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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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Monitoring ICD-10 Post-Implementation Issues

Monitoring ICD-10 Post-Implementation Issues | EHR and Health IT Consulting | Scoop.it

Planning and execution efforts toward successful ICD-10 implementation have been the largest resource-intensive undertaking by healthcare in decades. The last couple of years have enlisted dedicated planning by government agencies, healthcare plans, EHR vendors, and health information educators in facilitating the transition from ICD-9 to ICD-10.


The cost of ICD-10 preparation was a valid concern for healthcare. Physicians and other qualified healthcare providers were impacted financially with making initial capital investment in certified EHR systems. The cost of initial training for their private clinics or group practices added to expenditures. Time and resources have been allocated to electronic data exchange testing over two fiscal years in anticipation of possible system interface and program incompatibilities. Concurrently, healthcare professionals had prepared for the code system changes by participating in provider-to-vendor testing while EHR companies, clearinghouses, and healthcare plans have been focused on vendor-to-payer data transmission.


The healthcare industry had ample time to analyze the factors that currently affect efficient and uninterrupted quality healthcare, but have healthcare providers anticipated the factors that will affect their practices after implementation?


A national effort to transition to a new and improved, but vastly different coding system inevitably affects various groups and multiple healthcare transactions. As a result of inaccurate data capture and delays in medical billing, it is critical that providers and administration examine how ICD-10 impacts patient care and reimbursement.

There are different factors that contribute to inferior health data reporting and to delays in provider cash flow:


INACCURATE DATA CAPTURED


1. EHR keywords tend to mimic the alphabetic index of the code book and are not set up in user-friendly clinical terms. Physicians and other qualified healthcare providers may have difficulty in locating the most specific and accurate ICD-10 code when using keyword search and look-up tools in their EHR.


2. Physician documentation practices may not correlate to main terms and subterms in which the ICD-10 code book or electronic code books are organized, making it more challenging for coders or other designated staff members to find the most appropriate code based on the completed notes.


3. Lack of physician engagement and the decision to not seek training in ICD-10 documentation lends itself to inconsistencies of code assignments from one healthcare provider to another. Many EHR products carry over the diagnosed conditions in the patient's current and past medical history. Other providers from the same practice may choose to assign these same ICD-10 codes previously noted in the record. Even if the providers were to decide to assign their own code and not carry over the previous ones, the lack of uniformity in the practice not only implies that there are coding errors being made, but that the data collected by insurance carriers, independent research groups, government agencies, and public health organizations is not a valid representation of current illnesses. Additionally, incorrect data exchanged across electronic systems is useless information and potentially harmful to the patient's health when shared with outside healthcare providers and facilities involved in the care of the same patient. The movement toward ICD-10 was fueled by a critical need to improve the quality and effectiveness of patient care. Inconsistent and inaccurate data quality thwarts this purpose.


4. General Equivalent Mapping (GEMs) resources are intended to provide the most approximate equivalent code from ICD-9, cross-walked to each possible ICD-10 code. The translation is not a perfect one because ICD-10 includes a plethora of information that previously had not been part of the ICD-9 code description. For example, ICD-10-CM introduces combination codes that detail the underlying disease and current manifestation, routinely seen in diabetes affecting other organ systems. The new coding system has established several new concepts and features for


ICD-10 diagnostic codes, allowing providers to:


• Include information on laterality

• Identify if it is the patient's initial encounter

• Identify the gestational trimester in which the disease process was diagnosed (including the severity of illness)

• Include the external cause

• Expand on the description of injuries, fractures, complications, adverse effects, and poisonings to now include very particular information, such as:

– The Gustilo grade of an open fracture

– If underdosing or noncompliance is due to medication cost-reduction

– If the provider is treating a pregnant patient for a particular condition that first developed during the mentioned trimester and not the episode of care that she presented for

– If the resulting complication resulted intraoperatively or postoperatively


While GEMs serve as a time-saving tool, the matching ratio from ICD-9 to ICD-10 is most frequently not a perfect 1:1 correlation. Most ICD-9 codes will map out to multiple possible options for correct ICD-10 code selection. Exclusive reliance on the GEMs will lead to incorrect code submission on billing claims.


REVENUE DELAYS AND REIMBURSEMENT REDUCTIONS


1. The medical profession continues to be reimbursed on our current fee-for-service (FFS) system. National and Local Coverage Determination policies issued by CMS list and detail the diagnostic codes for symptoms and conditions that necessitate commonly performed diagnostic or therapeutic procedures. These acceptable diagnostic codes support the ordering or performing of any diagnostic tests or treatments. Incorrect ICD-10-CM assignment increases the number of "medical necessity" denials for CPT and HCPCS II procedures billed by physician practices.


2. CMS released data on healthcare providers, clearinghouses, and billing companies that participated in their July 2015 end-to-end testing with MACs and DMEs. Medicare published information stating 29,286 claims were received, but only 25,646 were accepted. Additionally, 52.7 percent of all submitted claims were professional services from healthcare providers, 2.6 percent of claims denied by CMS were due to submission of invalid ICD-9-CM codes, and 1.8 percent were due to invalid ICD-10 codes. This 4.4 percent denial rate was higher than the 3 percent reported in April's end-to-end denials. Health information managers (HIM) and providers spent 36 years learning how to assign three-digit to five-digit codes for a complete code selection. Now, providers and coders have to correctly select the required number of alphanumeric characters — anywhere from three characters to seven characters. Denials for invalid code submission further delay provider reimbursement.


3. Code assignment errors increase with untrained clerical and ancillary staff responsible for reviewing billed codes. Coding errors include: incorrectly assigned unspecified codes, codes of lesser specificity, missed diagnostic codes, and symptoms. This is especially critical for practices engaged in the HCC Risk Adjustment coding incentives in which captured data for severity of illness and comorbidities is directly tied to annual financial incentives for the practice.


4. The nearly quintuple growth in available diagnostic codes presents challenges when physician practices redesign their encounter form or superbill. Practices have to be selective about which commonly used diagnostic codes will be featured on the superbill for quick reference and which will be excluded.


5. Medical coders increase the number of queries addressed to healthcare providers for incomplete documentation and unspecified diagnostic conditions. While this is most likely to occur in the inpatient setting, physician practices with in-house medical coders will have billing claims held until the providers adequately respond to clarification requests.


6. Productivity rates decrease because of the increased time required to document properly for specific codes. Medical coders and HIM professionals take additional time to accurately locate and sequence the appropriate codes based on documentation. The increase delay in billing the professional claims increase the number of days in A/R and adversely affect the practice's cash flow. Independent providers and provider practices had been advised to budget for the anticipated financial impact at least six months prior to implementation.


EFFECTIVE MANAGEMENT AFTER OCT. 1


Several measures should be taken in order to streamline the transition in medical practices. Examination and revision of internal policies and processes is essential to ensuring that quality patient data is captured, while maintaining compliance in billing practices.


1. Provider practices should seek assistance from the EHR vendor.


• Vendors are best equipped to provide training and can also instruct office managers on how to run reports detailing the 50 most commonly used diagnostic and symptom codes in the practice.


• EHR companies can effectively re-label many diagnostic codes so that the keyword or main term appears as the clinician deems natural, and not necessarily as the medical coder is trained to look them up in the alphabetic index of the code book.


2. Practices should rely on industry resources for proper coding guidance.


• The American Hospital Association (AHA) publishes quarterly guidance on ICD-9-CM and now ICD-10 code assignment. Many challenging coding questions have been posed to the AHA by medical coders and the responses are available and organized by ICD-9 and ICD-10 codes.


• CMS has publicly released physician guidance on ICD-10-CM coding in multiple medical specialties. Information tips are available to registrants of their listserv. Also, the "Road to 10" online resources are specifically designed to assist physician practices in raising awareness and promoting physician engagement, as well as offering free training for physicians and other healthcare providers.


• The National Center for Health Statistics (NCHS), an agency under the Centers for Disease Control, has additional resources. NCHS offers official guidelines on proper ICD-10-CM and ICD-10-PCS code assignment.


• The ICD-10-CM/PCS Transition Workgroup is an online community forum hosted and managed by the NCHS (on phConnect Collaboration for Public Health) to assist physicians in this implementation (visit bit.ly/PHC-ICD10 for more information).


• The American Health Information Management Association (AHIMA) offers a number of physician coding resources, including an "ICD-10 Toolkit" developed in 2012 which still proves relevant and instrumental today (visit bit.ly/AHIMA-ICD10-toolkit for more information).


• The AMA has printed and electronic ICD-10 publications on coding and documentation intended for providers. They offer online and live training for physicians.


Practices will need training and retraining after reevaluating post-implementation operations. Staff members come and go and providers may take medical posts in other organizations. Consistent and high-quality data reporting is essential and will directly impact practices as our healthcare industry phases out the FFS model and moves toward a value-based payment model. Practices should be making provisions for educational reinforcement after ICD-10 implementation, and should strongly consider the benefits of employing certified medical coders and HIM professionals.


BEST PRACTICES


The financial health of physician outpatient practices is affected by accurate ICD-10 coding. Just as importantly, patient health outcomes are directly tied to proper coding. Proper planning is key to compliance and optimal revenue management.


Continuing education and employment of certified coders will minimize coding errors. Close monitoring of the revenue cycle and reassessment of internal processes will help identify gaps. Utilizing industry resources is a cost-effective means of improving processes. All of these combined are ingredients in the best recipe for post-implementation success.

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EHR Interoperability Limited in Integrated Care Facilities

EHR Interoperability Limited in Integrated Care Facilities | EHR and Health IT Consulting | Scoop.it

EHR interoperability has been brought to the forefront lately as various health organizations and government agencies push for nationwide health information exchange. Furthermore, as integrated healthcare and care coordination become fixtures in the healthcare delivery industry, interoperability of systems between different kinds of practitioners shows itself to be critical.

A recent study by Maribel Cifuentes, RN, BSN, Melinda Davis, PhD, Doug Fernald, MA, Rose Gunn, MA, Perry Dickinson, MD, and Deborah J. Cohen, PhD, discussed how EHRs operated in 11 practices that were integrating the delivery of primary and behavioral healthcare. The researchers found that when behavioral health and primary care begins to integrate, the two kinds of practitioners brought separate EHR systems with them. This caused challenges and subsequent workarounds and solutions associated with EHR interoperability.


The study took 11 integrated practices in the Colorado area and gathered data regarding how EHRs worked for their needs, the challenges practices faced, what kinds of workaround strategies practices developed, and what kinds of long-term solutions the practices identified in order to promote care coordination over an EHR.

