EHR and Health IT Consulting
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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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CMS Chief to Address ICD-10 Implementation in National Call

CMS Chief to Address ICD-10 Implementation in National Call | EHR and Health IT Consulting |

The Centers for Medicare & Medicaid Services (CMS) continues gearing up for the October 1 ICD-10 compliance deadline with Acting Administrator Andy Slavitt scheduled to address the ICD-10 transition during a national provider call later this month.

On August 27, Slavitt will provide a national implementation update as the nation reaches the five-week countdown to October 1. Also scheduled to speak are American Health Information Management Association (AHIMA) Senior Director of Coding Policy and Compliance Sue Bowman and American Hospital Association (AHA) Director of Coding and Classification Nelly Leon-Chisen.

Two recent surveys show industry-wide progress toward a successful ICD-10 transition in October. In July, the 2015 ICD-10 Readiness reportpublished by AHIMA and the eHealth Initiative stated that half of respondents had completed test transactions with payers or claims clearinghouses.

Despite these positive findings, the report also revealed that ICD-10 preparation gaps still remain for many providers in the area of testing and revenue impact assessments. Only 17 percent indicated that they had completed all external testing. Similarly, only a minority of respondents (23%) have contingency plans related to ICD-10 go-live.

More recently, latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) showed physician practices to be lagging behind their counterparts.

As compared to seven-eighths of hospitals and health systems ready for October 1, less than a half of physician practices indicated they would be ready. This disparity was also evident in the area of provider impact assessments. Only one-sixth of physician practices had undertaken the assessment versus three-fifths of hospitals and health systems. "This lack of progress is cause for concern as it will leave little time for remediation and testing," WEDI reported.

In a letter to Department of Health & Human Services Secretary Sylvia Mathews Burwell, WEDI cautioned that without a concerted effort the ICD-10 transition could lead to negative consequences for the healthcare industry.

"We assert that if the industry, and in particular physician practices, do not make a dedicated and aggressive effort to complete their implementation activities in the time remaining, there is likely to be disruption to industry claims processing on Oct 1, 2015," the organization stated.

Around the same time, CMS provided clarification about ICD-10 flexibilities it make available to providers following a joint statement with the American Medical Association (AMA) in June. The major ICD-10 flexibility is the federal agency's decision not to reject claims coded incorrectly in ICD-10.

"Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code," the federal agency stated. "The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims."

Here's a quick look at the agenda for the MLN Connects Call:

  • National implementation update, CMS Acting Administrator Andy Slavitt
  • Coding guidance, AHA and AHIMA
  • How to get answers to coding questions
  • Claims that span the implementation date
  • Results from acknowledgement and end-to-end testing weeks
  • Provider resources

As the entire healthcare industry counts down to October 1, CMS appears ready to ramp up its activities.

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Meaningful Use Program: Why it failed and how to save it

Meaningful Use Program: Why it failed and how to save it | EHR and Health IT Consulting |

Given the "epidemic of waste [that] blights the U.S. health care delivery system," investment in health care information technology systems is a no-brainer. After all, doesn't the magic wand of IT improve the efficiency of every industry it touches? Congress thought so, and, as a result, in 2009, it allocated $20.6 billion as part of the American Recovery and Reinvestment Act to encourage doctors and hospitals to adopt and use IT systems and migrate from their old paper records to the new electronic health record systems. 

Meaningful Use program

To decide who qualifies for these generous incentives, the Department of Health and Human Services, through the Centers for Medicare & Medicaid Services, designed a set of criteria called meaningful use, a three-stage compliance program that requires providers show they're using electronic health records in measurable ways. To receive the financial incentives, doctors and hospitals must attest to reaching different stages of meaningful use.

The first stage of the program was designed to drive medical providers to adopt the records. As long as the government was willing to pick up the tab, doctors were willing to buy fancy electronic health record software and not worry about using it. Electronic health record vendors enjoyed an artificial market created by the billions of dollars of incentives included in the Recovery Act's Health Information Technology for Economic and Clinical Health Act. The majority of providers successfully attested to this first stage and as a result, record adoption rates skyrocketed.

Why the second stage failed

Now that everyone had electronic records, the next stage of the program had to logically focus on using this technology. Unsurprisingly, the second stage was not welcomed in the medical community. As of February 2015, roughly a quarter of physicians had complied with the requirements of this stage. Despite the lackluster results of the second stage of the program, HHS has already proposed the rules for the third stage, which is primarily focused on health information exchange among providers. While my own research documents huge benefits of exchanging health information, I believe that before implementing more complicated rules and regulations, we should have a clear understanding of the reasons for which the second stage of the program has failed. Without learning from the past, the future will not be brighter.

