rocky mountain health plans stratus guide · stratus™ training videos 1. introduction to...

Rocky Mountain Health Plans

Stratus™ Guide

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Copyright © December 2018, Rocky Mountain Health Plans

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TABLE OF CONTENTS

Stratus™ Guide: Overview ____________________________________________________3

Accessing Stratus™ 3

Data Sources & Frequency 3

Getting Started 4

Drill Down Data Basics 5

Stratus™ Tabs 6

Stratus™ Training Videos 7

Stratus™ Use Cases _________________________________________________________8

Frequent ER Utilizers 9

Patients with 4+ Open Care Gaps & High Costs 11

Multiple Chronic Conditions & High Costs 13

Are Diabetics Seeing their Endocrinologists? 14

Diabetic Patients Having Zero PCP Visits in the Past Year 15

Are Asthmatics Driving Pediatric ER Costs & Utilization? 15

Patients who have taken and Antidepressant/Opiate 16

Cost Comparison: Total Population vs. Population with Depression 17

Patients who have been to the ER and are on an Anti-Depressant 18

Diabetics with no PCP visit in the Last Year and no HbA1c 19

Specialty Referral Patterns and Cost 20

References ________________________________________________________________21


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Rocky Mountain Health Plans Stratus™ Guide Best Doctors, a healthcare analytics company, has created a tool called Stratus™, which gives practices in

Colorado access to aggregated claims data from multiple payers. Stratus™ has the ability to deliver population

health insights to practices as well as the capability to drill-down to the individual patient level. This tool

includes cost and utilization data, gaps in care reports, population health analytics and more. The availability of

Stratus™ is made possible via the Colorado Multi-Payer Collaborative (MPC) whose goal is to foster

collaboration between public and private health care payers in an effort to strengthen primary care. The

Stratus™ tool supports practices working towards the Quadruple Aim – better patient outcomes, improved

provider satisfaction, lower cost, and improved patient experience (IHI, 2017).

Accessing Stratus™ Stratus™ is currently available to practices participating in CPC+ and SIM free of charge. Through

participation in these programs, key contacts at the practice site should have received registration information.

If you would like to gain access to Stratus™ but currently do not have a license, please contact your assigned

Quality Improvement Advisor (QIA) to get the SIM or CPC+ Stratus™ contact information.

To login to Stratus™, go to: https://stratus.bestdoctors.com/ssologin/login.aspx.

Data Sources and Frequency

Stratus™ aggregates claims data from participating payers and/or via the All-Payers Claims Database (APCD),

also known as CIVHC. Currently, participating payers included in Stratus™ are:

Anthem

Cigna (SIM Only via APCD)

CMS (Medicare via APCD for SIM)

HCPF (Medicaid via APCD)

Rocky Mountain Health Plans

United HealthCare

Data that is available within Stratus™ at the practice level is dependent upon both program participation (CPC+

or SIM) as well as the contracts that practice has with participating payers. Therefore, it is important to note that

your practice may not have access to your entire active patient population in Stratus™. For example, self-

insured payers are not represented in Stratus™. This must be taken into consideration as you validate and find

actionable data within the tool.

Best Doctors relies upon each payer to send them valid data via the APCD. This means that data refreshes in

Stratus™ are completed at the payer level. Further, patients within your Stratus™ account are represented based

upon each payer’s attribution methodology. There may be differences between attribution methodologies across

the participating payers. If you have questions on attribution methodologies, you will need to contact those

payers directly. For the RMHP attribution methodology, please ask your assigned QIA or Clinical Informaticist.

https://stratus.bestdoctors.com/ssologin/login.aspx


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Getting Started in Stratus™

When you login to Stratus™, there are several aspects to pay attention to in which to frame your session. Upon

login, you will first notice the Welcome tab. Here you can see the “Latest Updates” which will include any

Stratus™ updates.

Next, it is important to know where to locate the “Reporting Period and Data Refresh” information. The

Reporting Period on the Welcome Tab will tell you which time frame of claims data is included in Stratus™

that day. The Refresh Date indicates when the payers and Stratus™ last updated the tool. Essentially, this is

when data was last pushed to Stratus™.

