MED STAFF NEWS - Intermountain Physician

Transcription

INTERMOUNTAIN
MED STAFF NEWS
THIRD QUARTER
SEPTEMBER 2015
IN THIS ISSUE
OPENING MESSAGE
CLINICAL PROGRAM AND SERVICE LINE UPDATE
INTERMOUNTAIN BOARD GOALS
18 Cardiovascular
1
2
Message from Brent and Susan
2015 Board Goal Results – July Update
INTERMOUNTAIN SYSTEMWIDE INITIATIVES
17 Behavioral Health
18 Imaging Services
19 Intensive Medicine
4
Intermountain Innovations: Using Data to
Improve Care and Reduce Costs
21 Musculoskeletal
5
Patient Education Library Now Available on
the Health Hub Mobile App
23 Oncology
5
Transparency Initiative – Data Collection
and Sharing
25 Pediatrics
7
All Old ID Badges Will Expire on December 31
7
Zero Harm Update
8
Intermountain Health Answers Is Live
9
ICD-10 Implementation Begins October 1, 2015
ICENTRA UPDATE
10 Improvements to iCentra ahead of October 24
Launch in North Region
SHARED ACCOUNTABILITY UPDATE
11 New SelectHealth Share Product Launched
COMPLIANCE UPDATE
14 Understanding the Anti-Kickback Statute
QUALITY AND PATIENT SAFETY UPDATE
15 It Happened Here – Retained Foreign Objects
21 Neurosciences
25 Pain Management
26 Primary Care
27 Surgical Services
29 Women & Newborns
SELECTHEALTH UPDATE
30 Request for Confirmation of Diagnoses
30 SelectHealth Advantage Home Visit Evaluations
31 M-Tech Reviews Healthcare Technologies
32 Medical Policy Bulletin
NEWS FROM THE REGIONS
38 New Regional Vice President Joins
Intermountain’s Central Region
FITNESS FEATURE
39 If We Want Kids to Be Physically Active,
Make It Fun!
DEAR COLLEAGUES,
In our continuing efforts to improve communication between Intermountain and credentialed
practitioners, we are pleased to present the 8th installment of Intermountain Med Staff News,
our quarterly newsletter for the medical staff. We hope that you will find timely information
and news that will keep you informed and up to date. To make navigation easy, you can click
on any article noted in the table of contents that is of interest to you and you will be taken
directly to that article or, of course, you can read the entire newsletter.
We encourage you to reach out to either of us if you have questions, comments, or
suggestions. Thank you for all that you do in support of Intermountain Healthcare and the
patients and communities we serve.
Sincerely,
Brent Wallace, MD
Susan DuBois
Chief Medical Officer
Intermountain Healthcare
[email protected]
(801) 442-3866
Assistant Vice President
Physician Relations and Medical Affairs
[email protected]
(801) 442-2840
INTERMOUNTAIN MED STAFF NEWS | THIRD QUARTER
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INTERMOUNTAIN BOARD GOALS
2015 BOARD GOAL RESULTS  JULY UPDATE
JULY 2015 – BOARD GOAL PROGRESS
Clinical Excellence
PROGRESS
Create the foundation and framework for “Zero
Harm” (eliminated all avoidable medical errors)
Patient Engagement
Goal is on track
Goal is on track
Hospital
Value-based Purchasing Patient Experience Domain
On Track
Medical Group
Rating Clinic Experience as Excellent
On Track
SelectHealth
Rating their Health Plan 8-10
On Track
Complete two of the following to be on track:
Goal is on track
iCentra installed in two regions
Off Track
iCentra installed in three regions
Off Track
30 med-surg commodity categories will be standardized by
June 30, 2015. By the end of the year, achieve at least 90%
compliance for these 30 categories and have an additional
30 categories committed to standardization in 2016.
On Track
Demonstrated improvement for enhanced completeness of
documentation and coding
Of Concern
Operational Effectiveness
Physician Engagement
Goal is on track
75% of affiliated physician practices that request iCentra
interfaces will have access
On Track
New payment model in place with physicians participating
in the shared accountability product by the end of 2015
Of Concern
Geographic region committees will be functioning in at
least four regions
Of Concern
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INTERMOUNTAIN BOARD GOALS, CONTINUED
Community Stewardship
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Goal is on track
Develop Value-based SelectHealth Commercial Product for
launch by January 1, 2016
On Track
Achieve 95% of Cash Flow Target
On Track
Achievement of Community Benefit Initiatives
On Track
Employee Engagement
Goal is on track
LiVe Well Goal – 70% of employees enrolled in a medical
plan will earn the LiVe Well participation incentive for at
least one quarter. To receive a payout an employee must
complete two learning modules and one LiVe Well activity.
On Track
Achieve a Gallup Accountability Index score of 4.33
Off Track
Achieve a Gallup Grand Mean score of 4.15
On Track
If you have questions, please contact Brent Wallace, MD, at [email protected].
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INTERMOUNTAIN
SYSTEMWIDE INITIATIVES
INTERMOUNTAIN
INNOVATIONS: USING
DATA TO IMPROVE CARE
AND REDUCE COSTS
At Intermountain Healthcare, we successfully use data
to drive value within our healthcare system. This approach
allows us to better understand, and ultimately treat,
diseases; eliminate waste from the system; align incentives
so they match desired outcomes; and provide clinicians
with all the information they need to deliver high-quality
care. Essentially, our data-driven model helps us improve
health outcomes and reduce overall costs. Here are current
examples of Intermountain innovations that harness the
power of data to drive value:
DATA-DRIVEN CARE PROCESS MODELS
• Targeting Zero Initiative: This initiative reduced surgical
site infection rates by over 50 percent, resulting in
33 fewer serious infections at Intermountain Medical
Center per year, reduced patient suffering, and saved
$650,000 per year.
• Enhanced Recovery After Surgery (ERAS) Program:
This program aimed to standardize bowel surgery and
resulted in patients being able to go home two to four
days earlier and with fewer complications. The cost
of the surgery dropped from $18,000 per patient to
$12,000 per patient.
• Activity Tracker Protocol: Giving patients pedometer
watches to measure and remind them to walk after
surgery led to increased walking, shorter length
of stay, and a 50 percent reduction in readmission
rates. Intermountain is the leader in this research
and development.
DATA-DRIVEN, PHYSICIAN-SPECIFIC REPORT CARDS
ON OUTCOMES AND COSTS
• Blood Utilization Program: This program led to a 38
percent reduction in the number of patients who get
transfusions in our system, $7.5 million less in charges
to patients for blood products over 18 months,
decreased hospital acquired infections, and decreased
1-year mortality.
• Tonsillectomy Study: We studied the cost and
outcomes of five different ways we do outpatient
tonsillectomies on 20,000 children to determine the
technique with the best outcomes, lowest cost, and
highest patient/parent satisfaction. We were able to
share this data with our ENT surgeons who each have
their own score card and can see how they compare
to their peers. This has led again to a change in
practice that has decreased cost and complications.
At Intermountain Healthcare, we
successfully use data to drive value
within our healthcare system.
POINT-OF-CARE COSTING INFORMATION TO
ALLOW TRUE MARKET FORCES TO OPERATE
• ProComp Surgical Data System: We invented the
ProComp surgical data system that allows surgeons
and OR staff to see the true cost of everything we
use to care for patients. The surgeons and surgical
teams have this information in the operating room
at the point of healthcare delivery. Sharing this data
with the surgeons, along with their outcomes, led to
the surgeons deciding what was worth the cost and
what was not on behalf of their patients. This led
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INTERMOUNTAIN SYSTEMWIDE INITIATIVES, CONTINUED
to $43 million in savings in 2014 and $38 million in
lower charges to payers in the same time period. This
is currently being commercialized to share with other
healthcare systems.
EQUIPMENT-SPECIFIC VALUE DATA ANALYSIS
• EEA Staplers: After a cost and outcomes analysis
of two EEA staplers showed that both devices have
the same outcome, we got the supplier of the more
expensive device to match the price of the less
expensive device, saving $235,000 per year.
If you have questions, please contact Mark Ott at
[email protected].
PATIENT EDUCATION
LIBRARY NOW AVAILABLE
ON THE HEALTH HUB
MOBILE APP
Intermountain’s patient education library is now
available through the Intermountain Health Hub mobile
app. This on-the-go resource gives your patients easy access
to health information documents you may share during a
clinic or hospital visit: Patient Fact Sheets, Let Talk About…
info sheets, etc.
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We encourage you to let your patients know about this
convenient resource. The patient education feature lets
patients and physicians:
• Easily search for documents by name
• Navigate through a consumer-friendly list of medical
topics
• Filter adult versus pediatric documents
• “Favorite” documents for easy future reference
• Save documents to a mobile device
• Quickly share documents with others through email
You and your patients can download the Health Hub app
from Intermountain’s Mobile App Center or directly from
the App Store or Google Play. Search for “Intermountain
Health Hub.”
Intermountain’s Mobile App Center
If you have questions, please contact Tammy Richards at
[email protected].
TRANSPARENCY
INITIATIVE 
DATA COLLECTION
AND SHARING
Intermountain’s overall transparency initiative is
designed to provide clinicians and patients with complete
and accurate data on patient experience (satisfaction),
healthcare costs, quality, and patient safety. We believe
strongly that this type of data will engage patients in
making healthcare decisions and will help clinicians improve
overall outcomes in these areas.
DATA COLLECTION AND SHARING
A recent study conducted by National Research Corporation
looked at people’s behavior as they determine who to go to
for healthcare. The study discovered the following:
• 77 percent of consumers begin their healthcare
search online
• 45 percent read online reviews before booking
an appointment
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• 29 percent of consumers claim that viewing online
ratings/reviews is their first step in a doctor search
• 1 out of 3 patients said they have changed their
mind after reading negative reviews online
• 52 percent of seniors ages 65 and older view
ratings/reviews
• 70 percent of consumers would like to see performance
data before choosing a healthcare provider
Recognizing the importance of this type of consumer data,
we partnered with Dan Jones/Cicero to survey SelectHealth
and Medical Group patients by telephone about their
outpatient clinic visit experience beginning in March 2015.
These surveys consist of nine approved CG-CAHPS patient
experience questions. The data collected from the surveys is
shown as star-ratings (generated by our third party partner,
National Research Corporation) and patient comments on a
public site.
We began sharing the results and verbatim comments
with physicians on June 1, 2015 and began posting the
star-ratings and verbatim comments on our public-facing
provider directories on July 31, 2015.
KEY ELEMENTS OF THE PATIENT EXPERIENCE
TRANSPARENCY INITIATIVE
• Patients are notified at the beginning of the phone
survey that their responses are anonymous and will
be used to create a star-rating. They are told their
comments will be posted on Intermountain and/or
SelectHealth’s provider directories.
• Questions are limited to only the patient/physician
interaction at the time of the appointment.
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verbatim comments. Of those comments, 83 percent of
comments were positive, 7 percent were negative, and 10
percent were a mix of positive and negative.
NEXT STEPS
The next priorities for the patient experience transparency
initiative are to focus on the following:
• Patient experience with physicians for hospital-based
outpatient services: Outpatient Surgery, Emergency
Room, and Radiation Oncology
• Patient experience with physicians for InstaCare,
KidsCare, and WorkMed
• Patient experience with physicians for inpatient services
• Clinic level ratings / comments (roll-up of all physicians)
• Inclusion of all clinicians
• Hospital ratings and comments
If you provide outpatient services, please take the time to
review your ratings by logging into the Physician Portal at
www.intermountainphysician.org, then click on the
patient experience link under tools and resources.
