EHR and Health IT Consulting
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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Clinical Documentation Improvement Vital for Patient Care

Clinical Documentation Improvement Vital for Patient Care | EHR and Health IT Consulting |

Clinical documentation improvement programs lie at the heart of quality patient care and should accurately show a patient’s clinical status as well as inform which services were provided. According to the American Health Information Management Association (AHIMA), clinical documentation improvement programs transfer patient’s medical information into coded data, which is then part ofquality reporting, claims reimbursement, public health information, and disease tracking.

Health information management (HIM) professionals work as both coding experts as well as clinical documentation improvement strategists within their organizations to ensure meaningful information is captured.

In particular, clinical documentation improvement experts remain dedicated to ICD-10 implementation and the adoption of strong EHR systems across the healthcare continuum. HIM professionals work to assist physicians in remaining compliant with all patient documentation requirements.

Some policies that need to be followed when implementing clinical documentation improvement programs are hiring staff with the right education, experience, and credentials as well as ensuring ongoing education and training for such staff, according to AHIMA. The major roles that healthcare providers have in ensuring their clinical documentation is solid are reporting medical decision making, diagnostics, treatment plan, and outcomes of tests, treatments, and other procedures.

One partnership that is targeting clinical documentation improvement is Nuance Communications, Inc. and medical care predictive analytics company Jvion, according to a joint press release. The two companies are looking to better assist healthcare providers in meeting the requirements of a value-based reimbursement model.

Many medical facilities will likely experience various challenges when transitioning from a fee-for-service payment model to value-based care. Advanced Practice CDI from Nuance Communications should assist providers in this transition.

“We want to get paid for the quality of care and services we provide,” says Joann Hatton, director of Utilization Management and Clinical Documentation Management at Heritage Valley Health System, in western Pennsylvania. “It’s not about the money, it’s about improving patient care, but the positive financial impact of Nuance’s CDI program was clearly evident.”

When it comes to implementing clinical documentation improvement strategies and clinical quality metrics, Heritage Valley Health System saw a significant drop in their predicted mortality rate. This particular rate decreased by 27 percent after integrating clinical documentation improvement programs.

“Data drives our practice,” explains Jennifer Woodworth, director of Clinical Documentation Integrity Program at Swedish Health Services. “Physician and hospital compensation is tied to quality metrics, which means to prove that you are providing high quality care you need data. This real-time reporting allows us to drill down to ICD-9 and ICD-10 codes, complications and other specialized details to see how we are doing with the accuracy of physician documentation, and this enables us to create proactive initiatives that maximize our current resources.”

As more health IT tools are developed to assist providers with clinical documentation improvement programs, the healthcare industry will be ready to effectively transition to a value-based care payment model.

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ICD-10 Prep for Small Practices: 5 Ways to Get on Track

ICD-10 Prep for Small Practices: 5 Ways to Get on Track | EHR and Health IT Consulting |

Small medical practices have felt the ripple effect of the ICD-10 delay  in different ways, depending on how close to readiness they were at the time the new date was announced.

Recently, the Workgroup for Electronic Data Interchange released findings from an ICD-10 readiness survey that demonstrated a high degree of procrastination in how actively health organizations were working toward compliance with ICD-10.

If your practice is among those only partially ready or just in the initial stages of a transition plan, here are five key tips to keep moving forward toward compliance:

1. Make sure trading partners are on track. The most important step to a smooth ICD-10 transition is to look closely at trading partners. It’s important to focus first on your biggest payers. Will they be able to support your practice after the conversion deadline? Do they have a clear transition plan with milestones that are already being met? If not, your practice needs to understand why. Achieving compliance requires a cooperative effort among entities, and any trading partner showing signs it may not meet the deadline may require your practice to seek alternative partners. What would it take (in time and money) to transition to working with these new partners should the need arise?

2. Test systems for process flow. Start testing your practice’s internal systems, such as its information management, billing, and scheduling systems. Simulate a typical patient visit to the office and send data from each step to test the viability of work flows and flush out where bottlenecks occur. Remember that with each identified disruption, there is likely a correlated negative impact on revenue that should be calculated and rolled back into the plan (see Step #5: Revisiting the plan).

