Analytical Solutions to Common Healthcare Problems

In this module, you will explain why comparing healthcare providers with respect to quality can be beneficial, and what types of metrics and reporting mechanisms can drive quality improvement. You'll recognize the importance of making quality comparisons fairer with risk adjustment and be able to defend this methodology to healthcare providers by stating the importance of clinical and non-clinical adjustment variables, and the importance of high-quality data. You will distinguish the important conceptual steps of performing risk-adjustment; and be able to express the serious nature of medical errors within the US healthcare system, and communicate to stakeholders that reliable performance measures and associated interventions are available to help solve this tremendous problem. You will distinguish the traits that help categorize people into the small group of super-utilizers and summarize how this population can be identified and evaluated. You'll inform healthcare managers how healthcare fraud differs from other types of fraud by illustrating various schemes that fraudsters use to expropriate resources. You will discuss analytical methods that can be applied to healthcare data systems to identify potential fraud schemes.

In this module, you will define clinical identification algorithms, identify how data are transformed by algorithm rules, and articulate why some data types are more or less reliable than others when constructing the algorithms. You will also review some quality measures that have NQF endorsement and that are commonly used among health care organizations. You will discuss how groupers can help you analyze a large sample of claims or clinical data. You'll access open source groupers online, and prepare an analytical plan to map codes to more general and usable diagnosis and procedure categories. You will also prepare an analytical plan to map codes to more general and usable analytical categories as well as prepare a value statement for various commercial groupers to inform analytic teams what benefits they can gain from these commercial tools in comparison to the licensing and implementation costs.

In this module, you will describe logical processes used by database and statistical programmers to extract, transform, and load (ETL) data into data structures required for solving medical problems. You will also harmonize data from multiple sources and prepare integrated data files for analysis.