropriateness decision at the point of contact and/or service? Also, having a computer-assisted database management program would facilitate the documentation of advice-giving education, the flagging of patient problems that warrant special attention and follow-up, and feedback procedures.
The best opportunity not only to advocate for patients but also to improve accountability lies at the point of patient contact. Although this is not the usual place to begin documentation, it is an important, underrecognized, and constant referent ref·er·ent
A person or thing to which a linguistic expression refers.
Noun 1. referent - something referred to; the object of a reference . Furthermore, it may be the only reliable point where patients will contact us, if for no other reason than for authorization or advice.
Present Medical Data
What touches all aspects of medicine is "information." Data are not yet information. Nevertheless, medical information and clinical logic are essential ingredients of effectiveness and efficiency studies. [1-3] Unfortunately, much of the analysis of medical care is cost driven, with the claims trail being its only reliable dataset. The fact that allocation of resources allocation of resources
Apportionment of productive assets among different uses. The issue of resource allocation arises as societies seek to balance limited resources (capital, labour, land) against the various and often unlimited wants of their members. does not recapitulate re·ca·pit·u·late
v. re·ca·pit·u·lat·ed, re·ca·pit·u·lat·ing, re·ca·pit·u·lates
1. To repeat in concise form.
2. the medical logic has not seemed to matter. In theory, health maintenance organizations and other managed care systems should excel at Verb 1. excel at - be good at; "She shines at math"
excel, surpass, stand out - distinguish oneself; "She excelled in math" linking "claims" to the "clinical trail" (i.e., utilization monitoring in the pursuit of medical diagnoses and treatment). Nevertheless, no medical management system in America (and certainly not in Canada) asks physicians for their deductive reasoning Deductive reasoning
Using known facts to draw a conclusion about a specific situation. . When logic is sequestered se·ques·ter
v. se·ques·tered, se·ques·ter·ing, se·ques·ters
1. To cause to withdraw into seclusion.
2. To remove or set apart; segregate. See Synonyms at isolate.
3. in our charting (even in the computerized medical record) or is absent entirely, or the analysis of medical practice is kept so distant from the care process itself, it is not surprising that it is no easier to control costs than it is to anticipate physicians' behavior.
Present data management systems fail to document what happens to the patient throughout the entire episode of care and thereby inadvertently contribute to discontinuity dis·con·ti·nu·i·ty
n. pl. dis·con·ti·nu·i·ties
1. Lack of continuity, logical sequence, or cohesion.
2. A break or gap.
3. Geology A surface at which seismic wave velocities change. and depersonalization depersonalization /de·per·son·al·iza·tion/ (de-per?sun-al-i-za´shun) alteration in the perception of self so that the usual sense of one's own reality is temporarily lost or changed; it may be a manifestation of a neurosis or another . Gaps in our documentation (knowledge) interfere with our efforts to improve the efficiency of health care. Furthermore, an incomplete database plays havoc with our ability to learn from the past, improve quality and effectiveness, and develop strategies for the future.
There is confusion about what is meant by efficient health care delivery systems. Central to our understanding of the concept kf efficiency are its components: the actual outcomes of clinical intervention, the efficacy of the treatment, and the desirability  of observed outcomes and productivity. We must be able to feed information back about the physician performance, if we are to modify medical practice. [2,3] Somewhere in the available dataset, there must be information that will allow us to evaluate performance. Not unexpectedly, this also happens to be the place where we will find support for appropriateness decisions.
Some of the vital information by which we should measure/evaluate production may be missing or ignored. A comprehensive dataset about efficiency and cost-effectiveness, for example, should include data about patient calls, inquiries, understanding, and the like. Our methods of getting this type of information, however, are onerous (e.g., computerization com·put·er·ize
tr.v. com·put·er·ized, com·put·er·iz·ing, com·put·er·iz·es
1. To furnish with a computer or computer system.
2. To enter, process, or store (information) in a computer or system of computers. of the medical record) or unnecessarily labor-intensive (e.g., surveys and studies).
A Complete Picture
A complete picture of care in medically managed systems begins with any contact and ends at the outcome (intermediate or final). The continuity of medical care is the bridging of these two reference points. Presently, we do not have in place an effective method to track the patient from the point of contact.  If we wait for a point of service, we may delay tracking, or we may actually miss a few medical transactions that do not involve an encounter. We may even compromise our ability to assess accessibility.
Furthermore, the medical database is incomplete by our own admission. It is rare to find well-organized, comprehensible com·pre·hen·si·ble
Readily comprehended or understood; intelligible.
[Latin compreh , readily available, and accessible "problem lists." The incomplete database is the proximate cause An act from which an injury results as a natural, direct, uninterrupted consequence and without which the injury would not have occurred.
Proximate cause is the primary cause of an injury. of our inability to control or audit what we do and to improve the practice of medicine. With an incomplete or inaccurate database, we can neither improve continuity nor prove discontinuity. We cannot fully evaluate the use of health care resources (e.g., when trying to provide cross-coverage). Finally, we cannot, at times, even properly identify patients or their medical histories!