We understand this initiative may raise questions or
concerns for physicians. If you have questions or would like
more information about the initiative, please contact
Dr. Brent Wallace, Chief Medical Officer
([email protected] | 801.442.3866) or
Susan DuBois, AVP, Medical Affairs
([email protected] | 801.442.2840).
• Physicians need at least 30 ratings to have a
public profile.
• Ratings will roll off the public site on an 18-month cycle.
• The data are updated daily.
• All comments are reviewed. We are committed to
posting all comments so long as they don’t contain
vulgar language or patient identifiable information.
• Physicians are notified when we receive a negative
comment before it is posted to the public-facing
directory.
Between March 1, 2015 and July 31, 2015, we collected
70,533 patient surveys. During that same time frame, we
collected data on 2,211 physicians, with the average starrating for these physicians being 4.64 out of 5. More than
1,400 physicians met the required 30 ratings and have a
public profile. About 90 percent of all patients provided
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ALL OLD ID BADGES WILL
EXPIRE ON DECEMBER 31
As you may know, all Intermountain employees and
affiliated physicians are currently transitioning to a new ID
badge. This new ID badge enhances patient safety at our
facilities, as well as complies with a new state law regarding
healthcare provider identification. If you have not gotten
your new badge yet, please do so as soon as possible.
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ZERO HARM UPDATE
As a result of your help over the past few months, we
have completed the first of three important milestones in our
journey toward Continuous Improvement – Zero Harm.
After December 31, all old badges will expire. You will
not be able to access Intermountain’s clinical systems,
computers, buildings, Kronos, Courier Services, and other
resources without your new badge.
You can get your new ID badge during regular work hours
(9 a.m. to 5 p.m.) at the following locations:
• Any Intermountain hospital in Utah
• Intermountain’s Employee Services Center in Murray
• Intermountain’s Central Offices in downtown
Salt Lake City
Call ahead to the Security or Human Resources Department
in your region to make sure there is ID badge coverage
at the time and location you plan to visit. Contact your
manager to see if Human Resources will be scheduling an
ID badge session at your clinic.
Some medical staff have requested two name badges
to keep in multiple locations when they’re on call (in a
spouse’s car, for instance). If you’re regularly on call or
otherwise need two badges, you can make the request
wherever you get your badge (usually Security or HR,
depending on the facility). Allowing two badges is
ultimately at the discretion of each hospital’s medical
director.
Name Badge FAQ
If you have any questions about getting your new ID badge,
please review the Name Badge FAQ or contact the Security
or Human Resources Department in your region.
Diagnostic and safety culture assessments are finished at each
of our hospitals and in the Salt Lake Clinic, Central Region.
These assessments involved:
• Reviewing all serious patient harm events over the
last three years
• Classifying those events in serious safety event categories
• Calculating a Serious Safety Event Rate (SSER) for the
hospital/regions and Salt Lake Clinic
• Completing interviews with hundreds of staff, leaders,
and physicians across the Intermountain system to help
understand current perceptions of our safety culture
Our data suggests that although we have a strong vertical
approach to keep patients safe – for example, our best
practice care process bundles like central line infections,
surgical site infections, and hand hygiene monitoring – this
tactical approach is not sufficient. We need to establish a
horizontal/cultural approach based on behavioral interventions
if we expect improved safety for our patients and staff. This
cultural shift must be owned and lead by physicians.
In partnership with Healthcare Performance Improvement
(HPI), we are currently educating all Intermountain physicians,
leaders, and staff on targeted leadership commitments.
In the next few months you will be invited to participate
in Leadership Methods classes. You can begin to practice
these commitments (shown below) and implement
the accompanying behaviors immediately. The Safety
Commitments documents and other tools are available on the
Intermountain Zero Harm website.
continued on next page
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Many of you will be asked to participate in education,
attend daily safety briefs, and join Safety Event Review
Panels (SERP teams). Our Continious Improvement – Zero
Harm efforts must by driven and supported by each of you.
If you have further questions, please contact Brent Wallace,
your Regional Performance Improvement Leader, or your
Regional Quality Director.
INTERMOUNTAIN
HEALTH ANSWERS IS LIVE
POST-DISCHARGE PATIENT CALLING SERVICE
Intermountain Health Answers launched discharge
calling at Intermountain Medical Center and LDS Hospital
for inpatients and ED patients. Patients receive an
automated call 24 to 48 hours post discharge to follow
up on clinical symptoms and to ensure they make a
seamless transition back to a primary care provider. They
are asked about their understanding of their discharge
instructions, getting prescriptions filled, and getting followup appointments scheduled. If they have any concerns, a
registered nurse from the Clinical Communications Center
calls them back to answer questions and resolve any issues.
The rest of the Central Region and Primary Children’s
Hospital will receive the service over the next few months.
It will be implemented throughout the system by Q1 2016.
After Leadership Methods training is complete, every leader,
physician, and Intermountain employee will be expected
to complete Error Prevention training. These techniques
will further specify six behavioral changes we can all learn,
practice, and incorporate into our individual daily practice.
Once trained, together we will be 10 times less likely to
experience a human error and harm a patient.
You, as a physician, set the tone and move us along our
course by:
• Demonstrating a commitment to safety
• Giving people license to speak up for safety, then
thanking them for doing so
• Practicing the six error prevention techniques
It’s not just about being seen, it’s about what you are
doing and asking.
Early results have been very positive. The automated call
has reached 60 percent of inpatients, with 14 percent
requiring a follow-up call for issue resolution. The reach
rate for ED patients is at 42 percent, with 7 percent
requiring a follow up. The nurses have helped patients
schedule follow-up appointments, clarified discharge
instructions, and assisted in getting prescriptions filled.
A Success Story
A patient was discharged from an inpatient unit. When
the nurse from the Clinical Communication Center talked
to her, the patient shared that she did not have a required
oxygen tank. The nurse was able to conference with the
home health agency and make arrangements for a prompt
delivery of the needed equipment.
INBOUND ADVICE LINE
The inbound advice line is up and running 24/7 for
SelectHealth members and uninsured patients who have
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medical concerns. Using nationally recognized protocols,
the RNs triage patients to the most appropriate care setting,
which will range from home care to the emergency room.
Initial call volume has been predictably slow, but an increase
is expected as marketing materials are distributed.
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(IPAS) will also provide additional training to all inpatient
physicians, including affiliated providers, and is currently
scheduling training meetings before October 2015. In
addition Medical Group coders will provide education and
training to all Intermountain employed physicians.
CMS Press Release - July 6, 2015
If you have any questions about Health Answers, please
contact Ben Becker, Director of the Clinical Communication
Center, at 801.442.3258 or [email protected].
ICD10 IMPLEMENTATION
BEGINS OCTOBER 1, 2015
According to a CMS press release on July 6, 2015, the
Centers for Medicaid and Medicare Services (CMS) and
the American Medical Association (AMA) announced a
joint effort to ease the transition from ICD-9 to ICD-10
for physicians, providers, and payers. “The International
Classification of Diseases, or ICD, is used to standardize
codes for medical conditions and procedures. The medical
codes the US uses for diagnosis and billing have not been
updated in more than 35 years and contain outdated,
obsolete terms. On October 1st, the transition for ICD-9 to
ICD-10 will occur. Medicare claims processing systems will
not have the capability to accept ICD-9 codes for dates of
services after September 30, 2015, nor will they be able to
accept claims for both ICD-9 and ICD-10 codes.”
Intermountain Healthcare is committed to adopting the new
ICD-10 standards scheduled to go live on October 1, 2015.
Providers can begin to familiarize themselves with these
new standards by reviewing Precyse University’s compliance
training content available on Intermountain’s ICD-10
website. The Intermountain Physician Advisory Service
Intermountain’s ICD-10 website
ICD-10 CONTACTS BY REGION
REGION
CONTACT PERSON/EMAIL
North Region
Dr. Timothy Trask
timothy.trask@
intermountainmail.org
Central Region
Dr. Jason Spaulding
[email protected]
South Region
Dr. Daniel Ricks
[email protected]
Southwest
Region
Dr. Christine Foster
[email protected]
Rural & System
Dr. Masood Safaee
[email protected]
Medical Group
Adam Freebairn
[email protected]
Jason Denson
[email protected]
If you have any questions or you need additional
information regarding ICD-10 education, please contact the
appropriate person listed above.
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iCENTRA UPDATE
IMPROVEMENTS TO
ICENTRA AHEAD OF
OCTOBER 24 LAUNCH IN
NORTH REGION
iCentra will be implemented starting October 24 at
McKay-Dee Hospital, Cassia Regional Medical Center, and
Medical Group clinics in Weber and North Davis counties.
The iCentra configuration required for these locations
is nearing completion and will be finished and tested
in August.
Below are details about what we learned from the first
iCentra implementation in Logan and Bear River, what
improvements we made to the system, and how training
will be provided to those in the North Region.
• Since going live in Logan and Bear River earlier this
year, we’ve worked with our colleagues in the North
Region to understand and improve the user experience
and expand the support resources available to all
users. We redesigned key workflows, and the majority
of employees and physicians are using the system
effectively.
• We’ve made significant improvement in stabilizing the
system. Now 99 percent of sessions are disruptionfree. Initial problems with software memory leaks
that caused slowdowns or freezes have substantially
improved.
• The majority of Revenue Cycle metrics have improved,
and we’re keeping up with new accounts and claims.
Some earlier work queue issues are still being resolved,
but bills are going out and are being paid.
• We heard from many of those in the first
implementation that we needed to completely retool
the training curriculum, so we made many sweeping
improvements to the learning process that happen
both before and after go-live.
• Physician training will focus on computerized
physician order entry and their most common
workflows. In the hospital, these include admission,
rounding, discharge, and some examples of
complex orders.
• Physicians will complete a self-assessment to
establish readiness. One-on-one assistance with a
physician coach will supplement any knowledge
gaps. Best practices for physicians, such as the use
of templates and macros in Dragon Dictation, are
included in the training activities.
• Staff training will consist of classroom and on-unit
practice as they learn new workflows.
• The training domain includes most of the recent
system changes and is quite similar to the
production environment. New items that can’t be
put in the training domain are being identified to
address with staff.
• An important reminder for physicians and staff:
Pre go-live training is the first step of training.
Most learning occurs as you use iCentra. We’ll be
communicating soon about how physicians and nurses
in the North Region can practice in iCentra in the
months preceding implementation.
Intermountain has always been a leader in using technology
in innovative ways to help everyone work together to
improve care. iCentra represents the next step toward
meaningful solutions and technology that physicians,
nurses, and healthcare consumers can use now and into
the future.
If you have any questions, please email [email protected].
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SHARED ACCOUNTABILITY UPDATE
NEW SELECTHEALTH
SHARE PRODUCT
LAUNCHED
Recently, Intermountain Healthcare reached an
important milestone in our journey toward high-value
healthcare with the announcement of SelectHealth
Share—a new commercial health plan product for large
employers effective January 2016. This product represents
many years of planning and effort from both Intermountain
and SelectHealth.
SelectHealth Share offers affordable and predictable
rates—a three-year proposal with guaranteed rates in years
two and three. For participating large employers starting
in 2016, the guaranteed rates for years two and three is
4 percent—closer to the general inflation rate. This rate
structure is revolutionary and transformative in the health
insurance market.
With SelectHealth Share, all participants are accountable:
• Provider compensation reflects productivity, quality,
service, and total cost-of-care goals
communication applications, and cost transparency.
