3M™ Ambulatory Potentially Preventable Complications (AM-PPCs) Grouping Software

(DESCRIPTION) Logo, 3M Science. Applied to life. Text, The approach to better track patient safety in the outpatient setting. Ambulatory Potentially Preventable Complications. A.M.-P.P.C’s. Danielle Bowen Scheurer, MD, M.S.C.R., Chief Quality Officer, Medical University of South Carolina. Sandeep Wadhwa, MD, M.B.A., Global Chief Medical Officer 3M Health Information Systems. Miki Patterson, PhD, N.P., Product Owner, 3M Health Information System. July 19, 2023. (SPEECH) Welcome, everybody to today's webinar-- The Approach to Better Track Patient Safety in the Outpatient Setting. On behalf of Becker's Healthcare, thank you so much for joining us. Before we begin, I'm going to walk through a few quick housekeeping instructions. We're going to begin today's webinar with a presentation and we'll have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen. Today's session is being recorded and will be available after the event. You can use the same link you used to log into today's webinar to access our recording. If at any time you don't see your slides moving or are having trouble with the audio, try refreshing your browser. You can also submit any technical questions into the Q&A box. We are here to help at any time. And with that, I'm so excited to introduce our amazing speakers today. We're thrilled to be joined by Dr. Danielle Scheurer, the chief quality officer at the Medical University of South Carolina, Dr. Sandeep Wadhwa, the global chief medical officer at 3M Health Information Systems, and Dr. Miki Patterson, product owner at 3M Health Information Systems. Today, we will dive into patient safety and discuss how ambulatory potentially preventable complications can help track safety in the outpatient setting. (DESCRIPTION) Text, Learning objectives: Recognize impact of potential updates to U.S. News & World Report, U.S.N.W.R. Best Hospitals rankings. Understand the current challenges and opportunities related to patient safety in outpatient settings. Develop a roadmap for identifying and addressing gaps in current outpatient safety practices. (SPEECH) Our speakers will plan to discuss potential updates to the U.S. News and World Report best hospital rankings, discuss the current challenges and opportunities related to patient safety in the outpatient setting, and identify a roadmap for identifying and addressing gaps in current outpatient safety practices. Before we go ahead and dive in, we wanted to ask you all a quick question-- have you or a family member experienced a complication after an outpatient procedure? Kindly respond to the poll question directly on your webinar console. We will wait about a minute or so for responses to roll in. (DESCRIPTION) Text, A. Yes. B. No. (SPEECH) Thank you to all those who submitted their response. We'll wait about 15 more seconds for additional responses. We're going to take a look at our poll results. So very interesting to see it looks like about 40% of people have had a complication after an outpatient procedure while 60% have answered that they have not. But without further ado, I'm going to turn the floor over to Danielle to go ahead and get us started with our presentation today. All right. Well, thank you so much for having us I'm Danielle Scheurer, chief quality officer at MUSC Health in South Carolina. Our flagship hospital is in Charleston, and we have several newer additions of community hospitals throughout the state. Just wanted to give a tiny bit of a background about MUSC Health. And I think our process for reviewing quality and making quality better might make more sense if you have a little bit of background. So we are the only tertiary care academic medical center in the State of South Carolina, and so our mission reflects that. So our mission is to preserve and optimize human life in South Carolina and beyond through our tripartite mission, so we are very much in academic tertiary care grounded health science center. So we work and we care deeply about all three. Our vision is really to lead health innovation for the lives we touch and core values, compassion teamwork, diversity, accountability, and innovation-- many of which we'll touch on today. (DESCRIPTION) Text, M.U.S.C. by the Numbers. The only comprehensive academic health system in South Carolina. (SPEECH) A little busy slide, I'm not going to read all these numbers. But this is sort of our elevator speech, if you will, for MUSC Health by the numbers, just to give you a sense of where we are and where we're operating. Right now, we're seeing about 1.6 million patient encounters a year. We are each year, getting more and more enveloped in accountable care. So working with payers to shift away from fee-for-service into accountable care, we think it's better care for patients and better payment models in general. So currently, we have about 120,000 covered lives and aiming to grow that by the day. All told, our organization employs about 25,000 team members, 1,400 physicians. We have 16 hospitals, 2,700 licensed beds, and this is all in a milieu of 6 training colleges, where we have almost 1,000 trainees and over 200 students. So it's big complicated academic tertiary care health science center. And again, the only one in South Carolina. (DESCRIPTION) Text, M.U.S.C. Impact. A state map appears with regions outlined. Colored dots fill the regions. Blue depicts clinical locations, orange depicts research locations, and green depicts telehealth connected counties. (SPEECH) So this is just a visual depiction based on our tripartite mission. So places that we have clinical presence in blue, research locations in orange, and again, looking to grow that for obvious reasons to get people access to research opportunities throughout the state. And then we also have a very active and growing telehealth network. We're one of two centers of excellence in telehealth in the country. And obviously, that's been a game changer, I think, for us as far as staying connected to, in particular, in the rural areas of South Carolina of which the vast majority of South Carolina is rural, but really allowing access to care to patients who otherwise would never be able to drive to a physical MUSC Health location. So we're very proud of that telehealth network. (DESCRIPTION) A bar chart appears for the Ambulatory surgery center growth. (SPEECH) As you all well know, the growth in ambulatory surgery and ambulatory surgery centers throughout the US has been astronomical. It is a great site of care for a lot of ambulatory procedures. So to get the cost structure down, especially for procedures where the expectation of complications is low and the expectation for admission is low, those are typically better cared for in ambulatory settings. This graph is, obviously, a graph of the US and the specific types of ambulatory surgeries, ophthalmology, orthopedics, et cetera. But it looks very similar to the graph at MUSC Health, and I'm sure many other sites that are experiencing expansive ambulatory growth and flat, if not shrinking, inpatient surgical growth. And so this is an area where we're really excited as a quality team to really dig our teeth in and better understand. This has been a little bit of a blind spot, if you will, in monitoring, measuring, and really understanding what these patients experience as far as preventable complications. And that's why we're so excited about this partnership to better understand, analyze, and improve upon potential complications in the ambulatory space. (DESCRIPTION) Text, A sea of rankings. Leapfrog Hospital Safety Grade. The Joint Commission Hospital Inpatient Quality Reporting. I.Q.R.. Program Hospital Value Based Purchasing Program. Accountable Care Organizations. Best Hospitals U.S. News. Rankings. Hospital Compare. Hospital-Acquired Condition Reduction Program. Quality Payment Program. N.C.Q.A., C.M.S. Hospital Readmissions Reduction Program. Healthgrades. (SPEECH) So MUSC Health, just like all other health centers, are paying more and more attention to what I call a sea of rankings. Many of these rankings have been very focused on inpatient potentially preventable complications, such as hospital-acquired infections or patient safety indicators, et cetera. And really the vast majority of the quality metrics are still very inpatient-focused when the vast majority of care happens outside the walls of the hospital. So again, another good reason to figure out better ways of understanding what patients are experiencing in the ambulatory space and really encouraging some of these rankings programs to get more into the business of ambulatory complications rather than just focusing on the inpatient space. (DESCRIPTION) Text, Current opportunities and challenges. Over 70% procedures performed in outpatient settings. Limited outcomes/safety/quality measurement systems. Share results of a comprehensive quality outcomes system for ambulatory procedures. Trusted Objective Secure Data Methodologies. (SPEECH) Thank you, Danielle. Sandeep Wadhwa from 3M. I'm a chief medical officer. I think I'm at the altitude extreme from Danielle. I'm joining you from Denver, Colorado. Danielle, sometimes I think Charleston can run sea level or under sea level. So between us, we've got the span of the US covered from an altitude perspective. Very excited to share more about our partnership and also our efforts on providing insight on quality outcomes for outpatient procedures, both those that occur at an ASC setting, but also hospital outpatient and the system we're describing here can also look at office-based procedures as well. At 3M, we are focused on building methodologies, whether their payment methodologies or also quality methodologies. And we had been very aware that there was a gap in the market around measuring outcomes after procedures occurring in outpatient settings. And it's tricky to kind of be able to look at care after the day of the procedure and then link it back to the procedure and develop a quality system that-- where a follow-up event is plausibly related to the procedure in question. And so we've been working on this system for the past five years, maybe primarily interested in bringing a safety lens and looking at variation that's impactable or actionable in providing that insight by site and by the proceduralist. I'll also just quickly say we've been thinking about this issue with a very broad definition of procedure. That certainly we want to include the surgical procedures, but there's so much volume that is occurring from medical subspecialties, whether it's cardiology or GI or IR. And so we wanted to cast a wide net on being able to give health systems and providers, as well as payers and regulators a greater view of patient outcomes from this really important site of care. Next slide. Oh, guess I can control the slide. (DESCRIPTION) Text, U.S.N.W.R. updates. Inclusion of 3M Ambulatory Potentially Preventable Complications. Hospital Rankings Shift Emphasis to Objective Data Away from Expert Opinion. A time horizon table appears. (SPEECH) And as Danielle had indicated, we've been engaged or talking to the various public reporting entities. And U.S. News being a leader in that space just announced two weeks ago that they will be including evaluation of outpatient outcomes from facility sites, hospital outpatient departments for orthopedics and urology in this year's rankings of specialties. And they're looking to evaluate some more specialties and procedures for next year moving into OB/GYN, ENT ophthalmology, and some procedures, in particular, prostate, uterine cancer, hip and knee replacements. And so I think there's an opportunity here to kind of both advance insight on where things are going really well from a procedure point of view and spread those learnings across the system to be able to benchmark that, and then also look at where there may be opportunities. There's such a culture of quality and patient safety in inpatient settings. I so recall kind of surgical M&M, morbidity and mortality conferences. And I think there's a whole host of reasons that we don't, I think, have that same infrastructure for outpatient care. And so we're excited about being part of sharing some insights here on complication, safety, event rates, variation, and describe our relationship a bit further. Let me turn it over to Miki to walk through some results. (DESCRIPTION) A table appears titled, Top 20 PSGs 3M A.M.-P.P.C. rates. 