Although policymakers' hunch about the benefits of IT was correct, it failed to understand a nuanced condition under which this magic wand works: organic and voluntary adoption. Imposing these records on the medical community and forcing them to adopt and use this technology was destined to fail. Meaningful use is focused on adoption and use of electronic records as the final goal, which misses the whole point: that IT in health care, just like in any other industry, is a means to achieve the actual goal of efficiency. More importantly, meaningful use considers electronic health records as the only type of IT solution and ignores the fact that there are many other IT services that can help medical providers much more. The "one-size-fits-all approach," as American Medical Association President Steven Stack put it, of meaningful use ignores the differences between physicians and incorrectly assumes that medical care is mass-produced in the same way by all physicians and thus only one IT solution best addresses the unique needs of many different types of medical providers.

Policy recommendations

Meaningful use should have been integrated with the capitated payment models, in which the medical providers are paid a fixed amount per patient and are rather encouraged to provide the best care at the lowest cost. The need to cut costs and increase quality would have driven medical providers to adopt a wide variety of IT solutions that specifically address their unique needs. HHS should have set efficiency as a goal and let medical practices to find out the best way to achieve it through health care IT of their choosing. Instead of mandating physicians to record the smoking statuses and vital signs of all patients, send them reminders about their follow-up visits, and communicate with them through secure electronic messages, meaningful use incentives could have been allocated to fund a wide variety of different IT solutions suggested by medical providers.

Using a small part of the incentives now used for meaningful use compliance, we can run a pilot project and test this idea. HHS should call for proposals for IT projects that each provider, based on its own unique characteristics, deems the best way to cut costs and increase quality. Just like research grants, these proposals can then be evaluated by a panel of experts and funded only if approved. This approach will open up the market for meaningful and innovative IT solutions that actually help medical providers improve their efficiency.

Rather than being stuck with electronic health records as the only IT solution, we can have a national lab in which the performance of many different IT solutions will be tested. Medical providers will find their best way to be more efficient and will adopt the IT solutions that best fits their needs organically and voluntarily. Only then IT will work its magic in the health care sector.

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Meaningful Use Stage 3 Success Could Rely On Vendors

Meaningful Use Stage 3 Success Could Rely On Vendors | EHR and Health IT Consulting |

Today I was reading a report on the Health IT Policy Committee’s review of pending Meaningful Use Stage 3 rules — which would ordinarily be as about as exciting as watching rocks erode — when something leapt out at me which I wanted to share with you, dear readers.

The overview, brought to us courtesy of Medical Practice Insider, noted that proposed plans for the Stage 3 rule would allow providers to attest in 2017, though attesting wouldn’t be mandatory until 2018. What this means, editor Frank Irving notes, is that it would be up to EMR vendors to be ready for providers wishing to attest a year early.

The folks overseeing this discussion, the Advanced Health Models and Meaningful Use Workgroup, seem (wisely) to have had their doubts that vendors could be relied upon to meet the 2017 deadline. At the session, workgroup members proposed a couple of alternative ways of addressing this timeline. One was to make the 2017 deadline go away, requiring instead that EMRs have full 2015 certification by 2018. Another was to allow optional attestation in 2017, but if need be, with 2014 EMR certification.

I don’t know about you, but this whole thing makes me nervous. By “whole thing,” I mean adjusting the rules to deal with the likely resistance vendors will exhibit to keeping their roadmap in synch with federal requirements.

After all, consider the history of EMR vendors’ relationship with providers. As we’ve noted, HHS has paid out about $30B in Meaningful Use incentives under HITECH without insisting that vendors provide interoperability. And what have EMR vendors done?  They’ve avoided developing shared standards for interoperability with an alacrity which amazes the eye.

In fact, some EMR vendors — including top contender Epic Systems — have been slapping providers with fees for data sharing (even if they’ve kind of dropped them for now), at prices which could leave them millions in the hole. If that isn’t dead opposite to what those in public policy hope to see happen, I don’t know what is.

Bottom line, if the good people overseeing Meaningful Use want to see Stage 3 accomplish good things, they’ll need to see to it that the new rules give regulators some leverage when it comes to controlling vendors.

As the whole sad interoperability saga has demonstrated, vendors will not take actions that advance health IT on their own. Unlike in other IT markets, where interoperability and meeting regulatory deadlines have been the signs of a winner, EMR vendors actually have strong incentives to ignore providers’ business imperatives.