Patricia R. Richards, President and Chief Executive Officer
for SelectHealth, says, “We believe that a highly engaged,
collaborative relationship between individuals and their
providers is the foundation for high-value care at an
affordable cost, while helping people live the healthiest
lives possible.”
Built on a population health model. Distinct from
historical fee-for-service health plan products, SelectHealth
Share is built on a population health model that rewards
highly effective care. In this context, population health is
when healthcare provider organizations (health systems,
hospital organizations, physician groups) take on financial
accountability for the health of a population. A payer, such
as SelectHealth, contracts with the provider organization to
prepay a set dollar amount for a covered population (such
as a group of employees). We are committed to improving
population health. This is consistent with our mission—
helping people live the healthiest lives possible.
The SelectHealth Share product is an example of tangible
savings to patients and the community. We believe this
approach, which is based on a sustained commitment from
all participating parties, is the future of healthcare.
• Employers support and engage employees in a culture
of health
• Employees collaborate in making decisions that affect
their care and its cost
• SelectHealth provides innovative benefit plans that
engage members for better health
This is a sustainable model, driving continued innovation,
affordable costs, and better health outcomes. Numerous
tools are used to support this unique arrangement,
including advanced product designs, engaging wellness
programs, care management, digital and telehealth
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SHARED ACCOUNTABILITY UPDATE, CONTINUED
INTERMOUNTAIN AIMS TO PROVIDE
HIGHER QUALITY CARE WHILE
CREATING A MORE AFFORDABLE
COST TREND LINE.
When Intermountain launched our Shared
Accountability efforts in 2011, we had just
completed a five-year projection showing our
patient revenue growing at historical rates. We
set a goal to bring the healthcare trend line down
by growing healthcare spending at a slower rate.
Our goal was to provide all the appropriate
care, continue to improve quality, and bill the
community $700 million less by 2016 than we
would have if we didn’t make any changes.
We will achieve $300 million projected savings
to the community through efficiencies and
economies of scale. An additional $120 million
in lowered projected cost increases will be
achieved through continued improvements in
supply expenses and through our Staffing Best
Practices initiative. The remaining goal of $280
million in lowered projected cost increases will
come through better managing the amount of
healthcare provided, or “right-sizing” utilization
by following best practices related to appropriate
use of tests and treatments.
We are on track to achieve our goals. Last year,
we collected $400 million less than we would
have collected had we not launched the Shared
Accountability initiative.
Overall, demand for healthcare will continue to
grow. By providing care as effectively as possible,
we can optimize health, maintain high clinical
quality, and “bend the cost curve” so that care is
more affordable and available to those who need it.
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A network of more than 2,200 physicians supports
SelectHealth Share. SelectHealth has contracted with
physicians to serve on provider networks supporting
SelectHealth’s Share, Medicare Advantage, and Medicaid
products. These networks will grow to meet the overall
demand of the marketplace. Participating physicians agree
to “18 Shared Commitments” covering:
• Clinical excellence, integration, and improvement
• Patient access
• Accountability, operational commitment, and mutual
respect
We are developing measurement tools for these
commitments to be mutually supportive and to enable
collective success.
As a true collaborative effort, physicians are involved at
all levels of development and governance. A physician
payment model supporting these networks pays for care
provided, plus a performance-based payment for meeting
quality, service, and budget goals.
A Physician Payment Governance Committee, chaired
by Chief Medical Officer Brent Wallace, MD, will make
recommendations on measures, targets, and incentives;
consult on changes to and implementation of the model;
consult on population health contracts; and solicit input
from physicians. Committee members include affiliated
physicians, Medical Group physicians, Intermountain
leaders, and SelectHealth leaders.
Expanding the model to other health plan payers. In
addition to SelectHealth products, Intermountain plans to
enter into similar population health contracts with other
highly aligned health insurance payers. Intermountain
plans to contract with Intermountain Medical Group
and affiliated providers to organize a new Intermountain
provider network. This network will be similar to the
SelectHealth Share network, but will be a legally distinct
network to comply with Utah law. Intermountain will offer
this new provider network, along with hospital and other
healthcare services, to highly aligned payers for population
health contracts.
Physicians must be on the SelectHealth Share panel
to participate in the new Intermountain network.
However, if a physician chooses not to participate on the
Intermountain network, it will not affect their relationship
with SelectHealth. Further, providers participating on the
Intermountain provider network do not need to accept
patients from all payers that enter into population health
contracts with Intermountain.
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SHARED ACCOUNTABILITY UPDATE, CONTINUED
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Geographic committees are organized in each region
to support physicians in providing care to people
through timely access to network clinics and hospitals,
service excellence, quality of care, use of resources, and
other shared commitment objectives. These committees
are co-chaired by physician and administrative leads and
include both Medical Group and affiliated physicians.
Geographic committees do not have operational
responsibilities.
Improving quality of care while keeping costs affordable is
a key priority for Intermountain Healthcare, as articulated
by our vision, which says we’ll “Be a model health system
by providing extraordinary care and superior service at an
affordable cost.”
If you have any questions, please contact Steve Burrows at
[email protected].
13
COMPLIANCE UPDATE
UNDERSTANDING THE
ANTIKICKBACK STATUTE
At Intermountain we aim to foster a culture of
ethical behavior and compliance with federal and state
regulations and organizational standards. As a physician,
you play an important role in ensuring compliance at
your clinics and hospitals. Please be aware of specific
regulations related to your field, such as the Anti-Kickback
Statute, and report concerns.
CASE STUDY
Health Diagnostic Laboratory, Inc. (HDL) opened in 2008 and sold
laboratory tests that measured cardiovascular biomarkers. With
their process, as many as 28 tests could be conducted on one
vial of blood. Medicare may pay as much as $1,000 for some
configurations of these bundled tests. By 2013, HDL reported
$383 million in revenue.
HDL was allegedly paying physicians between $10 and $17
per referral for processing and handling fees, significantly
higher than most other labs. Some physicians reportedly made
thousands of dollars a week from this arrangement. The lab
also had a practice of routinely waiving patient co-pays and
deductibles, leading to the submission of unnecessary tests billed
to federal healthcare programs like Medicare.
As a result, three whistleblower lawsuits were filed under the
federal False Claims Act, and the Department of Justice (DOJ)
intervened. The DOJ alleged that the processing and handling
fees were kickbacks to induce physicians to refer patients to HDL.
While admitting no guilt, HDL settled for $47 million, entered
into a five-year corporate integrity agreement with the
Department of Health and Human Services’ Office of Inspector
General, replaced its CEO, filed for Chapter 11 bankruptcy
protection, and is awaiting permission from the Bankruptcy
Court to sell the company.
The takeaway message from this case study is something
we instinctively know – if it sounds too good to be true,
it probably is. Caution is advised when entering into
arrangements where the remuneration (on either side
of the transaction) is not commercially reasonable. For
example, when items or services are offered for free or
far below fair market value or when payment for services
greatly exceeds the normal going rate, there may be some
risk that one party is trying to induce or reward referrals
from the other.
The Anti-Kickback Statute prohibits offering, paying,
soliciting, or receiving remuneration to induce referrals of
items or services covered by federally funded programs.
The statute is intended to ensure that medical judgment
is not compromised by improper financial incentives and
is instead based on the best interests of the patient.
Kickbacks are said to drive up the cost of federal healthcare
programs with medically unnecessary tests. Violation of the
statute constitutes a felony punishable by a maximum fine
of $25,000, imprisonment up to five years, and automatic
exclusion from federal healthcare programs.
The Anti-Kickback Statute is also often used as the basis
for a False Claims Act prosecution. The DOJ says that the
False Claims Act is one of its most powerful tools to control
financial fraud in federally funded healthcare programs.
Since January 2009, it has recovered more than $15.2
billion in such cases.
Please be attentive to your transactions as criminal liability
attaches to both sides of such a transaction under the AntiKickback Statute.
If you have any questions or concerns regarding
compliance at Intermountain, please contact Don Martin at
[email protected].
14
QUALITY & PATIENT SAFETY UPDATE
IT HAPPENED HERE 
RETAINED FOREIGN
OBJECTS
Learning From Our Mistakes
CASE #1 DISPOSABLE WASHCLOTH
A baby’s umbilical cord tore during delivery, and the mother
suffered a 2nd degree laceration. The physician placed
a disposable washcloth in the vagina to help control the
bleeding, turning his attention to the infant with concern
of hypovolemia due to the torn cord. Radiopaque sponges
with tails are usually used in the vagina. During the
laceration repair, the physician failed to recheck the vaginal
cavity. A pre and post-delivery sponge count was performed
and recorded as correct. Washcloths are not part of the
count procedure.
What We Learned
• What were the causes: (equipment/supplies) Physician
used washcloth instead of the radiopaque sponges.
• What we learned: Equipment/supplies should be
used for intended purposes only. Any deviation from
the normal process needs to be communicated to all
procedural team members and documented.
CASE #2 WOUND VAC GRANUFOAM DRESSING
Six days after a back fusion, a 43-year-old female returned
to the hospital with a wound dehiscence and infection. She
returned to surgery for an I & D. A Wound VAC was placed
with six Granufoam dressings used during the procedure.
The patient underwent multiple dressing changes over
time. The patient continued to spike fevers and developed
significant mental status changes, elevated white blood
count, and hypoxia. The wound was explored, and retained
Granufoam dressings from the original Wound VAC
application were discovered deep in the wound.
What We Learned
• What were the causes: (procedural compliance)
Surgeon did not document the number of Granufoam
dressings used on the correct form or in the operative
report. As a result, the OR staff and the nursing
staff on the unit were not aware of the number of
Granufoam dressings originally inserted.
• What we learned: Use the appropriate procedure
and documentation forms and communicate to all
team members.
CASE #3 HEMOVAC
A 53-year-old male had a right total hip replacement with
a Hemovac drain placed but not sutured to the skin. At
the end of the case, the scrub tech held the dressings and
drain tubing in place and trimmed the tubing too close to
the skin. This caused the drain tubing to pull back into the
patient’s skin as the surgeon removed the drapes. Team
members assumed the drain had come out and steristripped the wound. Drain segments were not inspected.
The surgeon was informed the drain had accidently come
out. Charting initially stated drain placement. This entry
was later crossed out. On post-op x-ray, the retained drain
segment was not obvious. Upon returning six weeks later,
the retained drain segment was identified on x-ray and
removed without complications.
What We Learned
• What were the causes: (distraction) Scrub tech
distracted by multiple end-of-case activities and
inadvertently cut drain tubing off too short, thus it
pulled back under the skin and was not seen. (handoff) When patient was transferred to other areas for
ongoing care, care providers did not notice there was
no Hemovac drain in use, which is standard in a hip
replacement procedure.
• What we learned: ALL individuals who care for
patients need to be empowered to ask questions
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TABLE OF CONTENTS
QUALITY & PATIENT SAFETY UPDATE, CONTINUED
and speak up if things are out of the norm. We will
learn more about this as Zero Harm techniques are
rolled out regionally. In this case, no one stopped
and questioned why there was no drain placed on a
post-op hip patient. No validation steps were taken by
the physician and staff in consideration for risk of a
retained foreign object.
CASE #4 PORT-A-CATH
A 24-year-old female required a port-a-cath for
chemotherapy. This device has three pieces – the last
part should be tightened prior to insertion. The cath was
placed in Interventional Radiology and when no longer
needed, removed without difficulty about eight months
later. Approximately seven weeks after removal, the
patient noticed a hard lump in her chest. She was already
scheduled for an additional scan to evaluate response to
chemo. During this exam, a retained piece of the cath was
seen in the chest area. It was removed without difficulty.