19 to 21 Medicare F.F.S. H.O.P.D. (SPEECH) Sure. Hi. What I want to show you, I'm going to put the bottom line up front here so that you understand the data set that we started looking at. So if you look at the slide, I know it's really busy, but this is the top 20 procedure groups out of the 93 procedure groups that we have been looking at. And it's the data from Medicare hospital outpatient from 2019 through 2021, just so you kind of understand where we're coming from. So let's look at the top level. The number one procedure that's being done in hospital outpatients is an upper GI endoscopy procedure. And when you look at the data, you can start to understand how we're developing benchmarks. So there's 2 and a 1/4 million of these procedures that have been done in the past 3 years-- those 3 years. Of that, over 11,000 patients have gone to the emergency room with complications from an upper GI endoscopy procedure. 34,000 were unplanned admissions for complications directly related, or plausibly related, to that upper GI endoscopy procedure. They had the procedure, they went home, and then they returned to either the ED or were admitted. We're also able to surface all the complications that presented in an outpatient setting. When we looked at our benchmarks, we did not really want to utilize outpatient because that, one, may be the best place to treat that patient, and two, we're looking to see if there's a significant complication. So as we did our benchmarking, you can look at this last column, which is the complication rate. So having an upper GI endoscopy procedure, you have a 2.2% chance of having a complication related to that procedure. And to understand a little bit of the variation that we saw when we looked at these procedures and their complications, it made sense. So if you look at a routine cataract procedure, you yourself would think, there's not really a lot of complications that can come from just taking care of something in your eye. So as you look across, 0.21% chance of having a complication related to that procedure. So now look at dialysis shunt. We know that the patients are very sick that have to have dialysis shunt. They have kidney failure. So we know they're already sicker patients and they're having a procedure, which has a higher risk. So you can see this. Only 389,000 of these that were done, but 10,000 went to the ED with a complication from that shunt procedure, 16,000 were admitted. So when you look at that 6.75 rate, complication risk rate, that's how we come up with those rates. And I'll talk a little bit about the logic that goes behind it in a sec. (DESCRIPTION) A bar chart appears with the title, National Medicare risk-adjusted O.P. facility-based procedure complication variation, C.Y. 2021. Distribution of hospital A/E Medicare F.F.S. performance C.Y. 2021. (SPEECH) But because we could look at 100% claims data for all of those years, what we did look at was at a hospital outpatient level, there were some 3,261 of these different hospital outpatients. And they had to have done more than 200 at-risk cases, meaning one of the cases that go into our procedure groups. And we could look at what their actual complication rate was compared to what we expected with those rates that we just showed you. So now we have a way to kind of compare apples to apples across hospital outpatients. And you might see in the middle of this that the highest rate is less than 1. So understand first, that we don't believe all complications are preventable. They're all potentially preventable complications. But we also now have something to aim with. And when we started doing this work with inpatient potentially preventable complications, this is kind of what the curve looked like. But you can see there's longtails to the right and they're little bit to the left. So these hospital systems on the left-hand side are doing better than expected. So there's a lot of difference going on. So when you see variation, this is where you can impact it. So a little bit about what it is. So the definition of an ambulatory potentially preventable complication is a harmful event, such as a laceration accidental or a negative outcome. And I think this is where you're going to see a lot of action-- sepsis infection, hematoma, bleeding. They have to happen after an elective procedure, somebody scheduled this. So this is not emergency room procedures. And it has to be performed in an ambulatory care setting. And what we're really looking at is complications that are clinically plausibly related to that procedure itself. We're not looking natural progression of a disease like, oh, their hemoglobin A1c, their diabetes is out of control. We're not really looking for that in this component. So here's the logic, how did we make this? So we looked at some 2,900 different procedures with what we would thought had a risk. So they had a needle, a scalpel, intubation, some kind of medication, something was done to a patient that could potentially result in a complication. And we started anatomically. We started looking at things that can be done in the fingers and the hands and the elbows and all anatomic. And we looked at the risk of the procedures. So thinking about the hand, if you had a trigger finger done, one little finger, quick surgery, not a lot of complications kind of like the eye. But if you had a total shoulder done and you think about that, that's a longer procedure, there's a lot more blood loss. It's a very complex and higher-risk procedure. And we're able with this component to bubble up to the top those procedures that we have designated as the highest risk if you had more than one procedure done at a time. We can also look at service lines. We can look at facilities. We can look at a lot of different things. But that procedure is now chained out for 30 days and we're going to look for complications, so then there's logic that goes to the complication. So we divided it in some 1,500 different complications into 35 complication groups because we wanted to put like with like. And you'll see that there will be lung things and there'll be bleeding things, but we wanted to make sure that it was clinically plausibly related to that procedure. And we put on timing limits. Do we expect this to really be from that procedure at 20 days? Maybe, maybe not. So we have timing limits built into this software. We also wanted to see where they turned up. So in the software, we have four different complication types. The first is if they showed up in the emergency. The second is if they were an admitted patient. So that was present-- on this complication was present on admission. We also said we can find them in outpatient and we have a sneaky, little logic that's probably not going to be used much and we found a few results to this. But in Medicare, there is a rule that if you had a procedure and you were admitted within 72 hours of that procedure, you can't bill as an outpatient, it gets rolled into the inpatient. And we have logic that can find that. And when we did this, we made our Medicare and national benchmarks based on emergency and inpatient only, but we can report out the outpatient. (DESCRIPTION) Text, Risk adjustment approach. Age. Disability status. Oncology. Correlated with chronic conditions. (SPEECH) So you say, well, what about the risk? Did I take a sicker patient? My patients are always sicker than somebody else. Again, we are not looking at that patient's condition. We did find when we looked at all procedures that age was a factor, so we built that risk factor if you're over 75 or if you are over 85, you had a higher risk of a complication. Makes sense. We also find that under 65 with our Medicare, which is our disability status, they had higher risk of complication. And oncology-- despite thinking that oncology would have a higher risk down the line, what we found is in our 93 different procedure groups, there were only five that oncology had a higher risk. And it's also associated with chronic-- the numbers correlated well with chronic conditions. And I give you the example of that dialysis shunt, that is a chronic condition and they were all put in the same kind of situation. (DESCRIPTION) Text, Ample of complications. Lung issues, bleeding hematoma, infection sepsis, mechanical complications. (SPEECH) So this is just a sample of the complication types that we have for our groups. The lung issues, so we have aspiration pneumonia, pulmonary embolism. They're all falling into procedures. And we have bleeding, such as post-hemorrhagic and acute anemia, venous thrombosis. We also have various classes of infections that will go with specific procedures. And then really importantly, I want to show you that we have mechanical complications. But when we do this logic, a mechanical complication of, say, a muscle skeletal device is only going to be tagged to a procedure with a muscle skeletal device. So I just want to make sure that you understand we really did a lot of homework to make sure that the real procedures with complications really related to those procedures are what's coming to the top. (DESCRIPTION) A pie chart appears. Text, Top 10 complications. (SPEECH) So what we found was kind of surprising to me that out of all the procedures that we ran through, the number one complication coming to the ED or being admitted was septicemia or severe infection. And we did actually not know this. There is nothing that was able to aggregate all of this data before this. So UTI's, pulmonary and chest, other bleeding, so now we actually have some data on this. (DESCRIPTION) A bar chart appears. Text, Data by procedure subgroup P.S.G. 70 upper G.l. endoscopy. Medicare H.O.P.D. 19 to 21. (SPEECH) You say, so what? Well, this component will actually look at those upper GI complications and now tell you what they're coming in for. So you saw how many cases they went to the EDI inpatient, they have a 2.2% risk, of what? Of number one, coming in for a GI or peritoneal significant bleeding. So these patients had a procedure, they went home, and they came back with bleeding, or pulmonary and chest complications, or septicemia. So these are the ones they are coming in for. Now, we actually have some insight into what's going on. (DESCRIPTION) A table appears titled, Top 10 H.O.P.D. ortho P.S.G's. (SPEECH) And as you say the same thing, I can do it by service line. So look at these. These are the top 10 procedures-- orthopedic procedures done in hospital outpatient in the past 3 years. At the top is a total knee arthroplasty. Now, I'm going to show you some information. There's a lot of these cases. We have a 2.8% complication rate. And again, you can say, so what, Miki? Well, I'll tell you. What are they coming in for? They're coming in for anemia. (DESCRIPTION) A bar chart appears. Text, Complications of P.S.G. 13 total knee arthroplasty. Medicare H.O.P.D. 19 to 21. (SPEECH) Now, remember, total knees were in the hospital for two weeks, and then one week, and then three days, and then one day. And why do we keep them? We looked at their labs. We looked at their mobility. We looked at everything. And if they had some bleeding, we would transfuse them. Now, we're able to do a lot more things with trans-cinnamic acid and tourniquets, and all the ways that we're doing these minimally invasive procedures. However, if that patient came back to the emergency department with anemia, it was palpitations, they were fainting, they had fatigue, there were other things, and they would be treated by medicine and that surgeon may never know how many patients came back with anemia-- unless the patient came back, but that's just a little anecdote. (DESCRIPTION) Red arrows point to the three most common complications. (SPEECH) Oh, I'm just going to show you the places that we see here, you can start to look at your procedures. So now that we know they came in for anemia, UTIs, or infections-- what are we going to do? Look at all of these people with infections. What can we do about that? (DESCRIPTION) Text, Prevention: Post hemorrhagic anemia, acute anemia. Best practice. (SPEECH) Well, we can go back and look at our processes. They came in with anemia preoperative. Did we look at them preoperative? What were their medications? There were a lot of ways that we as 3M can start to highlight these areas for improvement. This is actionable data. (DESCRIPTION) A bar chart appears. Text, Driving network performance on complications, site of service. The best performing provider was 70% better than expected and the worst performer was 70% worse than expected. (SPEECH) And the same way of looking across your whole network. When we start to put the facilities in here and find out how many complications are coming in, this is state data. And if you look at it, the middle, the highest, is 0%, it's not zero complications. It's just where we expect them to be. Everybody on the left, the far left, that 70%, that's an orthopedic ASC that did 70% better than expected for outcomes. If you look to the far right, that's an orthopedic ASC that did 70% worse than expected for outcomes. So wouldn't this be good to know because you would concentrate your performance improvement on that