TEODOR TODHE MD (Foreign Medical School Graduate), MPA

** ****** *****, *********, ** 07506

Home: 973-***-**** / Mobile 201-***-****

acdpqt@r.postjobfree.com

PROFESSIONAL KNOWLEDGE AND SKILLS:

Business Intelligence Systems / Use of Clinical and Other Data to Inform

Decision Making

. Extensive experience in using aggregate data from EMR databases to

identify quality of care issues as a result of Providers' noncompliance

with Evidence Based Guidelines and Members lack of adherence to medical

directives to inform various QI interventions carried out by payers or

providers case coordinators or managers.

. Experienced in using diagnosis, procedures, and pharmacy utilization data

derived from electronic medical record, claims, and pharmacy databases to

identify areas of interventions and inform decision making in areas of

population health management, management of chronic conditions leading to

improved quality of care.

. Conceived the model of the Business & Clinical Intelligence tools that

use timely data from EMR, pharmacy databases, and claims to generate

actionable reports and inform decision making process of executives,

managers, and clinical staff in the following areas of operations:

a. Financial performance by monitoring revenue and costs,

b. Assessing utilization rates (IP, OP, and specialty care) and

effects of such rates on organization financial status, and

c. Monitoring the quality of care and health outcomes of

members/patients using quality indicators (HEDIS, STAR, etc).

d. Provide timely and effective solutions in case of gaps in care

Quality Measurement & Improvement in Health Care Organizations

. Expertise in quality of care measurement and performance improvement in

Payer and Provider organizations including ambulatory care networks or

hospitals acting as ACO or PCMH that is assessed by HEDIS/QARR, PQI,

PQRS, MU, STAR, or other sets developed by NCQA, AHRQ, NQF, CMS or

medical professional associations.

. Knowledgeable on measures' dynamics; uses data with ease to determine

timing when patients enter denominators and clinical events that make

them compliant with measures enabling organizations to better:

a. Plan and implement QI interventions to improve quality scores

especially for time sensitive indicators such as Depression

management, Part D Medicare Medication Adherence, or health outcome

indicators.

b. Establish a stable process of data capture from all sources that

accurately reflect the quality of care and meet State, Federal, or

National agencies' reporting requirements.

. Experienced in development and implementation of QI programs to improve

health outcomes of patients with chronic conditions focusing in problem

identification, root cause analysis, setting goals and objectives,

planning interventions, using indicators to monitor progress (examples

QIP, CCIP, PIP required by NYSDOH and CMS).

. Knowledgeable on QI techniques used to reduce variation in the processes

of care leading to improvement of quality and patient satisfaction,

reduction of medical errors, and malpractice exposure.

Leadership, Communication, and Management

. Experienced in development of new functional structures with objectives

aligned to organizational mission and goals.

. Strong skills in team building, defining team's job description,

communicating tasks according to staff capacities, and monitoring their

performance in view of program evaluation

. Experience in development of training curricula compounded by teaching /

coaching skills to enable staff to accomplish effectively the tasks and

grow professionally in areas of Quality / Process Improvement, disease

management, and HEDIS/QARR or other measures.

WORK EXPERIENCE

2013 Sep - March 2014 NYU LANGONE MC, Clinically Integrated Network (CIN),

New York, NY

Manager of Physicians' Performance Monitoring & Improvement

Worked to achieve accuracy of quality measures including HEDIS, Cost of

care, PQRS used to assess and improve the CIN performance in meeting

quality targets required by Federal and Commercial Payer contracts and in

view of a short and long term strategy carried out the following tasks:

. Analyzed payers' methodologies used to assess CIN performance and

identified weaknesses and flaws in their data processing systems that

would lead to inaccuracies in the calculation of rates and underreporting

of scores.

. Combined payers' quarterly and monthly reports to mitigate inefficiencies

as the result of delayed information (three months time lag in claims

data for example) to inform the work of case managers in their

outreaching activity to patients overdue for preventive or other

services.

. Explored the possibility of using multiple sources of data including EMR

databases, immunization registries, Labs DB, disease registries, RHIO

database or other systems in addition to claims data only, that provide

timely and reliable information about clinical events that become

numerator hits to improve scores and avoid under reporting.