NEXT
• What we learned: It was not clear who was
accountable for inspection and documentation of
the device. No clarity of roles. It is important to
remember to submit an iReport anytime there is a
device malfunction or failure. This action will support
further notification to the FDA for future product
improvement.
CONFIDENTIAL: This information is for an Intermountain
Healthcare Peer or Care Review Committee to evaluate and
improve healthcare. See Utah Code 26-25-1, et seq., U.R.C.P.
26(b)(1), or Idaho Code 39-1392, et seq.
If you have questions, please contact Jeanne Nelson at
[email protected]
What We Learned
• What were the causes: (human
factors) The individual who is
explanting a device needs to inspect
the device upon removal to ensure it
is complete and all pieces, including
the cuff, are accounted for and
documented appropriately.
16
CLINICAL PROGRAM &
SERVICE LINE UPDATE
Behavioral Health
AN INTEGRATED
APPROACH TO
BEHAVIORAL HEALTH CARE
The Behavioral Health Clinical Program continues to
implement a model that emphasizes overall health and
wellness, integration of services, and treatment of each
patient in the most appropriate setting. A systematic
approach is in place to enhance current services and
increase coverage across the system. Work has begun
in three regions to introduce Behavioral Health Access
Centers. The BHCP is assisting regional leadership teams to
define Access Center roles and anticipate budgeting and
recruiting needs. Behavioral Health teams in every region
are actively involved in recruiting providers and clinicians to
meet these demands.
The Behavioral Health Clinical Program is revising its
webpages on Intermountain.net to meet providers’ varied
needs. New pages will increase access to resources, share
information, and connect providers between specialty and
primary care clinics. In collaboration with United Way of
Salt Lake, Intermountain’s Integrated Care Management
team has established a resource list called 2-1-1 for use
by providers and clinicians. Links to 2-1-1 are located on
the new BHCP Community Resources page, along with
additional mental health and substance use disorder
resources by community.
In addition to new resources, the Behavioral Health Clinical
Program has been presenting the Suicide Prevention Care
Process Model at Medical Group Clinical Learning Days.
Acute care sessions have been held at various facilities with
Behavioral Health Units. Program leadership invites any
groups that may be interested in a thorough review of the
Suicide Prevention CPM or the Substance Use Disorder CPM
to please contact Carolyn Tometich.
If you have any questions about Behavioral Health Clinical
Program activities, please contact Carolyn Tometich at
[email protected].
17
Cardiovascular
INTERMOUNTAIN CV
PROGRAMS RECEIVE
NATIONAL ATTENTION
Within the Cardiovascular Clinical Program, we
continuously refine our clinical processes in order to ensure
high-quality care, service, and value for our patients. This
commitment to excellence is reflected in the success of our
CV programs, which recently received national attention. Our
program to rapidly treat STEMI patients systemwide specifically
gained national recognition for its success. Likewise, our heart
failure program was recognized for having some of the lowest
30-day readmission rates in the nation for hospitalized heart
failure patients.
ICENTRA UPDATE
We are excited by the progress being made to develop
comprehensive order sets for most clinical processes in
cardiology, electrophysiology, CV surgery, vascular surgery,
and thoracic surgery. These order sets appear to successfully
manage the office/hospital workflows using the Cerner
structure. Many clinicians throughout our system have
contributed significantly to the clinical content.
If you have questions, please contact Donald Lappe at
[email protected].
Imaging Services
TRANSITION TO
STRUCTURED
REPORTING OF IMAGING
EXAMINATIONS
Radiology reports are produced using voice dictation.
Traditionally, each radiologist has used his or her personal
approach, resulting in reports that vary considerably in
style, completeness, and content. In an effort to better
serve the needs of referring clinicians, Intermountain
Imaging Services is working with subspecialty radiology
leaders (section chiefs) and their respective clinical
colleagues to develop and deploy a standardized system for
formatting imaging reports. The intent is to: 1) standardize
formatting and headings; 2) ensure that clinical content
required by referring physicians is always included in the
report; and 3) bring consensus between radiology and
other clinical leaders around standardized content based on
best medical evidence.
The first set of standardized reports deployed on August
11. These reports were largely in pediatrics, but also
included standards for lung cancer screening CT reports.
These standardized reports were developed with significant
multidisciplinary input. Multidisciplinary groups are working
on standardized templates for other exam types, and the
portfolio of standardized report structures will increase
over time. We are confident that these changes will
improve efficiency for referring physicians and improve the
completeness and accuracy of imaging reports.
If you have questions, please contact Keith White at
[email protected].
18
Intensive Medicine
FOCUS ON REDUCING
OPIOID ABUSE
AND MISUSE
Dr. Brent James memorably said, “We count our
successes in lives.” In cooperation with Intermountain
Healthcare Community Benefits and the State Department
of Health, the Intensive Medicine Clinical Program (as well
as several other clinical programs) has embarked upon
a multiyear initiative to reduce unintentional deaths due
to opioid abuse and misuse. It was a long and winding
road that got us here, and it will take a sustained effort to
reverse the trend of this healthcare tragedy.
As many clinicians know, over the last two decades,
hundreds of thousands of Americans have died from
unintentional overdose on prescription medications.
Opioid pain relievers, such as morphine, hydrocodone,
oxycodone, and methadone, are the class of medication
most strongly associated with these deaths. Trade
names of these medications are among the most widely
recognized prescription drugs in America: Vicodin, Lortab,
and Percocet. Many times our patients ask for these
medications by name.
In the 1990s, the American Pain Society launched a
campaign to highlight the under-treatment of pain by
American physicians. The campaign recommended more
frequent pain assessments and improved analgesia through
use of opioid pain relievers. (The campaign was funded and
strongly influenced by manufacturers of these drugs.) The
Federation of State Medical Boards, the Joint Commission,
and other influential healthcare organizations soon adopted
policies supporting this emphasis on pain control. Physician
colleagues in all specialties decried the unnecessary
suffering of our patients due to inadequate use of opioid
pain medications.
The number of opioid prescriptions subsequently
skyrocketed. Between 1991 and 2013, the number of
opioid prescriptions in the United States doubled on a
per-capita basis from 76 million prescriptions in 1991
(305 prescriptions per 1000) to 207 million in 2013
(655 prescriptions per 1000).(1) The quantity of opioids
prescribed increased even more quickly. Between 1997 and
2007, the per-capita dose of prescribed opioid in the United
States increased from 96 milligram morphine equivalents
(MME) to 700 MME. This quantity would be sufficient
for every US adult to take a 5mg tablet of hydrocodoneacetaminophen (Vicodin) every four hours for a month.(2)
As prescription volume and strength increased, rates of
death increased in parallel.(2) Prescription opioid overdose
deaths more than tripled from 1991 to 2011, with 16,917
deaths reported in 2011. Prescription opioids represented
21 percent of all poisoning deaths in 1999, but by 2006
that proportion had grown to 37 percent.(3) Since 2003,
deaths from prescription opioids have exceeded those from
heroin and cocaine combined.(4,5) In 2011, unintentional
drug overdose was the leading cause of death among
individuals between age 25-44, and it surpassed motor
vehicle collision to become the overall leading cause of
death from unintentional injury.
Utah was not immune to these trends. In fact, Utah has
been one of the states most affected by the scourge of
opioid abuse and misuse. From 1999 to 2007, the number
of prescription opioid deaths in Utah increased over 600
percent, from 39 to 261 cases per year.(6) Methadone was
responsible for the largest number of prescription opioid
deaths in Utah from 2000 to 2006, although only half of
these individuals had a valid prescription for methadone
when they died.(6) By 2008, Utah had the second-highest
age-adjusted rate of drug overdose in the country, with
18.4 deaths per 100,000 compared to the national average
of 11.9 deaths per 100,000.(7) While there has been some
slight improvement in these statistics in recent years, the
incidence and prevalence remains unacceptably high.
“We count our successes in lives.”
– Dr. Brent James, Chief Quality Officer at
The Intensive Medicine Clinical Program has and will
play a significant role in ensuring proper use of opioid
medications. No one has to practice very long in our
hospitals to be touched by a patient or a family who has
suffered from opioid misuse, overdose, hospitalization, or
even death. And even when we leave the hospitals and
return to our own neighborhoods we don’t have to look
far to see family members or neighbors that have been
devastated by the scourge of this disease. As a leading
healthcare organization, we have a moral and professional
imperative to try to do something.
19
TABLE OF CONTENTS
CLINICAL PROGRAMS AND SERVICE LINE UPDATES, CONTINUED
Consequently, a number of organizations including
Intermountain Healthcare have organized together to
create the Utah Pharmaceutical Drug Community Project
(UPDCP), and Intermountain Healthcare has graciously
provided a large portion of the funding for this effort.
The aims of the UPDCP are to:
• Understand the opioid abuse problem relevant to each
clinical program and practice setting,
• Ensure clinicians know how Intermountain is getting
involved in the problem of opioid use and misuse,
• Ensure clinicians know which of their patients are most
at risk for misuse and abuse of opioid medications and
are thus at the most risk of overdose and death,
• Understand why opioids are over-prescribed, and
• To teach how our clinicians can make a difference in
preventing this huge medical and societal harm.
Under the direction of Intermountain Healthcare
Community Benefits, the IMCP is working with other
clinical programs, data analysts, and administrators to meet
the aims above. Currently the clinical program leaders
are traveling and meeting with the clinical groups across
the spread of Intermountain Healthcare in department or
other clinical meetings. In coming years, further initiatives,
including best practice guidelines and clinician-specific
prescribing data, will be deployed to help meet the aims of
the UPDCP.
The IMCP has long been involved in making the delivery
of healthcare safer, reliable, and patient-centered. This
initiative fits perfectly within that history and will help
us save lives consistent with the main measure of our
collective success.
NEXT
Sources:
1. Volkow ND. Testimony on Prescription Opioid and
Heroin Abuse before US House Committee on Energy
and Commerce, Subcommittee on Oversight and
Investigations. April 29, 2014. http://www.drugabuse.
gov/about-nida/legislative-activities/testimony-tocongress/2014/prescription-opioid-heroin-abuse.
Accessed July 1, 2014.
2. Centers for Disease C, Prevention. Vital signs:
overdoses of prescription opioid pain relievers---United
States, 1999--2008. MMWR. Morbidity and mortality
weekly report. Nov 4 2011;60(43):1487-1492.
3. Warner M, Chen LH, Makuc DM. Increase in fatal
poisonings involving opioid analgesics in the United
States, 1999-2006. NCHS data brief. Sep 2009(22):18.
4. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths
from opioid analgesics in the United States.
Pharmacoepidemiology and drug safety. Sep
2006;15(9):618-627.
5. CDC. CDC grand rounds: prescription drug overdoses
- a U.S. epidemic. MMWR. Morbidity and mortality
weekly report. Jan 13 2012;61(1):10-13.
6. Johnson E. HB 137 Final Report. 2009; http://health.
utah.gov/prescription/pdf/2009final_programreport.
pdf. Accessed July 1, 2014.
7. Centers for Disease C, Prevention. Adult use of
prescription opioid pain medications - Utah, 2008.
MMWR. Morbidity and mortality weekly report. Feb
19 2010;59(6):153-157.
If you have any questions, please contact SarahAnn
Whitbeck at [email protected].