The Reporting Period and Refresh Dates are also included at the top of each tab within Stratus™.


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The next data point to familiarize yourself with is the “Population Size” included in Stratus™ or, your

practice’s (n) of patients. Recall that based upon payer contracts and practice transformation program

participation, your practice will have a limited number of patients represented in the tool. This number is noted

in Stratus™ by an (n) on the Registry tab. Further, as you begin to filter data within the tool, each tab will

indicate in a box at the top the population size that is represented. Understanding your practices total (n) is

important to note because it will give you an idea about the percentage of your total patient population that is

represented within the tool.

For example, if you have 1,000 active patients in your practice and in Stratus™ the n = 750, then you know that

about 75% of your population is represented in the tool.

Drill Down Data Basics: Filtering Data Stratus™ has several drilldown capabilities in which to analyze your data. Some basic functionalities within

Stratus™ to help you navigate and filter the data within the tool are included below. To begin, it may be helpful

to see all of the available categories in which you can apply a filter. Do this by clicking on the “selections”

button which is located at the top right of the screen from within any tab (Pyramid, Pop Metrics, etc.).

When you select a category, you can then select several filters within that category by clicking and dragging

your mouse. This will highlight your selections in green. You will then see your “filtered” selection in the box

to the upper right-hand side of the screen.


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To erase a selection or filter, click on the eraser icon in the box. Or, simply click the Clear All button to start

completely over. You can select and de-select any combination of filters to begin to drill down your data.

Stratus™ Tabs

There are several tabs in Stratus™ that have various functionalities. Below are the definition and tips for each of

the tabs.

Primary Stratus Tabs:

Pyramid: This tab shows the distribution of your patient population based upon cost and population. The

brackets on the pyramid denote ratios of the percentage of cost in relation to the total population. As an

example, 4.1% of the population accounts for 52.1% of costs.

Key Performance Indicators (KPI): The KPI tab allows you to view and compare your practices

performance on key measures such as chronic condition rates, continuity of care, hospital admissions

and other quality indicators.

Registry: Once you have filters set in the box at the right hand top of the page, click on the registry tab

to get a list of patients who meet that criterion.

Patient Detail: When you are in the registry tab, click on a patient (it will highlight green). Then, click

on the patient detail tab to retrieve claims information on that specific patient.

Appendix: This tab includes a glossary of terms, frequently asked questions and use cases.

Support: This tab includes information on how to submit a help desk ticket for software support.

From the Welcome Screen, click the blue “Populations” button to access these additional tabs:

Pop Metrics: This will give you a breakdown of your population. It looks at age, gender, risk, chronic

conditions, and HCC risk scores.

Continuity: This tabs shows the patient-provider relationship verses the medical PMPM.

From the Welcome Screen, click the blue “Care Gaps” button to access these additional tabs:

Care Gaps: This tab shows, by condition or disease, the number of care gaps that the practice has based

upon attributed patients and claims processed.

Care Gaps Detail: Click on Care Gaps Detail tab to dive deeper into the care gaps. This will give you

patient level detail on each of the gaps in care.

Stars: This tab is a rating scale based upon care gaps.

From the Welcome Screen, click the blue “Utilization” button to access these additional tabs:

Trends: This tab reviews cost and utilization overtime. You can look at PMPM, ER rate, inpatient rate,

30-day admission rates, and specialist visit rates overtime.


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Med Cost: This tab displays annual changes in PMPM by Service Category. Additionally, it will display

medical cost analysis.

Visual Drill: This tab allows a drill down into visit and cost data for ER, Inpatient and Pharmacy claims.

Tabular Drill (previously called Med Cost Drill): This tab now includes Med Cost, Specialty, Pharmacy

and Injectables utilization data and can additionally be filtered by service category.

o Med Cost displays utilization by body system diagnostic categories and by highest cost or

highest utilization providers/facilities.

o Specialty (previously called Specialist tab) displays referral appointments by provider specialty

and by diagnostic categories.

o Pharmacy (previously called RX) filters pharmacy data by therapeutic class, product/drug and

highest cost or highest utilization providers/facilities.

o Injectables displays “Jcodes” by body system diagnostic categories, utilization/cost, and highest

cost or highest utilization providers/facilities.