With any luck, however, between tougher rules on Stage 3 and public pressure to achieve interoperability, EMR vendors will do the right thing.  They’ve certainly had long enough.

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ICD-10: CMS won't deny claims for first year

ICD-10: CMS won't deny claims for first year | EHR and Health IT Consulting |

In a surprise concession, the Centers for Medicare & Medicaid Services announced Monday that it would work with the American Medical Association on four steps designed to ease the transition to ICD-10.

Despite longtime disagreements on the topic, CMS will now adopt suggestions made by none other than the AMA with regard to the code set conversion. Those changes concern:

1. Claims denials. "While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family," CMS officials wrote in a guidance document.

2. Quality reporting and other penalties. "For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes," CMS explained. "Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes."

3. Payment disruptions. “If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” AMA president Steven Stack, MD, noted in a viewpoint piece on the group’s website.

4. Navigating transition problems. CMS intends to create a communication center of sorts, including an ICD-10 Ombudsman, "to help receive and triage physician and provider issues." The center will also "identify and initiate"resolution of issues caused by the new code sets, officials added. 

"These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change," wrote Stack.

While AMA played a pivotal role in bringing about these CMS concessions, it was not the only party calling for a smoother conversion to the new code set.

Some members of the U.S. Congress have publicly suggested a dual-coding conversion period wherein CMS would accept and process claims in both ICD-9 and ICD-10. Instead of dual coding, CMS indicated that "a valid ICD-10 code will be required on all claims starting Oct. 1, 2015."

So as things stand today, providers have to use ICD-10 come October – but CMS will be more flexible about denials and payments than it has previously suggested it would be.

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What does Stage 3 Meaningful Use Mean to Your Organization?

What does Stage 3 Meaningful Use Mean to Your Organization? | EHR and Health IT Consulting |

March 2015 saw the 3rd stage of Meaningful Use incentives come into effect. We take a look at what is included and how it will affect your organization’s efforts to seek these incentives.

As part of the HITECH Act passed by the Obama administration in 2009, electronic health records (EHR) were mandated for health care providers to provide a superior health experience with an electronic records system delivered more efficiently. Eligible providers (EP) are required to meet certification for each EHR stage in order to qualify for Centers of Medicare and Medicaid Services (CMS) Incentive Programs. The last stage of this Act was implemented in March 2015 as the Stage 3 Meaningful Use (MU) portion.

What is Stage 3 Meaningful Use?

Stage 3 Meaningful Use is the final implementation program to ensure that all direct care health providers are utilizing EHRs to effectively improve their delivery of health services. Within this stage there is greater flexibility and simplification for health care providers easing late adopters into HITECH and making those already apart of HITECH the ability to further develop their EHR programs. Requirements to meet the incentives given by the government as part of this program include several specific targets to be met in order to receive the incentives for joining the program.

The purpose of stage 3 is no longer just data capture, EHR adoption or improved information processes but focuses on improved outcomes. 25% of patients must be engaged in secure private messaging with their provider, 25% must be able to view or transmit data from their own records, 60% of lab work requests including imaging must be sent electronically, 80% of drug prescriptions must be sent electronically and lastly 15% of patients must generate health data using applications or health devices. These requirements differ depending on your health care institution’s choices for menu set objectives as opposed to core objectives.

Differences between Stages 1,2,3

Stage 1 focused on data capture and sharing information between the EP and the patient. It focused on ensuring data capture was in a standardized format. Then using that information to track key clinical conditions to enable effective communication for care coordination and using that to engage patients and their families in their care. Stage 2 focused on advanced clinical processes and the exchange of information. This stage dealt mainly with increasing information transfer electronically.

Stage 3 Meaningful Use focuses on taking the benefits from Stage 1 and 2 in order to improve safety, quality, efficiency of processes and information to affect an improved health outcome for patients.

Bottom Line for Your Health Organization

Although there is not a legislated mandatory adoption of EHRs for EPs, there are still consequences. The two most relevant are the loss of sizable incentives for developing your EHR program from the government. These incentives depend on whether you apply under Medicare or Medicaid. If you do not implement EHRs and certify under the MU program, you will lose 1% of the reimbursement under Medicare and Medicaid physician fee schedule covered amount per year to a maximum of 5% after five years.

Remember that your EHR programs still need to be HIPAA compliant for secure data collection, storage and transmission and require that a risk analysis assessment has been conducted for the MU programs.

