Quality Health
Resume:
TEODOR TODHE MD (Foreign Medical School Graduate), MPA
** ****** *****, *********, ** 07506
Home: 973-***-**** / Mobile 201-***-****
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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
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