Time Analysis: Allows you to filter your data and compare time periods for PMPM, Utilization/1000,

Unit Cost and Population data.

From the Welcome Screen, click the blue “Providers” button to access these additional tabs:

Provider Compare: This tab allows you to analyze highest and lowest performing providers on quality

score, hospital admissions, ER admissions, continuity and more.

Provider Analysis: This tab displays the same data as the “Provider Compare” tab but in a scatter plot.

Stratus™ Training Videos

1. Introduction to Stratus™

a. Video #1 - Stratus™ Training Guide

2. Utilizing the different buttons on the ‘Welcome’ tab

a. Video #2 - Population Button

b. Video #3 - Care Gaps Button

c. Video #4 – Utilization Button

d. Video #5 – Providers Button

3. Use Case Examples v1

a. Video #6 - Disease, Care Gaps, KPI, Med Costs

b. Video #7 - Frequent ER Utilizers, Facilities, Unit Costs

c. Video #8 - Prescription Section, Population Metrics, Registry Tables

4. Use Case Examples v2

a. Video #9 - Attribution, Care Gaps, Registry, Trends, last PCP visit

b. Video #10 – Patients with 3+ Chronic Conditions, Admissions Rates, ER Admissions, Provider

Analysis, and Depression Impact

c. Video #11 - Diabetics without PCP visits

https://protect-us.mimecast.com/s/wjFNCmZXEQHp38WytDW7YJ?domain=goteladoc.com

https://protect-us.mimecast.com/s/GFUYCn5JzrsX2gm9fp25-e?domain=goteladoc.com

https://protect-us.mimecast.com/s/33ZfCo2JOQfDR5v2U77Ctl?domain=goteladoc.com

https://protect-us.mimecast.com/s/GLM5CpYVzQF9WqA4txRjKW?domain=goteladoc.com


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Stratus™ Use Cases


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Frequent ER Utilizers

In this use case we are going to filter your practices data to look at patients that have 3 or more ER visits.

From the “Welcome” Screen, click on the tab. Make sure that the selections box is completely clear.

If the data is already being filtered, click the “Clear All” button next to the selections box.

Next, click on the “Selections” button to begin filtering your data. Under the “Medical Utilization” header, click

on ER visits. To filter your data to show patients with 3 or more ER visits, click the number 3 and drag your

mouse down through all values greater than 3. You can now close the “Selections” menu box.

*TIP: To double check that your “Selections” are accurate, take a look at the “Current Selections” box to

make sure your filter shows “Patient _ERCount” is NOT 0, 1, 2.*

The Patient Registry is now listing attributed patients in your practice that have 3 or more ER visits. Scroll to

the right on the Patient Registry table to find the “ER Visits” column. Double clicking the “ER Visits” column

header will sort the list from ascending to descending order by number of visits. Double clicking again will sort

by descending counts.

Take your analysis a step further and identify the leading facilities by cost that your patients are frequenting for

ER visits.

To begin, keep your selections in place (i.e., filtered data by patients with 3 or more ER visits). Click on the

“Welcome” tab. From here, click the blue “Utilization” button in the middle of the welcome screen. You will

notice that you now have different tabs listed across the top of the tool. Start your analysis by clicking the

.

The table at the top of this screen will display annual changes in PMPM cost by service category. Below you

will see a deeper analysis into medical costs.

Next, click on the tab. Click the blue “ER” button at the top left of your screen. This screen can then

be filtered by either “visits” or “costs.” With the blue “visits” button selected you are displaying ER Visit

Counts by Diagnosis Category. Scroll down to see the percent of patients by number of ER visits. Click the blue

“costs” button to change your displayed criteria from visits to costs.

You can use your mouse to highlight any of the data displayed on either of these graphs to further filter your

data – recall that you can always access the patient list on the tab.