right side of this graph. So I think it's just really, really good at showing things that we actually never had insight to before. (DESCRIPTION) Text, M.U.S.C. quality governance structure. Improve health care quality. Improve KPIs vertically and horizontally. Focus on sustained process improvement. Improve internal and external reporting and transparency. (SPEECH) So thank you, Miki. That was great. So you can see there's just an incredible array of data available through the tool. And then the next question is for hospital, or health system, or ambulatory surgery center, or even a group of physician practices, how do you tackle the data when it comes in. This is just an example. So we have been thinking through this. So again, a lot of our quality structures in many of our hospitals and health care systems have really been focused on inpatient data and quality improvement projects on the inpatient side. And what we've tried to do over the course of many, many years is extend our service lines into what we call ICCE, which are Integrated Centers of Clinical Excellence. So we get our ICCE leaders thinking throughout the spectrum of care, not just inpatient. And now they're really craving more ambulatory data, which is as you've just seen, we'll be getting to them soon. So what we've lined up at MUSC health is that each of our ICCE/service lines, extended service lines, have a quality safety manager or director depending on the scope and complexity of the ICCE that do a whole range of activities for that ICCE. So they certainly look at risk safety quality, they do external reporting, they do data analysis, they work with their ICCE leaders, they work with their operational partners. And more and more getting into all of our value-based care to make sure that the care of that patient in that service line/ICCE is appropriate across the spectrum of care. So really thinking about the longitude of care and not just an isolated area. (DESCRIPTION) Text, M.U.S.C. quality governance structure. (SPEECH) So all of our quality leaders report up to a system director, and we give them guidance on what it that is supposed to be in their strategic plan. So they look at system-level key performance indicators, so big things like safety, mortality readmissions, but again, a lot of those current state are focused on inpatient. They also look at very ICCE-specific key performance indicators. So for example, in the peri-op space, there's lots of KPIs around process. So making sure that patients are getting CHG bathing and that their timeouts are appropriate. And all of those kind of bread and butter safety checks that we do both in and outpatient settings and peri-op. Many population-based attributions like for the population in that ICCE of the patients who have diabetes, is their diabetes controlled? A lot of safety-related things-- so event reviews, hospital-acquired conditions, and anything coming through our event reporting system, where we do a common cause analysis, so again, regardless of whether it's in or outpatient. And then across the spectrum across the longitude doing more quality and performance improvement activities based on other key performance indicators that are specific to their ICCE, up to and including external data and registries. (DESCRIPTION) Text, How will we close the gap? (SPEECH) So in the example of ambulatory surgery key performance indicators, so you saw from Miki the breadth of data that is available through the tool. So really working with each one of those ICCE to make sure they understand. Just like Miki explained, when you say complication, what does that mean? How do it's related? What are the time, stamps? How do you risk adjust all of that? And then understanding for patients that are having a complication, understanding what is a typical workflow, ideal workflow, standard operating procedure for that area, and making sure that the team is following those key processes to avoid complications altogether. Things like medication reconciliation, again, CHG bathing, things that should be occurring in the ambulatory surgery space, but may not be occurring reliably. Analyze those process gaps and then put them into an improvement process. So again, looking at complications very specifically by population, making sure that we're getting that data analysis back to the teams that can have an impact. Going through those performance-- key performance indicators every week, making sure that if there are barriers to success, that those are getting escalated up through the QAPI team. And then again, revising workflows, standard work, or standard operating procedures as necessary. And then obviously, incentivizing and motivating our teams for success. So that's how we normally do quality and process improvement, and how we're going to weave this ambulatory potentially preventable complications into our existing infrastructure to close those gaps. (DESCRIPTION) Text, Summary. Promote patient safety in outpatient settings. Great and growing need for ambulatory standards of care and safety. Identify actual versus expected variations. Source comprehensive, trustable, actionable outpatient methodology and data. Foundation to value-based care in rapidly expanding ambulatory care. (SPEECH) Thanks, Danielle. And just kind of in closing, I think just to recap the topics we've been discussing, I hope the audience is hearing how we're approaching this awareness-- situational awareness, historical awareness of patient safety performance in outpatient settings. And just I think this is so important from a patient experience, patient safety perspective. And I think as we're seeing, many of the folks that look at measuring performance from a payer or quality point of view I think are going to be looking more carefully at procedures. And I'll also just kind of comment that a lot of outpatient care is hard to measure from a quality point of view. I practice geriatrics, the time to see impacts for hypertension care and diabetes care are not short. One of the interesting things about procedures is we're getting this ability to look at this 30-day window, which is a lot easier to measure and is a very relevant recovery period and really are able to look at post-acute care, post-event care as being kind of a longitudinal period here, where I think it promotes itself for the quality improvement infrastructure that I think we're much further along on the inpatient side, and now can kind of extend that to where care is overwhelmingly being delivered now in ambulatory and community settings. What's so important, I think, is that there's an ability to see your performance versus benchmarks versus average and best practice benchmarks. And to unpack that further to understand where there's opportunities for leverage or improvement. There's benchmarks available for efficiency and throughput in outpatient settings, and I think we're really excited to be able to bring in a safety quality dimension. And I suspect that this will be a lot of interest to the physicians and providers that may be insights that they weren't aware of before-- 2% complication rate is non-trivial when I'm making referrals. For me to know what my institution and what different proceduralists rates are, I think may even help informed-- help even inform informed consent. And so we're looking to work with additional health systems as we are starting this journey with MUSC. And I'll also say that I think that this will feed forward into a lot of value-based contracts, that there's an interest in how payers pick the providers that they want to work with in a neural network. And I also think as a health system, knowing your total cost of care and potentially preventable events and how you're performing kind of can inform your negotiation positions in these increasingly downside risk relationships. And so as we kind of move from upside sharing only to downside, I think having insights on relative performance become really important. So thank you. I think-- Clare, I think we wanted to save some time for questions. And I'll let you tee those up and we'll distribute them amongst ourselves Yes, perfect. Well, I would just like to thank all of our presenters for an excellent presentation. And yeah, we will now begin our question and answer session. So you can submit any questions you have by typing them into the Q&A chat box on your webinar console. And we'll go ahead and get started with the first few questions here. So just to kick us off, is there any data breakdown between adult and pediatric outpatient-- outpatient outcomes? Danielle, Miki, may I take that one? Yes, go ahead. Yes. So a great question. I'm really glad that came up. We did design the system to be inclusive of pediatric care. (DESCRIPTION) Text, Q and A. Danielle Bowen Scheurer MD, M.S.C.R.. Miki Patterson PhD, N.P. Miki dot Patterson at mmm dot com. Sandeep Wadhwa MD, M.B.A. S Wadhwa at mmm dot com. (SPEECH) And so U.S. News is focusing on Medicare for their rankings as they are when they're other-- when they look at mortality and discharge status, they're working with a Medicare database. But we designed the system to be inclusive of pediatric procedures. And what we are seeing is lower overall procedure volume, but a very similar rate of complications. Miki, you can correct me if I'm wrong, but my recollection is it was a shade below that aggregate 2%. And obviously, the mix of procedures for kids is different. All the newborn-- not all, but many of the newborn males are getting a circumcision, so that dries up volume in terms of births. But just when we look at ear, nose, and throat procedures, both whether it's ears or tonsils, or the frequency of hernia repairs, or GU procedures, we saw a fairly similar complication rate and we just think that will be of a lot of interest to pediatric sites of care, whether those are outpatient or ambulatory, and so the system is inclusive of pediatric cases as well. Miki, anything to add on peds? Yeah. So for this data, I just presented the large volume Medicare data, but we do have national benchmarks. And as Sandeep said, when we looked at, say, the lower GI or lower GU surgeries for youngsters, we saw that they were very similar to adults in almost every single area. Again, they were a little bit lower. The rates of complications for these younger people were lower, but they follow the exact same pattern. So if there was very few complications in the Medicare data, there were very few in the Medicaid and youngster deaths. So yes. So this next question is a bit of a two-parter, but how important are patient partnerships in developing metrics to measure health system's safety outcomes in ambulatory care and overall health, and how will your hospital system engage patients in this process? I can take that one. Incumbent upon quality leaders to develop and put in place metrics that are meaningful to patients. So if a patient-- if we're measuring something that they really-- that has no meaning or impact on them, it doesn't really make any sense at the end of the day to put a whole lot of effort into that. I do think that patients, obviously, feel and care about complication rates. I do also think that most patients do not expect to ever experience complications much less in an ambulatory setting. And again, the sheer volume of ambulatory procedures is so high that the vast majority of patients don't experience a complication. You saw those numbers. So even though the is low because of the volume of people getting those things done, cataracts, as Miki pointed out, upper GI endoscopy, et cetera, that the volume of people experiencing complications would be high. I think most health systems do have patient family advisory councils, where they do get feedback on implementing new procedures. So I think one area of opportunity in this space would be to help or have our patient family advisors help us on the pre-procedural or education side to help patients understand what the risk of the procedures are, again, that for the most part, I think this is pretty new information to both-- would be new information to patients and certainly on the health system side. So to get their help in making the information understandable from a patient perspective. Miki and Sandeep, do you want to add to that? Yeah. So one of the things that I think there is an understanding that if you're going to have an outpatient procedure, it's no big deal. It's I'm going to have a procedure, I'm going to go home. And one of the things that this is showing is what complications could happen. So as the patient goes home and thinks it was no big deal, if you pre-teach them, preoperatively teach them, OK, if you have dizziness, if you have this, if you have that, please call the office. Please be seen right away, because they may have some symptoms of a complication and may