One of the challenges many of the integrated practices faced was that the EHRs were not necessarily designed to collect a certain kind of data. For example, in a primary care facility that hired several behavioral health counselors (BHCs), the facility’s EHR may not have been conducive to collective behavioral health data.


Second, EHRs generally lacked templates for primary care physicians and BHCs to develop coordinated care plans.


Third, many EHRs were not interoperable with each other, hindering primary care physicians and BHCs from working together in delivering coordinated care. The EHRs were also not compatible with tablet devices that were used to collect behavior health information in the waiting room prior to appointments. These tablets were used to present questionnaires that would provide behavioral health data. However, the lack of interoperability between these devices and EHRs made it so the data collected in the questionnaire could not easily be uploaded into the EHR.


The study reports four workarounds that were developed in the face of these challenges. First, as stated above, when the primary care and behavioral health practices first integrated, the physicians often had their own separate EHR systems. In order to make sure both systems had patient information, physicians had to manually enter the data into both EHRs. While this method may have been effective in ensuring patient information was stored in both EHRs, it was not particularly time or financially effective.


Second, medical assistants had to manually scan printed documents into EHRs. While this method may have also been effective, it presented several time and financial issues. Furthermore, the scanned documents were often harder to find in the EHR, hindering the physician from delivering care to patients in a timely manner.


Third, practitioners relied on patients and other physicians to recall patient information. This workaround was not effective because patient and physician memory was neither reliable nor accurate. One physician reported having to recall patient information that was told to him several weeks before meeting with the patient. Due to the amount of time that had passed since he had last discussed this patient, he was unable to determine what kinds of services the patient needed. This resulted in the patient taking tests that had already been administered.


Fourth, practitioners employed “freestanding tracking systems,” such as spreadsheets, that were not a part of the EHR. For example, one practice stored information regarding adolescents taking selective serotonin reuptake inhibitor medications in an Excel spreadsheet. Although this was widely used amongst the practice, it took enormous effort from practitioners to maintain, and the information on the spreadsheet was not easily integrated into the EHR.


By the end of the study, researchers observed that practices began moving past workarounds and toward more long-term solutions to their challenges in order to make their integrated practices more sustainable in the future. The researchers noted that these solutions were created by each practice’s own HIT teams and required their own funding. Three key solutions amongst the participating practices emerged.


First, many practices created their own customized EHR templates. These templates existed within their pre-existing EHR systems, and simply added more fields for data entry that would be more suitable for practitioners’ needs. However, developing these templates was an arduous task.


“Creating customized EHR templates was time consuming and required dedicated HIT staff working collaboratively with BHCs and primary care providers,” the researchers reported. “Practices that did not have access to these resources were not able to create customized templates as readily, or had to pay EHR vendors to do so.”

Second, some practices purchased EHR upgrades and reported several improvements from doing so, including increased interoperability, enhanced reporting templates, and more interfaces for integrating primary and behavioral health care.


However, EHR upgrades were considerable financial investments for practices. Practices were not allowed to upgrade their EHRs using the money allocated to them by participating in the study, so the upgrade needed to be a part of the individual practice’s investments. This financial burden made it so only five of the 11 participating practices were able to upgrade their EHRs.


The final emerging solution was the union of two EHRs. At the start of the study, four of the 11 participating practices were using two different EHRs -- one for behavioral health care and one for primary care. By the end of the practice, three of them were in the midst of merging those two EHRs, and one had built an interface that extracted data from multiple EHRs and stored the data in one place. While these solutions were quite complicated and costly, they were the most effective in overcoming interoperability challenges.


Despite the advances these practices made, the researchers maintained that integrated providers may still face hurdles in the future.


“EHR systems are not yet optimally designed to meet the needs of practices integrating behavioral health and primary care,” the researchers stated. “Our study found that EHRs generally lack features essential to support key integration functions such as documenting and tracking longitudinal data, working from shared care plans, and template-driven documentation for common behavioral health conditions such as depression.”


The researchers provided guidance on how to improve EHR use in integrated care situations, stating that perhaps systems need to start being designed for integrated care, as should different incentive programs.


“In the future, HIT systems should be intentionally designed, in cooperation with clinicians; to support and enable these integrated care functions, as well as the different modes of communication and care coordination tasks that occur between multi-professional members of integrated teams,” the researchers maintained.


Furthermore, the researchers stated that more financial incentives should be provided to allow practices to make these kinds of changes. Although several EHR and interoperability incentive programs exist, none of them provide incentives that would help practices change their EHR systems to make it more usable in an integrated practice.

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NIST Ties Limited EHR Usability to Patient Safety Risks

NIST Ties Limited EHR Usability to Patient Safety Risks | EHR and Health IT Consulting | Scoop.it

The National Institute of Standards and Technology (NIST) has issued new guidance for ensuring patient safety by improving EHR usability.


The results from a technical evaluation, testing, and validation of EHR usability list three "major critical risk areas: the EHR data identification, EHR data consistency, and EHR data integrity.


"Ultimately, the data from this study demonstrate that during safety-critical tasks and times, patient safety is negatively affected, in part because mistakes and critical use errors occur more frequently and because users are highly frustrated, and thus more likely to employ workarounds, such as relying upon supplemental artifacts, e.g., paper ‘shadow charts’ or whiteboards," the authors conclude.


The NIST report identifies a handful of ways EHR problem areas contribute to inadequate patient care:


  • clinically relevant information being unavailable at the point of care
  • lack of adequate EHR clinical documentation
  • inaccurate information present in the clinical record
  • inability to retrieve clinical data


Based on empirical analysis of inpatient and ambulatory EHR use, the NIST document proposes three EHR usability enhancements that EHR technology incorporate to eliminate or reduce risks to patient safety.


The first centers of how critical patient identification data is presented. According to NIST, this information should be presented in a reserved area. The authors of the report recommended reserving the upper left-hand corner of all screens or windows and remain persistent regardless of scrolling or navigation throughout the EHR. Additionally, they hold that a patient's name appear with last name first, followed by first and middle names, modifiers, data of birth, age, gender, and medical record number (MRN) number. For EHR mobile technology, the NIST guidance allows for the presentation of this information horizontally to maximize screen space.


The second enhancement calls for the use of visual cues to "reduce risks of entering information and writing orders in the wrong patient's chart." The enhancement would prevent EHR users from entering information into multiple charts simultaneously as well as visually different between read-only and editable charts. Under this guidance, EHR users would have to deliberately enable the software to move between charts and maintain unrestricted access and provide clear cues when an EHR user moves between charts.


The third and final enhance places an emphasis on supporting the effective identification of "inaccurate, outdate, or inappropriate items in lists of group information by having information presented simply in a well-organized manner." The NIST document contains several examples:

3.1 Lists of patients assigned to a particular clinician user should be presented in consistent, predictable locations within and across displays and print-outs and the content should not vary based on display location.

3.2 The status of a note and order as draft as compared to final shall be clearly indicated on appropriate displays.

3.3 Clearly indicate the method by which the system saves information, whether auto-save or requiring deliberate action to save, or combinations thereof.

3.4 Inputted information should be automatically saved when a user transitions from one chart to another.

3.5 The language used should be task-oriented and familiar to users, including being consistent with expectations based upon clinical training.

3.6 Enable a user to easily order medications that have a high likelihood of being the appropriate medication, dose, and route. The likelihood is increased when displays are tailored to specialty-specific user requirements, comply with national evidence-based recommendations, are in accordance with system, organizational, unit, or individual provider preferences specified in advance, or are similar to orders made by the same physician on similar patients, on the same patient in the past, or providers with similar characteristics.

3.7 Support assessing relationships of displayed information and allowing users with appropriate permissions to modify locations and relationships for inaccurately placed information, including laboratory results, imaging results, pathology results, consult notes, and progress notes. This includes information within a single patient’s chart as well as information placed in the wrong patient’s chart. The information about the time and person that made the change should be viewable on demand.

On top of these recommendations, the guidance provides two use cases to illustrate the components of EHR usability testing in identifying and mitigating potential patient safety risks in both inpatient and outpatient settings. 

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How Improving Physician EHR Use Can Benefit the Diagnoses

How Improving Physician EHR Use Can Benefit the Diagnoses | EHR and Health IT Consulting | Scoop.it

Although physician EHR use has many benefits, including increased care coordination and patient engagement, issues with interoperability and health information exchange sometimes hinder the diagnosis process.

Such was the case with the first Ebola patient in Dallas, Texas last year. According to a post by Dean Sittig, PhD, and Hardeep Singh, MD, MPH, there are various different EHR practices that could have been done that may have potentially changed the outcome of the patient’s Ebola diagnosis.


Sittig and Singh based their theories on an Institute of Medicine (IOM) report that made suggestions for best practice uses for EHRs that would make diagnosis easier and more precise. According to the authors, had some of these practices been in place during the time of Ebola Patient Zero’s hospital visits, his diagnosis may have been more effective.


First, Sittig and Singh discussed the care coordination benefits of EHRs and how they may not have been fully utilized at the time of Ebola Patient Zero’s first emergency room visit. Although Ebola Patient Zero’s medical and travel history were taken by the ER nurse, that information was not passed along to the ER doctor, something which may have been prevented had different EHR practices been in place.

We recognize that there are many other ways to improve teamwork but in this day and age a major component of making teams function well is having EHRs that support teamwork and communication. Unfortunately, EHRs are not inherently designed this way and substantive ‘real-world’ usability testing is needed in order for them to do so,” wrote Sittig and Singh.

The authors suggest that EHR interfaces could improve both nurse and physician workflows in such a way that care coordination and teamwork would be better facilitated. For example, note-taking screens should not necessarily distinguish between physician notes and nurse notes, Sittig and Singh suggest. Instead, all members of the care team should be privy to all of the patient’s medical history.


“The ability to review every patient’s complete medical history in a longitudinal manner is a key factor in making an accurate and timely diagnosis. EHR screen designs could be greatly improved if they were shared among all EHR users, regardless of vendor,” the authors wrote.

Furthermore, Sittig and Singh discuss certain misuses of EHR technology. For example, the authors suggest that perhaps EHR quality measures and incentive programs should not always require nurses be tasked with gathering information regarding patient flu vaccination history. The authors maintain that although it is impossible to know whether this change in workflow would have improved Ebola Patient Zero’s diagnosis, it is a commonly acknowledged fact that certain required EHR incentive measures have an effect on how clinicians communicate with patients.


Sittig and Singh state that Ebola Patient Zero is a case study for all of the work that can be done to improve EHR use in diagnostic settings. These improvements can be made through industry collaboration and the sharing of best practices. Furthermore, the pair states that EHRs need interoperability to allow for collaboration and to help paint a complete picture of the patient’s care. Through the participation of policymakers and industry stakeholders, Sittig and Singh state that EHR healthcare can become safer and more effective.