Next, identify providers with the highest ER rate per 1,000 patients. Return to the Welcome screen and click on

the “Providers” button. Click the tab.


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On the left hand side of the screen you should notice several blue buttons. Click on the “ER per 1000” button.

The data will sort by Location, Highest Performing Provider and Lowest Performing Provider. Select the

“Lowest Performing Provider” by highlighting that providers name and bar graph with your mouse. You can

now return to the tab to view a list of this providers patients that have frequented the ER.

Click on the “KPI” tab to view panel profile information on this provider. Is the selection older or younger than

the “Total Population?” Are patient’s sicker based on disease? Review results on the “Coordination of Care”

button.

To save this filter, click the at the top of the screen to create and name a “bookmark.”

Next Steps: Consider using this data to identify where gaps may exist in care transition processes within your

practice. Are you receiving alerts and notifications from hospitals and emergency departments in a timely

fashion? Are you receiving all the pertinent information regarding the visit?

Further, consider identifying potential high risk patients on this list that may not be triggered in your risk

stratification methodology. Should they be?


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Patients with 4+ Open Care Gaps with PMPM Costs Greater than $1,000

In this use case we are going to filter your practices data to look at patients that have 4 or more open care gaps

that also have per member per month costs greater than $1,000.

From the “Welcome” Screen, click on the tab. Make sure that the selections box is completely clear.

If the data is already being filtered, click the “Clear All” button next to the selections box then return to the

Welcome screen.

To begin, click on the blue “Populations” button located in the middle of the screen. Next, click the

tab. On the left hand side of the screen you will notice 4 blue buttons. Make sure that the “Medical PMPM”

button is selected. Use your mouse to draw a box that includes all the dots (patients) on the scatter plot that are

at and above the $1,000 PMPM range. Now click on the “Gap Count” blue button located to the left of the

scatter plot. Again, using your mouse, draw a box that includes all dots (patients) on the scatter plot with 4 or

more open care gaps. Now that your data is filtered, click on the tab. Scroll all the way to the right of

the registry table to find the “Open Care Gaps” column.

To take your analysis further, dive deeper into these open care gaps. Start by returning to the “Welcome”

screen. From here, click on the “Care Gaps” button located in the middle of the screen. Now, click on the

tab. See the patient level detail by clicking the “jump to registry” button at the bottom of this

screen to identify how many open care gaps exist for each patient as well as for what measures. Use the

“Additional Selections” criteria at the top of the page to filter your data further.

Return to the “Welcome” screen and click the blue “Utilization” button in the middle of the screen to begin

diving into PMPM medical costs for these patients. Clicking on the tab will allow you to compare the

selected patients against the “BOB” (book of business) by PMPM. You can also compare this list of patients

with the “Total” by ER rate per 1000, Inpatient rate per 1000, 30-day Readmissions and Specialist Visits per

1000 by clicking on the blue buttons at the top of the page.

Click on the and/or tabs to begin identifying why PMPM costs are so high for these

patients.

Analyze your data by changes in PMPM by service category under the tab. Review the data in the

table titled “Medical Cost Analysis” to see trends in both utilization and cost.

Analyze your data by Primary Diagnosis and Relative Unit Cost per facility via the and/or

tabs to identify the most common and/or expensive procedures or facilities.


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Take your analysis even a step further by seeing if you can identify trends between care teams and the panel of

patients they represent with open care gaps. To begin, start at the “Welcome” screen.

Click on the “Providers” button located in the middle of the screen. Next, click the tab.

Using the blue buttons on the left hand side of the screen, find and click on the “Total Quality Score” button.

Using your mouse, draw a box around the providers having the lowest quality score.

View the filtered data on the following tabs to analyze performance:


Next Steps: Consider using this data to identify where gaps may exist in certain chronic and/or preventive

measures. Understand that while this is claims based data and the information within your EHR may be more

current, gaps may be closed in instances where another provider or practice is addressing the patient’s condition

and/or screening(s).

Further, this registry list can be exported to a working excel document that your clinical team may find value in

when preparing and scheduling patient visits.