20
Musculoskeletal
BUNDLED PAYMENT CARE
INITIATIVE BPCI
The following are Intermountain Healthcare hospitals
within these counties that perform Lower Extremity Joint
Replacement and are required by CMS to participate with
the Bundled Payment Model:
The Musculoskeletal Clinical Program (MSKCP) met
with physician representatives on July 28 to discuss the
new CMS mandate regarding the Comprehensive Care for
Joint Replacement (CCJR) Model or Lower Extremity Joint
Replacement (LEJR) Model. Please review the summary
of this initiative.
• American Fork Hospital
CMS identified the mandatory participation of most
hospitals performing Lower Extremity Joint Replacement
in 75 metropolitan areas, by their respective county,
within the United States. The Bundled Payment Model
is scheduled to begin on January 1, 2016. The two
Metropolitan Statistical Areas (MSAs) identified by CMS for
Utah are as follows:
• Utah Valley Regional Medical Center
• Ogden-Clearfield, UT: Box Elder, Weber, Davis, and
Morgan Counties
• Bear River Valley Hospital
• McKay-Dee Hospital
• Orem Community Hospital (does not perform LEJR
procedures)
Please take time to review the summary of this CMS
initiative, and share it with the appropriate people in your
respective regions.
If you have any questions, please contact Joan Lelis at
[email protected].
• Provo-Orem, UT: Juab and Utah Counties
Neurosciences
KEY INITIATIVES FOR
THE NEUROSCIENCES
DEVELOPMENT TEAMS
The Neurosciences Clinical Program has established
or transitioned all of its development teams targeted for
the first year rollout. Listed below are the six teams, their
medical directors, and initiatives they will be focused on
over the next year. In addition to their development team
roles, the medical directors also sit as members of the
Neurosciences Clinical Program Guidance Council. We
encourage you to reach out to them with any questions or
suggestions for their teams or initiatives.
SPINE DEVELOPMENT TEAM
Medical Director: Dr. Stephen Warner,
[email protected]
Initiatives: This team is focused on creating a care
process model for acute low back pain through surgical
care management, creating and implementing a patient
outcomes tracking tool for conservative and surgical
management for spine patients, the management of spine
implants and vendor relationships, and standardizing back
brace use and clinical indications.
21
TABLE OF CONTENTS
STROKE DEVELOPMENT TEAM
Medical Director: Dr. Kevin Call, [email protected]
Initiatives: This team is focused on creating care process
models for hyper-acute stroke (ED to intervention), acute
stroke (in-hospital management and rehab), and prevention
and post-stroke care management (SNF to clinic).
Additionally, they will be standardizing neuro checks for
hospitals across the system, as well as iCentra order sets
and work flows.
EPILEPSY DEVELOPMENT TEAM
Medical Director: Dr. Tawnya Constantino,
[email protected]
Initiatives: This team is focused on creating a care process
model for seizure care management in the ED, designing
a hub & spoke model for continuous EEG monitoring and
epilepsy care, and developing EEG technician training and
education guidelines.
NEUROSURGERY DEVELOPMENT TEAM
Medical Director: Dr. Ben Fox, [email protected]
Initiatives: This team is focused on standardizing the
care of intracranial bleeds, creating neuro critical care
and intraoperative monitoring guidelines, and developing
systemwide iCentra order sets and work flows for
neurosurgery patients.
NEXT
CONCUSSION MANAGEMENT
DEVELOPMENT TEAM
Medical Director: Dr. Eric Robinson,
[email protected]
Initiatives: This team is focused on the development
of a care pathway for concussion management across
multiple specialties (ED, Primary Care, Neurology, Sports
Medicine). They are establishing clinical criteria for
defining which pathway patients with concussion should
follow and coordinating new software trials and rollout
for concussion management.
DEMENTIA DEVELOPMENT TEAM
Medical Director: Interviewing physician candidates
Initiatives: This team is focused on collaborating with
Brigham and Women’s on the development of a care
pathway for dementia patients in the primary care and
outpatient settings. They are establishing a dementia
patient registry for Intermountain patients and building
iCentra works flows for dementia care management.
If you have questions, please contact the appropriate
development team medical director listed above.
22
Oncology
ADVANCING
INTERMOUNTAIN’S
ONCOLOGY INITIATIVES
OUTCOMES-BASED RESEARCH
The Oncology Clinical Program and our disease-specific
development teams have initiated more than 40 quality
improvement and outcomes-based research projects. A few
examples include: low risk breast cancer cases with advanced
imaging in the surveillance period; MRI use to incidence of
bilateral mastectomy; colonoscopy frequency status post
definitive cancer surgery; rectal cancer patients receiving
treatment without staging; and prostate cancer quality of
life, including patient reported outcomes.
As a primary reviewer and voting member of the National
Cancer Institute’s (NCI) Cancer Care Delivery Research
Steering Committee (CCDR), Mr. Bott has reviewed three
concepts this past quarter from the following National
Clinical Trial Network (NCTN) Research Bases: Alliance,
Children’s Oncology Group (COG), and the Southwest
Oncology Group (SWOG).
PRECISION MEDICINE INITIATIVE
Intermountain Precision Genomics (IPG) continues to grow
as more doctors regionally and nationally begin to adopt
the test. In fact, its genomics core laboratory, located in
southwest Utah, is now certified to accept tissue samples
from cancer patients in California.
Volumes of test requests have continued to grow each
month. At the beginning of the year, the lab averaged
about five samples per week with a turnaround time of 21
days. Now, the average turnaround time is 16 days, and
the lab is receiving about 10 orders per week. In addition
to providing its testing and interpretation services to
oncologists, IPG is in early discussions with pharmaceutical
and biotech companies, such as Loxo Oncology and
AstraZeneca.
The Oncology Clinical Program is partnering with
Intermountain Precision Genomics, the Oncology Clincial
Trials Office, Investigational Drug Services, Central Lab, the
Office of Research, and many other departments to expand
its clinical trial portfolio, while introducing early-phase and
targeted investigational clinical trials. The phase I program
will be physically located at IMED; Dr. Craig Nichols has
accepted one of two academic medical oncology physician
positions and will co-lead this program. Dr. Nichols starts
December 1, 2015. Recruitment is ongoing for the second
academic medical oncologist position.
GENETIC COUNSELING
Exciting advances and rapid change also continue in the
area of germline genetic testing for cancer susceptibility. The
costs of performing this testing continue to decline despite
expansion of the numbers of genes tested in various clinical
situations. Taken together, these factors contribute to everincreasing complexity surrounding testing decisions and
create evermore demand for genetic counseling services.
After some turnover in staffing, the recent hire of three
licensed genetic counselors for oncology, two in the Central
Region and one in the South Region, brings the total to four
counselors. Plans to expand genetic services for oncology
further and to improve the coordination of these services
through recruitment of a director-level genetic counselor are
in the works. The implementation of Progeny, a systemwide,
genetics-specific database, is also in the final stages. These
plans are being coordinated with the overall goal of the
precision genomic initiative.
ONCOLOGY CLINICAL TRIALS OFFICE
This past quarter, the Oncology Clinical Trials (OCT) Office
has developed many standard operating procedures (SOPs)
and is actively preparing for its emerging Neuro Oncology
and Phase I clinical trial programs. The OCT currently has
35 open and actively enrolling trials, with 122 projected/
annualized 2015 enrollments. This is a 21 percent clinical
trial enrollment increase from 2014.
REGIONAL UPDATES
North Region: Plans are underway to build a new
outpatient medical center in Layton, Utah. The new center
will provide the following outpatient services: radiology/
screening mammography, surgery, pharmacy, and infusion
services, among others. Infusion services and the pharmacy
will be in place to provide excellent care for cancer patients,
as well as meet other infusion needs, close to home. The
targeted opening of this new outpatient medical center is
mid-year 2017, with a groundbreaking tentatively planned
for late fall 2015 or early spring 2016.
Central Region: The Central Region opened its Neuro
Oncology Clinic on August 10, 2015. This clinic will be open
each Wednesday, and when the need arises, it will expand its
hours to Monday and Friday mornings.
23
TABLE OF CONTENTS
The Central Region also started a High Risk Cancer Clinic
and is currently seeing patients with high risk breast cancer
lesions (ADH, LCIS), family history of cancer, known mutation
carriers, and those who received radiation to the chest as
children. Patients will receive information about high risk
screening guidelines and follow up, genetic counseling,
chemoprevention, and surgical interventions. This clinic is run
by Dr. Teresa Reading and a team of genetic counselors.
The Central Region is in the final phase of development of
an outreach marketing package. The materials will include a
description of all the oncology services offered in the region
and identification of all the physician cancer specialists. The
packets will be used when marketing to rural physicians as
well as providing information to all new physicians that are
employed in the region.
The Oncology Clinical Program and IMED leadership, in
partnership with Integrated Care Management, are assessing
feasibility to develop a Cancer Concierge program. This
program will be designed to streamline the new patient
intake process and assist patients with seamless patient
navigation throughout the full menu of cancer services,
including specialty and ancillary care. The Central Region
is considering piloting this program at IMED for neuro
oncology and unassigned patient referrals.
On August 5, 2015, Radiation Oncology received official
notice from the American College of Radiology (ACR)
regarding approval of its three-year reaccreditation.
South Region: The Outpatient Palliative Care Clinic opened
at Utah Valley Regional Medical Center on August 4, 2015.
Dr. Gary Garner is acting medical director for this clinic.
NEXT
Southwest Region: The Intermountain Southwest Cancer
Center welcomes two new medical oncologists. Dr. Zachary
Reese, who completed an oncology/hematology fellowship
at the University of Utah, joined the team in July 2015, and
Dr. Ryan Wilcox, who completed an oncology/hematology
fellowship at Mayo Clinic, joined in August 2015.
Beginning Sept 4, 2015, the BMT physicians will be
conducting a clinic once a month at Dixie Regional Medical
Center. The team is excited for its patients to have BMT
transplant consultations and follow-ups in St. George.
The Southwest Region’s nurse navigation program has also
been conducting an oral medication support class each
month for the past year for its oral therapy patients. They
have done a study demonstrating that this class increases
understanding and compliance with oral therapy. Below is
the content:
• Week 1- Monitoring Medications, Resources, and
Support-Nurse Navigators
• Week 2- Know Your Medications-Pharmacist
• Week 3- Medication Delivery and Financial ResourcesFinancial Advocates
• Week 4- Motivation, Change, and Survivorship-LCSW
and Nurse Navigators
INTERMOUNTAIN BIOREPOSITORY
Currently, the Intermountain BioRepository (IBR) is providing
service for 20 research projects in development and active
phases, as well as collaborating with Oncology Clinical
Program physicians from surgery, pathology, and oncology.
Biomarker and molecular studies are being performed
to evaluate ovarian cancer, head and neck cancers,
bladder metastasis, lung cancer, and paraganglioma/
pheochromocytoma, among others. The IBR is expanding
the fresh tissue collection program with new protocols
in ovarian, colorectal, and head and neck cancers and is
recruiting additional Intermountain doctors to participate.
The IBR collaborated with the Oncology Clinical Program and
Office of Research on a CDMRP grant application for the
study of neurofibromatosis, for which Dr. Lincoln Nadauld is
the principal investigator. Dr. Brad Isaacson from the Office
of Research facilitated the grant submission, and Dr. Melissa
Cessna from the IBR is a co-investigator. The goal of this
proposal is to determine clinical and genomic indicators of
NF-associated tumors and functionally validate the candidate
genomic drivers in a genetically tractable model to improve
future clinical care. This project will collaborate with Dr.