delay care. So I think this actually just brings out if patients are coming back with something, you can teach them they'll call your office sooner, or you can take care of that beforehand. I just think having patients aware of this potential of complication and what symptoms to look for I think is going to be helpful. And I'll just build upon those comments that we think there's a real dimension of patient empowerment. A lot of times when patients are making decisions about where to go for a procedure, you rely on word of mouth and kind of using your informal networks. And the more we can kind of contribute to adding a lens of some objective data to help inform decision making, I think that's a good thing. And just to Danielle's point, I think this notion of patient partnerships and voice of the patient is something that we're also welcoming in terms of feedback and areas for improvement and focus and evolution. So really appreciate the question. Are each of the complication types weighted the same or differently when evaluating providers? Miki, do you want me to-- Sure. The system kind of looks at four complications, four potential complication categories-- office-based, emergency room, inpatient follow up, and kind of direct admits. When you have-- within 72 hours, if you're directly admitted that we capture-- we have that as a measure. The office visit and direct admit are not part of our benchmark norms. We think those are important areas for understanding and unpacking why-- what's the cause and reason for those settings for follow up care. So we are in our norms file kind of looking at emergency room visits and inpatient as kind of our-- they're disaggregated but one can add them together as we did to kind of show that complication rate. And I think payers or quality regulators may have a different weighting system, but our benchmark is kind of looking at the emergency room and inpatient rates as being the two key events that are part of our norms file. Miki, anything to add on that. No, I think that just understanding that the complications that belong to that procedure are what is being followed, and it's not weighted differently by the procedures, except that these are the complications from those particular procedures and that's the complication rate that we're benchmarking. And it works for ASCs, it works for any-- it works for anybody's data that wants to go into that. And I think that's one of the things I wanted to make sure people understood that you can put whatever data in here, and it will bring out your specific information. Just Miki, I'll make one more quick comment, which is we are using indirect rate standardization. So if the only procedure you were doing was a cataract, we would not-- the software would weight the complication rate for that volume accordingly so that that center is not looking exceptional against a center that predominantly was doing hips. We're looking at the rates within the procedure type and weighting accordingly. And so if there is a higher complication rate with those cataracts that the weighting would bear that out in a comparison file. So what role has CMS played in monitoring complications secondary to ambulatory surgery? I got that. Danielle, you mind if Miki goes to bat on that? OK. So one of the things that we looked at is what are the CMS regulations for procedures, and what are the regulations for ASCs. And you'll see that they have-- a lot of them are procedure-based, meaning do they come back and follow up for, do they have vision improved for cataracts or colonoscopies? But they don't have anything comprehensive as yet. So I think this is going to be one of those eye openers and first steps of finally seeing that you can look into these in a really, really rich way. Yeah. I would add that Outpatient Quality Reporting, OQR, and ASQR differ. And that what we're talking about-- allowing here is a drill down by these procedure groups rather than an aggregate value. And that we're also looking at follow-up care that is a potential complication, not just all ER visits within a certain period. Danielle, any other insights about how you're using OQR CMS measures? Yeah. No, I agree. I think the-- I think the difference between current state and what we have here is just the level of specificity, and I think the data is much more credible because it goes to great lengths to link what complications would be related to the procedure as opposed to just overall things like readmission rates and things like that. So I think the level of specificity with the data lends a lot more credibility, and therefore, I think, we'll get more traction in process improvement from key stakeholders because of the credibility of the data. We have to win the hearts and minds of the providers. So the first reaction is this doesn't apply to me. Right. Every time. Moving on to our next question-- how do we tie together outcomes from procedures performed in the outpatient and inpatient settings? Miki, I can jump in on that. So two ways, one is we work with the health systems facility and physician billing data or out of the data warehouse, the clinical data warehouse, and are able to link together the procedure with the follow up care that's in the system. And as wide a net as we can cast, we can kind of connect the dots between events in time and space. And so that's kind of a path 1. Path 2 is brothers and sisters, when we can get payer data, we jump on it because the payers are able to see out-of-network care, and so the system also can operate with payer data. And many of our clients have risk sharing arrangements, and with that comes these payer claims data assets. And so those are the two ways that we're trying-- that we link the subsequent care to the incident precipitating procedure. And I believe we have time for one more question. What process does MUSC use to ensure the OPDs under the med center follow the PNPs. Can you repeat that? Yes. What process does MUSC use to ensure that OPDs under the med center follow the PNPs? So Danielle-- There were some acronyms there, I'm not-- I think the OPD would be the outpatient department, kind of the hospital outpatient department. OK, yes. So the facility. And then, Claire, that second acronym I could guess, but what was the second acronym, Claire? Yes. PNPs, I believe it's referring to regulatory agency regulation. So I think that's where our ICCE structure comes in handy. So we expect consistency in care despite location of care. We do run into this. Sometimes different clinics have different regulatory oversight. So we just take a single standard approach to what is the right care paradigm and what are the regulatory expectations regardless of if we're actually getting a site visit or not. So I think the ICCE infrastructure helps us standardize that across sites regardless of who's actually paying us a visit, Thank you for all of those great answers, and thank you to our audience for the great questions. Unfortunately, that's all the time we have for today. But I would just like to thank Dr. Scheurer, Dr. Wadhwa, and Dr. Patterson for an excellent presentation, and I'd like to thank 3M Health Information Systems for sponsoring today's webinar. To learn more about the content presented today, please check out the resources section on your webinar console and fill out the post-webinar survey. Thank you to everyone for joining us today, and we hope you all have a wonderful afternoon. Thank you. Thank you.

Sandeep Wadhwa and Miki Patterson � Tracking and preventing outpatient procedural complications � Described Video (DESCRIBED VIDEO) The 3M Science applied to life logo appears on screen over a red and purple gradient background. Logo fades and text appears on screen that reads: Tracking and preventing outpatient procedural complications (SANDEEP WADHWA) This is really sophisticated logic to kind of look at events after you leave the same-day surgery suite. (DESCRIBED VIDEO) Sandeep Wadhwa, who is seated in front of a dark background, begins speaking and title text appears on screen over video: Sandeep Wadhwa, MD Global chief medical officer 3M Health Information Systems (SANDEEP WADHWA) We're looking at emergency rooms, hospitalizations, office visits. (MIKI PATTERSON) If you look at in the past, say five years, all the procedures that were typically done as inpatient have now moved to outpatient, and I use orthopedics as an example. (DESCRIBED VIDEO) Video cuts to Miki Patterson, who is seated in front of a dark background. Title text appears on screen over video: Miki Patterson, PhD, CNP Clinical transformation consultant and product owner 3M Health Information Systems Miki begins speaking. Clips of Sandeep and Miki alternate through the end of the video. (MIKI PATTERSON) Spines and joints have 168% increase in being done outpatient. So, a hospital used to have all their procedures done and now up to 70% of all the procedures are being done in an outpatient basis. They're being done in ambulatory centers, in cardiac centers, in GI centers, and there's no real oversight. (SANDEEP WADHWA) We really think this is a powerful tool that is actionable and really can help make a patient's safety better for anyone going through your elective surgeries or hospital outpatient suite. (MIKI PATTERSON) It's much more actionable data that you're going to get from this. (DESCRIBED VIDEO) The 3M Science applied to life logo appears on screen and fades away.

(DESCRIPTION) Slide presentation. Text, Welcome! We will start at 1:00 PM ET/10:00 AM PT. Advancing Outpatient Safety with Reliable and Actionable Insights. April 25, 2023. Click "Join Audio" and adjust your settings before we begin. MGMA logo. Daniel Williams' video feed appears in the upper right corner of the screen. He is seated and speaking to camera. (SPEECH) Hi, everyone. This is Daniel Williams, Senior Editor of Industry Content at MGMA. Welcome to today's webinar, Advancing Outpatient Safety with Reliable and Actionable Insights. Thanks so much for joining us. (DESCRIPTION) New slide. Text, Thank you! Logos: 3M, M asterisk Modal, 3 M dot com slash H-I-S. (SPEECH) We would like to thank 3M Health Information Systems for sponsoring today's webinar. You can visit their website at 3m.com/his to learn more about improving patient safety and all things capture to code. Please see the slide for available credits for the live and on-demand experiences. To claim all credit types, you must complete the session evaluation following the webinar. (DESCRIPTION) New slide. Text, CME/CPE Pre-session knowledge assessment: If you plan to apply for CME or CPE credit, please answer the poll question now. (SPEECH) Now, anyone claiming CME or CPE credit, you will need to answer the pre-session knowledge assessment. It's about to pop up on your screen. And I'll give everybody about 30 seconds to submit their answer. (DESCRIPTION) New slide. Text, Housekeeping: Chat, ask a question, additional resources. (SPEECH) We highly encourage interactivity at our digital events. So please use the chat button to talk to your fellow attendees. And look for that Q&A button when you want to ask questions for the presenters. Any additional resources such as the slides and session evaluation can be found in the learning management system where you accessed this program. The education for this session will now begin. (DESCRIPTION) Logo: 3M, Science, Applied to Life. Text, Advancing Outpatient safety with reliable and actionable insights: Ambulatory Potentially Preventable Complications (AM-PPCs). MGMA. Sandeep Wadhwa, MD, MBA. Miki Patterson, PhD. 3M Health Information Systems. April 25, 2023. (SPEECH) In today's webinar, Dr. Sandeep Wadhwa, Global Chief Medical Officer 3M Health Information Systems, and Dr. Mickey Patterson, product owner of 3M's ambulatory potentially preventable complications grouping software will share actionable insights for advancing outpatient safety measures. Dr. Wadhwa, Dr. Patterson, I know you have a lot of great information. So I'm going to turn this over to you now. (DESCRIPTION) Sandeep's video feed replaces Daniel's. (SPEECH) Daniel, thank you for the kind introduction and for the little pop quiz. I was thinking about those questions too. We look forward to seeing folks' pre-post responses on that. Thank you so much for joining us today. We're excited to share with you some advances in how to look at post-procedure care, and particularly looking at related complications, and quality defects, and beginning to get more insight about 30-day outcomes post-procedure. We have a really rich infrastructure for looking at 30-day events on inpatient care and technologies advancing now to be able to look at procedures as well and add that lens to how we improve our ability to care for patients. So Mick, you can go to the next slide. (DESCRIPTION) New slide titled, Learning