3. Test with trading partners. Once your practice’s internal systems pass your tests with flying colors, conduct end-to-end testing in cooperation with your external partners. An AHIMA/eHealth Initiative survey reveals that 65 percent of organizations will be able to begin testing before the 2015 deadline; 63 percent will begin those tests this year. That’s good news for some of the industry, but your practice’s entire ecosystem will succeed or fail based on how well the collective functions together. Start by sending the most common types of test claims using ICD-10 codes. You may need to shift timelines to include the use of testing environments and the additional time that may be required to adjust to processing the test claims. If your practice has a large number of trading partners, test with the biggest ones first.

4. Survey your practice management vendor. Your practice management vendor is one of the most important pieces of the process. Review the CMS checklist of questions and the recently released list of 15 ICD-10 readiness questions. Will your PM vendor’s software require any hardware upgrades? Can its solution handle both ICD-9 and ICD-10 codes? Dual coding is important to mitigate the risks of being totally down should something go deeply wrong with using ICD-10 coding. What resources are available to help with test transactions? Review the vendor contract and examine the cost/benefit of any changes that will cost time or money.

5. Revisit the budget and implementation plan. After you take the above steps, revisit the budget and re-assess existing implementation plans. The e-Health/AHIMA survey reveals 35 percent of practices believe their revenue will go down after October 2015. Expected areas of difficulty include coding, documentation, and reimbursement.

While getting ready for ICD-10 is a massive process for a practice, the challenges are not insurmountable. Sharing and collaboration of best practices among organizations is a wise use of effort, and trading partners may already have dedicated resources to test the claims process with a variety of partners simultaneously.

Most importantly, don’t lose sight of the fact that beyond compliance, there is an industry upside to using ICD-10. The new codes are superior and in the end, it’s all about increasing the quality of care.

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Reigniting ICD-10 Momentum in Your Organization

Reigniting ICD-10 Momentum in Your Organization | EHR and Health IT Consulting |

Now that Congress has rejected requests to delay ICD-10, it’s time to get on the bandwagon or risk significant financial implications. ICD-10 touches virtually every aspect of your organization’s processes and systems, and failure to prepare and comply with the mandate will have a significant impact on your reimbursements.

If your organization has lost momentum or has not started the ICD-10 journey, hiring internal resources or working with external experts will be necessary to meet the deadline. Below is a cheat sheet – based on best practices and industry guidelines – of essential questions to ask leadership and next steps:

  • Is ICD-10 a priority for your leadership team?
    Evaluate organizational awareness of ICD-10 and confirm leadership is in place to drive the transition. Successful ICD-10 planning involves defining project leadership, executive sponsorship, and reporting structures. Given the far-reaching organizational impacts of ICD-10, without defined roles and responsibilities, a critical remediation area may be missed. Identify stakeholder accountability for ICD-10 compliance and designate project managers to lead revenue cycle, coding and clinical documentation improvement (CDI), and IT system initiatives. Develop a project communication plan that sets expectations about what should be communicated to whom, the reason for the communication, frequency, and method.
  • Are your systems ready and have you evaluated the impact of ICD-10 to all system workflows?
    Assess operational readiness by taking an enterprise-wide systems and process inventory to identify where codes are used. Utilize assigned project managers to uncover all systems and processes where ICD-9 codes are sent, received, or stored. Conduct workflow analyses to ensure understanding of how systems and processes are impacted. This exercise can provide immediate benefit to an organization as workflows operating inefficiently are identified. Develop a prioritized project plan and remediation timeline for each impacted area. For example, technology and workflows need to be optimized within patient access to assure compliant orders for dates of service on or after October 1, 2015. Conduct regular reporting on initiatives and ensure stakeholders are being held accountable for designated tasks.
  • Does your staff have appropriate organizational awareness and knowledge of ICD-10?
    Understand what roles individuals play within your organization with respect to ICD-9 code usage, and employ a role-based training initiative. While coders, CDI specialists, and providers will need the majority of training, areas, such as patient access, ancillary departments, business offices, and IT should not be overlooked. Also, keep in mind the impact on your quality team. Patient populations monitored by core measures, as well as other quality metrics are determined by ICD-9 codes. When selecting a training vendor, confirm the vendor offers courses tailored by job function and provides the necessary courses for coders and specialty-specific training for providers. Track and communicate training progress and ensure training compliance is an organizational priority. As part of your strategy, attempt to incorporate training with other planned education to reduce workflow disruption.
  • Are you establishing ongoing experience with the new code set?
    Act fast to incorporate dual coding initiatives. Based on experiences with ICD-10 in other countries, research suggests that allowing coders to simultaneously code in ICD-9 and ICD-10 allows them to achieve proficiency and decrease productivity loss. Dual coding has been shown to significantly reduce the anticipated 40 to 60 percent inpatient and estimated 20 percent outpatient productivity loss. The first step is to create a project plan that identifies coders, checks systems, and determines expected coding system upgrades. Next, create a strategy for managing dual coded data to be analyzed. A coding roundtable of key stakeholders from an organization’s coding team should be developed to create accountability and drive documentation improvements during the dual coding process. As part of the learning process, coder education should initially emphasize documentation requirements for coding the most common conditions within the organization and those with the highest allowed amounts. A minimum of six months of practice is recommended.
  • Are you conducting internal and external testing of systems for ICD-10 compliance?
    Define testing goals and document a plan to test each impacted system internally and conduct external testing to the greatest extent possible. Appropriately testing impacted applications is a complex and time-consuming process and should not be seen as a last step. Many variables — including competing organizational priorities and resource availability — as well as clearinghouse, payer, and third-party tester schedules, can influence the testing timeline. Designate a well-defined team to undertake, define, and monitor the testing readiness plan for your impacted systems and software. Each impacted system should be reviewed for the type of testing that is needed. Billing systems are the most complex and must be ready to send ICD-10 coded bills to payers or payment will be denied. Testing of billing systems should include all of the workflows where codes live, (e.g., claim edits that currently contain ICD-9 codes). Use your high volume and high value codes for testing, and determine the ICD-10 workflow for each impacted application. Then, complete individual testing of applications by running the applications through the identified workflows. Once that process is complete, begin integrated testing through following the process for codes to flow to downstream applications and out to the payer. If you haven’t been selected for payer testing, then work with your clearinghouse to test claims externally through them.
  • Is your CDI program optimized and ready for ICD-10?
    Emphasize clinical documentation process improvements to realize bottom-line gains now while preparing for ICD-10. While most healthcare systems have a CDI program, many are not achieving the desired results in appropriately coding conditions to the highest level of specificity. For example, if the organization is not able to code the specific type of congestive heart failure in ICD-9, the problem will only worsen in ICD-10 with requirements for greater specificity to attain complications and co-morbidities (CCs) and major complications and co-morbidities (MCCs) for many DRGs. While revamping a CDI program is a separate goal, perfecting ICD-9 queries and introducing ICD-10 queries early will help prepare an organization for ensuring compliance with the increased specificity ICD-10 demands.
  • Have you planned for predicted delays in cash flow?
    Create a contingency plan to mitigate potential productivity and revenue losses. Hope for the best, but prepare for the worst. Based on Canada’s ICD-10 experience, coding productivity may drop by 50 percent immediately following implementation. Performance improvements may take at least 90 days to be realized. If claims are suspended, rejected, or delayed following ICD-10 implementation, have a plan available in advance to quickly respond to different scenarios. Alternatively, some providers and payers have drafted stopgap provisions in their contracts to maintain a consistent cash flow and “true up” every three months.

While changing processes, systems, technologies, and staff resources to accommodate the shift from ICD-9’s 17,000 to ICD-10’s 140,000 codes may seem overwhelming, there is still time to meet the requirements by taking a prioritized and focused approach.  Having the right mix of expertise and staffing is necessary to meet the upcoming deadline.  Contingency plans will also help mitigate losses following ICD-10 implementation. Beyond getting paid, ICD-10 also promises to improve clinical outcomes by increasing the specificity and accuracy of clinical documentation to guide patient care decision-making. It’s an investment that is worth the effort.