. Proposed the schema of a DATABASE with tables storing data on clinical

events as denoted by ICD, CPT, Pharmacy codes (NDC) or other from all

possible sources, to effectively manage the information and generate

actionable reports informing the decision making process in:

o Clinical care provision, care coordination, or management of cases

with chronic conditions

o Planning and Implementing QI interventions addressing issues in

process of care or individual behavior

. Modeled and submitted the proposal for an Business & Clinical

Intelligence IT tool that uses data from the DATABASE enabling users to

monitor the organization performance in provision of clinical care and

inform QI interventions

. Created education materials describing HEDIS indicators to help providers

use the codes that properly denote the processes of care provided and

getting deserved credits in view of quality scores

2004 - 2013 METROPLUS HEALTH PLAN, New York, NY

Senior Manager Quality Improvement Programs (April 2009 - September 2013)

Recognized the superiority of Electronic Medical Records data versus claims

data in reporting the quality of care in payer or provider organization and

to that effect:

. Envisioned and laid out the schema of the IT platform to enable payer and

provider organizations using data from EMR databases in reporting

HEDIS/QARR/PQRS/Medicare Star or other required data to State or Federal

agencies.

. Organized and led the work of QI Unit (defining the job description of

programmers, led the hiring process, coached and instructed them in

mining the EMR databases, providers and payer's claims, and pharmacy

databases to produce the required reports for quality reporting purposes.

. Led the work of EMR databases data mining to generate reports used in

HEDIS / QARR reporting process:

o Wrote the specifications for all the reports

o QA-ed the final product for accuracy and leading to quasi

perfect capture of all qualifying events (test results,

screening events, etc) that members in denominators of QARR

measures had during measurement periods. The using of EMR

reports in HEDIS/QARR reporting process boosted health plan's

performance in HEDIS/QARR in the last three years. (NYS in 2011

QARR Quality Incentive Rewards accounted for a 2.5% premium

increases or an aggregate of $34 million in bonus incentive

money).

. Proposed the development of web based application Business Intelligence

Tool that uses timely clinical and pharmacy data to display gaps in care

and identify members non-compliant with standards of care on a timely

basis and inform the action of case managers in view of QI or Disease

Management programs for conditions such as depression, asthma, diabetes.

. Managed the Health Plan's P4P Program by coordinating the activities of

various departments' staff in processing claims and clinical data used to

assess providers performance and determine reward payments; conducted

periodic provider performance analyses and recommended interventions to

improve the program outcomes

Provider Quality Improvement Analyst (2004 - 2009)

. Led various QI interventions including data driven analysis in of process

variation, root cause analysis of problems and interventions leading to

reduced out of control variation in clinical and administrative

processes.

. Analyzed the pharmacy benefit program of the plan and established a

monitoring process on payments to PBM enabling the organization to

identify cases when plan paid the PBM amounts above the contractually

agreed prices leading to considerable savings, recovery of overpayments,

and preventing similar errors going forward.

. Analyzed the performance of Health and Hospital Corporation (HHC) of New

York City and other provider facilities in QARR indicators identifying

problems related to: a) providers' adherence with evidence based medicine

and b) members' non adherence to medical directives; recommended

proactive interventions to modify clinical care processes, provider

behavior, and improve disease management program performance.

. Actively participated in provider education process by publishing

articles in health plan's Provider Newsletter focusing on providers

adherence to evidence based guidelines affecting the quality of care and

HEDIS/QARR scores such as the use of imaging studies for low back

pain[1], FU visits after discharge of patients with mental health

disorders, prescription of controllers for asthma patients,[2] depression

management,[3] screenings of members with persistent medications, etc.

. Developed the curricula and conducted the training of nurses in clinical

data abstraction from paper based and electronic medical records used in

reporting HEDIS/QARR hybrid measures performance; created training

materials such as progress notes from paper and electronic medical record

screens to mimic real clinical records for practicing purposes during the

training process.

. Used data based on ICD-9 codes, services codes, pharmacy utilization

data, and other variables, to identify members/patients with chronic

condition to be enrolled in various Disease Management, QIP or CCIP

interventions.

. In view of a Work Flow Design project analyzed the claim submission /

billing system in several Health & Hospitals Corporation facilities

identifying process flaws and implemented interventions that improved the

billing process and revenue collection.

. Developed the model for a computerized tool to monitor members'

utilization of services costs incurred by the health plan in a timely

manner; defined utilization and cost indicators to be incorporated in the

tool to inform decision-making process of health plan executives.