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Why Our Independent Practice May Be at Its End

Why Our Independent Practice May Be at Its End | EHR and Health IT Consulting | Scoop.it

We are many things: husband and wife, doctor and administrator, and parents. When you first meet us we appear pretty vanilla, but in fact, in our lives, when we come upon two metaphorical roads diverged in a wood, we often choose the one less traveled by. This month, on September 9, we celebrated 15 years of marriage and took time to reflect on our path so far and where we think we're going next.


Here are a few unusual choices we've made along our path so far. We met on Match.com in 1999 when very few people did that. We got engaged only six months after meeting and married nine months after that. Uncle Sam paid for Terence's medical school education which meant we spent the first six years of his career — and our marriage — as an active-duty military couple. The Air Force took us away from our home state of Massachusetts; we lived three years in Dayton, Ohio, and the next three in Albuquerque, New Mexico. In 2006, we opened our solo pediatric micro-practice even though everyone, including our accountant at the time, told us it couldn't be done. And in 2008, we met a beautiful four-and-half-year-old little boy whom we adopted a year later.


From 2006 to 2014, our micro-practice model worked well for us. We enjoyed an average income for primary-care pediatricians in our area all while maintaining work-life balance and giving patients long appointments that run on time. We also continually received high marks on patient satisfaction surveys and performed very well on the quality measures set by our independent physician association (IPA). And, because we were small and flexible, it was easy for us to adapt to changes, like integrating behavior health, into our model. It's not that small practice ownership has even been simple, but until recently we could make it work.


Our model in 2015, though, has stopped working as well. Understanding why our revenue is down, over 20 percent, is pretty easy and almost all due to the consolidation of insurance companies. To be clear, our problems are not at all uncommon; we see many primary-care peers, in all sorts of different practice models, suffering for the same reason. We are losing confidence that any independent practice model has the power to survive against the oligopoly of powerful insurance payers.


The pressure to abandon independence, and along with it the many benefits to ourselves and our patients, is increasing exponentially. The day is drawing near when we must choose between the road everyone else is taking —namely to abandon independence — or find a more creative road less traveled. For now, we appear to be on a single-lane, one-way highway to selling out without an off ramp to stay independent in sight.

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Wearables Data May Prevent Health Plan Denials

Wearables Data May Prevent Health Plan Denials | EHR and Health IT Consulting | Scoop.it

This story begins, as many do, with a real-world experience. Our health plan just refused to pay for a sleep study for my husband, who suffers from severe sleep apnea, despite his being quite symptomatic. We’re following up with the Virginia Department of Insurance and fully expect to win the day, though we remain baffled as to how they could make such a decision. While beginning the complaint process, a thought occurred to me.


What if wearables were able to detect wakefulness and sleepiness, and my husband was being tracked 24 hours a day?  If so, assuming he was wearing one, wouldn’t it be harder for a health plan to deny him the test he needed? After all, it wouldn’t be the word of one doctor versus the word of another, it would be a raft of data plus his sleep doctor’s opinion going up against the health plan’s physician reviewer.

Now, I realize this is a big leap in several ways.


For one thing, today doctors are very skeptical about the value generated by patient-controlled smartphone apps and wearables. According to a recent survey by market research firm MedPanel, in fact, only 15% of doctors surveyed see wearables of health apps as tools patients can use to get better. Until more physicians get on board, it seems unlikely that device makers will take this market seriously and nudge it into full clinical respectability.


Also, data generated by apps and wearables is seldom organized in a form that can be accessed easily by clinicians, much less uploaded to EMRs or shared with health insurers. Tools like Apple HealthKit, which can move such data into EMRs, should address this issue over time, but at present a lack of wearable/app data interoperability is a major stumbling block to leveraging that data.


And then there’s the tech issues. In the world I’m envisioning, wearables and health apps would merge with remote monitoring technologies, with the data they generate becoming as important to doctors as it is to patients. But neither smartphone apps nor wearables are equipped for this task as things stand.


And finally, even if you have what passes for proof, sometimes health plans don’t care how right you are. (That, of course, is a story for another day!)


Ultimately, though, new data generates new ways of doing business. I believe that when doctors fully adapt to using wearable and app data in clinical practice, it will change the dynamics of their relationship with health plans. While sleep tracking may not be available in the near future, other types of sophisticated sensor-based monitoring are just about to emerge, and their impact could be explosive.


True, there’s no guarantee that health insurers will change their ways. But my guess is that if doctors have more data to back up their requests, health plans won’t be able to tune it out completely, even if their tactics issuing denials aren’t transformed. Moreover, as wearables and apps get FDA approval, they’ll have an even harder time ignoring the data they generate.


With any luck, a greater use of up-to-the-minute patient monitoring data will benefit every stakeholder in the healthcare system, including insurers. After all, not to be cliched about it, but knowledge is power. I choose to believe that if wearables and apps data are put into play, that power will be put to good use.

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EHR Use Hindered by Revenue Loss, Lack of Interoperability

EHR Use Hindered by Revenue Loss, Lack of Interoperability | EHR and Health IT Consulting | Scoop.it

EHR use has been on the rise since the 2009 passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act provided financial incentives for EHR implementation. However, do the gains of EHR adoption outweigh the substantial costs?


A recent study written by Tara O’Neill of the American Action Forum takes a look at these questions and states that although there are considerable benefits to EHR adoption, these come with costs that can only be resolved with changes in healthcare policy.


Since the passing of the HITECH Act, EHR adoption has risen to 76 percent, and over 468,000 Medicare and Medicaid providers have received some sort of subsidy from the Centers for Medicare & Medicaid (CMS) for reaching certain meaningful use standards. That totals to approximately $30.4 billion in subsidies, or $65,000 per provider.


Those subsidies are paid for a good reason-- according to O’Neill, the total cost for an individual provider to adopt an EHR is $163,765, and for five providers $233,298. Unfortunately, many adopters have yet to see the payoff for this investment, O’Neill writes. However, O’Neill cites a study by David Dranove, et al, which states that providers with a strong IT system may see larger payoffs come into effect in as soon as three years following the EHR adoption process.


“...in IT-intensive areas, hospitals with basic EMR systems saw cost decreases of 3.4 percent three years after adoption,” she writes. “As the number of workers in IT-related jobs continues to increase and EMR technology is adapted and improved, all areas may begin to see cost decreases.”


O’Neill also states that the lack of interoperability is hindering the productivity rates of EHRs. Because many systems do not do well with exchanging information between different hospitals, EHRs are being primarily used as tools within a specific healthcare facility. However, meaningful use standards are aiming to change this and to increase interoperability and health information exchange (HIE).


And while some of this lack of data exchange may be a result of the high cost of EHR adoption, O’Neill suggests that this may also be intentional “data blocking.” This is because providers and payers are reluctant to share with other providers important patient information that would help the other providers treat the patient.


“Essentially, under the current payment models, one person’s revenue gain is another person’s revenue loss,” she writes. “Thus, it will likely require a complicated policy solution in order to bring all of the players together for the benefit of society as a whole.”


As more healthcare organizations begin to adopt EHRs, patients are seeing more electronic files being created on their behalf. This poses as serious security risk, O’Neill says, one that can be very costly.

“The average cost of data breaches in the health care industry has been more volatile and has increased sharply in the last two years,” O’Neill writes. “The average cost of a data breach in the U.S. in 2014 was $217 per compromised record, compared to $398 in the health care industry.”


Additionally, data breaches are becoming increasingly expansive. Compared to 2014, the total number of records compromised per breach increased by 160 percent in 2015. This means that although there have been fewer breaches to date in 2015 than in 2014, the overall costs of data breaches is significantly higher.

O’Neill states that this may be an effect on the increased overall number of EHRs.


“With the growing number of electronic records and increased sharing among providers, the number of records potentially accessed in a single incident is growing exponentially,” she writes.


O’Neill recognizes the benefits EHRs could have on the healthcare industry, citing improvements in population health management and care coordination. However, she states that in order to see those gains, policymakers and healthcare professionals alike will have to cooperate and rework legislation to make EHR use more effective.


“As EMR adoption continues to increase along with the type of information gathered, policymakers should work with experts and the public to ensure that the appropriate balance is struck between sharing information to allow advancements and providing necessary privacy protections,” she writes.

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How Should DoD Secure Health Records?

How Should DoD Secure Health Records? | EHR and Health IT Consulting | Scoop.it

The Department of Defense is about to move forward with its multi-billion dollar plan to overhaul its electronic health records system. But when you're an organization such as DoD, supporting 9.5 million active and retired military personnel and their beneficiaries, there are variety of important privacy and security challenges that must be prioritized and tackled, privacy and security experts caution.


In late July, the DoD awarded a $4.3 billion, 10-year contract to Leidos Partnership for Defense Health, a group of three main vendors that include EHR provider Cerner and consulting firms Accenture and Leidos Inc. The contract, which has the potential to be worth $9 billion if DoD exercises all its options over 18 years, involves the Leidos Partnership team transitioning the Pentagon's existing proprietary EHR system onto a Cerner off-the-shelf EHR at about 1,000 DoD sites worldwide, including military hospitals in the U.S., as well as health clinics in remote places such as Afghanistan.


However, as the Leidos partnership embarks on the massive overhaul, there are several critical privacy and security issues that need to be addressed to safeguard patient data throughout the plan.


Additionally, many of the challenges faced by the DoD in its EHR project are also similar - but much larger in scope - to the privacy and security concerns that healthcare organizations in the private sector face when undertaking their own EHR system migrations.


Those issues range from protecting patient data as its moved from one platform to the next, to thoroughly vetting the consultants involved with the EHR work.

Migrating Data

"Several security and privacy challenges exist as the DoD transitions from its old EHR to the new system," says Keith Fricke, principal consultant at consulting firm, tw-Security.


"Migrating from one EHR to another often involves importing historical data from the old system to the new one. The data set may be rather large," he notes. "Extracting data from the old EHR will likely result in a large interim database or data file. The database may need to be sent to the new vendor for data field mapping or importing."


Yet, it is not practical to send data extracts this large over a data connection. "Instead, it is better to send the data sets on an encrypted external hard drive, tracked via shipping provider," he says.


Data integrity issues are among the biggest challenges involved with such massive EHR undertakings, says Tom Walsh, founder of tw-Security. "Often times, the data mapping between an old system and new systems misses something. The only thing worse than no patient data is the wrong patient data."


To counter those problems, the data extraction process must include mechanisms to validate the data ultimately imported into the new EHR exactly matches the data stored in the old EHR, Fricke advises.