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Congress Strongly Leaning towards 2015 ICD-10 Implementation

Congress Strongly Leaning towards 2015 ICD-10 Implementation | EHR and Health IT Consulting |

October 1, 2015 looks like it may be the final ICD-10 implementation date after members of Congress and representatives from the healthcare industry voiced their support for the new code set during a hearing of the House of Representatives’ Energy and Commerce Committee’s Subcommittee on Health.  Despite lingering opposition from some stakeholders worried that small practices will fold under the financial burden of adopting the new codes, the majority opinion has turned in favor of refusing any more delays.

“The last minute delays do nothing to relieve the pressure for the small practice that struggles under this administrative burden,” said Dr. Michael C. Burgess (R-TX), an obstetrician and gynecologist. “It does put the health systems and insurers in a difficult position as well.  In fact, it punishes those who have done exactly what Congress has requested.”

“Each delay has been costly to the healthcare system,” added Rep. Gene Green (D-TX).  “The ICD-10 transition is an important part of bringing our healthcare system into the 21st century.”

The panelists testifying during the hearing included representatives from medical groups, vendors, payers, and AHIMA, the majority of whom also expressed enthusiasm for keeping the ICD-10 implementation date as it is.

“It is critically important for the health care system to move forward with this new system under the current timetable,” said Carmella Bocchino, Executive Vice President at America’s Health Insurance Plans (AHIP) during her testimony. “Doing so will establish a strong foundation for allowing health plans and health care providers to identify and report conditions and medical treatments in more specific ways, ultimately leading to more effective measurements of quality and health outcomes.”

Bocchino noted that the nation’s major private payers have poured significant time and resources into preparing themselves and the industry for the switch.  Aetna, Cigna, and Humana have conducted extensive ICD-10 testing over the past two years, she said, while many of the Blue Cross Blue Shield organizations have provided educational resources and readiness checks for providers throughout the preparation period.

“We need it.  We’re ready,” stated Richard F. Averill, MS, Director of Public Policy for 3M Health Information Systems.  “Congress rightly wants to move the health care system to focus more on value over volume. I’m here to tell you – you can’t do it with ICD-9. You need ICD-10. It is simply time to have our diagnosis and procedure coding systems reflect modern medicine. ICD-10 is a long overdue replacement for the outdated ICD-9-CM system for reporting diagnosis and procedure information. If we are to rate hospitals and physicians based on their outcomes, we need ICD-10. If we are to better assess what procedures, technologies, or approaches best aid improving patient care, we need ICD-10.”

The hearing comes on the heels of a Government Accountability Office report affirming that CMS has properly prepared its Medicaid systems to handle ICD-10 claims.  However, significant skepticism remains about the ability of CMS to handle such a massive undertaking in light of its history with major IT projects.

“All roads eventually lead to CMS,” said Dr. Burgess.  “And if you will pardon me, that does appear to be a weak link in the chain.  From to the Sunshine Act reporting website…when CMS flips the switch, something breaks.  Any time they flip a switch that involves the processing of data, their systems fail.”

“So it begs the question: is flipping a switch on October 1 the right move?” Burgess asked.  “And if it is, what is the contingency plan for any problems that may develop?  Today I am anxious to discuss not just the implementation plan, but I’d also like to talk about the contingencies if everything doesn’t go exactly as planned.”

Contingency planning has largely been left up to individual providers, which are encouraged to take steps such as keeping cash on hand to mitigate the impact of delayed or denied claims.  CMS itself has said little on the matter, and is currently focused on conducting end-to-end testing with a select group of sample providers throughout the spring.  Recent research has suggested that the financial impact for healthcare organizations may be less than predicted, allowing some breathing room for revenue cycles after go-live.