Objectives. Text, Review the current challenges and opportunities to track and improve patient safety with elective procedures. Recognize the broader implications of safety incidents on shared risk and value-based care (VBC) contracts. Identify a roadmap to identifying gaps in current outpatient safety practices. (SPEECH) I'll kick off these first few slides and then turn it over to Mickey. And then I'll come back to discuss the kind of close this out. It's nice to see folks from across the country. Texas and New Jersey representing so far. Just a couple of learning objectives. And again, I kind of teed up this conversation as beginning to advance our approaches for measuring post-acute events after elective procedures. And we'll take a really broad definition of procedures and kind of expand that definition from surgical procedures to also include procedures that occur in radiology settings or in all of the internal medicine subspecialties to which I belong. Though was a geriatrician, we don't do too many procedures in ambulatory surgical suites. And so the other part that we thought would be really interesting in this conversation was how looking at procedures could inform shared risk and value-based care contracts for a lot of our listeners today as being an area where there's almost a double, triple bottom line in terms of not only if we're able to reduce some complications, does that increase the patient experience? But it also reduces excess costs. And so as more relationships are being formed and interest is being formed, working directly with medical groups doing procedures. We think this is an area of getting more insight really can help improve performance on value-based care contracts. And then lastly is being able to drill down on where there's better than expected performance against benchmarks and where there's opportunities. By the different physicians, many of you may have several different sites where procedures are occurring. And being able to identify by procedure type, by site, and by practitioner starts to give insights on how to address for performance improvement and perhaps even opens up conversations around, are we getting the complexity of the procedure adequately and appropriately reflected in our coding? Next slide. (DESCRIPTION) A new slide shows a photo of a sign in front of a hospital that reads, Outpatient Services Drop Off, Outpatient parking. Text, Have you or a family member experienced a complication after an outpatient procedure. A, Yes. B, No. (SPEECH) So let's start off with a quick question. And part of this is we're just interested in whether you or a family member-- take a broad definition of family, whatever works for you on how you define a family, if it's spouses, kids, parents, grandparents-- have had a complication after an outpatient procedure, whether that's a surgical procedure, or an endoscopy, or any other procedure? We'll give you a second to feed that information back to us. Wowza. Boy, that is-- Mickey and I have spoken to a couple of audiences. That is a higher percentage, isn't it, Mickey, than I think we've been-- typically in our audience I think-- well, Mickey, what's your sense of just our informal feedback so far? Yeah, somewhere in the high 40s or 50s. Yeah. And so I think we're seeing it on the call here with over half the folks. (DESCRIPTION) New slide. Text, Safety Incident impact for elective procedures. Post procedure adverse events: Challenging to systematically analyze. Contribute to impaired patient recovery, excess paint and suffering, negative patient experience. Professional edict to "do no harm." Litigation costs. Reputation. Insurance premiums and inclusion in care networks. VBC opportunity: Excess emergency department (E-D) and inpatient admission for complication care. Staff time (MD, RN, ancillary services, consultants and supplies). Loss of reimbursement penalties. (SPEECH) And I think we can go to the next slide. I think part of the setup for this conversation is there a sense by patients that these procedures, if they're occurring in an outpatient setting, have a lower risk of complications. And we as providers don't see the patients after the discharge that day. And so obviously, the inpatient setting we're watching folks for overnight or even longer. And also, there's literature that patients may underestimate the severity of symptoms or signs post-procedure, that they may not appreciate-- they may go into the procedure thinking that it's low risk. And so these are parts on the patient side what may be factors that end up manifesting themselves later when things arise to a level of involvement. But part of the other challenge is it's tricky to analyze post-procedure events that were kind of separated both in time and space that the post-procedure care may not be at the site where the care was rendered initially, where the procedure was given. Someone may end up at a different ER. And how you kind of link events together and have a view of a post-procedure window across different sites of care, whether it's an office, an ER, an inpatient setting, has been tricky to do. The other reason why we think this is an important topic is it is central to understanding this edict and extending the edict of doing no harm. There may be an initial focus at the day of the procedure and really focusing in on the best practices to ensure the procedure goes smoothly and kind of bringing some more light to the post-acute period to having that expanded definition of excellence on the day of and then also expanding and helping to support excellence for the next-- in our case, we're looking at 30-day windows here as a relevant range. And as previously mentioned, we think getting more insights for your groups and your practices on where you're doing better or not kind of just helps in so many domains in terms of improvement. And where we are particularly interested in is this intersection between the patient experience and also efficient use of healthcare resources. And that post-procedure events lead to kind of excess emergency room, office visits, supply, inpatient resources, which in an increasing environment of value-based care become areas where we can act upon that have that impact of both enhancing the patient experience, as well as being more efficient in how we use total cost of care and total resources. Next slide, Mickey. (DESCRIPTION) New slide titled, Outpatient procedure trends. Text, Orthopedic procedures have shifted to ambulatory centers (ASCs), with hip and knee replacements seeing the greatest percentage of shift. Technological advancements and Medicare coverage for these procedures being performed in ASCs have aided in these shifts. A bar graph titled, Percent of change in procedures performed at ASCs between 2019 and 2021. Spine arthroplasty, 36%. Shoulder replacement, 45%. Spinal fusion, 73%. Hip replacement, 150%. Knee replacement, 168%. (SPEECH) And so this kind of speaks to the trend that has been going on for 20 years. In a prior life a couple of Governors ago, I was the state's Medicaid director. And this line of outpatient spend was stunning to me in terms of just having to plan for a budget. Every year we were planning for 10%, 15% growth on outpatient services. And we saw a 2% decrease year over year in inpatient. And that was 15 years ago practically, right at the Great Recession. And that trend has just accelerated and continued. And we're finding that we're able to do more procedures in places that are convenient to patients, mainly in community settings, and are doing more procedures and more complex procedures in day settings. And what we're particularly interested at 3M is adding a lens of patient safety quality outcomes to that window. Next slide. And (DESCRIPTION) New slide. Text, Current opportunities and challenges. An aerial photo shows three men gathered together, a man in a white coat and stethoscope shaking the hand of a man wearing a tie, standing with a man in blue scrubs holding a tablet. Text, Greater than 70% procedures performed in outpatient setting. Limited outcomes/safety/quality measurement systems. Share results of a comprehensive quality outcomes system for ambulatory procedures. Trusted objective secure data methodologies. (SPEECH) oh, Mickey, here's the answer to our question. So just kind of more data to support that trend, where we're now more than 70% of procedures, surgical procedures are occurring in outpatient settings. And I did not train as a proceduralist. I probably trained as a talker and a diagnostician. But there was such a rich infrastructure around surgical morbidity and mortality in the inpatient setting. And Mickey is a leader in orthopedics. And and we have such a rich culture of learning from what we did well and where we could have done better on that inpatient setting. And we see this trend of bringing back culture of-- and it exists today. So I'm not trying to imply it doesn't exist today. I think that as data is able to be linked and we're able to apply technology and software, we're able now to get better views of this dominant side of care. And frankly, we have very limited tools for looking at post-acute care. I'll let Mickey kind of describe our work in this area. But we think that there's an opportunity to add to the measurement methodologies out there for outpatient safety. And this is work that 3M has been involved with for 40 years. There's a role for the private sector in maintaining, and updating, and innovating on quality, and safety, and payment. Great that we have government options. They serve a purpose. But we also think that having a private sector option allows for choice, and enhancement, and responsiveness. So Mickey, let me turn the floor over to you to kind of talk a little bit about what we've built here. Sure. (DESCRIPTION) Miki Patterson's video feed replaces Sandeep's. New slide. Text, 3M Ambulatory Potentially Preventable Complications (AM-PPCs) compared to A-S-C-Q-R. 3M AM-PPCs: 3M Ambulatory Potentially Preventable Complications, computerized grouper for billing or claims. A-S-C-Q-R: Ambulatory Surgical Center Quality Reporting, very manual process. A chart compares 3M AM-PPCs and A-S-CQ-R in the following categories: Measure scope, procedures included in measure, procedures excluded from measure, procedure definition, complication defined, and risk adjustment. (SPEECH) So we're going to talk a little bit about the differences between ambulatory potentially preventable complications. I'm going to call them AMPBCs because it's easier. And what kind of quality outcomes are we looking at now for these same complications. And as you look, you know that the ambulatory surgery centers, the quality is really looking at processes. There's the same biggies, wrong site, wrong side, wrong patient. But they also have is the cataracts, improve someone's vision, and did they have normothermia? We go deeper. And what we're going to show you is 1,500 different complications put into groups. We're looking for 30 days, not just how many counts of the occurrences. We're also looking for, where did they show up and what procedures. So when we start to look, I'll give you a little bit more detail when I talk to you about the logic. But we think that the AMPBCs are a much richer way to start to look at our data. (DESCRIPTION) New slide. Text, USNWR evaluating inclusion of elective procedure safety in 2023 ranking. Outpatient outcome measurement: We recently began working with 3M Health Information Systems: Licensed 3M's Ambulatory Potentially Preventable Complications (AM-PCC) Grouping Software. Exploring potential use in specialty rankings and procedure rankings. Initial exploratory work will focus on: ear, nose and throat, gynecology, urology. The first two paragraphs of an article titled, Hospital Rankings Shift Emphasis to Objective Data Away from Expert Opinion. (SPEECH) I did want to say that US News World Reports has actually licensed our grouping software and are considering using it for the 2023 hospital rankings. They did say that they were starting with ENT, GYN, and urology. And expect to hear something from them in the June time frame to be used if they're using this for the July rankings. (DESCRIPTION) New slide. Text, Ambulatory potentially preventable complication. Harmful events (e.g., accidental laceration) or negative outcomes (e.g., sepsis) that develop after an elective procedure was performed in the ambulatory care setting and that may result from processes of care and treatment rather than from natural progression of an underlying illness and are therefore potentially preventable. (SPEECH) So I'm going to talk a little bit of details of, what is an ambulatory potentially preventable complication? It's a harmful event. So it's an accidental laceration, or a negative outcome such as an infection. It has to develop after