Another factor that needs close oversight is ensuring that role-based access controls to patient data are maintained from the old system to the new, especially where highly sensitive information, such as behavioral health data, is involved, Fricke says.


Privacy and security expert Kate Borten, founder of consulting firm The Marblehead Group, says it's equally important to ensure that the consultants working with or accessing the sensitive data are scrutinized. "I expect that many contractors will have access to PHI throughout this major project," she says. "It is very important that they be thoroughly vetted, that they be given the minimum necessary access permissions, and that they be monitored."

Long Haul

Because the DoD project will last several years, it's important to have measures in place to safeguard data during the various project stages.

"Workers should use simulated PHI rather than actual PHI as much as possible," Borten says. "Too often, PHI access is granted for development, testing, and training purposes, when simulated PHI could and should be used instead."


However, often a test environment must have real patient data in order to perform a true functional test, Walsh notes. "Security controls for test environments can often be less stringent. People using the test environment may forget that the data they are working with represents a real patient. Generic user accounts with easy to remember

passwords may be set up to help facilitate functional testing."


So, to avoid possible breaches or unauthorized access to PHI, the test environment needs to have security controls set to the same level as the production environment, Walsh recommends.


Because there will be thousands of people involved with the project - including individuals working for contractors and subcontractors - another danger is a watering down of security measures and practices that should be in place throughout the project, at all locations, for all personnel involved with the work.


"A front line worker may honestly say, 'I didn't know,' and it is a true statement," Walsh says. "Privacy and security education must be conducted for everyone involved."


As for securing data during project stages, Fricke recommends that data be stored on servers located in a secure data center and accessed via virtual desktops. "Doing so significantly reduces the likelihood that data is being stored on contractors' laptops or hard drives of workstations," he says.


"If storing data locally on laptops and desktops is required, these devices must be usingencryption."

User Access

In addition, Fricke suggests that two-factor authentication be used for any remote access to the data being worked on for the migration. "We've seen news stories in the past year about foreign countries targeting US government systems for hacking and exfiltration of data," he says. "The vendors involved in this EHR migration must ensure that all systems involved in the process have proper security patching levels, well-maintained malware protection, and 24x7 audit log monitoring."


Also, if any of the individuals working on this project had their information compromised in the Office of Personnel Management breach, extra care must be exercised to avoid becoming a victim of a spear-phishing attacks.


Because the DoD EHR systems contain healthcare data for U.S. military personnel, then the information potentially could be a hot target of the most devious cyberattackers, Walsh notes.


"The data in these systems are not just any patient. This is the patient data of the men and women who willing chose to serve our country," he says. "Our military personnel are prime targets for domestic and foreign terrorists. Workforce clearance will have to be strongly enforced for anyone involved, but especially far more rigid for any person with elevated privileges, such as system administrator, super user, etc."


Finally, because the DoD project will last at least a decade, maybe two, it's vital that all project work is thoroughly documented, Fricke says.

"It is important that from a project management perspective, the project managers ensure all project documentation is kept very current," he says. "There is always staffing turnover of project managers and contractors in a project this large and with the long timelines expected. Gaps in documentation will cause potential delays, potential rework and possible lapses in security practices as turnover occurs."

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What’s the Glue Holding EHR Migration and Conversion Projects Together?

What’s the Glue Holding EHR Migration and Conversion Projects Together? | EHR and Health IT Consulting | Scoop.it

Are you considering migrating from an older EHR to a newer EHR or are you in the process of that conversion? If so, you are well aware of the complexity of this process. There are a lot of reasons that drive the EHR conversion decision, but the primary reason that organizations undertake EHR conversion is simply to improve patient care and safety by providing clinicians and caregivers with the right information at the right time.


It’s easy to think that this is all about the technology. EHR conversion is far more than an IT project. It is a central business issue that needs to be strategically sponsored and backed by upper level management. In our previous post, we addressed the issue of aligning integration goals for business and technology.  In a project of this magnitude, aligning business and technology goals becomes critical. Implementation takes hard work, time, and is very expensive. Effectively dealing with scope, budget & time creep, and change management matched to the stated business goals is the key to success. The complex planning needed is just one part of the story but the actual execution can be extremely problematic.


Since the primary reason for undertaking EHR conversion is to improve patient care and safety, clinical workflow is top-of-mind and coupled to data exchange and flow through your systems. On the IT side, your analysts define the project requirements and your developers build the interfaces based on those requirements. But the team that plays the most critical role is your quality team. Think of them as your project’s glue.


QA has layers of responsibilities. They are the ones that hold the requirements as the project blueprint and make sure that those requirements, driven by the pre-identified business needs, are being met. They also make sure that all defined processes are being followed. Where processes are not followed, QA defines the resulting risks that must be accommodated for in the system. A subset of responsibility for QA is in the final gate-keeping of a project, the testing and validation processes that address the functionality and metrics of a project.


Analysts work to build the interfaces and provide QA with expected workflows. If those workflows are not correctly defined, QA steps in to clarify them and the expected data exchange, and builds test cases to best represent that evolving knowledge. Identifying workflow is often done blindly with little or no existing information. Once the interface is built, those test cases become the basis for testing. QA also plays an important role in maintenance and in contributing to the library of artifacts that contribute to guaranteeing interoperability over time.


Though it is difficult to estimate the actual costs of interfacing due to the variance implicit in such projects, functional and integrated testing is often up to 3x more time consuming than development. It’s important to note that this most likely represents defects in the process. Normally, in traditional software development those numbers are inversed with QA taking about 1/3 of development time. It’s quite common that requirements are not complete by the time the project lands in QA’s lap. New requirements are continually discovered during testing. These are usually considered to be bugs but should have been identified before the development phase started. Another major reason for the lengthy time needed is that all testing is commonly done manually. A 25 minute fix may require hours of testing when done manually.


In technology projects, risk is always present. QA teams continuously work to confine and evaluate risk based on a predefined process and to report those issues. The question continually being asked is: what are the odds that X will be a problem? And how important is that impact if there is a problem? Here the devil is in the details. QA is constantly dancing with that devil. Risk is not an all or nothing kind of thing. If one were to try and eliminate all risk, projects would never be completed. QA adds order and definition to projects but there are always blind alleyways and unknown consequences that cannot be anticipated even with the most well defined requirements. Dealing with the unknown unknowns is a constant for QA teams. The question becomes how much risk can be tolerated to create the cleanest and most efficient exchange of date on an ongoing basis.


If QA is your glue, what are you doing to increase the quality of that glue, to turn that into super glue?What you can do is provide tools that offset the challenges your QA team faces. At the same time, these tools help contain project scope, time & budget creep, and maintain continual alignment with business goals. The right tools should help in the identification of requirements prior to interface development and throughout that process, identify the necessary workflows, and help in the QA process of building test cases. De-identification of PHI should be included so that production data can be used in testing. Tools should automate the testing and validation process and include the capability of running tests repetitively. In addition, these tools should provide easily shared traceability of the entire QA process by providing a central depository for all assets and documentation to provide continuity for the interoperability goals defined for the entire ecosystem.

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Three Common EHR Missteps

Three Common EHR Missteps | EHR and Health IT Consulting | Scoop.it

Family physician Saroj Misra is an educator, and thinks that physicians are at the low end of the learning curve when it comes to EHRs.

"Despite the fact that we've had EHRs in some form or another for the last 15 to 20 years … we are surprisingly behind the times in terms of how they work; what they do, and, most importantly from a physician's perspective, how they help in the delivery of healthcare," says Misra.


That is probably a perspective that many physicians would share. In the 2015 Physicians Practice Technology Survey, Sponsored by Kareo, only 53 percent of 1,181 respondents said they had a fully implemented EHR system. And, despite seeing an improvement in documentation (66 percent), 68 percent said they did not see a return on their investment in EHR. Respondents said one of their top information technology problems was "a drop in productivity due to our EHR," indicating a significant disconnect between the intent of EHR and its reality.


If you are wondering what EHR trip-ups other physicians are struggling with, our experts tell us these areas are the worst offenders.


INADEQUATE TRAINING


Inadequate training on EHR systems for both physicians and clinical staff can be a significant source of frustration. Yet there are many other demands for a physician's time and money. It is a paradox that devils many practices: If a practice doesn't go "off line" and dedicate enough time to initial training on the EHR, implementation and subsequent productivity will suffer. But few practices can afford to take a full week or more away from patient care.


Tom Giannulli, chief medical information officer for EHR vendor Kareo, counsels physicians to avoid learning a new system while they are seeing patients. "EHRs have learning curves, for some they may be steep, and if you do not ascend the curve in a productive learning environment, you will be paying for it with wasted time and frustration," he says.


Misra, who directs the development and implementation of curriculum at Michigan State University's College of Osteopathic Medicine, incorporates technology use in his teaching. He says in order to have true success with understanding and efficiently using the EHR, physicians need to "commit time each week to relearning [the system]." He gives the example of a "power-user" who goes beyond learning basic system functionality and commits time each week to really learn what the system can do. Understandably, that might sound like a pipe dream, given the lack of excess time in a busy practice. But there are ways around that limitation. Misra recommends carving out one to three hours each week for a single physician or staff member to learn the functionality of the practice's EHR. "Then, that person becomes a liaison or a de facto liaison to the EHR vendor," he says, "but also a person who can educate and provide ongoing education for the physicians and the office staff."


ACTION STEPS:


• Training should be timely, and repeated for both new staff and current users.


• Training should focus on specific tasks that staff/providers will use daily.


• Identify a practice "super-user" who will be a clinic resource/trainer/ IT support person.


INADEQUATE IMPLEMENTATION


Marissa Rogers is program director for a large family medicine residency at Genesys Regional Medical Center in Burton, Mich., and a practicing member of a 46-provider faculty practice. She says her providers often struggle with spending too much time on documenting the patient encounter in the EHR. She encourages her residents to chart on the computer when the patient is in the exam room, to "get the meat of what the patient is telling them," but admits it is not always an easy task. "It's very difficult for physicians to do because we are used to wanting to talk and listen [to our patients]," she says, "… But in the new world that we are living in, we now have to get used to having a computer in front of us."


Rogers says completing the patient note while the patient is present in the exam room is a necessary component of providing a summary of care for the patient to bring home — a meaningful use requirement. So for physicians who are not ace typists, being required to enter the patient note during the encounter can slow down their day and reduce overall productivity.


