YOUR VOICE 4: October 20, 2010 DiversityRx: 7 th National Conference on Quality Health Care for Culturally Diverse Populations, Baltimore, MD “Collecting and Using Patient Demographic Data to Create Equitable Health Care Systems: Perspectives from a Community of Practice” Kathryn Coltin, MPH Catherine West, MS, RN Cheri Wilson, MA, MHS, CPHQ Boris Kalanj, LISW, Moderator
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YOUR VOICE 4:
October 20, 2010
DiversityRx: 7th National Conference on Quality Health Care for Culturally Diverse Populations, Baltimore, MD
“Collecting and Using Patient Demographic Data to Create Equitable Health Care Systems: Perspectives from a Community of Practice”
Kathryn Coltin, MPH Catherine West, MS, RNCheri Wilson, MA, MHS, CPHQ Boris Kalanj, LISW, Moderator
Community of Practice (CoP) #3: Participant Introductions Name Work Setting
Session Objectives
Provide audience members with meaningful, replicable information and best practices related to REAL data collection and use;
Outline barriers and best practices that are relevant to a variety of health care organizations (hospitals, clinics, health plans, etc.) at varying points on the continuum of implementation;
Discuss larger regulatory and HIT-related developments that impact this area of work;
Problem solve with audience members; and Highlight key benefits/outcomes of the CoP.
Goals of a CoP
To create an informative and supportive environment for people to learn more about the topic, share their expertise, get advice, and create a base of knowledge that will benefit others.
What is a CoP?
A small group (12-20 participants) of professional colleagues ‘Meet’ monthly on a specific topic Via teleconference or virtual learning platforms Purpose: to discuss common practice challenges and share
information about strategies and resources. Supported by a listserv for ongoing dialogue between meetings
and a wiki where the information base developed over the course of the project is documented for use by others.
Initial meeting period is 12 months—groups may continue to meet as interest and funding permit.
2 - Not of Spanish/Hispanic Origin 96.09% (96.09%-99.54%) 98.3% 93.3%
9 - Unknown*** 2.04% (.37%-2.04%) --- ---
Notes
* Separate categories in U.S. Census Date: Asian, Native Hawaiian and Other Pacific
Islander** Category added in 2006
*** Not a U.S. Census category
Race: Data Elements
Race EPIC EPR Sunrise (POE)HSCRC (State
Reporting)
HRET Disparities Toolkit (based on OMB Federal
Reporting)A - Asian/Pacific Islander (Asian or Pacific Islander) X X X X American Indian/Alaska
Native XAsian X
B - African American (African American) X X X X
Biracial X Black/African American X
Caucasian/White X Declined X
H - Hispanic X X X I - American
Indian/Eskimo/Aleut (American
Indian/Eskimo/Aleut) X X X X
M - Multiracial (Multiracial) X X X XNative Hawaiian/Other
Pacific Islander XO - Other (Other) X X X X
U - Unknown (Unknown) X X X X Unavailable X
W - White (White) X X X X
Ethnicity: Data Elements
Ethnicity EPIC EPR Sunrise (POE)
HSCRC (State Reporting)
HRET Disparities Toolkit (based on OMB
Federal Reporting)Spanish/Hispanic
Origin X
Not of Spanish/Hispanic
Origin X
Unknown X
Hispanic or Latino * X
Not Hispanic or Latino * X
No separate category X X
Note
* Dropdown list, but
currently not populated
Recommendations Standardize the race, ethnicity, and primary language categories across information
systems EPIC
Ask all patients, not just new patients, about race, ethnicity, primary language, and interpreter needs.
Make interpreter needs more visible on the scheduling screens. Modify the question, “Do you currently have any special needs?” to include “need
an interpreter.” Currently includes such things as “need a wheelchair.” Sunrise
Determine who is responsible for identifying a patient’s race, ethnicity, and primary language as well as checking “Interpreter required” box.
Modify patient demographic form to state both race and ethnicity. Add a language field in the various information systems
Field to include not only foreign languages, but sign language and Braille as well. This will make it easier to identify and address the needs of these patient
populations. Review the Registration process to assure correct data and the need for an interpreter
is collected consistently
Collecting, Reporting and Using REaL Data To Reduce Health Care Disparities
Kathryn Coltin
Harvard Pilgrim Health Care
Diversity Rx Community of Practice 3
October 2010
Harvard Pilgrim Health Care Background and Context Harvard Pilgrim Health Care is a non-profit health plan serving over 1
million commercially-insured members in MA, ME, NH and RI. Of these, almost 70% reside in Massachusetts
In 2004 Harvard Pilgrim became one of ten founding members of the National Health Plan Collaborative to reduce racial & ethnic disparities.
This step fueled a steadily growing initiative to measure, report and reduce disparities in the care and service our members receive.
Harvard Pilgrim has been ranked the #1 health plan in the U.S. based on quality since 2005*.
Even so, disparities exist in the care some of our members receive.
The Commonwealth of Massachusetts mandated collection and reporting of patients’ race, ethnicity and language by acute care hospitals in January 2007 and extended this mandate to health plan collection of enrollees’ REaL data beginning July 2010.
$$$ Penalties are tied to non-compliance in achieving specified reporting thresholds.
*Based on NCQA’s U.S. News and World Report and Consumer Reports Best U.S. Health Plan Rankings
Harvard Pilgrim Health CareData Collection Channels—different strokes for different folks
calls)√ Live telephonic care: Care/Case mgmt, Disease
mgmt Provider initiatives
√ Contracting requirements√ Enhancements to existing provider transactions Pay for reporting (based on EHR meaningful use
data)?