an elective procedure. So there's no emergency room procedures here. And it had to be performed in an ambulatory care setting. These are key pieces so that we're only looking at scheduled elective procedures. And we're not really looking for a problem that had medical issues from an underlying illness. We're not looking for worse kidney because they're diabetics. We're really looking for a complication that was related to that particular procedure. (DESCRIPTION) New slide. Text, Identifying, locating and quantifying procedural complications. Procedure groups: 93 procedure groups which include more than 2,900 elective procedures. PSGs include similar procedures that also share the same relative risk. A classification hierarchy is applied to select a single and primary procedure group that best classifies outpatient encounters. For example: colonoscopies, upper GI endoscopy, biopsies, cataracts, arthroscopies. (SPEECH) So here's the logic. And there's about three or four little chains of this logic. So I'm going to just give you an overview of this. There were some almost 3,000 procedures. And what we did was we started anatomically looking at these procedures and then grouped them together by the complexity of the procedure. And to give you an example of this, if you had, say, a trigger finger release, that's not really complex. It's pretty routine. But if you were an outpatient and you had a total shoulder replacement done, much more complex. That's in a different procedure group. And we expect different complications. When we did this, we were able to do a hierarchy. So if you had more than one procedure done at the same day, one of those, the highest risk, would bubble to the top. And then we linked it for 30 days out looking for a complication. (DESCRIPTION) Complication groups (AM-PPCs): 35 total complication groups which include greater than 1,500 unique complications. Complications must meet defined timing requirements. (example: 48 hours for infection.) Complications plausibly related to the procedure. Sepsis, UTIs, bleeding, pneumonia, infections, hemorrhage. (SPEECH) The logic for the complication is such that we have some 1,500 different unique complications. And we also group them. So we group them in hematomas, and lung problems, and infection problems. We also had those complications needing to meet timing requirements. And they had to be plausibly related to the procedure. So you wouldn't have a problem with an eyeball related to a cardiac procedure. (DESCRIPTION) Complication setting: Emergency room visits, inpatient admission, outpatient encounters. Available on premise (CGS) or cloud (GPCS) with Medicare and national benchmarks. (SPEECH) And then the most important one is, where did that complication show up? So we are able to look at 100% claims and see that some of these complications showed up in the emergency department. Some were inpatient admissions. And that's not a readmission because they were done outpatient. So it wasn't a readmission. Or the complication showed up in an outpatient encounter. When we did look at these, we also started to think, what are we going to gear this on? So when we looked at benchmarks, we wanted to make sure it was a significant complication. So we excluded in our benchmarks those outpatient encounters. We only looked at the emergency room and inpatient as significant complications. And then this component is available on the grouping software that's either on-premise or in the cloud. When we did make those benchmarks, we started with the Medicare benchmarks. And then we added to national benchmarks. That includes pediatrics. (DESCRIPTION) 3M AM-PPC: Risk adjustment approach. Case adjustment: procedures with higher risk of complication grouped together. Plausible procedure and complication relationship: Clinically relevant focus on complication to procedure relationship limits effect of chronic conditions. Elective procedure focus: Less procedure complexity, care team informed by knowledge of chronic conditions (exclude ED procedures). Research: Chronic conditions reported on claim at time of procedure have few complications. Age, disability status, oncology adjustment: correlated with chronic conditions, frailty, ability to self manage. (SPEECH) And I want to talk a little bit about our risk adjustment approach. So the basic premises that we used was we wanted the procedure to be the risk adjustment because it was elective and because these patients were going to be done in outpatient and expected to go home. That's how we started to categorize. And we make sure the complication is plausibly related to that procedure, whether it was an anesthesia, or a puncture, or things like that. And then we put them into different complexities. So we put the less complex procedures in a group. And when we did do the data-- and I'll show you a little bit about the data after that-- but it made sense. When we thought these were highly complex procedures, they did show that they had higher rates of complications. And we have looked at the chronic conditions. And actually when we started to look at it, if somebody had an oncology diagnosis in five of our procedure groups, they had a higher risk. So we built that adjustment in. We also had an age adjustment. So if you are over 75 or over 85, you had increasing risks. So we put those risk adjustments in. When we did the Medicare data, we also noted under 65 had a higher risk. And these would be the dual status. These would be patients that had disabilities. So it kind of made sense when we went through it. And again, we're always learning. We're doing research. But this is where all of the data has brought us. And I'll give you a little more explanation about that. (DESCRIPTION) A new slide shows a flow chart titled, Knee procedures and example of 3M AM-PPC exclusions. It begins with two branches: In gray, Text, Exclude: Knee procedures done as inpatient or observed for 23 hours and admitted. In Blue: Include: Knee procedures that are elective, performed in ambulatory setting. From the blue box is a row five other boxes: In gray: PSG 3 Knee Arthroscopy, PSG 14 Knee Arthroplasty Revision, PSG 28 Open Knee Fracture and Ligament Repair, PSG 29 Other Knee and Soft Tissue Procedures. In blue: PSG 13 Knee Arthroplasty. An arrow points below the blue box to another blue box: PSG Assigned: 13 Knee Arthroplasty. From that blue box is a row of four boxes. In gray: ED visit day 1 with fever, ED visit day 15 for burn on hand, ED visit day 32 with hematoma and hemorrhage. Each gray box has "excluded" written in red and the reason. The blue box reads: ED visit day 10 with deep vein thrombosis: Included, plausibly related to procedure and meets timing requirements. (SPEECH) But when we did the logic for this, we have this exclusion logic. So when we looked at all of the claims data, the first thing we did was eliminate anything that went inpatient. If they didn't make the 24 hours for observation, they're not considered an ambulatory procedure. So let's use knees for an example. You can see the five groups here. We have knee arthroscopy, which is a very less complex than a total knee, and a revision total knee, and fracture repairs. So if you particularly went into the group of having a total knee joint done, you would be in PSG 13. And we would start to look out from then on for any complications. And we would tie it. Now, we did talk a little bit about that 24-hour window for the fever, for infection of a wound. And we're going to keep that on our back burner. It's excluded at this time, so we can look at more data. But we think it takes more than 24 to 48 hours to develop a wound infection that can be seen post surgery. We also looked at DVTs. So if this patient came back to the ED with a deep venous thrombosis, that's plausibly related to that knee joint surgery. It makes sense. But if you came back and had a burn on your hand, that is not really plausibly related. So that would be excluded in our logic. However, if you did come back 32 days after and had a hematoma or a hemorrhage, we would flag it. It's outside the 30-day window. But it is an event. And that would be a flagged event. (DESCRIPTION) A new slide, titled Complication Groups, shows a long list of AM-PPCs with descriptions, each one with a different number code. (SPEECH) So here's a little bit more definition about what complication groups are. If you look on the left hand column, pneumonia, aspiration pneumonia, pulmonary embolism, these are very common complications. And they're used for inpatient potentially preventable complications. But (DESCRIPTION) A red box outlines two codes in the right-hand column: 101, Post-procedural infections of eye and adnexa. 102, post-procedural complications of eye and adnexa. (SPEECH) if you look on the right hand column, we have started to put in the complications directly tied to procedures, such as a post-procedure infection of the eye and adnexa. This would be correlated with eye procedures. And the same thing with muscle skeletal. So (DESCRIPTION) A new slide shows a chart titled Top procedure '19/'20 FFS Medicare HOPD 3M AM-PPC. It shows, PSG, Description, At-risk procedures, ED complications, IP complications and AM-PPC Rate. (SPEECH) here's a lot of data to show you. But I want to walk you through it so you understand what we came out with. When we looked at all of the Medicare fee-for-service hospital outpatient data, and we looked at the top 20 procedures, top 15 procedures, at the very top the number one procedure done for this group was an upper GI endoscopy procedure. There were over a million and a half of these done in '19 and '20. Of those, almost 7 and 1/2 thousand were seen in the emergency department for complications related to that upper GI procedure. And some 23,000 were unplanned admissions from complications from that upper GI procedure. Hence giving us that complication rate at the end. (DESCRIPTION) On the chart, the 103, Routine Cataract Procedures row is underlined in red. At-risk procedures, 487,922. ED complications, 114. IP complications, 938. AM-PPC rate, 0.2%. (SPEECH) If you look down a little further, you can see 103, the routine cataract procedures. Again, a half a million of these are being done. Very few are coming to the ED. Very few are being admitted. And the risk rate is 0.2%. So that made sense to us that a very low risk procedure would have low risk. Again, upper GI, almost 2%. And when we look at it, if you look down here at number 94, upper genitourinary stent and guidewire, now this is a very complex procedure. These are sick patients. We're putting stents in them. There's 174,000 done. But of those, 5,600 come to the ED. And 9,000 are being admitted. And because we know that's a high risk kind of a procedure, it made sense-- look at the risk of complications, 7.6. So it did pan out when we started to look at these procedures. (DESCRIPTION) New slide titled, Data by PSG 70 upper gastrointestinal edoscopy procedure. A bar chart shows AM-PPC for the procedure. At the top at 0 AM-PPC 70 is, Infection, Inflammation and Clotting Complications. At the bottom is Gastrointestinal and Peritoneal Complications or Significant, dot, dot, dot, at about 10,500 AM-PPC 70. (SPEECH) What we're also able to do is not only look at the complications what comes to the ED and gets admitted. But we know what the complication was. So if you look at this upper GI that we looked at that top layer, when we started to look at the data, the highest percentage were coming in for gastrointestinal or peritoneal complications or significant bleeding. And this was after they had been discharged and gone home from a procedure. So this is not direct admits. So when we look at this, we are now able to see. We can focus on where we need to make improvements. We need to find out what's going on in these particular cases. (DESCRIPTION) New slide titled Complications by complication group. A pie charted titled Complication Frequency Medicare 2020. Septicemia and Severe infections, 20%. Urinary Tract infection, 18%, other pulmonary complications, 14%, Moderate infections, 5%, Hemorrhage and hematoma, 9%, pneumonia and other lung infections, 6%, Infection, inflammation and other complications of devices, implants or grafts except vascular infection, 5%, Major gastrointestinal complications or significant bleeding, 5%, post-hemorrhagic and other acute anemia, 5%. (SPEECH) And another surprising thing when we looked at all of that data for 2020, of all of the outpatient procedures, septicemia and severe infections came up number one. And that's 20% of all complications for all outpatient Medicare procedures for that year. So it does tell us we have a significant problem here. Urinary tract infections, what's happening post-procedure with those urinary retentions? Are they getting infections? Are they