Another productivity drag? Misra says physicians commonly fail to make use of time-saving EHR features like shortcuts, templates, built-in coding, and voice recognition software to dictate the patient note. And, when he visits other clinics, he often sees them using out-of-the-box templates provided by the vendor, which he believes slows down physician work flows. Knowing your practice's work flows and how they are affected by the EHR can allow your practice to create customized templates that will speed up documenting the patient encounter.


"Many EHRs have the ability, with time and effort, and that's the problem, to make some modification to these [templates]. But most physicians find those barriers too high, in terms of time and effort. But if they did [modify the templates]… that would speed things up immensely for them," says Misra.


Elizabeth Woodcock, principal of Woodcock & Associates, a practice management consulting firm, says that in some cases, it is not possible to customize EHR documentation to fit practice needs, especially in the case of a unique specialty practice like a fertility clinic. But even when customization is not possible, Woodcock says that correctly configuring the EHR during implementation is crucial. Small things like incorrectly setting up the dictionary can cause a physician to hate his EHR and negatively affect "the whole course for the EHR for years and years to come," she says.


ACTION STEPS:


• Integrate the EHR into clinical work flows, and revisit work flows after implementation.


• Develop templates/customization that work for the specific practice.


• Ask the vendor for system enhancements to facilitate improved work flows, where possible.


INADEQUATE TECH SUPPORT


Many practices have vendor-provided tech support onsite for the first week of EHR implementation, and after that they are essentially on their own. Obviously that can be a huge detriment to a practice. Woodcock advises administrators to have tech support return within 90 days after the initial implementation, for one or two days, to answer questions that have cropped up at the practice.


Misra advises practices to communicate with the vendor on a regular basis. He suggests that the appointed EHR "super-user" should also be the practice's vendor liaison. "That person should not only be communicating back to the vendor what they need and what's working, but they should be communicating back to the office what updates are coming out for the software."


Large health systems typically have their own onsite tech support, which is a definite plus for busy practices. But that doesn't always mean your practice can get the personal attention it deserves. Woodcock says a new trend that she sees beginning to take hold in health systems is the use of an EHR optimization team. "Their goal is to make that system work better for you." She says these professionals tend to have EHR vendor experience and approach their work from a "lean-thinking" perspective.


ACTION STEPS:


• Build in adequate tech support in the initial vendor contract, with a return visit within 90 days.


• Develop a practice work group (physicians and staff) that will initiate and support EHR implementation/use.


• Task the EHR super-user to act as a vendor liaison.


SOAP NOTE SLOWDOWN


According to a member survey of the American College of Physicians, most of whom were experienced EHR users, 89 percent of respondents said they experienced slower data management; 63.9 percent said the SOAP (subjective, objective, assessment, and plan) note documentation took longer; 33.9 percent said it took longer to review medical data; and 32.2 percent said it took longer to read another clinician's note using EHRs.

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ICD-10 Implementation Progresses; Doc Practices Lag

ICD-10 Implementation Progresses; Doc Practices Lag | EHR and Health IT Consulting | Scoop.it

The latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) shows industry-wide progress in preparing for the ICD-10 implementation deadline although physician practices continue to lag behind health IT vendors, health plans, and health systems.


"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 states in a letter to the Department of Health & Human Services Secretary Sylvia Mathews Burwell.


Speculation about another ICD-10 delay contributed to the industry's ICD-10 preparation, WEDI claims.


"Uncertainty over further delays was listed as a top obstacle across all industry segments. While the delays provided more time for the ICD-10 transition, it seems that many organizations did not take full advantage of this additional time," the letter reads.


According to WEDI, the joint announcement by the Centers for Medicare & Medicaid Services (CMS) and American Medical Association concerning ICD-10 flexibilities after October 1 — which appeared after the survey was concluded — should go a ways toward removing this obstacle.


"Physician practices may now be working more quickly toward compliance, since the potential for further delay has been removed," it adds.


The survey included nearly half as many respondents as a similar survey conducted earlier this year in February 2015 yet still shows good progress across the healthcare industry with respect to ICD-10 compliance.


Health IT vendors demonstrated good progress over the past few months, particularly in the area of product availability:


Three-quarters indicated their production-ready software or services were available to customers. This is an increase from less than three-fifths in the February 2015 survey.  One-quarter responded that their products would not be available until the second or third quarter of 2015, but no one responded that their products would not be ready by the compliance date.


The findings reveal a dip in the percentage of health plans having completed impact assessment — from four-fifths to two-thirds — which WEDI attributed to the respondent makeup of this latest survey. That being said, health plans excelled in external testing activities with close to 75 percent of these respondents reporting having completed external testing.


Echoing the findings of AHIMA and the eHealth Initiative on provider ICD-10 readiness in July, the WEDI survey has found room for improvement for physician practices.


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," says WEDI.


In an accompanying letter to HHS Secretary Burwell on the subject of enhancing the ICD-10 transition, WEDI calls on the federal agency to make publicly available information about the readiness levels of Medicaid agencies and offer additional educational outreach to aid the healthcare industry through the historical change.

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IT, EHR systems go dark at 13-hospital system

IT, EHR systems go dark at 13-hospital system | EHR and Health IT Consulting | Scoop.it

The computer system, including the electronic health record platform, at a 13-hospital health system went black this week, resulting in a 20-hourlong outage.


BJC HealthCare, in St. Louis, Missouri, reported a computer outage Tuesday afternoon that impacted its IT systems across 13 hospitals. 

All IT systems went dark, "including clinical, revenue cycle, e-mail, word programs and other applications," hospital spokesperson June McAllister Fowler told Healthcare IT News.


As for what caused it? The health system's IT department is still working with an external vendor to do a root cause analysis, she said. Applications were brought back online 20 hours later on July 29.


"There are no indications that either patient data or employee information was impacted by the technology issues," said McAllister Fowler. During the downtime, clinicians and health system employees resorted to manual paper-based patient management processes.

The financial implications of BJC HealthCare's computer system outage might not be pretty. In fact, a single minute's downtime for an organization can be hugely costly. Groups that experience data outages should expect to hand over $7,900 per minute of outage time, according to a 2013 report published by Ponemon Institute and Emerson Network Power.


Healthcare organizations on average can expect to pay $690,000 per outage incident, representing a whopping 41 percent increase since 2010. Of course, those numbers depend on myriad factors including complexity of IT systems and length of downtime, but it's still no small bill.


These costs include business disruption costs, which average to nearly $239,000; just shy of $184,000 in lost revenue costs; and end-user productivity shortfalls, pegged at $140,543, according to the data. The report also underscores UPS system failures, accidental/human errors, cybercrime, weather and water/heat or CRAC failure as accounting for the majority of outages.  


This is not the first reported outage this year. Back in March, the two-hospital Rideout Health in Northern California saw its McKesson electronic health record system go dark for about a week, due to a HVAC burnout. Health system officials cited HVAC units in an off-site data center following one of them burning out and the other overheating shortly after.


Boston Children's Hospital also reported back in March that its EHR had crashed and was down for about five days, citing a hardware issues related to data storage

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Maximizing Your EHR: 5 Strategies

Maximizing Your EHR: 5 Strategies | EHR and Health IT Consulting | Scoop.it

The way in which physicians interact with data as it pertains to patient care has clearly identified the EHR as a critical tool. The statistics speak for themselves — approximately 78 percent of all office-based physicians had an EHR in place as of 2013, according to a 2014 study in Health Affairs. However, this doesn't mean that physicians are satisfied with the EHRs they have; recent studies, including a 2014 report in JAMA Internal Medicine, have shown that even experienced EHR users find significant decreases in productivity, losing on average, 48 minutes of productivity every workday. It becomes critical, then, to find ways to maximize the use of existing EHRs in an effort to improve efficacy for patient care and reduce end-user frustration.


The biggest problem with an EHR system is not the product itself — it is the way we learn to use it and how we communicate with those who make and update it. These five strategies might help to reduce both the frustration level and inefficiency that many doctors feel come with their EHRs.


1. Train and train again. Most EHR training occurs prior to "going live" and is often not tailored to individual "teams" within the office (medical assistants, front-desk staff, physicians, billers). In addition, once the initial training is done, most offices rarely do any further training. The reality is that "relearning" your EHR is critical to maximizing its advantages. Consider appointing one individual in your office (or one from each stakeholder group) to set aside time each week or month to "retrain" on the EHR. The focus should be on capabilities (what can it do) and needs (what do we need it to do).


2. Check your "flow." Work flows in your office need to be looked at before and after an EHR is implemented. Have your office manager and/or you (the physician) spend a day watching how a patient moves through the process of being seen — from check-in to check-out. When you identify choke points (be they people or processes), work on how to fix and redirect those tasks.


3. Use shortcuts. Most EHRs have huge amounts of customizability that physicians often forget to take advantage of. Learn how to use encounter templates and order sets to speed the process of getting data into the system. Don't forget about dictation and transcription capabilities as well.


4. Engage the portal. Using the patient portal to allow patients to manage common tasks and requests can dramatically reduce the amount of work your staff needs to do. Recent CMS guideline changes allow for reimbursement of "non-face-to-face" visits for chronic diseases — using the patient portal as a tool for this type of patient interaction is an optimal strategy.


5. Communicate with the vendor regularly. It's important to remember that you are a client when it comes to the EHR and that you are paying for services as well as product. Don't hesitate to ask for further training or retraining if needed. Make sure the EHR vendor has regular meetings with your office staff designee to keep you updated on changes to the EHR system.


Strategies such as the ones above will help your practice get the most out of the EHR it has, while waiting for the day when healthcare has an EHR physicians actually want.

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Exporting EHR Data to Excel Improves Finance Reporting

Exporting EHR Data to Excel Improves Finance Reporting | EHR and Health IT Consulting | Scoop.it

EHR and practice management (PM) systems come with built-in reporting capabilities but digesting all that information can be overwhelming. However, leveraging the power of Excel to sort and manipulate the data stored in your EHR can help you spot trends faster and implement steps to drive revenue growth.


“Excel is a great way to slice and dice your practice management data so you can really use it to improve,” says Nate Moore, CPA, MBA, an independent consultant and coauthor of “Better Data, Better Decisions: Using Intelligence in the Medical Practice.” “Excel allows you to filter, trend, and get your arms around reams of data.”


Excel offers an interactive tool called pivot tables that allow users to quickly sort, filter, and manipulate data, says Moore, who moderates the Excel Users Medical Group Management Association Community, an online resource for practice administrators. It gives users much more flexibility than an EHR, which typically offers a limited number of canned reports.


For example, your PM system can probably produce a general report on your collection rates at the front desk at the point of service. But a pivot table would allow you to slice that data in a variety of ways, such as individual employees’ collection rates by location or time of day.