Outcome measures, largely relegated to quality assurance discussions, evade practical appliction in utilization management Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. . The unfortunate truth is that the results of our medical efforts may be unrelated to what we have done or will do on behalf of the patient. There are essentially two reasons for this state of affairs. When we have not sufficiently compensated or accounted for population, demographics, severity of illness, and local variation in practice patterns, what we claim to observe may, in fact, not be real. A "complete picture of care" and the ability to develop medical strategies requires a fairly complete database and sophisticated statistical understanding. The second reason is the contribution of unforeseen events, variable compliance, unstandardized practices, and a general inability to observe the complete process of care.
Tier 1 is cause and effect; it is the medical part of the process. Tier 2 is the quality and utilization review/management process. The complete process encompasses both tiers, and every step is critical.
The clinical process of medicine is fairly straightforward. The pursuit of the diagnosis, or the clinical trail, is a scientific process of elimination The process of elimination is a basic logical tool to solve real world problems. By subsequently removing options that may be deemed impossible, illogical, or can be easily ruled out due to some sort of explicit understanding relative to the entire set of options, the pool of . How, then, can the result of that pursuit be made credible or confirmed as reasonable or appropriate through retrospective utilization review u·til·i·za·tion review
A process for monitoring the use, delivery, and cost-effectiveness of services, especially those provided by medical professionals. of health care resource expenditures? Physicians will tell anyone that utilization control is not their overriding concern in patient management. Moreover, because the e ical outcome may or may not be related to a physician's skill, industry, or past performance, it is perplexing per·plex
tr.v. per·plexed, per·plex·ing, per·plex·es
1. To confuse or trouble with uncertainty or doubt. See Synonyms at puzzle.
2. To make confusedly intricate; complicate. that management would judge physicians' performance on the basis of utilization standards alone. Indeed, retrospective auditing and trend studies do not anticipate utilization very well. It might be better to manage the care before or as it happens, rather than simply react to it.
Health promotion personnel have advocated a more preventive approach to medicine. However, they have not been able to convince the insurance and medical establishment of the efficacy of their method. Insurance systems cannot relate to known risk and, furthermore, do not want to remove any premiums from their existing revenue stream; i.e., excluding people who are only potentially sick.
The major challenge seems to be bringing to the forefront information about the "more manageable aspects" of health behavior, e.g., smoking, sedentary sedentary /sed·en·tary/ (sed´en-tar?e)
1. sitting habitually; of inactive habits.
2. pertaining to a sitting posture.
of inactive habits; pertaining to a fat, castrated or confined animal. life-styles, stress reactions, and the like. How can we use these data to improve our advocacy role? How can the information help us decide what service is appropriate and what is not? The answer, it would appear, is the cooperative creation of an accessible profile of the patient's medical history--with past, present, and potential problems.
The value of having a reliable chance to determine appropriateness or at least to monitor care should be obvious. The most reliable opportunity to not only perform this service, but also improve the utility of the medical database, [1-3] is the point of contact. (This may or may not be the point of service.) Medicine Optimally Managed is different from other database systems in that it interfaces an intelligent, caring, expect communictor who is knowledgeable about the patient and the policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental of the managed care system. Although the specific items in the database are likely to vary between settings, they will always contain organized lists of data, generally prepared choronologically to reflect the process and the complete picture of care.
The theoretical advantages of such an information system includes its ability to advocate for patients, explain the rules, determine appropriateness, reduce medical/legal risk, monitor care from the point-of-contact to final disposition, ensure accountability, provide follow-up for patients, and even create the framework for risk prediction and medical strategy. Furthermore, it also presents an opportunity to insulate in·su·late
tr.v. in·su·lat·ed, in·su·lat·ing, in·su·lates
1. To cause to be in a detached or isolated position. See Synonyms at isolate.
2. physicians from inapproprite, inefficient (nonreimbursable) use of their time.
In our conceptualization con·cep·tu·al·ize
v. con·cep·tu·al·ized, con·cep·tu·al·iz·ing, con·cep·tu·al·iz·es
To form a concept or concepts of, and especially to interpret in a conceptual way: of a relational database relational database
Database in which all data are represented in tabular form. The description of a particular entity is provided by the set of its attribute values, stored as one row or record of the table, called a tuple. management scheme, it is necessary to first tract the flow of information that a triage-type person would access and control (figure 1, page 22). Next, the triage triage
Division of patients for priority of care, usually into three categories: those who will not survive even with treatment; those who will survive without treatment; and those whose survival depends on treatment. algorithm is put forth (figure 2, page 22). The key to this method is that critical information can be put to good use from a centralized location (figure 3, above). The eventual disposition for the patient contact or transaction can be easily correlated with (or sought because of) contact information.
