By Karen O’Hara
Richard Covert, M.D., M.P.H., is on a personal crusade to elevate occupational health metrics from the bowels of the operation to the in-boxes of medical professionals and administrative decision-makers in hospitals and clinics.
“You don’t want to beat people up with metrics,” he said. “You want to use them to help providers understand how they are practicing.”
Dr. Covert, medical director of SSM WorkHealth, a hospital-affiliated program in St. Louis, Mo., believes metrics are the key to establishing a practice as the gold standard in any given market.
He got his start in performance measurement about eight years ago when he developed a one-page report featuring financial and service performance measures for an operator of regional occupational medicine clinics. He developed a more relevant “report card” after determining that metrics established for performance analysis in primary care settings were not applicable to occupational health settings. In particular, he found disability data were not specific enough to be useful.
“In most cases, when you are trying to set up occupational health benchmarks, you are often flying by the seat of your pants,” he said. “You have ‘best practices data’ for primary care, and while there are new ACOEM (American College of Occupational and Environment Medicine) guidelines for evaluation and treatment available, there is still a paucity of data on how to manage a practice’s quality of service.”
Program-Specific Goals
In 2005, Dr. Covert was inspired by the work he was doing as a Malcolm Baldrige National Quality Award examiner. The award, created by an act of Congress in 1987, is the highest level of national recognition for performance excellence a U.S. healthcare organization can receive.
“As a Malcolm Baldrige examiner, I received a good education on what it takes for a company to be excellent,” he said. “That experience stimulated my interest in metrics because Baldrige expects employers to use a set of assessment tools. The rules are specific: You have to identify the ‘Mission, Vision and Values’ of the organization and then define a process by which you will achieve them. Award applicants need to define their benchmarks and then demonstrate whether they are actually achieving their goals through the use of a well-organized set of metrics.”
Dr. Covert’s personal goal is to “try and grind down to the essential valuable parameters” using all of the analytical tools he has it his disposal, including specialized software. At SSM WorkHealth, the team utilizes Occupational Health Research’s Systoc software (an NAOHP Vendor Member) to gather and sort relevant data. Excel spreadsheets are used for comparative analyses.
Initially, the metrics were designed for internal use to assess corporate performance. The data now is also used to benchmark the organization and for external marketing purposes. For example, in the St. Louis market, SSM WorkHealth found that employers seemed to find particular value in physical therapy referral rates and total-cost-per-claim comparisons when evaluating competing providers.
Performance Categories
For the clinics he oversees, Dr. Covert has narrowed performance measurement down to four basic categories:
1) patient flow/productivity;
2) case management;
3) charting and record keeping, and
4) coding and billing. Tables 1-4 feature parameters used in each of these categories.
Dr. Covert has also developed Excel spreadsheets to track commonly seen injuries in the following categories: back; knee; shoulder; wrist/forearm/ hand; wounds/abrasions/bites/ burns; and ankle and lower leg injuries. Cases in each of these categories are tracked by ICD-9 code, number of cases, average days on modified duty, average lost time, average costs and total costs. For example, for back injuries, data are collected for specific diagnoses including low back pain, SI joint dysfunction, lumbar sacral sprain/strain, SI sprain/strain; back sprain/strain; back contusion; low back contusion; and lumbar sacral plexus injury.
“From a patient flow standpoint, I simply want to know how we are doing,” Dr. Covert explained. “I look at how many people we see a day, new visits, follow-up visits, ratio of follow-ups to initial visits, number of physicals and fitness-for-duty exams and lacerations. Then I look at time in and time out so I can see how long it takes for us to handle a drug screen, an initial injury exam or a physical exam.”
These results are shared with staff and posted on the program’s website. Dr. Covert tracks his own performance along with that of the clinicians he supervises in order to acquire a more objective view.
Sometimes the data reveal aspects of a practice that are not immediately obvious. For example, in one instance he found that patient demographics played a role in a situation in which one clinic had shorter than average case durations, fewer follow-ups and lower costs per case in comparison to other affiliated clinics. It turned out that clinicians in that location saw a higher than-average percentage of truck drivers and treated more eye injuries in comparison to the other clinics. These data serve as guideposts to help assess what is occurring in a particular setting or with a specific provider, Dr. Covert said. With regard to case management, Dr. Covert’s intent is to obtain a comprehensive picture of how cases are being handled. For example, if the X-ray-to-initial-injury ratio is higher than average or the case opening-to-case closure rate is lower than 80-90 percent, intervention may be needed. Case management data also are used to track ancillaries and referrals emanating from WorkHealth, as well as pharmaceuticals and supplies. The program does not currently track prescriptions per case, but a field may soon be added for that purpose.
“You want to maintain control of the case to the greatest extent possible,” he said. “We track all referrals, including both in-network and out-of-network ancillaries, so we can demonstrate downstream revenue. One of the reasons occupational health programs have difficulty tracking downstream dollars is that different entities within their system do not allow them to bill for it. It’s much easier to track if we are billing it for ourselves.”
Charting and record keeping is a matter of accuracy, thoroughness and getting staff involved in review. Electronic medical records help simplify the process. Systoc enables “point and click” and note confirmation functions during patient encounters; there is no need for dictation. Employers have online access to relevant information via iSystoc, the software’s web-enabled version. About 15 randomly selected charts are subject to quarterly peer review. For coding, SSM WorkHealth has retained Bill Dunbar & Associates, another NAOHP Vendor Member, to ensure that money is not left on the table and to understand why certain providers’ treatment is down-coded, with associated lower reimbursement.
“I use some of the Bill Dunbar data for benchmarking,” Dr. Covert said. “They can parse out occupational health cases on a national basis – percentage, averages, right or wrong – for certain codes. We use a spreadsheet to calculate coding-related dollar variances to determine how we stack up against national averages – are we over-coding or under-coding initial visits and follow-ups – and if so, by how much?
“Over the course of a month, the amounts should not be off by more than $1,000. We are looking for red flags and activities outside the norms.” Dr. Covert estimates he spends six to eight hours a month on metrics management. The more staff support a medical director has, the less time he or she should need to devote to the task.
From this point forward, he plans to focus on the development of a “performance dashboard” template for benchmarking. Dashboards are a popular approach to displaying key parameters because they provide a quick and easy way to share data with staff and external customers.