2001-2004 MOUNT SINAI SCHOOL OF MEDICINE, Health Policy Department,

New York, NY

Quality Improvement Research Analyst

. Performed data collection and analysis of quality indicators regarding

the access to care and clinical processes variation for inpatient and

outpatient services.

. Provided insight on development of data processing tools according the

steps in the process of care in view of disease management interventions

for different pathologies investigated.

March - August 2000 HEALTHSOURCE / HUDSON HEALTH PLAN, Tarrytown, NY

Consulting

. Conducted assessment of quality of care provided to plan members and

analyzed plan's compliance to State requirements and HEDIS/QARR

indicators.

. Proposed improvement in data collection process, analysis of various

steps in the provision of care to plan members and improvement of case

/disease management programs using clinical data.

. Ideated and proposed a computerized tool to inform case managers about

changes in health status of members enrolled in disease management

programs like diabetes, congestive heart failure, and asthma using claims

and clinical data available at that time.

1998 - 2000 LAKESIDE ASSOCIATES CORPORATION, Saddle Brook, NJ

Consulting

. Performed data analysis on volumes and types of services provided by

hospitals to advise expansion or retraction of services and support

decision-making in their strategic planning process.

MINISTRY OF HEALTH AND ENVIRONMENT PROTECTION, Tirana, Albania

Director of National Hospital Service

. Supervised the work of other ministry staff and consultants on Sector

Development / Strategic Plan for the country's hospital service program

for the upcoming years.

. Applied quality improvement techniques to improve the provision of care

in Neonatal Units, Emergency Departments, and Pediatric Departments of

hospitals around the country and reorganized these services in view of an

improvement and re-engineering process.

. Conceived the plan for a computerized IS for the sector defining the data

set necessary to support analysis, help the decision-making processes,

planning the budget, monitoring the activity and expenses, and increasing

the efficiency for the entire hospital service.

Chief of Maternal and Childhood Health / Ambulatory Care Sector

. Actively participated in strategic planning and reorganization of primary

care services of the country after political system changes and during

economic transition period during the 1990s.

DISTRICT Children's Hospital, Shkoder, Albania

Worked as Pediatrician Hospitalist for 12 years

EDUCATION

NYU - Robert F. Wagner Graduate School of Public Service, New York, NY

Master of Public Administration in Health Care Policy and Management

HARVARD SCHOOL OF PUBLIC HEALTH, Boston, MA

Certificate Program - Managing Health Care Programs

UNIVERSITY OF TIRANA SCHOOL OF MEDICINE, Tirana, Albania

Diploma of MD

SCIENTIFIC ACTIVITY

INTERNATIONAL HEALTH POLICY, Clermont-Ferrand, France

. Speaker at the international conference of Health Care Financing in Low

Income and Developing Countries presenting the policy paper on "Informal

health markets in developing countries - A critical review of policy

alternatives and government role" [4]

. Published in country's scientific journals in Albania scientific articles

addressing public health issues and children's health such as prevalence

of Vitamin D deficiencies in children, Vitamin D intoxication (case

reporting), Pneumocystis Carini Pneumonia in Prematurely Born / Low Birth

Weight Children (case reporting), parenteral nutrition, etc.

SKILLS

Microsoft Office Applications (used extensively and proficiently Excel and

Access), IDX, HDS/MISYS CPR (now QUADRAMED), EPIC, Extensive use of

Microsoft SQL Programming language, COGNOS, beginner in Java programming

language, fluent Italian and Albanian

LinkedIn Profile:

https://www.linkedin.com/profile/view?id=4889329&trk=nav_responsive_tab_prof

ile

[pic]

[1] Compliance with Clinical Guidelines - Low Back Pain Management.

http://www.metroplus.org/docs/MetroMonitor/MetroMonitor%20Fall%202008.pdf

[2] Todhe, T. Treatment of Asthma and Provider Performance Assessment.

MetroMonitor, Provider Newsletter, 2009, Vol X, Issue II

https://www.metroplus.org/getattachment/Provider-Services/News-

Communications/Provider-Newsletters/Spring-2009-MetroMonitor.pdf

[3] Todhe, T. Management of Depression in the Ambulatory Care Setting

MetroMonitor, Provider Newsletter, Summer 2009,

https://www.metroplus.org/getattachment/Provider-Services/News-

Communications/Provider-Newsletters/Metro-Monitor_Summer-2009.pdf

[4] http://www.cerdi.org/2eme-colloque-international-financement-sante-pays-

developpement-sessions-paralleles.html

Contact this candidate