having to go to the emergency room or waiting too long and needing to be admitted? Pulmonary complications, hemorrhage hematoma. See this red one here, the mechanical complications? This (DESCRIPTION) The red wedge of the pie chart is labeled, 21,032, 7%. (SPEECH) is actually good to highlight that there may be problems with an implant or a device that we may not know of. So this information is really helpful for us to start to look and give your head a scratch and say, I wonder what's going on there? (DESCRIPTION) New slide. Text, AM-PPC surfaces contamination issue. Vignette: Previously healthy 65-year-old presented to the E-D with symptoms of sepsis two weeks after Upper Gastrointestinal Endoscopy Procedure. E-D doctor thought it odd that this was the fifth person in the past couple months with a similar story. Outcomes: AM-PPC reveals 2x as many complications than expected for Upper GI Endo resulting in sepsis. Root cause analysis: After new endoscopes were purchased for the GI group, Central Sterile never changed to the manufacturer's new sterilization method. What can we learn: High rates of procedure complications relative to a benchmark can serve as a trigger for review (or basis for performance improvement incentive). (SPEECH) And here's an analysis of what this could surface. If you have a 65-year-old presenting to the ED with symptoms of sepsis two weeks after that upper GI endoscopy and having an ED doc think, wow, this is kind of odd. This is like the fifth person that I've seen with this kind of scenario in the past couple of months. So when you looked at it, if you looked at those upper GIs and you saw that they had sepsis relating from that, you could start to do a root cause analysis. What did this find? And this actually happened nationwide a few years ago is that the GI groups were purchasing these new scopes. And they never alerted central sterile that they're new scopes. Central sterile never knew that there was a new manufacturer sterilization method. So this kind of data would help you do that root cause analysis and maybe change the way you attack something, look at something, or just trigger a review to look at the process. (DESCRIPTION) New slide. Text, National Medicare risk adjusted OP facility-based procedure complication variation (CY 2020). A bar graph titled, Distribution of hospital A/E Medicare FFS performance CY2020, showing HOPDs at A/E. The bars form a standard bell curve, the highest center bar going up to just over 250 at just before 1 A/E. (SPEECH) And this is what our rankings look like when we took all of the outpatient facilities and compared them. So this is 2020 data. And we have an expected kind of centrally. But you can see that some of the facilities were much better than expected. And some of the facilities were less, they were worse than expected. So these on the right hand side, these facilities that had more complications than you would expect would be the place that you would start to concentrate on. (DESCRIPTION) New slide. Text, Driving network performance on complications: site of service. A bar graph shows number of providers along the y-axis and percentage better than expected and worse than expected along the x-axis, with 0% in the center. The tallest bar is 12 providers at 0%. The shortest bars are 1 at negative 70%, negative 50%, and positive 60% and positive 70%. Text, The best performing provider was 70% better than the worst performer. 1 year, greater than 2,500 complications, costing $13.3 million, for providers performing below expected. (SPEECH) And this is just another example with a smaller data set. This is a statewide. And particularly, this had an orthopedic surgical center that was 70% better than expected. And it also had an orthopedic surgical center that was 70% worse than expected. And if you think about all of these complications that are happening greater than expected, these impact your margin. These impact your patient safety and outcomes. So it would be good to know where are the issues coming from. (DESCRIPTION) New slide. Text, Data by service line. A flow chart shows Procedure subgroup PSGs along with their total procedures, complication seen in E-D, complication inpatient admit, and risk IP and E-D. (SPEECH) And when we did this, we talked about doing it in anatomically. But we also did it by service line. So you could go and look in-- and I use spine because I'm orthopedics. And orthopedics and neurosurgery both do spines. But we took that all apart, that kind of division by utilizing cervical spine procedures or fusion procedure, which is a higher risk group. And same thing with lumbar. If it was a lumbar spine procedure versus the ones with fusion and higher complexity. And we could see by how many procedures which came to the ER and what was that risk of having a complication. Sandeep, I'm going to pass this on back to you. (DESCRIPTION) New slide. Text, AM-PPCs, documentation and coding quality, Top 10 procedure by volume: angiography and catheterizations. Coding Guideline: PSG 53, Coronary Angiography Procedures: at-risk cases, 564,725. Rate, 1.84%. PSG 52, Left and combined heart catheterization procedures: at-risk cases, waiting on data. Rate, 2.83%. Left Heart catheterization procedures have an expected AM-PPC rate that is 57% relatively greater than coronary angiography procedures. (SPEECH) Thank you, Mickey. Really appreciate you kind of reviewing all the insights that one can get from this approach. And listeners on the call, we welcome your thoughts and your thinking about how kind of a 30-day insight for the procedures that are going on with your groups could be useful. And I think the piece that we're really excited about is being able to show some of those benchmarks, that how are you doing against folks that look like you? And we're getting more and more data into our database. But the other part that we've been looking at is how important coding may be on capturing and making sure that the case is in the right risk group. And so in this case, if the procedure was a coronary angiography, we kind of expect a 1.8% revisit rate. But if they did also go into the left heart and do an EF, an ejection fraction, and you go through the aorta, that becomes a more complex procedure. And you're increasing the complication rate by a third, almost to 3%. And so we're talking to some of our coding experts. And the professional [? may ?] not look that different. But often times, this may be an example where if this isn't coded with the left heart cath procedure and just got coded as coronary angiography, we'd be putting that patient into a different risk group, just as Mickey was describing. And so we think as folks look at their outcomes that there's both a chance to do a check on the coding accuracy, as well as starting to look at the quality procedure. So Mickey, we can take a look at the next slide too. (DESCRIPTION) New slide. Text, AM-PPCs, documentation and coding quality. Top 10 procedure: cataracts. Coding guideline: complex cataract removal: CPT 66982 is defined as "extracapsular cataract extraction removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (i.e., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage. Routine: PSG 103, Routine Cataract Procedures: at-risk procedures, 487,922. Rate, 0.19%. Complex: PSG 104, Complex Cataract Procedures: At-risk procedures, waiting on data. Rate, 0.31%. Complex cataract procedures have an expected AM-PPC rate that is 63% relatively greater than Routine Cataract procedures. (SPEECH) I also just wanted to pull an example of a low risk procedure, cataracts. That's something in geriatrics we're very keen to address just as a leading cause of blindness that is reversible and treatable. But you can see exactly what we expect, which is a pretty low complication rate, 2 in 1,000. But if it's a complex procedure, that increases, again, by a third. And this can be very tricky on the coding side in terms of getting the-- it's complex coding rules. But I think that this would be another area kind of in addition to the quality improvement areas that we would expect folks, depending on your procedure suite, to now have more of a quality lens for why coding is really important to kind of complement the traditional being made sure you're being paid in full for the service being rendered for the complexity of the procedure. We think having this quality safety lens will further contribute to kind of accurate, complete coding. (DESCRIPTION) New slide. Text, AM-PPC mechanical failures. Vignette: AM-PPCs reveal higher than expected mechanical complications from the new joint center. Patients were being admitted for joint revisions less than 30 days following a joint placement for one facility. Outcomes: This rate was noticeably high and points to the device or application. What can we learn: High rates of procedure complications relative to a benchmark can serve as a trigger for review (or basis for performance improvement incentive). (SPEECH) And so this is another kind of vignette of where we think there will be insights. And I invite you to think about in your own settings for the common procedures that are being done by either by the doctors on the call or by the practice sites that, in this case, this example of being able to look and see if the rates of mechanical complications are higher than expected, and then drill down and say, OK, let's apply a lot of the root cause analysis and all of the total quality management tools that we have at hand to improving that post-acute experience, and identifying root causes, and building on the practices that I think are in place, but now being able to extend them to perhaps more procedures, and have benchmarks, so that you're able to get a richer sense of relative performance. Next slide. (DESCRIPTION) New slide. Text, Establish baseline for elective procedure complications. 1, Integrate into your BI environment. 2, Input your billing, EDW or claims into grouper which feeds your analytics engine. 3, Conduct system-wide analysis by site, service line and provider for assistance. 4, Benchmark to Medicare or national norms. 5, Assess, aggregate, site, service line actual to expected. 6, Create actionable data for clinicians, HOPD, service lines. (SPEECH) And we're kind of wrapping up here. We are interested if there's folks on the call who would like to learn more. We see this system as informing your business intelligence environment. And we are coming to the table with some Medicare and national benchmarks, but can complement that with information from your own system and start to build out more recent data. Always the drag with these payer databases is that there's a lot of latency. And and we're able to bring them more current with your information, and then invite that analysis by procedure, by physician, by site, how are we doing on post-acute care events, and where are we doing really well, and let's learn from those sites, and expand that out, and then ultimately kind of driving towards actionable results that are kind of aligned around patient safety. Next slide. (DESCRIPTION) Next slide. Text, Summary: Promote member safety in outpatient settings. Growing need for ambulatory standards of care and safety is great. Identify actual versus expected variations. Source comprehensive, trustable, actionable outpatient methodology and data. Foundation to VBC in rapidly expanding ambulatory care. (SPEECH) And so in closing, we're looking forward to spending a little bit of time discussing your questions and kind of advancing the safety lens both from the procedure to that 30-day window. And as Mickey had mentioned, US News is evaluating this system on the outpatient facility side. But we built the system so that it also can look at events at ACs and even office events. And so we're able to look at procedures in a wide range of where they occur. And part of what we think is really important is recognizing that there are risks with every procedure. And that that's why that slide that showed the different rates, we don't have a strong opinion yet on what's the right rate. For us, this reminds us of what re-admissions looked like 20 years ago, where that slide that Mickey showed you was not a normal distribution. It had more of this tent approach. And there's a lot of variation. And on that second slide, you saw a lot of what we call fat tails, where you have outliers. And so we expect with more of this focus on 30-day results to see that curve kind of take on more of an upside down U and the extremes get pulled in. And we see more concentration around the center. And we start to see that move to the left. And so we would love to invite a follow up if partnership or collaboration on that would be of interest. And our team works very closely with many payers on value-based care contracts. And so as your thinking about