In addition, you can connect Excel to the server where your data is stored so you are always working with the most current numbers, says Moore. That allows you to quickly run the same types of reports with updated data.


“A lot of practice administrators don’t run reports as often as they’d like because they take so much time to run and analyze using the PM and EHR,” says Moore. “Using Excel streamlines the process, making it more likely that reports will actually get produced.”


Moore offered a few examples of how pivot tables might be used to dig deeper into financial reports and zero in on potential problems:

1. Focus on overdue accounts. A general report on aging accounts receivable from your PM system might contain hundreds of pages, making it difficult to focus on specific trends. Exporting that data into pivot tables allows you to zero in on problem areas, such as claims overdue by 60 days categorized by insurer.


2. Gage productivity. If your compensation system is based on productivity, you can look at work relative value units by individual providers or during certain time periods.


3. Monitor workflow. Larger practices can monitor and compare activity at different locations. For example, how many patients did one employee register at a specific location vs. another employee at a different office?  How many appeals or claims did each individual employee process at each office?


4. Analyze your patient base. Using a basic pivot table, you can see all of your new patients in a given year categorized by month of visit, referring physician, diagnosis code, insurance, or clinic location. Analyzing the data reveals trends, such as how many patients each physician saw in each year over the past five years.


5. Group data. You can group data to spot referral trends. For example, how many commercially insured patients did one group of referring physicians refer to each individual provider in your practice, for each of the past five years?

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BI4Results's curator insight, November 10, 2015 2:33 PM

Really, exporting to Excel? This process should be a fully automated self-service BI solution

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ICD-10 Compliance a Struggle for Some Physician Practices

ICD-10 Compliance a Struggle for Some Physician Practices | EHR and Health IT Consulting | Scoop.it

October 1 has come and gone, and nearly two weeks in to ICD-10 compliance most of the healthcare industry is relatively mum on the transition to the newer clinical diagnostic and procedural code set. More than likely, healthcare organizations and professionals are busy enough adapting to ICD-10 and its more specific set of codes.

That’s not to say some are not speaking out or in support of ICD-10 compliance.


Two recent weekend reports in the Florida’s Crestview News Bulletin and Maine’s Bangor Daily News paint two very different pictures of ICD-10 compliance at the two-week mark.


Apparently, some physician practices in the Florida panhandle are going through the motions in adapting to the federal mandate for ICD-10 compliance which began back on October 1. Brian Hughes reports that medical offices are encountering difficulties with the code set.


“Large practices and medical companies, such as Peoples’ Home Health, usually have coders on staff. Their only job is to enter the numbers into billing records and insurance reimbursement forms,” he writes. “For smaller offices like Dr. Herf’s and Mir’s, the increased coding tasks take away staffers’ time with patients.”


Betty Jordan, the manager of physician practice of Abdul Mir, MD, views ICD-10 as more of a hindrance than a help.


“It requires so much extra work. If my doctor treated someone for rheumatoid arthritis, there’s hundreds of codes. It’s got to be specific,” she told the Crestview News Bulletin.


“It is horrible for a primary care doctor,” she further revealed. “For a specialist, they deal with the same things over and over. For us in family practice, we see all kinds of things. It’s overwhelming.”

For an administrator at the practice of David Herf, MD, the challenge of ICD-10 compliance is the result of increased specificity being married to an increase amount detail.


“It’s really, really detailed,” Andrew Linares told the news outlet. “Instead of just saying, ‘cyst of the arm or trunk,’ you have to get really specific.”


For one of the physician practices, adapting to ICD-10 is akin to learning a whole new language.


The climate in Maine appears much sunnier regarding ICD-10 compliance. Jen Lynds reports high levels of preparation among Maine healthcare organizations and professionals leading to a smooth transition.


“Health care providers across the state began working Oct. 1 with a new system of medical codes that has them describing illnesses and injuries in more detail than ever before, and officials from hospitals and medical associations said earlier this week that they are prepared for the challenge,” she writes.


According to Gordon H. Smith, the Executive Vice President of the Maine Medical Association, complaints are scarce as are ICD-10 implementation delays. Director of Communications for the Maine Hospital Association reports the same situation.


That being said, leadership at Eastern Maine Medical Center are preparing for transition-related productivity decreases for coders and billers used to the previous code set. However, things are still proceeding as planned.


“Our transition to ICD-10 has gone very smoothly here at Eastern Maine Medical Center,” Director of Coding and Clinical Documentation Improvement Mandy Reid told the Bangor Daily News. “We are using nine contract coders through outside vendors to support the ICD-10 go-live, and we secured them several months ago to be prepared. We also have added three positions in the outpatient area to help support growing volume, as well as ICD-10 coding.”


The lesson learned so far is that a clinical practice’s ability to invest in ICD-10 preparation (e.g., training) correlates to its present-day confidence in ICD-10 compliance.

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Ensuring Quality Throughout the Evolution of Clinical Documentation

Ensuring Quality Throughout the Evolution of Clinical Documentation | EHR and Health IT Consulting | Scoop.it

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.


When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.


Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.


Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.


Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

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Four ICD-10 Myths from a Critical Doc

Four ICD-10 Myths from a Critical Doc | EHR and Health IT Consulting | Scoop.it

Have you ever stood near the tracks and listened to a train coming? When the train is far away all you can hear is the distant echo of the whistle. It’s easy to ignore.  As the train gets closer you hear the engine and see the smoke. As the train comes to the station it becomes a thundering, screeching, hissing mass of steel.

If you are close enough, it can even startle you.


With an Oct. 1 start date imminent, the ICD-10 train is getting awfully close. Anyone harboring hopes of Congress rescuing us at the last minute is kidding himself. If your practice is not prepared, there are plenty of health IT companies out there who will gladly take your money to rescue you safely away from the tracks.


The supporters of ICD-10 —bureaucrats, health IT vendors, and medical academicians —have been assuring us this is for our own good. The era of big data in healthcare is coming, so they say, and ICD-10 is the perfect vehicle for collecting the rich, detailed data that will bring the next big age of medicine. ICD-9 is decades old and needs to be replaced by a system which can accommodate the advances in diagnostic acumen of recent years. Privately, these groups ridicule our misgivings and assume that we’ll complain for a while and just get over it.


Last February, Congress held hearings on ICD-10. This was supposed to be the last decision-making step before committing to the program. In reality, it was a choreographed farce designed to suppress the concerns of real-world physicians. The witnesses included two health IT vendors, two lobbyist groups, one academic physician, and two private practice physicians. All but one of the witnesses, the late urologist and president of the Medical Association of the State of Alabama, Jeff Terry, supported ICD-10.  Most of the remaining witnesses either stood to benefit financially from ICD-10 or were insulated from its effects by the academic environment.


But there is more to ICD-10 than the propaganda peddled by supporters.  Let’s look at some of the myths about ICD-10:


1. ICD-9 is outdated and needs to be replaced.  The former is true.  The latter is not.  The structure of ICD-9 (five numeric placeholders) theoretically allows for 100,000 codes.  ICD-9 could have been easily expanded by adding one or two placeholders and allowing letters to be used. This would expand capacity to over two billion codes. It would have allowed horizontal expansion (i.e., the addition of Ebola infection to the appropriate category —a favorite example of ICD-10 supporters) as well as vertical expansion (the breakdown of otitis media into left vs. right).  This could have been done without rendering any ICD-9 codes obsolete. 


2. ICD-10 based big data will improve patient care.  ICD-10 supporters would have us believe that ICD-10 based data will lead to medical miracles falling from the sky.  These utopian fantasies fail to consider the implications of the scientific method.  Medical advancements come only from experiments based on hypotheses.  Hypotheses dictate experimental design, including the methods and structure of data collection.  Lacking any hypotheses, ICD-10 creates a one-size-fits-all data collection method for all fields of medicine.  This makes absolutely no sense.


3. ICD-10 will improve quality of data collection.  I almost believed this until I began to prepare my practice for ICD-10 months ago.  Instead of a rational expansion of diagnoses I found —for my specialty, at least —a haphazard, nonsensical collection of codes created seemingly at random.  I’m not talking about the “burned by water skis on fire” stuff we have all heard about.  I discovered that every code related to ear pathology is obsessively divided into left ear, right ear, or both.  Even “vertigo of central (nervous system) origin,” which by definition does not involve the ears, requires a choice of left or right ear!  But other diagnoses —facial paralysis, head and neck cancers, sinusitis, and others —have no ICD-10 division by side.  The diagnosis of vocal cord paralysis, in which the side of involvement has long been recognized to be clinically significant, is not separated by side.  In fact ICD-10 has fewer codes for vocal cord paralysis than does ICD-9.  Does this mean that ear disorders are more worthy of big data research than sinusitis, head and neck cancer and vocal cord paralysis?  Who decided that?  There is no way, for otolaryngology at least, that such a poorly designed coding system will yield any useful data.  Don’t hold your breath waiting for any big data medical miracles.


4. Third-party payers are ready.  Who are they kidding?  Didn’t CMS claim that healthcare.gov was ready two years ago?  How many test payments to providers were sent?  There is no way to adequately test a system this complex before it goes live. Remember that CMS and private insurers have no risk on the table.  If their systems “mysteriously” fail to pay claims, they benefit by keeping the cash they would otherwise have paid out.  On the other hand, physicians will be unable to pay rent and make payroll if payments on claims are interrupted more than a few days.


The only rationale that explains ICD-10 is the desire of its supporters for a top-down, big government, centrally controlled healthcare system that regards doctors and patients as nothing more than cogs in the machine.  The folks at the top fancy themselves worthy of conscripting the rest of us into becoming uncompensated data collectors.  Doctors know that quality of care starts from the bottom, not the top —with a doctor, a patient, an exam room, and a conversation.  At best, ICD-10 will be an expensive distraction that draws money and time away from patient care.  At worst, it will paralyze the health care system.

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CMS Confirms Readiness to Assist During ICD-10 Transition

CMS Confirms Readiness to Assist During ICD-10 Transition | EHR and Health IT Consulting | Scoop.it

The ICD-10 compliance deadline of October 1 is less than a week away, creating a frenzy of preparation amongst coders, billers, and providers. The Centers for Medicare & Medicaid Services (CMS) senior officials recently held a conference call to answer questions regarding implementation, and specifically addressed the issue of CMS as a resource come October 1.


The September 24 call included CMS Principal Deputy Administrator Patrick H. Conway, MD, MSc, and ICD-10’s recently appointed ombudsman William Rogers, MD.


The bulk of the call consisted of a question and answer session which generally revolved around the roll of CMS as a resource for clinician practices experiencing issues with transition. Specifically, many callers were concerned with the potential government shutdown that could occur on October 1 if Congress cannot reach an agreement on the federal budget.