Larry Meyer from the University of Utah and Department
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of Veteran’s Affairs and Dr. David Jones from the University
of Oklahoma. The IBR is also assisting in the development
of a large-scale retrospective cancer genomics study with
Dr. Lincoln Nadauld and Derrick Haslem’s team from
Intermountain Precision Genomics in St. George.
IBR leadership attended the Leaders in Biobanking
conference in Toronto, Canada in July and learned about
technical advances in fresh tissue collection, innovative
methods for biobanking best practices, and challenges of
informed consent/re-consent. The conference offered the
ability to network with established biobank experts and learn
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what is working, why it is, and how the IBR can bring this
knowledge back to its department to nurture its continued
development, leverage the resource of material, and better
align with the vision of research at Intermountain Healthcare.
If you have questions about IBR initiatives, please contact
Greta Koontz at [email protected] or Dr. Melissa
Cessna at [email protected].
If you have questions about these oncology initiatives,
please contact Brad Bott at [email protected] or Dr.
William Sause at [email protected].
Pain Management
TAPERING OPIOID
PAIN MEDICATION FOR
PATIENTS WITH
CHRONIC PAIN
“Tapering Opioid Pain Medication for Patients with
Chronic Pain” is a newly developed clinical practice
guideline and patient education fact sheet developed by
Pain Management Clinical Services’ Functional Restoration
Chronic Pain Development Team to assist providers with
tapering patient’s opioid pain medications.
The fact sheets and guidelines are available for order
through the iPrint store.
CGL019 Tapering Opioid Pain Medication for
Patients with Chronic Pain
FS052 Opioid Medication for Chronic Pain
FS454 Cutting Back on Opioid Pain Medication
If you have questions, please contact Linda Caston, Pain
Management Clinical Services at [email protected].
Pediatrics
NEW SKIN AND SOFT
TISSUE INFECTION CARE
PROCESS MODEL
This topic was chosen because skin and soft tissue
infections (SSTI) are so common. Between the years of
1997 and 2005, there was a 50 percent increase nationally
in these infections. The largest increase came from patients
younger than 18 years old.
The Pediatric Infectious Disease Development Team
is publishing a new care process model titled “Assessment
and Management of Skin and Soft Tissue Infection.” This
care process model should be used for the care of pediatric
patients above the age of 3 months.
In addition, care of these conditions is costly and varies
widely. In a recent study in children, two-thirds of the
children with SSTI were exposed to either unnecessary
broad-spectrum antibiotics or prolonged duration of
antibiotic therapy, and in some cases they were exposed to
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both. Considering the alarming rise in antibiotic-resistant
organisms and the emerging impact of antibiotic overuse in
chronic disease, it would be wise to use antibiotics in care
of patients with SSTI judiciously.
Please review this new care process model and implement
as appropriate.
Skin and Soft Tissue Infection Care Process Model
If you have questions, please contact Carolyn Reynolds at
[email protected].
Primary Care
GETTING UPSTREAM
OF CHRONIC DISEASE
TO SUPPORT
POPULATION HEALTH
HIGH BLOOD PRESSURE
We continue our focus on rapid cycling for High Blood
Pressure management. The research shows that for every
34 patients that are in control of their blood pressure,
one heart attack can be avoided. From our reports, we
had 73,086 patients in control in August 2014, and now
in August 2015, we have 78,082 patients in control. By
applying this statistic we have saved an additional 146
people from heart attacks over the course of the last year.
Additionally, our rate for percent in control for the system
has risen from 61 percent to 66 percent over the last year.
To improve processes we are continuing our collaboration
with both the American Medical Group Association
(AMGA) and the Utah Million Hearts Coalition. To evaluate
blood pressure control, our primary care clinics and
some specialty clinics participated in the Million Hearts
Assessment. From this assessment we learned that one of
the greatest challenges to BP control was time. Many clinics
reported it was difficult for patients to rest before their
blood pressure was measured in the clinic, and if the BP
was elevated, there wasn’t always an opportunity to allow
for another measurement at the end of the visit.
The Hypertension Specialty Clinic is up and running at the
IMC campus, and patients can be referred for specialty
consultation if there are diagnostic challenges or if the
patient is taking three to four mediations and are still
not in control. The Hypertension Specialty Clinic can be
reached at 801.507.3577.
TELEHEALTH FOR PREDIABETES AND DIABETES
EDUCATION BEGAN IN OUR RURAL FACILITIES
In an effort to help people live the healthiest lives possible,
we are leveraging TeleHealth in our rural facilities to extend
access, strengthen teamwork, and improve care. Presently,
there are 1,600 patients with diabetes and 463 patients with
prediabetes in our rural facilities. A recent study published
by the Primary Care Clinical Program in the Journal of
Multidisciplinary Healthcare showed that diabetes selfmanagement education improves quality of care and clinical
outcomes determined by a diabetes bundle.
Our rural facilities do not have CDEs so we are providing siteto-site visits between physical locations with synchronous
audio and video communication from the American Fork
Clinic to all other rural clinics within Medical Group.
CHRONIC KIDNEY DISEASE
The prevalence of chronic kidney disease (CKD) is on the
rise and is often undiagnosed. CKD is a significant risk
factor for cardiovascular disease. Patients at stage 2 have
a 51 percent greater risk of death from cardiovascular
disease than non-CKD patients. Additionally, patients with
stage 3 are more likely to die from cardiovascular disease
than to progress to dialysis. There are also increased
hospitalization and medical expenditures in patients with
CKD. The Primary Care Clinical Program CKD Development
Team has just completed updating the CKD care
process model. Through adoption of care process model
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guidelines, we will be able to prevent the progression of
CKD in the patients we serve. Presently, there are 166,000
patients with CKD seen within our system.
ICENTRA
The Primary Care Clinical Program continues to define best
practices for configuration and implementation of iCentra.
Most recently we are adding two additional care process
models (Lipid Management and CKD) to the clinic workflow.
FLASHCARD APP IS NOW AVAILABLE FOR
PRIMARY CARE CPMS
The Flashcard App is a provider tool that offers flashcards
that summarize key decision points from a care process
model. These flashcards:
• Provide brief decision advice or quick
reference information
• Contain algorithms that aid in the diagnosis
or treatment
• Link to the CPM or guideline they support
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To download the electronic app:
• Go to physician.intermountain.net on your
phone, scroll to the bottom of the page, and click
on “Physician Apps.” Once on the “Physician Apps”
page, select “Best Practice Flashcards,” and the app
should launch and install.
• By the 3rd week of August the flashcards will also be
available through the Physician Mobile App, which can
be downloaded through the Apple store.
Things to know:
• This app should automatically update as CPMs
are updated
• The Flashcards App is currently only available for
iPhones & iPads
• An android version is in production and should be
available shortly.
If you have questions, please contact Tonya Schaffer at
[email protected].
Surgical Services
INTRAOPERATIVE
LACERATION CODING
When a tear or laceration is documented in the
operative report, the provider should document if the tear or
laceration is incidental or inherent in the procedure or if it is
a complication of the procedure. Properly documenting this
information ensures the appropriate diagnosis and procedure
codes are assigned.
intervention. Additionally, the provider should document a
cause and effect relationship between the care given and the
tear or laceration.
In ICD-9-CM and ICD-10-CM, the term “complication” does
not imply that improper or inadequate care is responsible
for the problem. It indicates that the patient’s care was
complicated and required additional intervention.
Using terms such as “inadvertent,” “incidental,” or
“inherent” in conjunction with laceration or tear indicates
that the tear/laceration did not complicate the procedure
and no diagnosis codes would be assigned.
Per the AHA Coding Clinic for ICD-9-CM, injuries to
surrounding organs or tissues during a procedure such as
serosal tears may be unavoidable, and only the provider
can determine if these are surgical complications. However,
a dural tear or laceration would always be considered
a complication due to the significant potential for
cerebrospinal leakage.
For a tear or laceration to be considered a complication of
care, it must be an unexpected or abnormal circumstance.
The provider should clearly state that the tear or laceration
has complicated the surgical operation and requires
If you have questions, please contact Jeannette Prochazka
at [email protected].
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FACT SHEET:
HUMAN CELL, TISSUE,
AND CELLULAR
AND TISSUEBASED
PRODUCT RECEPTION
This information regarding human cell, tissue, and
cellular and tissue-based product reception applies to
Intermountain Healthcare hospitals, Medical Group, and
Ambulatory Surgical Centers.
IMPORTANCE OF CARE
The U.S. Food and Drug Administration (FDA) and the Joint
Commission require Intermountain facilities to only receive
human cells, tissues, and cellular and tissue-based products
(HCT/Ps) from FDA-registered manufacturers or distributors
that provide acceptable shipping conditions and are able to
track the HCT/P bi-directionally to minimize the introduction,
transmission, and spread of communicable disease.
KEY POINTS
• Human cell, tissue, and cellular and tissue-based
products (HCT/P) are an article containing or
consisting of human cells or tissues and cellular
and tissue-based material that is intended for
implantation, transplantation, infusion, or transfer
into a human recipient.
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• HCT/P can be requested via the Human Tissue
Request Form or by working with the facility’s tissue
coordinator to order the tissue.
• Intermountain facilities follow the tissue suppliers’ or
manufacturers’ written directions for transporting,
handling, storing, and using tissue.
• The assigned Intermountain employee documents
the receipt of all tissues and verifies at the time of
receipt that package integrity is met and transport
temperature range was controlled and acceptable for
tissues requiring a controlled environment.
ADDITIONAL RESOURCES
• U.S. Food and Drug Administration: 21 CFR Part
1271.265, 1271.290
• The Joint Commission Standard TS 03.01.01, TS
03.02.01, TS 03.03.01
• Human Cell Tissue Cellular and Tissue Based Products
Receipt Policy
CHECK YOUR KNOWLEDGE
• How can I ensure that I have the correct HCT/P for
my patients?
• Who can order HCT/P in my Intermountain facility?
If you have questions, please contact Jeannette Prochazka
at [email protected].
• Intermountain facilities must confirm that tissue
suppliers are registered with the U.S. Food and Drug
Administration (FDA) as a tissue establishment.
• The FDA requires each establishment that performs
recovery, processing, storage, labeling, packaging, or
distribution of any human cell or tissue maintain a
tracking system that enables the tracking of all HCT/Ps
from the donor to the recipient or final disposition.
• Intermountain has a tracking system able to track the
product from reception at the Intermountain facility to
the recipient or its final disposition.
• Intermountain facilities assign responsibility to one
or more individuals for overseeing the acquisition,
receipt, storage, and issuance of tissues throughout
the hospital.
• Intermountain facilities only receive HCT/P products
that have been ordered by an Intermountain employee
from an FDA-registered manufacturer or distributor.
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Women & Newborns
CHANGES TO NEONATAL
CHEMISTRY CODES
NEONATAL BILIRUBIN
In the past year, there have been changes to the
neonatal chemistry codes as a result of new equipment in
the lab. These changes have affected how orders need to
be written to obtain the correct results for treatment and
follow up, as well as to provide patients with a proper bill.
Intermountain has corrected the pre-printed Well Newborn
Standing Orders. However, we continue to see practitioners
write orders incorrectly, as well as receive incorrect orders
from the provider’s office.
The primary order concerns occur when a clinician orders a
Neonatal Bilirubin or Bili, which continue to be ordered
on newborns for outpatient follow up lab work. If entered
in Tandem, this order will be transposed to a Total Bilirubin
with the explanation “Bilirubin, Neonatal (Total Only) – for
fractionated, order BILTDI.” Total Bilirubin is the “standard”
to measure for neonatal bilirubin assessment.