Dispositions may reflect way stations on the clinical trail or "immediate outcomes" (e.g., the patient was hospitalized), or when not "final," they may serve as a sort of "tickler file Noun 1. tickler file - a file of memoranda or notices that remind of things to be done
data file, file - a set of related records (either written or electronic) kept together " in the interests of folow-through and continuity of medical care. In summary, it becomes exceedingly important to relate the clinical trail to the claims trail when assessing efficiency or cost-effectiveness. In addition, other dispositions--administrative decisions, precedents, feedback procedures, etc.--may be of relevance. It is noteworthy, in this context, that any such systems must have the ability to remember the decisions we make and the thought processes This is a list of thinking styles, methods of thinking (thinking skills), and types of thought. See also the List of thinking-related topic lists, the List of philosophies and the . we went through. Thus, it must have updating capability and ways to recall the clinical pathways clinical pathway Critical pathway, treatment pathway Clinical medicine A standardized algorithm of a consensus of the best way to manage a particular condition Modalities used Teletherapy, brachytherapy, hyperthermia and stereotactic radiation. we have taken.
Data management requires that we (1) access all the relevant data, from point-of-contact to outcome (intermediate and final disposition), (2) provide a computer interface to improve our ability to interact with and then advocate for the patient, (3) control patient movement (or at least monitor it well), (4) use the same data to link the process of care with the outcome, and (5) learn from these data what works and what doesn't. 
Doctors need feedback about their patients and effcacy. What transpires and is recorded in the office and hospital chart is only of use during an encounter. Rather than rely on the vicissitudes vicissitudes
changes in circumstance or fortune [Latin vicis change]
vicissitudes npl → vicisitudes fpl; peripecias fpl of medical practice and variable documentation skills, systems should be designed to capture, correlate, and reconcile certain lists of medical care/service information. We must standardize the dataset. In so doing we may use it in the determination of effectiveness and efficiency. In preparation for the future, we must use such intelligent systems to learn from the past and our shared, collective experience.
A relational database program that takes mainframe data and brings them into a micro- or minicomputer (1) An earlier medium-scale, centralized computer that functioned as a multiuser system for up to several hundred users. The minicomputer industry was launched in 1959 after Digital Equipment Corporation introduced its PDP-1 for $120,000, an unheard-of low price for a computer in also brings this kind of data access and management into the realm of possibility for most physicians working in patient care environments. The "appropriateness-decision" that we must make as part of our responsibility to insurers is also justifiction for their subsidy of the installment of such a program.
Studies of point-of-contact data management schemes have demonstrated the utility of the approach.  It is not hard to realize the benefits of such a system: repersonalization, continuity, documentation, tracking, the preparation of data to become information.
The major challenges include demonstrating the utility and security of the data management scheme to physicians, achieving cooperation from them to contribute their medical databases (even diagnoses related to claims will do at the outset), and setting up the programming that is required to allow a generic software (1) Ready-made software. Shrink-wrapped software. Contrast with "custom software." See shrink wrapped software and COTS.
(2) (Generic Software, Inc., Madison, MS, www.genericsoftware.com) A company that specializes in software for IBM midrange computers. system to be loaded into computer memory (RAM) and run with the data stored in mainframe computers. 
 Bohen, O., and Burbe, T. "New Directions in Effective Quality of Care: Patient Outcome Research." Federation of American Health American Health Inc. is a company that manufactures health supplements. It is located in Holbrook, New York. One of its products is labeled the "Chewable Original Papaya Enzyme" with the attached registered trademark, "The 'After Meal Supplement'". Systems Review 21(5):50-3, Sept./Oct. 1988.
 Kaplan, J., and O'Connor,P. "Productivity Can Be Econometrically Considered in an HMO HMO health maintenance organization.
A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, Setting: Its measurement and Implications for an Incentive Program." Presented at the Group Health Institute, Philadelphia, Pa., June 1984.
 Kramer, R., and Kaplan,J. "Physician Performance Evaluation Performance evaluation
The assessment of a manager's results, which involves, first, determining whether the money manager added value by outperforming the established benchmark (performance measurement) and, second, determining how the money manager achieved the calculated return and a Further Definition of Productivity." Presented at the Group Health Institute, Minneapolis, Minn., June 1986.
 Kaplan, J., and others. "An Argument for a
Point-of-Contact Management system." Medical Interface 2(2):23-8, Feb. 1989.
 Kaplan, J. "Accountability, Efficiency, Effectiveness." Medical Interface 3(5):13-16,40, May 1990.
 Kaplan, J. "Real Time Management Technology: Improving Accountability, Efficiency, and Effectiveness." Presentation at Group Health Institute, Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. , Calif., June 12, 1990.
Jeffrey G. Kaplan, MD, MPS, is Executive Vice President for Medical Affairs, Health Services health services Managed care The benefits covered under a health contract Medical Crop., Baldwinsville (Syracuse), New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of . He is a member of the College's Forum on Computers and Information Technology and an associate member of its Society on Managed Health Care Organizations.