“In the event of a shutdown, we will continue -- and I want to be clear on this -- to pay claims,” Conway said. “We will continue to implement the ICD transition.”


Rogers made it clear that the Medicare administrative contractors (MACs) would still be working in the event of a shutdown, so claims will be accepted and paid during that time.


Conway elaborated on that point during another question, stating that payment systems are an essential part of the Medicare program and would still function in the event of a shutdown.


“In terms of staffing, we do have the flexibility to ensure core operations are operational and in effect,” Conway stated. “And obviously, our payment systems are a core piece of the Medicare program that will continue to be fully operational.”


Conway also addressed the issue of claims processing timelines and how that will affect real-time assessments of the transition. Although it would be ideal for CMS to have a clear idea of the state of the transition as soon as it occurs, Conway explains that due to the typical billing timeline, it will in reality take about one billing cycle.


“The Medicaid claims can take up to 30 days to be submitted and processed,” he said. “This end can take approximately two weeks. The Medicaid claims can take up to 30 days to be submitted and processed. For this reason, we expect to have more detailed information after a full billing cycle is complete.”


The questions on the call revolved around the cost of ICD-10 implementation, especially considering systems upgrades. According to Conway, the cost greatly relied on the specific circumstance of the practice or facility. Rogers shed light on the costs for smaller practices.

“[M]ost smaller practices just use a super bill,” Rogers explained. “t requires a little bit of an expansion of the number of diagnoses on the superbill. But they can easily cross walk their ICD-9 based super bill to an ICD-10 super bill.”


Rogers also assured callers that CMS has ample resources to ensure a smooth transition, and that they themselves will be able to serve as a resource for clinician practices. He explained that he, along with all of CMS, can serve as a major resource for providers who have questions regarding the transition process, and encourages providers to contact the ombudsman email address when in need of assistance.

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July ICD-10 Testing Shows CMS Readiness for Implementation

July ICD-10 Testing Shows CMS Readiness for Implementation | EHR and Health IT Consulting | Scoop.it

In preparation for the October 1 ICD-10 implementation deadline, the Centers for Medicare & Medicaid Services (CMS) have completed their third Medicare fee-for-service end-to-end testing with great success, according to a recent CMS report. This is the third successful CMS ICD-10 testing to occur in 2015.

The testing week, which occurred between July 20 and 24, included healthcare providers, clearinghouses, and billing agencies. These entities utilized the help of Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) to file their claims. Participants from previous tests were invited to partake in the July tests, thus bringing a considerable amount of returners to this session.


The July test was a success, according to CMS, with an 87 percent acceptance rate of the 29,286 claims received. The rejection rate for ICD-10 errors was 1.8 percent, and the rejection rate for ICD-9 errors was 2.6 percent. However, majority of rejected claims were not ICD-10 related. Among others, these included invalid NPIs, claims outside of the covered date range, and invalid place of service. CMS confirms that many of these same errors occurred in previous test sessions.

Additionally, CMS states that many rejected claims may have been submitted with errors on purpose. This practice, referred to as “negative testing,” is intended to ensure that CMS’ rejection processes are functioning properly and will indeed reject a provider’s invalid claim.


CMS reports a larger cross-section of volunteers this test session, with about 1,200 organizations selected to participate in the test. There were 493 organizations returning for previous tests. Additionally, 1,400 National Provider Identifiers (NPIs) participated in the test, and approximately 12 percent of those were repeats from prior tests.


This test brought about similar results to previous tests performed in January and April. In January, CMS reported an 81 percent approval rating between January 26 and February 3. This test included 661 volunteers. Just like this most recent test, the January test boasts a high success rate, with a majority of rejected claims resulting from non-ICD-10 related errors.

Tests performed in April were likewise successful. With 875 participants, CMS reported an 88 percent acceptance rate, which is consistent with the July tests. The number of rejections due to ICD-10 and ICD-9 errors are also consistent with the July tests, with a majority of rejections being due to other provider-related issues.

As providers and payers alike continue to prepare for the impending October 1 ICD-10 deadline, these test results bring promise to CMS. Not only have CMS’ systems shown a proven capability for accuracy, but they have shown consistent accuracy, with only a seven percent difference between the best and worst test performances. Provided these positive results, CMS has shown that it is ready for this new coding system.

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NYC Hospitals Face Massive Problems With Epic Install

NYC Hospitals Face Massive Problems With Epic Install | EHR and Health IT Consulting | Scoop.it

A municipal hospital system’s Epic EMR install has gone dramatically south over the past two years, with four top officials being forced out and a budget which has more than doubled.


In early 2013, New York City-based Health and Hospitals Corp. announced that it had signed a $302 million EMR contract with Epic. The system said that it planned to implement the Epic EMR at 11 HHC hospitals, four long term care facilities, six diagnostic treatment centers and more than 70 community-based clinics.


The 15-year contract, which was set to be covered by federal funding, was supposed to cover everything from soup to nuts, including software and database licenses, professional services, testing and technical training, software maintenance, and database support and upgrades.


Fast forward to the present, and the project has plunged into crisis. The budget has expanded to $764 million, and HHC’s CTO, CIO, the CIO’s interim deputy and the project’s head of training have been given the axe amidst charges of improper billing. Seven consultants — earning between $150 and $185 an hour — have also been kicked off of the payroll.


With HHC missing so many top leaders, the system has brought in a consulting firm to stabilize the Epic effort. Washington, DC-based Clinovations, which brought in an interim CMIO, CIO and other top managers to HHC, now has a $4 million, 15-month contract to provide project management.


The Epic launch date for the first two hospitals in the network was originally set for November 2014 but has been moved up to April 2016, according to the New York PostHHC leaders say that the full Epic launch should take place in 2018 if all now goes as planned. The final price tag for the system could end up being as high as $1.4 billion, the newspaper reports.


So how did the massive Epic install effort go astray? According to an audit by the city’s Technology Development Corp., the project has been horribly mismanaged. “At one point, there were 14 project managers — but there was no leadership,” the audit report said.


The HHC consultants didn’t help much either, according to an employee who spoke to the Post. The employee said that the consultants racked up travel, hotels and other expenses to train their own employees before they began training HHC staff.


HHC is now telling the public that things will be much better going forward. Spokeswoman Ana Marengo said that the chain has adopted a new oversight and governance structure that will prevent the implementation from falling apart again.”We terminated consultants, appointed new leadership, and adopted new timekeeping tools that will help strengthen the management of this project,” Marengo told the newspaper.


What I’d like to know is just what items in the budget expanded so much that a $300-odd million all-in contract turned into a $1B+ debacle. While nobody in the Post articles has suggested that Epic is at fault in any of this, it seems to me that it’s worth investigating whether the vendor managed to jack up its fees beyond the scope of the initial agreement. For example, if HHC was forced to pay for more Epic support than it had originally expected it wouldn’t come cheap. Then again, maybe the extra costs mostly come from paying for people with Epic experience. Epic has driven up the price of these people by not opening up the Epic certification opportunities.


On the surface, though, this appears to be a high-profile example of a very challenging IT project that went bad in a hurry. And the fact that city politics are part of the mix can’t have been helpful. What happened to HHC could conceivably happen to private health systems, but the massive budget overrun and billing questions have government stamped all over them. Regardless, for New York City patients’ sake I hope HHC gets the implementation right from here on in.

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Burke Autrey's curator insight, September 21, 2016 3:56 PM
Tracking companies who bring in Interim executive talent when it counts... Congratulations to Clinovations and HHC who clearly see the value of tapping into interim executives.
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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 | Scoop.it

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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Nine Types of Usability Problems with Electronic Health Systems

Nine Types of Usability Problems with Electronic Health Systems | EHR and Health IT Consulting | Scoop.it

There is no shortage of complaints about the usability of Electronic Health Record systems (EHRs). More and more evidence is emerging regarding the lack of EHR usability. Speaking at the 2013 Healthcare Information and Management Systems Society (HIMSS) Conference & Exhibition, Michael S. Barr, MD, MBA, FACP, of the National Committee for Quality Assurance (NCQA) warned that:


“Satisfaction and usability ratings for certified electronic health records (EHRs) have decreased since 2010 among clinicians across a range of indicators.”


Barr’s presentation at HIMSS focused on “ the need for the Meaningful Use program and EHR manufacturers to focus on improving EHR features and usability.”


The healthcare industry in the United States is facing a crisis as medical facilities have spent hundreds of billions of dollars implementing electronic health record (EHR) systems, yet many patients and the physicians and nurses that care for them are seeing few benefits.


In a recent article published in the The Journal of the Human Factors and Ergonomics Society examined 50 studies with the keywords: electronic medical records and electronic health records combined with interface design, usability, safety, and errors published after 2000. Their review of EMR and EHR usability studies revealed nine major types of problems:


  1. Naturalness
    All information in the display should appear in a natural order. Naturalness also refers to how familiar and easy an application is to use and to what extent it follows the “natural” workflow of the system.
  2. Consistency
    This principal basically means that knowing one part of an interface should be relevant for use of other parts. A particular system action should always be achievable by one particular user action.
  3. Preventing Errors
    Interactive system interfaces should be designed in a way that prevents errors from happening in the first place.
  4. Minimizing Cognitive Load
    Human short-term memory is limited in capacity (Miller, 1956). Interfaces should be designed in a way to reduce mental workload for users. Users should not have to memorize system information or database content (Molich & Neilsen, 1990).
  5. Efficient Interaction
    Human–computer interaction should be designed for efficiency by minimizing the number of steps to complete a task or providing shortcuts for users (Belden et al., 2009).
  6. Forgiveness and Feedback
    Molich and Nielson (1990) wrote that interactive systems should provide feedback in real time in order to keep the user informed about what is currently going on. Appropriate feedback should also inform users about the consequence of actions they are going to make (Belden et al., 2009).
  7. Effective Use of Language
    Molich and Nielson (1990) wrote that all dialogs should be presented with clear words and phrases that are familiar to users. In the health care domain, there are many terms and abbreviations that may be familiar to specific users but may be meaningless to others.
  8. Effective Information Presentation
    The design of EMR interfaces, in terms of the amount, type, and organization of information, influences complexity and usability from a user perspective.
  9. Customizability/Flexibility
    Customization is the capability of an EMR interface to be modified based on the needs of each health care provider. Flexibility, or the capacity of an interactive system to be customized, is one of the 14 usability principles identified by Zhang and Walji (2011) in their research toward developing a unified framework of EMR usability.