commercial or Medicare or even seeing more Medicaid procedures going into value-based care contracts, we'd welcome partnership. And one thing I forgot to mention earlier was we did build the system to also include pediatric cases. And so we have been showing you a lot of Medicare data. The Medicare data tends to be a little bit more available. As a former Medicaid guy, I think a lot about kids and moms. And so we have built this out to also look at patient safety event for those adolescents and kids that are getting inguinal hernias, or getting tubes placed in their ears, or the whole range of procedures that kids get to are also included. Final slide. This is the slide that always makes me nervous, Mickey. Let's go there. (DESCRIPTION) A new slide shows phots of Miki and Sandeep. Text, Thank you. Miki Patterson, PhD, NP. miki dot patterson @ m m m dot com. Miki is spelled M-I-K-I. Sandeep Wadhwa, MD, MBA, swadhwa @ m m m dot com. (SPEECH) I feel like there's truth in advertising. Are we matched up here? I feel like the hair is getting whiter. And the Vision's getting a little worse. But we wanted to leave you with our contact information and invite follow up directly. And Daniel, if there's questions, we can spend a few minutes going through. That sounds great. Thank you, Sandeep and Mickey. Great presentation. We do have some questions that have come through. And just as a reminder to everyone, just go to that Q&A button down there. You'll see that icon at the bottom of the screen. Click on that and drop your question in there. So first question up, how much of these growing inpatient numbers to have procedures at ASCs are contributed to COVID worries and not wanting to be at major hospitals, do you think? This attendee says, I hear this a lot in my surgical practice, not as much recently, but absolutely heard it a lot in '21 and 2022. Lauren, thank you for that question. I think it's a very perceptive question. And your hypothesis, it follows our sense of the trend too, that we see institutional settings as being increasingly reserved for higher risk and complex procedures. Particularly during COVID, I think we were getting our hands on more ASC data and saw that trend with more procedures going on with ASCs, as you did too. I'll make one side comment, which was Lauren, we saw lower infection rates at the height of COVID. And I hesitate to say this. And I think we'll probably prepare a paper on this. But we're seeing those infection rates begin to climb up. But it looked like in 2020 and 2021, this nationwide focus on sterility everywhere sort of played out in our data. So Mickey, I think we're super eager to run the most recent data set we have to see that trend. So Laura, I think your point is well made that COVID accelerates this trend. And we just think there's this broader trend around convenience. And that's kind of favoring these less institutional sites of care. Mickey, anything to add on that? No. Well, I just think that that's right. It did sort of force the hand of people who wanted or needed procedures done to go outpatient. But I think it was starting to happen. That sort of gave it a giant boost. And I don't think it's going to go back. I think that's just the way it is. But the data didn't show that we had many less infections and complications from the 20s, 2020, during the COVID time. OK, thank you all for that answer. Next question up, how do you anticipate this could or will in the future be used from the consumer side? Knowing that the ASC I'm headed to is 70% better or worse than the benchmark would influence my decision. Anonymous attendee, excellent question. This was somewhat of the exact motivation on why we were investing on building on this system, was to give the public, to give the whole system visibility on performance and to do so in a way that was thoughtful, that's risk adjusted, that's clinically related. And this is, I think, where US News kind of jumped on this, which was to give consumers more visibility on patient safety in outpatient settings. But their work tends to focus on hospital outpatient facilities. So I think the ASC visibility is still something to come. And as we talk to all payer claims databases, or public reporting efforts, or people who have complete-- I think particularly, Mickey, within different states is my guess where we'll see the ASC sites being included. Now, on the other hand, anonymous, I think that there's an opportunity for the groups themselves to tell a safety story within their market. I think so much of the-- you guys tell me. I'll see you at some event in person at some date. And we'll have a drink of your choice. But I think that people are making choices oftentimes on reputation or name, Daniel, and that there's an opportunity to start for folks to say, hey, our patient safety rate is half the regional or norm in their area. So I think folks will start to distinguish themselves independently to the consumers as part of their efforts and how they describe themselves. And this can help tell a broader story. And I think we're seeing that, just to answer your question, I think this is kind of where I think US News is going on the facility side. And I think we'll start to see, Mickey and Daniel, more folks looking at bigger databases and wanting to have more informed decision making for consumers. And I think the other piece of that is we compare apples to apples. So no matter where you did this procedure, on the C spine, or the knee joint, or whatever, everybody's in the same pile. They're all grouped together because of the procedure, not necessarily where they go. But when we did do a little glimpse into the 2021 data from CMS, the ASC had much less complex procedures being done. You would agree that that's where they go. However, there really isn't a lot out there to say how well is this particular ASC. And I think this is a tool that will help. OK, just a reminder to everyone, we do have some time left. So please drop those questions into the Q&A. Got a couple more here for you all. What are some examples then of action plans after these insights are raised? And how quickly might you expect to be able to close these care gaps? I'll take that. So one of the things that-- we looked at total joints. So I love to do this because it makes sense to me. But when total knees, when we looked at the complications for them, the number one complication was anemia and acute anemia. So as a clinician, as somebody that's going to go look at this, did they have an adequate crit before they started? Did we do a lot of cauterization? Did we use trans anemic acid? Was the tourniquet up? There is a lot of things that you can start looking at in that realm. So I think once you start to understand what your complications are, you can start to do something about it. People just don't know. I just think a procedure was done. And then they went home. And unless they came back in a couple of weeks to get their stitches out, you don't really know what happened. You think they did great or somebody called them. But if they did go to an urgent access clinic or they went to the ED, you may get notified. But it's a while from now. But not everybody knows those outcomes. And now getting this data group that we can start looking at national benchmarks, I think that's going to be really helpful for the future. That's great. Let's go to the next question. We've got time for that. Are there any ways to leverage these insights proactively when considering incremental risk contracts? Mickey, I can start on that one. I think that if groups are equipped with their performance, it really can help inform your negotiations with the payers. That you're able to start to have a story that expands beyond access and price. And often, I wanted to say this earlier too, sometimes people will focus on mortality as a measure, Daniel. And it's great. It's just those are very rare events. And so when you are able to look at ER visits and inpatient, you start to be able to distinguish performance a lot more readily. And so I would say that the piece I'm excited about is the groups being able to showcase their strengths in a way to the payers that I don't know if the payers appreciate. And I think it just starts to influence the negotiations. And then the other piece is kind of this opportunity within a contract to say, OK, are there opportunities here, where a simple change or a focused effort with a particular provider or site can not only give better patient experience and safety, but also reduce some costs that kind of fit into this movement towards bundled payment? I mean, there's a lot of talk-- the action-- I mean, you guys are closer to it. We hear that a lot with orthopedics and oncology. But as we start to get interested in that, I think getting the experience on performance, Daniel, starts to build up the expertise and experience with insights. OK. Got one more question here. And again, everybody, we do have time for probably one or two more. So if you do have something, drop it in that Q&A section. So we've talked a lot about the data. So where are the blind spots? Where are the blind spots in that data? Mickey, you want me to start? Sure. I can do-- I think the-- I think some of the blind spots on the data are the payer data for our benchmark tends to be complete but not recent. And so one blind spot is when we're pulling data from our partner sites that they may not have access to the emergency room or inpatient experiences. And so that can be a blind spot if there's not a relationship with kind of regional ERs or inpatient. We can catch that, but dated from the payer. But I think that's one blind spot that we're trying to get a sense of systemness on when we're pulling data out of the group's databases. Mickey, your thoughts? Yeah, I think one of the things that we thought of when a large hospital system, if they're running their data through it, there will be a little bit of leakage because they might go to a local ED near their house if they came to a big center to have their procedure done. So there is that in the mind. But when we looked at this particular 100% Medicare to start with, we did have all comers. But it is years old now. And as we do every year, we'll catch it up. But I think that is the blind spot that we have. OK. I think we've got time for one more. So why are inpatient PPCs so much easier to identify than the outpatient ones? They're a captive audience. So if you're inpatient and you have a complication, you're already still inpatient. It's in your chart. It can be captured. The problem is when you have your procedure done at the ASC and you go home and it closes at 5:00, you're not actually going to go back there with your problem. So they can't necessarily catch it. And I think that is the ease or not ease. But the fact that we now can do this through 30-day either billing or claims is worlds ahead of what we-- we were not even able to find out what all these complications were. All right, well, Sandeep, anything you wanted to add to that? You feel good about Mickey's answer there? I do. Daniel, there's no amount of time I can't fill with my own voice. So I'm trying not to do that, Daniel. So I thought Mickey's answer was great. OK, perfect. Well, I want to thank you both for a great presentation. And I want to thank everyone in attendance for attending, first of all, and then also helping drive that conversation during the Q&A. That was great. Thank you all for doing that. (DESCRIPTION) New slide. Text, Thank you! Logos: 3M, M, asterisk, Modal. Text, 3 M dot com slash H-I-S. (SPEECH) The education for this session is now ended. We would like to thank 3M Health Information Systems for sponsoring today's webinar. You can visit their website at 3m.com/his to learn more about improving patient safety and all things capture to code. (DESCRIPTION) New slide. Text, Thank you for attending! Additional content questions? ask 3 M H I S @ m m m dot com. [REQUIRED], Fill out the evaluation to be able to claim CE credits. A screenshot from the MGMA page shows a green arrow pointing to a link that reads, Evaluation: Zoom Webinar. Text, Webinar questions? Contact E D at mgma dot com or www.mgma.com/events. (SPEECH) And if you do have content questions, email ask3mhis@mmm.com. And if you have a webinar question, contact ed@mgma.com. And if you haven't already, please be sure and click on the evaluation link. It's located in the learning management system. After completing this evaluation, which is required to claim credit, please allow 24 hours for system communications to process credit for this session. For more information on all of our conferences and webinars, please see the MGMA events page. Thanks, everyone. Look forward to seeing you at another online event soon. Sandeep, Mickey, thank you again. That was awesome. Thank you, Daniel.