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Populations with Multiple Chronic Conditions and High PMPM

In this use case we are going to filter your practices data to look at patients that have multiple chronic

conditions and also have high per member per month costs. To begin, start at the Welcome screen and click on

the blue “Populations” button located in the middle of the screen.

From here, click on the tab. There are 4 blue buttons located near the center of the screen, click on

the “Chronic Conditions” button. You will notice there are 4 different graphs located under the blue buttons:

Your practice’s distribution of chronic conditions

Your practice’s “chronicity distribution” – count of chronic conditions

Your practice’s PMPM difference from the average by chronic condition

Your practice’s PMPM difference from the average by chronicity – count of chronic conditions

In this case study, we want to filter the data to patients that have 3 or more chronic conditions. On the

“Chronicity Distribution” graph, and using your mouse, draw a box around 3 or more chronic conditions.

Next, click on the tab. Make sure the “Medical PMPM” blue button on the left of the screen is

highlighted. Using your mouse, draw a box around patients with $1,000 and more in PMPM costs. You can now

refer to the tab to begin to identify patients that have 3 or more chronic conditions and PMPM costs

in excess of $1,000. To further analyze this population, go to the tab to look at key performance

indicators. Click on the “Coordination of Care” button to review metrics such as ER Visits/1000,

Admissions/1000, Readmission rates and % of patients not seen in the past year.

Using this same set of filtered data return to the Welcome screen and click on the blue “Providers” button to

analyze provider level performance on utilization metrics. Click the tab to analyze and compare

your provider’s performance on ER per 1000 and Admits per 1000. Then, using your mouse, draw a box around

the lowest performing providers on either metric to filter your registry down to these patients.


Next Steps: Consider using this data for quickly identifying patients that may need care management services

to help reduce unnecessary utilization. You may also use this registry to inform your risk stratification

methodology.


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Are Diabetics Seeing their Endocrinologists?

In this use case we are going to filter your practices data to identify diabetic patients that are not seeing their

endocrinologist. Please note that based upon CPCi data, information about a physician’s specialty is not

reported. Therefore, deductive measures have to be used to address this question.

To start, ensure any previous selections have been cleared and go to the tab. Click on the gray

“selections” button and select the following:

Under “Medical Utilization” then Specialist Visits, select all values except for 0

Under “Disease” then Diabetes, choose Yes

Also consider choosing 0 for PCP Visits

In this case study, it will be simpler to filter and sort your data in Excel. Click the button on the top right

of the patient registry table to export your registry to Excel. Once the file opens, click “Enable Editing” at the

top (if prompted). Column AG shows the number of “Specialist Visits.”

Click and select “filter” to apply filters to the file. You can now filter column AG from lowest to highest

count which will allow you to quickly identify any patient showing “0” for Specialist Visits which are likely not

under the care of a Specialist, especially an Endocrinologist.

Return to the Stratus tool to take this analysis a step further. Keeping your selections in place, return to the

Welcome screen and click on the blue “Utilization” button. Click on the tab. Click on the blue

“Specialist/1000” button to review population trends in your practice. Next, click on the and then

click on the blue “Pharmacy” button in the middle of the page to review the most used prescriptions by count

and cost.

What medications are being used?

Are any particular prescriptions costing more than others?

Are any facilities more expensive than others?

Do those facilities write scripts for expensive NDC Rx names?

Can less costly NDC Rx names be prescribed instead of the more expensive brands?


Next Steps: Consider using this data for quick identification of patients that may or may not be seeing a

specialist for their Diabetes care. This data can potentially assist in closing gaps on metrics, or may identify

where gaps in communication on the co-management of Diabetic patients may exist.


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Diabetic Patients Having Zero PCP Visits in the Past Year

In this use case we are going to filter your practices data to identify diabetic patients that have not seen their

primary care provider in the past year.