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Future of Health IT: “It’s Time to Build Something Magnificent”

Future of Health IT: “It’s Time to Build Something Magnificent” | EHR and Health IT Consulting |

When it comes to health IT policy mandates, provider organizations have long questioned what’s behind the rulemaking process, with many showing further concern regarding federal leaders’ expertise levels and their lack of willingness to change based on public opinion. At the Centers for Medicare & Medicaid Services (CMS), senior technical director of Medicaid health IT Jason McNamara pays no attention these criticisms. “Those types of comments are tied to the old 1970s and 1980s way of thinking about the government, which was slow and hard to move, which sort of like a battleship in the ocean, took time to change. That’s not part of the government I’m with now,” McNamara says.  

McNamara has a wide variety of skills and projects he works on at CMS, ranging from Medicaid electronic health record (EHR) incentive programs to meaningful use rule development to health information exchange (HIE) strategies to consulting on state health IT development under the state innovation model (SIM) grants. McNamara, who focuses on the Medicaid side at CMS, recently spoke with HCI Associate Editor Rajiv Leventhal further about the perception of the government in the health IT landscape, as well as current trends and challenges he’s seeing in the industry from a policy perspective. Below are excerpts from that interview.

Tell me about how you got involved with CMS and what your current role there is?

I work in the data systems group, and if you think about the data systems group, in the context of Medicaid, we essentially work on anything IT related as long as it touches the administration of a Medicaid program or Medicaid beneficiaries. So I like to loosely interpret that as the IT arm of Medicaid. I am a technologist by trade; I spent five years in the Marine Corps, and have trained in communications and technology. I set myself up for a public safety IT focus, which evolved into health IT over the years,  and 15 years later, here I am. I also did work as a consultant implementing EHRs, building proprietary systems for large hospital systems, eventually moving over to the Department of Defense (DoD) and Veterans Administration (VA), having worked on their clinical applications as well. I was clinical operations director for ALTA, the DoD EHR system. Then in 2012 with HITECH legislation coming down, I have been managing EHR incentive programs ever since.

What are your insider thoughts on the DoD EHR contract bid?

Well it’s needed, it’s time to modernize that infrastructure. If you look at the infrastructure that’s in place, it’s antiquated. Some of those legacy systems were developed in the 1970s and 80s. Clearly it’s time to change the way they’re deploying their clinical technologies. This proposal will give us an opportunity to modernize a much needed environment. I have to maintain vendor neutrality here, but folks know some of the largest vendors that have partnered to help develop interoperable solutions, and it’s good that they have come to the table here.

What are the biggest priorities right now for you at CMS?

We have been very focused on Affordable Care Act work; we spent a lot of time deploying that, and now we’re breathing easier and are more focused on modernizing our systems on the Medicaid side, moving them into a real-time, progressive, shared-service model across Medicaid states. We are also heavily focused on data, deploying systems both at the state and federal levels to help analyze the massive amounts of Medicaid data we have. That is huge for us over the next 12 months.  And then we are of course continuing to work on health IT an HIE, an area that has lot of area for growth both from a policy and deployment perspective.

Ideally, in a perfect world, what would be the role of the government in this industry?

It depends on the topic. If you look at the National Health Information Network (NHIN), that was an Office of the National Coordinator for Health Information Technology (ONC) program,  and they managed it 100 percent at the federal level. As time progressed, they changed that and it got run over to a non-profit, Healtheway, who has since taken it over. In that regard, the government was widely used as a kickstarter to deploy that program, which is now self-sustaining in the private market. So I think it was important to push that forward. We took a step back and let the market drive that, and it’s been successful.

 Standards are an interesting topic as to what role the government plays, and we’re still trying to figure that part out. There has been a lot of conversation around open source products, as we have been playing with this idea in the Medicaid space. But how do we administer those open source products? What is our role? We have started to dabble in that market, but how do we translate that back into the community and let them market-ize the platform?

Basically, there isn’t one answer to this question. Everyone would agree that government has an important role, and we have to figure out what that looks like in each separate scenario.

How would you respond to the criticism that federal leaders aren’t appropriately apt to make such impactful health IT policy decisions?

In our government, these are folks who are industry experts who gave up lucrative positions and high paying jobs to help do good. They come from the smartest universities such as Harvard and Johns Hopkins, they were CIOs in large hospitals, and data geeks form get go with three or four computer degrees. So I don’t see this in the world I live in. It is true that it’s difficult for policy makers to keep in touch with where the rubber meets the road. We have to understand the impacts of the policy decisions and how it translates, and we’re getting better at it. We are receptive to public reception and very perceptive into how folks see the program. I’m a technologist, I started by implementing EHRs, so when someone tells me I don’t know what I’m talking about with EHRs, it is offensive. The government is made up of people who want to do good and are here for good reasons. They are underpaid and overworked. I know colleagues that haven’t had a day off in two or three months. So I can’t really associate with those types of comments.