Language onlyMOST
LEAST
Acc
epta
bilit
y to
mem
bers
25
Harvard Pilgrim Health CareCollection of REaL Data
Secure web portal includes a Member Profile, which was modified to include Race, Ethnicity and Language preferences
Collecting REaL data from providers Harvard Pilgrim added self-reported REaL to medical record
documentation standards for physician offices in Dec. 2007
● December 2008 chart audit found average compliance rate <5%
Harvard Pilgrim began requesting REaL from MA hospitals and one large physician group in Fall 2008
● No standard file format or coding system has been adopted statewide to facilitate sharing data
● HPHC accepts hospital-specific file formats and codes, then maps fields and codes to HPHC standard data dictionary
● Negotiations with hospitals re sharing REaL data lengthy and not always productive; some have requested payment for data, while others have referred our request to the MA Hospital Association
● Administratively burdensome for hospitals to provide REaL data directly to each health plan; state agency should develop a mechanism to share the data hospitals currently report to the agency with all health plans in the state.26
Harvard Pilgrim Health CareCollection of REaL Data
Harvard Pilgrim Health CareUsing the data—first make it usable
Significant IT investments made since 2008 to enable collection, analysis and reporting of REaL data
Built electronic file feeds from each data channel to a staging area where automated standardization of file formats and coding occurs
Built tables in Enterprise Data Warehouse to house standardized REaL data that are uploaded from the staging area
Incorporated most recent RAND algorithms for indirect estimation of race/ethnicity using geo/surname coding
● Validated indirect estimates against self-reported race/ethnicity values
Built logic to reconcile conflicting REaL data values across self-reported data sources
● Algorithm determines “best” REaL data for analysis and reporting
Self-reported REaL data trump indirectly estimated data for use in internal analyses to identify and monitor disparities in care
Harvard Pilgrim Health CareUsing the data—an evolving portfolio of measures
Imaging for low back pain in adultsNote: Italics indicates outcome measures. Blue font indicates measures with observed
disparities, most of which have been reduced, though not yet eliminated
Added in 2007 Preventive Care/Access
Well VisitsInfants 0-15 mo.Children 3-6 yr.Adolescents 12-21yr.
Chronic Care Diabetes
BP control Acute Care
Strep Tx prior to antibiotic Rx for children w/ Pharyngitis
Appropriate antibiotic use for children w/URI
Added in 2010 Patients’ care
experiences Medical Home
Harvard Pilgrim Health CareUse of REaL Data for reporting—defining a disparity
Harvard Pilgrim defines an actionable disparity as a performance rate for a given population group that is >6 percentage points below that of the population group with the best rate (i.e., the benchmark group)
Why? This definition works across all types of disparities that we measure For racial/ethnic disparities, the white non-Hispanic population is
frequently not the benchmark population Comparison with the benchmark population is consistent with our
goal of assuring the highest quality care, not just equal care The margin of error on many measures is +/- 5% or higher Our overall population rates for most measures are above the
national 90th percentile rate Preventive care measures have very large denominators, so very
small differences (1-2%) are statistically significant, but not clinically significant
Acute illness and chronic disease measures have smaller denominators and large differences (>6 percentage points) are often not statistically significant, but can be clinically important
Harvard Pilgrim Health CareAnalyzing disparities—our Annual Equity Report
Measures for current year performance (or
two year performance for measures with small
Ns) are usually displayed using bars for each
reporting category within a measure.
Separate graphs are used to display
performance for each attribute (race,
ethnicity, gender, education, income, etc.).
HEDIS Rates for Comprehensive Diabetes Careby Indirectly Estimated Race/Ethnicity
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
HEDIS Measure
Pe
rfo
rma
nc
e R
ate
Black 91.0% 62.8% 92.3% 70.8%
Hispanic 88.7% 54.1% 88.4% 58.0%
Asian 91.6% 63.1% 92.0% 62.5%
White/other 88.5% 60.8% 90.9% 58.9%
HbA1c Rate Eye Exam Rate LDL Tx RateNephropathy
Monitoring Rate
Colorectal Cancer Screening Rates by Race/Ethnicity 2003-2009
55%
57%
59%
61%
63%
65%
67%
69%
71%
73%
75%
77%
79%
81%
2003 2004 2005 2006 2007 2008 2009
Performance Year
Perc
ent S
cree
ned
Black Hispanic Linear (Black) Linear (Hispanic)
Measures with data for
multiple years are trended on
separate line graphs showing
each group that had an
actionable disparity when
compared with the
benchmark group
Harvard Pilgrim Health CareInterventions to reduce disparities
Diabetic Eye Exams (2005-2009) ID physician practices with high concentration of Hispanic members
Solicit applications for funding of QI interventions (Quality Awards Program) Conduct community based interventions in communities with a high proportion
of Hispanic residents Offer onsite eye exams and patient education Pilot a member incentive to waive co-pay for eye exam
Remove referral requirement for dilated eye exam for diabetes
Asthma medications (2006-2009) Review and enhance all patient education materials
Update and improve existing materials Increase availability of materials in Spanish and other languages Lower the reading level and improve health literacy Promote through IVR outreach
Colorectal Cancer Screening (2005-2009) Enhance telephone-based outreach and bilingual educational mailings
IVR call offered in English or Spanish with culturally appropriate messaging Pilot for collection of self-reported race/ethnicity using IVR Supplemental educational materials available in Spanish and Portuguese Won 2007 NCQA Multicultural Innovation Award