1. Peer Review Thomas C. Platt, M.D. Chief Medical Officer Cherry Health 100 Cherry St SE Grand Rapids, MI

2. Presentation Outline What is Cherry Health Reactive Peer Review Ongoing Peer Review Specific Examples

3. Cherry Health FQHC established 1988 as Cherry Street Health Services Name change to Cherry Health in 2014 Approximately 800 employees serving 60,000 patients in 23 sites

4. Cherry Health Services include: –Family Practice –Pediatrics –Internal Medicine –Obstetrics/Gynecology –Dental –Counseling

5. Cherry Health Other Services Provided: –Optometry, Optical –Traveling School Programs (Dental, Vision) –Psychiatry –Case Management –Medication Assisted Treatment Program –Correctional Residential/Re-entry –Employee Assistance Center –Clubhouse –Health Promotion

6. Reactive Peer Review An event occurs that raises question about quality of care given by specific provider Group of peers convened to review –May include appearance by provider Recommendations made to CMO –Education –Limitation –Dismissal

7. Reactive Peer Review CMO has ultimate decision Process is protected from discovery Example: –Physician sees pt for first time –Pt given Rx for tramadol –Pt OD’s

8. Ongoing Peer Review A process in which practitioners regularly review and give feedback on each other’s work No universal standard Can be simple or complex review Frequency of review varies

9. Peer Review at Cherry Health When I first arrived 2006… –Medical Director doing chart reviews: Problem list Medication list Allergies Physical done in past year SOAP note –Each provider had 10 charts reviewed quarterly

10. Phase 2 Peer Review at Cherry Health When I assumed role as Medical Director –EHR use starts –Need to find other measures –Need to involve all providers in process –Need to keep it simple to start

11. Phase 2 cont’d Adult providers look at mammography in women 50-75 yr Pediatric providers look at adolescent well child exams School based providers look at RAAPS (Rapid Assessment for Adolescent Preventive Services) (Most sites still using paper charts, so providers review others at same site)

12. Phase 3 Look for universal measure across all services –Smoking Was pt asked If smoker, were they counseled Measure in children was asking about second hand smoke

13. Current Process The previous reviews were really “chart audits” rather than “peer review” Let the computer keep track of data (mammograms, A1c’s, etc) and generate reports Use Peer Review to look at quality of encounter note: can you follow the thought process?

14. Process Each provider given specific visit to review of like provider each month Provider fills out form and forwards to CMO CMO reviews for trends, etc Copy then sent to provider being reviewed Findings reviewed at provider meeting

15. Examples Different specialties may require different tools

16. CONFIDENTIAL Quality Peer Review Chart Audit Provider being audited:_____________________________ Provider doing audit:_____________________________ Patient name, DOB:_____________________________ Date of visit for audit:_____________________________ Is there a chief complaint/reason for visit with HPI adequately documented?YES NO Comments: Does the physical include appropriate findings pertinent to HPI?YES NO Comments: Does the assessment/plan appropriately address HPIYES NO Comments: Is patient on controlled substance prescribed by CSHS (pain med, ADHD med, etc)?YES NO If so, was use of controlled substance addressed (e.g. contract, UDS, MAPS)?YES NO Comments: Health Maintenance issues addressed?YES NO

17. Psychiatry Tool Medication Utilization Evaluation Reviewer: _________________________________________ Date of review: ______________ Physician Reviewed: _________________________________ Client Reviewed: _____________________________________ 1. Was the medication prescribed to the client appropriate based on the needs and preferences of the person served? (a) The documentation does not show that the clients needs and preferences were taken into account when prescribing the medication. (b) The documentation does not show that the clients needs and preferences were taken into account when prescribing the medication; however the rational was documented (c) The documentation does show the client’s needs and preferences were taken into account when prescribing the medication. 2. The documentation shows the efficacy of the medication (a)The documentation does not show the efficacy of the medication (b)The documentation does show the efficacy of the medication

18. Psychiatry Tool cont’d 3. The documentation of the medication review shows that side effects, unusual effects, and contraindications were identified and addressed in the note (a) The documentation does not show that side effects, unusual effects, and contraindications were identified and addressed in the note (b) The documentation shows that no side effects, unusual effects, and contraindications were identified (c) The documentation does show that side effects, unusual effect, and contraindications were identified and addressed in the note 4. If tests are necessary, the documentation shows those tests were conducted (a)The documentation does not show that necessary tests were conducted (b) The documentation does show that necessary tests were conducted 5. The documentation of the medication review identifies the use of multiple simultaneous medications if prescribed. (a) The documentation does not identify the use of multiple simultaneous medications if prescribed. (b)The documentation does identify the use of multiple simultaneous medications if prescribed. 6. The documentation of the medication review identifies medication interactions (a) The documentation does not identify medication interactions (b)The documentation does identify medication interactions 7. The documentation indicates the clients satisfaction in regards to there medication (a) The documentation does not identify the clients satisfaction in regards to there medication (b) The documentation does identify the clients satisfaction in regards to there medication

19. Peer Review: Vision Reviewer:________________________________ Encounter/DOB:___________________________Date of Service Evaluated:____________ Is there a chief complaint/reason for visit with HPI adequately documented? (e.g. for a ‘well child’ vs. ‘medical complaint’) Did the Provider complete the HPI and indicate in the record? Does the exam include appropriate findings pertinent to CC/HPI? Does the assessment/plan appropriately address CC/HPI? (e.g. #1 CC matches #1 Assessment) If a student exam, was there clear documentation from attending? If diagnostic tests were ordered is a separate report completed and the document generated? Additional Comments or Suggestions:

20. What do we find? Commonest concern is that the chief complaint doesn’t match the diagnosis –MA typically enters the CC, but pt and provider end up discussing something else – provider doesn’t redo the CC

21. Occasionally the provider does not provide enough detail in the assessment to support action –e.g. pt with hematuria put on abx, but differential diagnoses not mentioned, or follow up plan if abx fails not given (e.g. CT urogram)

22. Goals of Peer Review Monitor performance Feedback to provider Be a learning process –Individual –Group Improve quality

23. Questions?