Please take this time to review the acceptable lab orders in
the table below.
If you have questions, please contact Teri Kiehn at
[email protected].
DEACTIVATED - DO NOT ORDER
CORRECT ORDER
Code
Name
Code
Name
BILN
Neonatal Bilirubin
BILT
Bilirubin, Total
BILC
Bilirubin, Conjugated
BILD
Bilirubin, Direct
BILU
Bilirubin, Unconjugated
BILTDI
Bilirubin, Total, Direct, and Indirect
BILNCU
Neonatal Bilirubin Fractionation
BILTCU
Bilirubin Fractionation
BILTC
Bilirubin, Total and Conjugated
BUBC
Bilirubin, Conjugated and
Unconjugated
NEOCMP
Neonatal Comprehensive
Metabolic Panel
CMP*
Comprehensive Metabolic Panel
NEOHFP
Neonatal Hepatic Function Panel
HFP
Hepatic Function Panel
CRPN
CRP (C-Reactive Protein), Neonatal
CRP
CRP (C-Reactive Protein)
*Please note CMP includes a total bilirubin. If you also want a direct bilirubin (BILD), you must order both.
29
SELECTHEALTH UPDATE
SELECTHEALTH REQUEST FOR
CONFIRMATION OF DIAGNOSES
Many primary care physicians will soon be receiving (or may have already received) a request from Cognisight to confirm
that specific diagnoses for selected patients are complete and accurate. We have partnered with Cognisight to perform
medical record reviews to capture diagnoses in patient records that were not submitted on claims. This effort is to satisfy a
Centers for Medicare & Medicaid Services (CMS) requirement for health plans to compile and report complete diagnostic
profiles annually for Medicare Advantage members.
We ask that providers carefully review and determine which, if any, of the diagnoses listed on the form were recognized,
considered, and/or treated during the referenced 2014-noted encounter. The form must be signed and dated within one
year of the date noted at the top of the addendum form.
If you have questions about this process, please contact Jason Brockett at 801.442.7977 or [email protected].
SELECTHEALTH ADVANTAGE
HOME VISIT EVALUATIONS
SelectHealth has partnered with a company called MedXM to provide an in-home comprehensive health assessment
for selected members of SelectHealth Advantage. A physician, nurse practitioner, or physician assistant working with
SelectHealth Advantage will complete this assessment. The purpose of this visit is to:
• Improve the health and wellness of SelectHealth Advantage members by allowing SelectHealth to better understand
their healthcare needs and coordinate their care accordingly.
• Assess the services our members are receiving under their SelectHealth Advantage coverage and determine whether
they are eligible for additional healthcare screening services for improved member care and for HEDIS and/or
Star Rating purposes.
• Determine whether the member qualifies for other services offered by SelectHealth such as care management or
chronic condition management.
• Conduct an environmental scan of the home for safety risks and need for adaptive equipment.
As part of this program, a representative from MedXM may be calling your patient(s) to schedule an appointment for an
in-home comprehensive health assessment visit. Please encourage them to accept this invitation and schedule the visit
at their convenience.
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SELECTHEALTH UPDATE, CONTINUED
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If your patient chooses to accept the invitation and schedule a health assessment, here is what they can expect:
• A licensed, credentialed healthcare provider will come to their home to review their current health status, medical
history, and any current prescription medications.
• The visit is expected to take approximately 45 minutes to one hour.
• There will be no cost to your patient, and participation will in no way impact their premiums, benefits, or copayments.
• The results will be sent to you as their Primary Care Physician (PCP) within 45 days of their scheduled health assessment.
This visit is not meant to take the place of any existing doctor’s appointments or any care you currently provide to your
patients, nor the payment you receive for any services, such as an Annual Wellness Visit. This program is voluntary and does
not affect your patient’s healthcare coverage in any way.
If you have questions, you can call SelectHealth Provider Relations at 800.538.5054 (toll-free),
Monday through Friday, 8:00 a.m. to 5:00 p.m.
MTECH REVIEWS EMERGING
HEALTHCARE TECHNOLOGIES
M-Tech is SelectHealth’s formal process for reviewing emerging healthcare technologies (procedures, devices, tests,
and “biologics”) for the purpose of establishing coverage benefits. Existing technologies are, at times, also examined
through this process.
The following is a list of recent technologies reviewed by M-Tech Committee:
TECHNOLOGY
DATE REVIEWED*
COMMITTEE DECISION
Anterior Lateral
Ligament Repair of
Knee
July 28, 2015
Not Covered. There is a lack of substantive published evidence
demonstrating anterolateral ligament repair/reconstruction to be safe
and effective in producing clinically meaningful outcomes.
MAGEC/VEPTR for
Scoliosis
July 28, 2015
Covered. Current evidence suggests MAGEC growth rods are
to likely be clinically equivalent to the established titanium VEPTR
though direct head-to-head comparative studies are lacking. There
also seems to be potential cost savings related to the reduction in
surgical procedures though the upfront cost of the MAGEC system is
significantly more than the VEPTR rods.
Propel Stent for
Chronic Sinusitis
July 28, 2015
Not Covered. Current evidence fails to allow for conclusions
with regard to the effectiveness of this therapy as it compares to
alternative standard therapy.
*Date Reviewed does not necessarily reflect the date of implementation of coverage policy.
Other technologies currently under active assessment by the M-Tech Committee include the following. As the reviews are
completed, notices will be sent to stakeholders accordingly to inform them as to SelectHealth’s coverage determinations:
• Bariatric Surgery
• Decipher Prostate Cancer Classifier
• Cologuard for Colorectal Cancer Screening
• Entarra Gastric Pacemaker for Gastroparesis
• ConfirmMDx Prostate Cancer Test
• Hemorrhoid RFA Ablation
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• Iluvien Stent for Ocular Conditions
• Prolaris for Prostate Cancer
• iStent for Glaucoma
• Prosigna Breast Cancer Gene Expression Profile
• Ligament Sparing knee replacement devices (e.g.
Biomet Vanguard XP knee)
• Psych Med Genetic Testing
• Magnetic Resonance-guided Focused Ultrasound
(MRgFUS) for Bone Cancer
• SIRT for Liver Cancer
(MRgFUS) for Prostate Cancer
• Sublingual Immunotherapy
• RFA of Low-grade Dysplasia in Barrett’s Esophagus
• SphenoCath SPG Block for Migraine Management
• VBLOC for Weight loss
(MRgFUS) for Uterine Fibroids
• Vermillion OVA1 for Ovarian Cancer
• Oncotype DX Colon
If you have questions regarding coverage of these or any other technologies or procedures, or if you would like SelectHealth
to consider coverage for an emerging technology, please email us at [email protected] or call 801.442.7585.
All SelectHealth medical policies and technology assessments can be viewed on our website. Go to selecthealth.org, click on
the “Provider” tab (upper right corner), enter your log in information, and then click on “Policies and Procedures” (left side of
page) to be directed to the website.
MEDICAL POLICY BULLETIN
The following tables contain a directory of policies, effective dates, and a summary of changes. You can access the full
policy text by going to physician.intermountain.net/selecthealth/policies and searching by policy number.
NEW POLICIES
POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
565
Cryoablation for
Desmoid Tumors
(NEW)
6/2/2015
SUMMARY OF CHANGES
New policy developed for cryoablation for the treatment of
desmoid tumors.
SelectHealth Commercial does NOT cover cryoablation for the
treatment of desmoid tumors as this procedure is considered
unproven and not medically necessary.
SelectHealth Advantage does NOT cover cryoablation for the
treatment of desmoid tumors as there are no specific Medicare or
InterQual guidelines for medical necessity that specifically address
these services, SelectHealth commercial will apply.
SelectHealth Community Care does NOT cover cryoablation
for desmoid tumors as there are no Utah Medicaid or InterQual
specific guidelines for medical necessity that specifically address
these services, SelectHealth commercial will apply.
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POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
570
Genetic Testing:
Molecular
Profiling for
Determining
Therapy of
Molecular
Tumors (NEW)
7/28/2015
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SUMMARY OF CHANGES
New policy developed for molecular profiling for determining
therapy of molecular tumors.
SelectHealth Commercial does NOT cover molecular profiling
for determining therapy of molecular tumors as it is considered
investigational and not medically necessary.
SelectHealth Advantage covers molecular and genetic testing
consistent with Medicare Local Coverage Determination (LCD)
L24308 and Noridian guidelines on specific covered and excluded
molecular tests. Where Medicare policy does not explicitly outline
coverage and there are no InterQual guidelines, commercial plan
policy will apply.
SelectHealth Community Care covers selected genetic testing
covered by Medicaid when Utah Medicaid criteria are met, as
outlined in the Utah Medicaid Laboratory Services Manual. Refer
to the Medicaid Code Look-Up Tool for coverage status of specific
codes. For those codes that are covered by Utah Medicaid but
addressed with criteria in the Utah Medicaid Code Look-Up Tool,
commercial criteria will apply.
REVISED POLICIES
POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
SUMMARY OF CHANGES
129
Hyperbaric
Oxygen Therapy
(Revised)
6/2/2015
Raynaud’s Phenomenon added as a noncovered indication.
150
Mohs Surgical
Guidelines
(Revised)
5/25/2015
Addition under Commercial Policy:
Change criteria to clarify amount of tissue required to be
removed and anatomical location to read:
• In cosmetically sensitive areas where preservation of as
much normal tissue as possible is important to maintain
normal appearance and optimize the potential for cure and
to minimize the potential for recurrent surgery, if >2 cm
diameter tissue must be removed
• Skin cancers > 4.0 cm in diameter on any location
172
Reduction
Mammoplasty
(Breast Reduction)
(Revised)
5/8/2015
Addition of “Documentation of signs and symptoms provided by
a practitioner independent of the requesting surgeon’s practice”
under criteria for coverage.
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POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
223
Continuous
Glucose
Monitoring (CGM)
Systems with
and without Real
Time Monitoring
(Revised)
5/4/2015
Oral Appliances
for Sleep Apnea
(Revised)
5/7/2015
Sphenopalatine
Ganglion (SPG)
Injection in the
Management
of Headaches
(Revised)
5/15/2015
Radiofrequency
Ablation (RFA) of
the Dorsal Root
Ganglion (DRG)
of the Spine
(Revised)
5/15/2015
492
559
226
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SUMMARY OF CHANGES
Revision under “Replacements will only be allowed when All of
the following criteria are met:
#2-Documentation is provided demonstrating the member has
used the device at least 50 percent of the time for a 30-day
period within the past 90 days.
#3d-The member demonstrates stability or improvement in the
A1Clevel.
Under criteria for coverage:
#6-addition of “Temporal Mandibular Joint Syndrome or other
TMJ-related pathological processes insufficient dentition to
support device stability”
Addition of new LCDs L34775 and L34779 under SelectHealth
Advantage was added. Since these CMS LCD’s do not list
headaches as a covered diagnosis for these procedures, this
procedure is not covered for this diagnosis.
SelectHealth Community Care language was added:
“SelectHealth Community Care does NOT cover sphenopalatine
ganglion (SPG) block for acute and chronic headaches because
SelectHealth has found this procedure to be not medically
reasonable and necessary since current evidence is insufficient
to determine the efficacy and safety. As there are no other
Utah State Medicaid specific guidelines or InterQual guidelines
for sphenopalatine ganglion (SPG) block for acute and chronic
headaches, commercial plan policy applies.”