To start, ensure any previous selections have been cleared and go to the tab. Click on the gray

“selections” button and select the following:

Under “Medical Utilization” and PCP Visits choose 0

Under “Disease” and Diabetes choose Yes for Diabetes

Your data is now filtered to show diabetic patients who have not had a primary care visit in the past year. Care

Coordinators or Practice Administrators can use this data to filter by provider. Recall that the registry can be

sorted by double clicking on column headers. You may also choose to choose specific providers from within the

“Selections” criteria.


Next Steps: Consider using this data with your clinical team to quickly identify patients that may require a

Diabetic visit in your practice.

Are Asthmatics Driving Pediatric ER Costs and Utilization?

In this use case we are going to filter your practices data to identify whether asthmatic patients are driving

pediatric ER Visits and costs.

To start, ensure any previous selections have been cleared and go to the Welcome screen. Click on the blue

“Utilization” button in the middle of the screen. Go to the tab. Select the blue “ER” button on the

left hand side of the screen.

Using your mouse, highlight Diseases of the Respiratory system to filter your data. Next, click on the

tab to begin analyzing your data as it relates to cost, specialty, pharmacy and injectables. From

here, you can identify whether there are facilities with a combination of both high utilization and high relative

unit costs.

Use the tab to identify your list of patients.


Next Steps: When working on an emergency department utilization campaign, consider targeting certain

populations, like asthmatics, to focus your intervention. This report could be used by care managers and staff to

identify patients to target to reduce unnecessary ED utilization and thus reduce costs.


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Filtering to Patients who have been Prescribed an Antidepressant/Opiate

In this use case we are going to filter your practices data to identify patients who have taken an Antidepressant

and/or Opiate.


“Utilization” button in the middle of the screen. To narrow down to anti-depressants, first click on the

ribbon at the top of the page. Ensure that the blue button “Pharmacy” is highlighted. Then, using

the “Selections” button, under “Medication Details” select the Antidepressant categories underneath “Therp

Class.” See below:

From here, go to the tab. Click on the “Panel Profile” button to review the disease profile for these

patients. Refer to the registry tab for a list of these patients.

Repeat the steps above to identify patients with “Opiate Agonist” prescription history.


Next Steps: These registries of patients can quickly help your practice determine the level of need for further

behavioral health intervention development and targeted population management. As you are working on your

behavioral health plan, this could be utilized to identify gaps where a patient may benefit from other or

additional treatment types besides antidepressant and/or opiate, like counseling. If you are starting a pain

management group, this list could quickly identify patients that may be good candidates.


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PMPM Comparison between Total Population and Population with Depression

For this case use, we are going to compare PMPM between your practice’s total patient population in

comparison to patients with a diagnosis of depression.


“Utilization” button in the middle of the screen. Go to the tab. Make sure that the highlighted button in

the Trends ribbon is “PMPM by Service Category.”

The top graph labeled “Trending PMPM by Service Category” gives you the total PMPM for the entire patient

population by month. Write down the PMPMs you want to compare to the population with a diagnosis of

depression.

Next, filter your current selection to only focus on patients with a diagnosis with depression by selecting “Yes”

for Depression underneath the Disease section.

The top graph labeled “Trending PMPM by Service Category” gives you the total PMPM for the patient

population with a diagnosis of depression by month. Write down the PMPMs you want and compare to the total

patient population.

To get a list of patients with a diagnosis of depression, click the tab


Next Steps: Consider using this data for monitoring the patients with depression population. This comparison

can be utilized to track to see if behavioral health interventions are working across the populations. This could

help target whether there needs to be further interventions on ED utilization, outpatient services, etc. It may also

help with defining your practice population’s needs for further funding and resources to support behavioral

health within and outside of your primary care practice.


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Patients who have been to the ED and are on an Anti-Depressant

For this case use, we are going to view which patients who have been to the emergency department and are on

an anti-depressant.


“Utilization” button in the middle of the screen. Go to the tab at the top of the page. Make sure the

highlighted blue buttons are “ER” and “Visits.”

Then, click the button for the tool to narrow down the claims in the tool.