Overall, the hearing acknowledged that ICD-10 is a necessity for the healthcare industry as it transitions to value-based care and team-based population health management, both of which rely heavily on the improved specificity and more granular data of ICD-10.

“It’s been on the agenda for a long time,” said Rep. Chris Collins (R-NY).  “This isn’t something that should be new to anyone.  I certainly have a lot of physician friends and I understand there is a cost to implementing anything new.  I’m also a data guy, and I know that with data, while it may not be a positive for that patient today, at some point in time being able to deep dive into data is important.  Especially with healthcare costs going up in this country as they are, someone will be able to use that data.  I would see data collection as a very major part of why we’re doing this.”

Barring the appearance of another behind-the-scenes shocker like the surprise delay in 2014, it appears that ICD-10 implementation is building enough momentum to barrel through continued objections from the American Medical Association and other groups that remain worried about the costs and impacts of the codes.  If the October 1, 2015 deadline sticks this time, providers that may have been banking on an additional extension will need to squeeze a number of preparation activities into a quickly shrinking window of just under eight months.

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Hoping for ICD-11 is “Waiting for Godot,” ICD-10 Coalition Says

Hoping for ICD-11 is “Waiting for Godot,” ICD-10 Coalition Says | EHR and Health IT Consulting |

Clinging on to the current outdated ICD-9 code system until ICD-11 is ready for use at some unspecified point in the future is akin to the endless idle loitering of Vladimir and Estragon in Samuel Beckett’s classic play Waiting for Godot, says the Coalition for ICD-10 in a new opinion piece.  After waiting more than twenty years for the implementation of ICD-10, the healthcare industry simply cannot afford another two or three decades for the newest code set to be finalized and ready for use.

“Based on the World Health Organization’s (WHO) current timeline, ICD-11 is expected to be finalized and released in 2017,” the commentary explains. “For the US, however, that date is the beginning, not the end.  As with every WHO version of the ICD codes, ICD-11 would need to be adapted to meet the detailed payment policy, quality assessment and other regulatory requirements of US stakeholders.”  The country could be waiting until 2041 for the entire pre-implementation process to be completed, the Coalition adds.

Meanwhile, the healthcare industry will be forced to continue to use a significantly outdated code set that cannot account for many emerging health threats or new advances in technologies, diagnoses, and procedures.  That’s just fine with representatives from the American Medical Association (AMA), whose House of Delegates voted to reject an internal report noting that implementing the changes inherent in ICD-10 would provide an important foundation for the eventual adoption of ICD-11.  The report concluded that skipping ICD-10 all together was “not recommended” as a viable course of action, yet the AMA continues its resistance to the ICD-10 codes – and the Coalition continues to fight back against their reticence.

“The US simply cannot wait decades to replace ICD-9, a code set that was developed nearly 40 years ago,” the Coalition states. “US healthcare data is deteriorating while at the same time demand is increasing for high-quality data to support healthcare initiatives such as the Meaningful Use EHR Incentive Program, value-based purchasing, and other initiatives aimed at improving quality and patient safety and decreasing costs.”

The AMA argues that the expense of ICD-10 implementation is overwhelming for smaller physicians struggling keep their doors open, pinning the costs at anywhere from $50,000 to $225,000 for a small provider.  Despite contradictions from AHIMA, the cost of the switch has been a major selling point for opponents.

However, after two one-year delays, the tide seems to be turning in support of ICD-10.  Not only is the Coalition growing, but Congress has stepped in to enforce the idea of a 2015 due date.  Will the wait for Godot be over in October?  The Coalition would certainly like to see an end to the “unending barrage of excuses” and continual delays.

“Waiting for ICD-11 is simply not a viable option,” the blog post concludes. “The absurdity of the endless waiting in Waiting for Godot culminates in frustration: “Let us not waste our time in idle discourse! Let us do something, while we have the chance!” Yes, the wait needs to be over. It’s time to stop wasting time. It’s time to get ICD-10 implemented.”