Addition under SelectHealth Advantage: SelectHealth
Advantage covers radiofrequency ablation of the dorsal root
ganglion of the spine consistent with Medicare Local Coverage
Determination (LCD) L34127, L33842, L34775, and L34779.
Addition under SelectHealth Community Care: SelectHealth
Community Care covers non-pulsed radiofrequency rhizotomy
of the cervical and lumbar spine. Since there are no Medicaid
guidelines on this procedure, InterQual guidelines will apply.
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POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
265
Radiofrequency
Ablation (RFA) for
Back or Neck Pain
(Radiofrequency
Neurolysis, Facet
Joint Rhizotomy)
(Revised)
5/15/2015
518
Physical Therapy
(PT) Occupational
Therapy (OT)
(Revised)
6/10/2015
Addition under SelectHealth Commercial:
SelectHealth covers physical therapy (PT) and occupational therapy
(OT) for habilitative services on non-grandmothered (transition
relief) Small Employer and Individual commercial plans.
SelectHealth does NOT cover physical therapy (PT) and
occupational therapy (OT) for habilitation for any other indications
not mentioned above.
357
Gene Expression
Profiling for
Monitoring Acute
Rejection in
Cardiac Transplant
(Allomap®)
(Revised)
7/17/2015
Addition under SelectHealth Commercial Plan:
Exclusion Criteria: The addition of >5 years after heart transplantation
386
Gender
Reassignment
Surgery (Revised)
6/17/2015
This policy was specifically for American Express members and
now the wording has been changed to include “only for plans
with the gender reassignment supplemental coverage and
SelectHealth Advantage members.”
SUMMARY OF CHANGES
Addition under SelectHealth Advantage:
SelectHealth Advantage covers non-pulsed radiofrequency ablation
(RFA) of the lumbar, thoracic, and cervical facet joints consistent
with Medicare Local Coverage Determination (LCD) L34127,
L33842, L34775, and L34779.
Addition under SelectHealth Community Care:
SelectHealth Community Care covers non-pulsed radiofrequency
rhizotomy of the cervical and lumbar spine when all of the
medical necessity criteria are met according to the Special note
on Medicaid Coverage Look-Up tool, also available on the State
of Utah Medicaid Program Medicaid Information Bulletin (January
2014, page 21 14-34) and State of Utah Medicaid Provider
Manual, Section 2, page 35.
Also, the term “gender dysphoria” has replaced “gender identity
disorder” throughout the policy.
444
Trancatheter
Aortic Valve
Implant (TAVI)
Transcatheter
Aortic Valve
Replacement
(TAVR) (Revised)
7/10/2015
Addition to the description section of the policy.
In June 2015, the first repositionable transcatheter valve, the
CoreValve Evolut R received FDA approval. This is the first valve
which can be repositioned after initial deployment so as to
reduce valve leakage or other issues.
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POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
334
Neuropsychological
Testing (Revised)
7/10/2015
Clarification of language was made on this policy to include:
SelectHealth does NOT cover computerized or standard
neuropsychological testing when performed to establish a
baseline (prior to injury) assessment for individuals participating
in sporting activities or similar scenarios as the validity of this
testing has not been proven in the published literature.
185
Negative Pressure
Wound Therapy
(Revised)
7/16/2015
Change made under Indications for initial approval from three
week trial of therapy will be authorized to 30 day trial of therapy
will be authorized if all of the following conditions are met.
509
Fetal Cell Free
SNA (cfDNA)
Testing for
Down Syndrome
(Revised)
7/16/2015
Added Exclusion
SelectHealth Commercial: SelectHealth does NOT cover fetal
cell-free DNA (cfDNA) in multiple gestation pregnancies or any
other indication.
430
Left Atrial
Appendage
Closure
(LAAC) devices
(Watchman®)
(Revised)
8/6/2015
Removed following requirement:
545
Propel® Implant
for the Treatment
of Chronic
Rhinosinusitis
(Revised)
7/28/2015
Updated policy to reflect recent evidence from technology
assessment completed 7/28/15. Noncoverage of this technology
not modified.
302
Cochlear
Implantation
(Revised)
8/6/2015
Change made to include coverage and link updates:
SUMMARY OF CHANGES
SelectHealth Commercial removal of language under criteria
for coverage as it no longer applies: “The device is being used
as part of the required post approval registry of approximately
2,000 newly enrolled patients, followed to at least 2 years to
evaluate acute procedural and longer term outcomes, similar
to those from the pivotal study, with FDA to make the final
recommendations with respect to study size. In addition, that the
patients enrolled in the premarket trial (PROTECT-AF), both arms,
be followed for 5 years.”
SelectHealth Community Care covers cochlear implants only
for children under 21 and pregnant adults on a case-by-case
basis, consistent with codes covered in the Utah Medicaid LookUp Tool and Utah State Medicaid Policy. As Utah State Medicaid
does not have specific coverage criteria, InterQual procedure
criteria for cochlear implants are used to determine coverage
for these devices. Audiology services and related devices are not
covered for non-pregnant adults.
36
TABLE OF CONTENTS
POLICY
NUMBER
POLICY NAME
AND LINK
EFFECTIVE
DATE
SUMMARY OF CHANGES
524
Bone-Anchored
Hearing Aids
(BAHA) (Revised)
8/6/2015
Changes made to include coverage and links updated:
NEXT
SelectHealth Advantage covers implantable bone-anchored
hearing aids (BAHA), also called Osseointegrated implants, subject
to Medicare criteria found in Medicare Benefit Policy Manual,
Chapter 16-General Exclusions from coverage, Section 100.
SelectHealth Community Care covers implantable boneanchored hearing aids (baha), also called Osseointegrated implants,
only for children under 21 and pregnant adults on a case-by-case
basis, consistent with codes covered in the Utah Medicaid LookUp Tool and Utah State Medicaid Policy. As Utah State Medicaid
does not have specific coverage criteria, SelectHealth commercial
coverage criteria are used to determine coverage for these devices.
Audiology services and related devices are not covered for nonpregnant adults.
If you have questions, please contact Jill Peterson at [email protected].
37
NEWS FROM THE REGIONS
NEW REGIONAL VICE
PRESIDENT JOINS
INTERMOUNTAIN’S
CENTRAL REGION
Moody Chisholm has joined
as Regional Vice President
of Intermountain’s Central
Region, succeeding Larry
Hancock. Moody offices in
the south office tower on the
Intermountain Medical Center
campus; he’s available at
[email protected]
or 801.507.9517.
Moody comes to Intermountain with more than 30 years
of healthcare experience, most recently as President and
CEO of St. Vincent’s HealthCare in Jacksonville, Florida.
St. Vincent’s HealthCare is a multi-hospital Catholic health
system and a ministry of Ascension Health, the nation’s
largest Catholic nonprofit healthcare organization. St.
Vincent’s is comprised of four medical centers totaling
1,145 beds, a physician enterprise with 242 employed
providers and a primary care residency program, and
extensive community ambulatory entities.
Moody earned an MBA at Nova Southeastern University
in Fort Lauderdale, Florida, and a bachelor’s degree in
business administration and economics at Appalachian
State University in Boone, North Carolina.
“Moody was chosen from among a number of excellent
candidates,” says Laura Kaiser, Intermountain’s Executive
Vice President and Chief Operating Officer. “He brings a
wealth of experience with key accomplishments in his former
role that include establishing a strategic vision for a dual
strategy to optimize opportunities in the transition from
fee-for-service to value-based payment models. Throughout
his career Moody has overseen significant improvements in a
wide range of key measures including patient safety, quality,
employee and physician satisfaction, and finance. Moody has
a style of servant leadership focused on clinical quality and
operational effectiveness. He will quickly become a strong
member of the Intermountain team.
“Moody shares Intermountain’s values and our commitment
to our mission of ‘Helping people live the healthiest lives
possible.’ I have every confidence he’ll be a great asset to
Intermountain and to the Central Region.”
If you have questions, please contact Lonnie Owen at
[email protected].
38
FITNESS FEATURE
IF WE WANT KIDS TO
BE PHYSICALLY ACTIVE,
MAKE IT FUN!
With summer coming to a close, how can parents and
kids stay active given the competing demands of work and
school? I’ve devoted previous fitness features to strategies
aimed at supporting regular physical activity for adults
including active transportation, accessing fitness facilities,
and integrating functional physical activity into daily life
like yard work and gardening in the summer and shoveling
snow in the winter.
But how do we help our kids get the 60 minutes of
moderate to vigorous physical activity they need each day?
I don’t know about your kids, but mine are less keen on
yard work, gardening, and snow shoveling. Heck, I can’t
even get them to walk the dog they so dearly love! The
key is to help kids take advantage of school-based physical
activity and to make being active fun!
School-age children and adolescents spend the majority
of their waking hours in school. Activities before,
during, and after school offer the greatest opportunity
to increase physical activity. Activities that count toward
the accumulation of 60 minutes per day of moderate
to vigorous physical activity can include walking to and
from school, physical education classes, recess activities,
recreational activities in and around the school day, and
sports participation.
Unfortunately though, only 3.8 percent of elementary
schools, 7.1 percent of middle schools, and 2.1 percent
of high schools offer daily physical education classes. In
addition, a minority of kids either walk or bike to school.
In fact, amongst kids living within a mile of school, only
a third walk to school compared to almost 90 percent
40 years ago. Of all the potential kid-centered options
for physical activity, sports participation may be their
best opportunity. Currently, a majority (65 percent) of
youth under the age of 17 will participate in at least one
organized sport. Since sports typically occur outside the
academically focused school day, they represent a real
opportunity for kids to engage in physical activity that
supports health and quality of life.
The benefits of sports participation extend beyond just
physical health and energy balance. Sports participation
also leads to improved academic performance and lower
rates of substance use and teen pregnancy. Yet despite
these benefits, dropout rates from sports are high, with as
many as 70 percent dropping out in their teen years. Why
do kids drop out? The primary reason is a lack of positive
experiences associated with sports participation, aka it’s not
fun anymore.
As physicians, it’s not our job to make sports fun for
our patients, but knowing what components of sports
contribute to fun may help us counsel a child or adolescent
who has lost interest in sports. This information could also
be used as a tool to identify the determinants that resonate
the loudest with an individual and help them find their way
back into sports.
The key is to help kids take
advantage of school-based
physical activity and to make
being active fun!
39
TABLE OF CONTENTS
FITNESS FEATURE, CONTINUED
So what are the components that contribute most to the
“fun” in sports participation? Three dimensions rise to the
surface: 1) positive team dynamics, 2) trying hard, and 3)
positive coaching. “Positive team dynamics” encompasses
playing well together as a team, being supported by
teammates, and showing good sportsmanship. “Trying
hard” includes trying your best, exercising and being
active, and being strong and confident. “Positive coaching”
involves a coach treating a player with respect, encouraging
the team, and serving as a positive role model.
school to make it feasible. We can and should advocate
for high quality physical education in local schools and
school districts and encourage participation in afterschool
sports and activities. Finally, we must keep in mind during
all of these conversations the importance of making sports
and activities fun, while understanding what makes these
activities fun.
If you have questions, please contact Liz Joy, MD, at
[email protected].
Activities in and around
school hold the most promise
for promoting access and
achievement of recommended
levels of physical activity.
Physicians can suggest active
transportation as an option for
those who live close enough to
40

MED STAFF NEWS - Intermountain Physician

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