What did you think about the news that Karen DeSalvo is likely out at ONC, and what would you like to see from the next National Coordinator?

I think it's a logical step for her career and her success.  Karen is a dear friend and colleague and she is one who can just get things done. There's value in that mindset no matter where you are in the health system. I think the next coordinator will have to continue to push the community with health IT adoption and interoperability. More importantly, push agencies towards modernizing their various policies that have a direct or indirect impact in the use of technology.  In short, the last five years have been spent laying the foundation. It's time to build something magnificent. 

What are your biggest challenges and pain points right now at CMS?

The way we have done business in the last 30 years is significantly changing; helping become a change agent is a very sensitive thing around everything related to Medicaid. We are not your grandmother’s Medicaid program anymore—it’s a different environment and building that trust is something we’re very focused on. It will become more complicated and important as we liberate data and start to tell stories about our beneficiaries. We have begun to publish a lot of data, and then folks get access to it, analyze, and make connections. We need to make sure communications across systems is continual, that’s a big focal point for us.

With respect to EHRs, we are very mindful of providers who have never had technology in practice. They are a minority but they do exist, as a specific percent are struggling with that. So it’s a challenge considering that from a policy perspective. Also, from a federal perspective, figuring out what’s the value in what we pay for? The data systems group has a $5 billion IT portfolio across states, but what does that mean and how do we create an environment where we make taxpayers dollars most effective installing systems? That’s very complicated, especially when working with legacy systems.  

You help write the EHR certification criteria for the meaningful use program. Can you get into detail about what’s behind that?

We create an advisory group, which comes from the private sector—doctors and CIOs—not public servants.  That committee looks at the program, takes public comment, and has very intimate conversations about how it will look from a clinical and systems perspective, and how it will be deployed. So we take in recommendations, and sometimes the idea starts with a simple Word document. We’ll toss around ideas and end up with some direction. The committee acts as an objective filter for that. So once we do that, we make a notice for proposal.  

For the meaningful use program, we put that on the street and take public comment. We are required to respond back—most people don’t even know that. If there’s a policy objective or measure we use and there’s a lot of comment, we can go back, change it and finalize it. We take our process from the Hill, we interpret what we think they’re trying to achieve for regulation, and then we finalize that with our rulemaking process. Then we go forward and deploy the program. When we start to hear questions from provider groups or associations, we create a sub-regulatory guidance, which provides clarity to what we intended when people have difficulty interpreting things. And we can use riders to modify and make amendments as well.  

What has the Stage 3 feedback been like so far?

I think we are at a place where Stage 3 was an aggregate of comments that we have heard over the years. We have learned lot of lessons with Stage 1 and 2, and we are now seeing a much more simplified version. How is this connecting to other programs? It aims to simplify the administration process. Folks have been generally favorable—there have been some concerns about the details of the regulation, and we will publicize those as we start to finalize it. Stage 3 is a much needed policy change, generally speaking.

You have worked with a ton of EMR vendors in the past. How would you rate their willingness to be more open systems?

I think at the end of day, vendors are there for their customers. That means a few things: customers have to hold the vendors accountable, customers have to be knowledgeable, they have to know what they want, and they have to know what’s happening. Too often we see providers pointing fingers at vendors, but are you asking them the right questions and holding them to those standards? Chances are if you hold someone to a standard, he or she would like to perform to that standard.

I think vendors want to support their customers, do good by them, stay in business, and grow revenue, and the way to do that is to solve problems of customers. You can’t get answers to those problems unless you ask questions, though. The vendors are trying, some have built infrastructure around housing their data in an effort to move data within the context of their own systems. I think that’s okay for now. But when folks talk about restricting and closing access, that’s a problem for me. We meet with vendors regularly, people don’t realize that. If we’re hearing problems from providers over and over again we can go right to the executive leaders of those vendors to work those out.

If you had to give a message to the industry as they move forward in a challenging time, what would it be?

We have to keep asking questions and challenge the data. We have a data-saturated environment right now. There is a lot of noise around that data, but what does it all mean? A very important piece of all this, and this ties into interoperability, is the semantics of the data. Let’s keep challenging the data, keep asking questions, and if we have asked so many questions and challenged different pieces, then we have created this fog, but we could sift through that to find direction and truth. It’s not about you, me, a specific provider or vendor, it’s about the collective. What are we doing as the collective to move forward? Let’s have the conversation that way.

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