To narrow down to anti-depressants, first click on the ribbon at the top of the page. Ensure that the

blue button “Pharmacy” is highlighted. Then, using the “Selections” button, under “Medication Details” select

the Antidepressant categories underneath “Therp Class.” See below:

To get a list of patients with a diagnosis of depression, click the tab


Next Steps: This registry can quickly identify where patients may need care management services, different

treatment, and/or further support. This data can be utilized to track behavioral health utilization overtime and

may help support the justification for further resources needed in your practice.


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Which Specialists does our Practice Refer to the most and what are the Costs?

For this case use, we are going to look at which specialists the practice refers to the most. This can be beneficial

when analyzing referral patterns, potential care compacts, and better care coordination.


“Utilization” button in the middle of the screen. Click on the ribbon. Then click on the blue

“Specialty” button.

The first table labeled “Referral Appointments by Provider Specialty” shows you the specialty types and costs.

The second table labeled “Referral Appointments by Level 2 Diagnostic Categories” gives you percentage of

patients, costs, and counts of events by certain diagnoses. To dive into this data further, go down to the table

labeled “Referral Appointments by Top Providers.” This will give you a list of top providers based upon cost

and count of events.


Next Steps: Consider using this data to further develop referral patterns. You may find out that one specialist

costs more than another with still providing high quality care. Furthermore, this data can help support care

compacts to improve communication and referral pathways amongst the medical neighborhood.


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Who are our Patients with Diabetes who have not had a PCP visit in the Last Year and

not had an HbA1c?

For this case use, we are going to find the care gaps for patients with diabetes who have not been seen within

the last year and not had an HbA1c. This report could be utilized as a working list to help staff in the practice

reach out to these patients and get them scheduled for a diabetes visit.


“Care Gaps” button in the middle of the screen. Go to the tab.

In this tab, first filter the Measure Group drop down menu to “Comprehensive Diabetes Care.” Then, filter in

the Measure drop down menu to “HbA1c Testing (CDC).” Lastly, change the Gap Status drop down menu to

“Open.” The filters should look like this:

To filter so that it shows a list of patients who have not been seen by a PCP in the last year, click on the

Selections button, and underneath the Utilization category select ‘0’ under “PCP Visits.”

To get a list of patients that have had no PCP visits in the last year and who have not had an HbA1c completed,

go to the tab


Next Steps: Consider using this data with your clinical team to quickly identify patients eligible for pre-lab

visits as preparation for a Diabetic check with their primary care provider.


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References

Teledoc. (2017). Stratus User Guide (Vol. 2.7, Tech.).

Best Doctors Stratus™ Clinical Intelligence Application (2018). Glossary, FAQ’s and Use Cases. Retrieved

from: https://stratus.bestdoctors.com/QvAJAXZfc/opendoc.htm?document=clients%5Ccpci-

provider%5Cdeployed%5Cqvw_visualization%5Cstratus-%20cpci%20provider.qvw&lang=en-

US&host=QVS%40bdusacdqvprd1.usa.hrt.local

Institute for Healthcare Improvement Triple Aim Initiative: Better care for individuals, better health for

populations, and lower per capita costs. (2017). Institute for Healthcare Improvement. Retrieved 3

November 2017, from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

https://stratus.bestdoctors.com/QvAJAXZfc/opendoc.htm?document=clients%5Ccpci-provider%5Cdeployed%5Cqvw_visualization%5Cstratus-%20cpci%20provider.qvw&lang=en-US&host=QVS%40bdusacdqvprd1.usa.hrt.local





http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx


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information and a description of your proposed use in your request. If permission is granted to insert the

document(s) into your materials, the documents will need to be inserted "as is" (no changes) with the

following note: “Document created by Rocky Mountain Health Plans and included in this resource with

their permission.”

Users will not repackage RMHP document(s) or other materials for commercial purposes or otherwise

offer for sale.

Provider practices may request permission to adapt documents to meet practice unique needs by

contacting Rocky Mountain Health Plans [email protected].

Information provided in this manual is intended to be accurate and reliable. However, Teladoc Health,

Inc. assumes no responsibility or liability for its use or reliability upon its contents; nor for any

infringement of rights of third parties which may result from its use.

mailto:[email protected]

mailto:[email protected]

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