Given that these nine types of usability issues persist across many Electronic Health Systems, it is the responsibility of all EHR vendors to reach out to specialists in Healthcare Usability, and solve them. Usability in healthcare is unique in that the creation of more usable systems not only can save these companies money—with reduced development, training, support, and documentation costs—it can save lives!

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NIH Clinics Receive Stage 7 HIMSS Award for EHR Adoption

NIH Clinics Receive Stage 7 HIMSS Award for EHR Adoption | EHR and Health IT Consulting | Scoop.it

The National Institutes of Health (NIH) Clinical Centers has become the first federal healthcare clinic to receive a HIMSS Stage 7 Award, according to a public announcement Friday. The NIH clinics join a select group of healthcare facilities who have received this award for excellence in EHR adoption. Healthcare facilities qualify as HIMSS Stage 7 by transitioning completely from paper health records to EHRs.


The HIMSS Stage 7 Award signifies that the NIH clinics have reached the highest level of the Electronic Medical Record Adoption Model (EMRAM), a decade-old system for monitoring the effectiveness of EHRs for all HIMSS hospitals. The EMRAM operates on a scale of 0-7, 7 being the highest level. This year, only 3.7 percent of hospitals attained this ranking, proving just how prestigious this award is for NIH.


In order to receive this award, NIH had to go through rigorous examination. “The validation process to confirm a hospital has reached Stage 7 includes a site visit by an executive from HIMSS Analytics and former or current chief information officers to ensure an unbiased evaluation of the State 7 environments,” the organization stated.


According to an NIH press release, the clinic has been using electronic health records since the 1970s, but are being awarded for their most recent accomplishments in electronic health record use. These accomplishments include eradicating the use of all paper healthcare records, using electronic records for research to improve quality of care, and improving interoperability amongst their electronic medical record systems and those at other authorized healthcare centers.

HIMSS evaluated the NIH’s Clinical Research Information System (CRIS), the clinic’s fundamental software used for electronic medical records. Used by over 2,750 clinic staff members, CRIS is used in a variety of settings.


“NIH experts rely on CRIS to manage patient protocol information, write medical orders, retrieve laboratory results, documents progress notes and other aspects of medical care,” NIH says.

HIMSS says it was a clear choice awarding NIH with Stage 7.


“The NIH Clinical Center is a remarkable place doing remarkable things with its EHR for the patients they serve,” said John H. Daniels, CNM, FACHE, FHIMSS, CPHIMS, Global Vice President, Healthcare Advisory Services Group, HIMSS Analytics. “From automatically capturing discrete data on anomalies found in digital imaging to providing pharmacogenomics clinical decisions support to physicians, they are clearly a Stage 7 organization.”


The NIH Clinical Center is the research hospital for the National Institutes for Health. Using clinical research, the NIH clinics aim to improve treatments, which in turn should improve the national health. A branch of the Department of Health & Human Services (HHS), NIH is the nation’s primary source for clinical research.

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Challenges of EHR Cloud-Based Solutions for Rural Providers

Challenges of EHR Cloud-Based Solutions for Rural Providers | EHR and Health IT Consulting | Scoop.it

Urgent care provider ClearChoiceMD (CCMD) spans northern New England, operating clinics in rural areas whose EHR technology and other systems rely on multiple forms of connectivity to access clinical data centrally housed in New Hampshire.


By leveraging an array of connectivity options, CCMD has begun aggressively expanding its operations throughout Vermont, New Hampshire, and Maine and along the way come face to face with the challenge of keeping vital health information accessible and available at the point of care for its urgent care providers.


Using an EHR cloud-based technology and a mixture of connection options, the growing healthcare organization is able to provide care in hard-to-reach areas outside larger cities in Northern New England. As CCMD IT Director Alex Fuchs reveals in an one-on-one interview withEHRIntelligence.com, keeping EHR cloud-based solutions operational in a rural environment with limited connectivity requires maintaining multiple arrangements with internet service providers, both grounded and over-the-air, and exploring new opportunities for connectivity.


EHRIntelligence.com: What makes CCMD unique and what are its top challenges in terms of health IT?


Alex Fuchs: We're a relatively small organization compared to some of the large hospital groups that are out there. We have some pretty aggressive growth targeted. We tend to predominantly open in areas that are very rural, underserved communities outside of major cities that don't have easy access to healthcare. Those are our target markets for the most part. In opening in locations like that, it tends to present challenges at least on the IT end of things because we do have a centralized infrastructure but everything is so distributed and being so rural things like bandwidth and connectivity are hand to come by.


EHRI.com: What kinds of connectivity does the organization employ?

AF: Being so distributed, we don't have a ton of options and the options we do have are generally pretty limited. As an example, we have a location up in Scarborough, ME, and the extent of connectivity there were bonded T1s, bonded DSL lines, and business cable lines. We hedge our bets and for every facility that we open, we make sure we run at least three different ISPs with three different paths. The third ISP is always an over-the-air 4G backup in case someone takes out a pole or kind of infrastructure. We’re trying to be as redundant as possible because our EHR or billing system is cloud-based or based out of our centralized infrastructure here at the corporate office in New London, New Hampshire, where all of infrastructure is located. We have a data center consisting of multiple virtual server hosts, a couple of SANs and NASs that we use for data backup. Everything is out of that corporate office. From there all the other sites either use an MPLS or site-to-site VPN link to phone home. Loss of connectivity is pretty devastating to business.


EHRI.com: You recently contracted with Evolve IP, but how have you managed EHR downtime and disruptions to other systems beforehand?


AF: As a new company, we didn't have established policies and procedures to deal with something like that. It was very much a situation of making it up as we went along. We have since developed very comprehensive outage procedures. We train on them every so often, so the staff is well aware of what to do when there is an outage. I guess you could say luckily we got to practice not that long ago when we experienced a power outage at one of our busier locations. We now have a mechanism to go to paper if need be, but we really haven't had to do that very much because we have a number of tablets in the environment and can actually run right off those battery-powered tablets to continue operations for about two and a half hours. It's only if it carries on longer than that that we need to make a change.

 

Before we made this partnership with Evolve IP, one of our biggest issues was that we were consolidating bandwidth using our SonicWALL appliances that we have deployed at all of our individual clinical locations, and that wasn't a very smooth way to consolidate the different ISPs that we had to those locations. We had issues with the fail-over process when an ISP did experience an outage. Those types of lines are not nearly 100 percent. Unfortunately, in many locations we find ourselves relying on that as a form of connectivity. The 10 to 15 millisecond interruptions that we had in service that caused that fail-over process to take place were actually causing a larger disruption to the business than if we had just waited out the interruptions.

EHRI.com: How does the organization go about exploring new connectivity options?


AF: That is definitely something we're looking at at some of our more rural locations. The problem is New England in general doesn't have a great fiber network unless you're in a major metropolitan area like Boston. We starting to see companies like Comcast, Sovernet Communications, and FastRoads building out their fiber networks and reaching more and more of our locations. And as they have done those build-outs, we started installing dedicated fiber circuits — at least 30 Mbps to 40 Mbps fiber circuits at all of our locations — where that is available. Thus far, we're up to five out of ten that are serviceable by fiber. We're hoping that continues to increase. We have another pending installation in another location that will make us six out of ten. It is something we continue to keep an eye on.


EHRI.com: Would this kind of business model be possible without today's connectivity options?


AF: I don't really think it would. Part of our efficiency, and part of our ability to compete with some of the larger hospital groups, is the fact that we use an EHR vendor that is specifically geared at the urgent card setting. That is a cloud-hosted system. We don't host that on premise. It is delivered via a Citrix app. That is one of our magic bullets, as it were, of our formula and business strategy that allows us to compete because it does cut down significantly on the amount of time it takes us to see patients.


Last time I visited the emergency room, I sat in the waiting room about three hours and the whole process maybe was six to ten hours overall. Our target and we meet it about 95 percent of the time is from the time a patient walks in our front door to the time he leaves should be an hour or less across the board. That is the game changer for us. We wouldn't be able to do that without the various technologies we employ.

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A Billion Here..And the New DOD EHR Contract

A Billion Here..And the New DOD EHR Contract | EHR and Health IT Consulting | Scoop.it

Everett Dirkson, the Illinois Senator, did not actually say “A billion here, a billion there, pretty soon, you’re talking real money”, although he did say he wished he had. The billions, or $4.3 billion to be exact, that I have been thinking about is the Department of Defense two year contract with Cerner, Accenture Federal and Leidos to provide an EHR to 8 hospitals in the first year and eventually 55 hospitals and 600 clinics. This is the first phase of a $9 billion 10 year deal. I was comforted to learn that this is a 20% savings compared to the previously estimated $11 billion. The also-rans for this award were Epic and Allscripts, and their respective partners.


The $9 billion for seems to me to be a good deal of money. That’s $13.7 million per unit including the hospitals and clinics for the same EHR system for the same customer, but it does include training. This is seemingly not a high number for a hospital EHR, but it probably is for clinics although real costs are elusive. Beyond the cost there are two other aspects of the deal that caught my attention.


One was the announcement that this was going to be off-the-shelf version of Cerner’s existing product. A good quote relative to this from Undersecretary of Defense for Acquisition, Technology and Logistics Frank Kendall is “The trick … in getting a business system fielded isn’t about the product you’re buying, it’s about the training, the preparation of your people, it’s about minimizing the changes to the software that you’re buying” In other words, forget about usability and other issues with the software and instead try to force the users into compliance with the needs of the product. Maybe the high cost per unit takes into account the amount of training that is going to be needed to help people overcome their dislike for the system.


This take-the-software-as-is approach might be viewed in the context of recent news that 20% of community hospitals want to change their EHR vendor. This report also included that 54 percent of respondents were unhappy with the usability of their system and 53 percent said their system lacked functionality. One wonders if these hospitals will shop any more carefully when they seek to change vendors, and if they will like the new product any better than the old. The DOD approach also is in sharp contrast with recommendations from a recent AHRQ webinar on “Using Health IT to Support Improvements in Clinical Workflow”. Note that the title was not “Changing Clinical Workflow to Accommodate Health IT”. One such recommendation was to actually understand clinical workflow before you try to improve it and to use this understanding to design the IT component. This seemingly obvious recommendation is unfortunately an intellectual breakthrough.


Another interesting thing about the Cerner award is that Cerner was included in assertions that the major EHR vendors have not only failed to enable interoperability but have worked against it in support of their proprietary interests. National Coordinator for Health IT Karen DeSalvo was asked about this during a May Senate hearing. Her answers were basically that it was a solvable problem, which of course is different from a problem that will be solved.


It will take a few years until we find out of the $4.3 billion, or the $9 billion has been well spent, and if the DOD’s EHR will be able to talk to either the VA’s system or the private sector.

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