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Is Physician Fear of ICD-10 Turning Them Off Preparation? |

Is Physician Fear of ICD-10 Turning Them Off Preparation? | | EHR and Health IT Consulting |

There are a lot of reasons for healthcare professionals to dislike the notion of ICD-10.  More mandates, more money, more work, and more complications that do nothing but take highly-trained physicians away from the business of patient care have been repeatedly cited as reasons why the industry should just forget the new code set all together.  But new research from AHIMA shows that frustration, empty pockets, and exhaustion may not be the only things slowing down the ICD-10 adoption process.  Many physicians in a series of focus groups expressed straight-up fear about how the new codes will impact their practices – and even more worryingly, expected their EHR vendors and billing services to do most of the heavy lifting as October 1, 2015 draws near.

“ICD-10 is scary for most people,” one physician admitted during one of the interview sessions.  The large-scale changes required to bring clinical documentation up to the appropriate level of detail and specificity are of great concern to many physicians, not only due to necessary changes in their workflow, but also because of the uncertain impact on their reimbursement.

Physicians may be jittery about the unknowns of the future, but they aren’t necessarily being proactive about addressing them.  Blaming a lack of simple educational tools, comprehensive resources, and specialty-specific guides to clinical documentation improvement (CDI), physicians in the focus groups are generally taking a wait-and-see approach to problems that may arise from documentation issues.  They will address issues as they occur and learn as they go after implementation.  They expect their EHR and billing system vendors to provide them with templates and order sets that will make documentation easier, and tend to think the biggest problems will only hit providers who perform a wide variety of procedures or see very complex patients.

“I have not done anything except read an article or two about how codes are going to increase in ICD-10,” a participant said. “I am relying on my billing service to do that. With respect to the hospital, they have not really given us any formal training for ICD-10 at all.”

“Physicians…typically don’t want to spend very much time on training for things like this,” added another. “It’s hard to engage them, so finding a set of materials that they will respond to positively would be valuable.”  Hiring an HIM or CDI professional to develop educational programs and train physicians on ICD-10 issues seemed an attractive path for some physicians, but others worried that hospitals with the resources to maintain an HIM department may only invest in significant training for inpatient coding, leaving the less lucrative outpatient coding aside.

“Hospital coding is totally depending on ICD-9 and as they convert to 10, they will do the training (for inpatient). But that is inpatient. What about outpatient? The hospital will train you as they have a vested interest. For outpatient, I don’t know,” remarked a participant.

“For surgeons, nothing came from formal groups; most of the information regarding ICD-10 preparation and training would come from the hospital side as they have the best interest in training the physicians mainly for hospital utilization and reimbursement purposes,” agreed another.

Will EHR vendors and billing partners pick up the slack?  Physicians certainly hoped so, believing that vendors would provide training and assistance if their hospitals and specialty associations didn’t give them adequate education.  The groups called ICD-10 a “new language” for them to learn, and put specialty educational materials at the top of their wish lists.  One requested “ICD-10 for dummies dumbed down by specialty,” while others asked for easy-to-understand crosswalks and a top-ten list of the most frequent reasons claims are being rejected.

The problem, many of the responses seem to indicate, is that ICD-10 isn’t meeting physicians where they are.  CDI itself is not the issue, nor is the extra burden of added time and education, even if the thought of spending a few lunch breaks or extra evenings in a specificity seminar isn’t enticing.  ICD-10 has taken on a life of its own as the big bad wolf of the healthcare industry, its shadow of trepidation growing deeper each time the new code set is delayed.  Many physicians want to view the changes as a positive development, but feel that available resources aren’t helping them do so.  “Articles on ICD-10 are fear-based,” said a participant.  “I try not to go there.”

So where will they go?  To health information management professionals, hopefully, or to CDI experts offering outsourcing services or workshop materials that will preempt the watch-and-wait attitude that may result in significant reimbursement disruptions.  It isn’t fear mongering to say that preparing in advance for ICD-10 is a wiser course of action than simply hoping that the storm will pass by without serious damage, or letting fear of the unknown preclude the search for resources that will meet a specialist’s particular needs.  ICD-10 will require effort, but the industry has been preparing for the switch for a long time, and the right training is available to those who look for it.

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