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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ICD-10 Compliance a Struggle for Some Physician Practices

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

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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EHR System Satisfaction Declines to 34% Among Physicians

EHR System Satisfaction Declines to 34% Among Physicians | EHR and Health IT Consulting |

Multiple motivations are driving EHR adoption in the healthcare industry from the EHR Incentive Programs to the promise of increased healthcare efficiency. Yet in a recent survey by AmericanEHR Partners and the American Medical Association (AMA), researchers found that physician satisfaction is on the decline.

The report finds that in 2010 a total of 61 percent of respondents were satisfied or very satisfied with their EHR systems. In 2014, after the total number of EHR users has increased, a mere 34 percent of respondents are satisfied.

Additionally, nearly half of respondents reported that EHRs actually decreased efficiency, with 42 percent saying EHR technology made it difficult to improve efficiency, 72 percent stating it was difficult for EHRs to decrease physician workloads, 54 percent saying EHRs increased total operating costs, and 43 percent saying their practices have not yet overcome these challenges.

The report notes that other findings in the survey heavily depended upon whether respondents were satisfied or dissatisfied with their EHR system. This means that there was polarized variation in responses depending upon how respondents felt about their EHR systems. Naturally, respondents who were satisfied responded positively to the survey questions, while those who were dissatisfied did not.

For example, when responding to questions regarding staff time spent processing and refilling prescriptions, 42 percent of all respondents said they were satisfied with their EHR. However, of those who were dissatisfied with their overall EHR use, only 25 percent were satisfied in the processing and refilling prescriptions category. Of those who were satisfied with their overall EHR use, nearly 69 percent were satisfied with the process and refilling prescriptions category.

However, there were some questions all respondents were generally able to agree upon. Merely nine percent of respondents — or 19 percent of those who were satisfied with their EHR — reported that adopting an EHR system decreased their practices’ overall costs. Likewise, only 13 percent of respondents — or 21 percent of those pleased with their EHRs — reported that their EHR technology made a positive impact on a number of their employees.

The report also indicates that primary care physicians tend to be more satisfied with EHR systems than specialists. This is because primary care physicians on average have worked with EHR systems for longer than specialists have, and therefore have figured out the best and most efficient ways to use them. The report also indicated that it took an average of three years for physicians to get used to working with an EHR and to resolve the initial challenges the systems presented.

Shari Erickson, MPH, Vice President of the American College of Physicians Division of Governmental Affairs and Medical Practice, contends that as EHRs continue to be integrated into physician practice, satisfaction ratings will increase.

“Perhaps we are getting over the curve in EHR adoption,” she said. “It may be that as we see more practices that have been using these systems longer we will see satisfaction begin to rise.”

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CMS Chief to Address ICD-10 Implementation in National Call

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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How Does Physician EHR Use Lead to Legal Complications?

How Does Physician EHR Use Lead to Legal Complications? | EHR and Health IT Consulting |

While physician EHR use has benefits for healthcare delivery, it poses various legal challenges different from paper records, according to two members of the Healthcare Group at Sands Anderson PC.

"On the one hand, EHR have given health-care providers, and those who sue them and those of us who defend them, access to more information than was available with the traditional paper record,"write Matthew Curtis and Michelle Warden. "But on the other hand, EHR have raised a host of new questions and challenges, and as the systems evolve they promise to highlight more conflicts between good clinical care and effective legal representation."

The two legal experts point to several areas of conflict that EHR technology currently present and which could prove more difficult as the technology matures — who accesses the chart, how is data in the chart managed, and what types of information comprise the chart.

"As EHR systems evolve, more and more conflicts likely will arise between what is good for the doctor and his patient and what is good for the attorney and her client," add Curtis and Warden.

A handful of examples demonstrate where confusion can arise. For one, there is the uncertainty resulting from prepopulated fields, such as for indicating "within normal limits" for the neurological system:

Unless the provider opens that field and selects a different response, it will appear to a subsequent reader that the patient’s neurological system was normal. But was it really? Perhaps the patient’s neurological status was not pertinent to the examination at that time, and the physician never assessed it or made any effort to change the prepopulated information. An audit trail (essentially a log that records who did what at what time within an electronic record) may indicate whether the field in question was prepopulated, accessed, or changed but audit trails can only tell you so much.

A patient chart, meanwhile, is much clearer in indicating whether the physician has indeed marked a field.

Electronically populated fields – that is, data coming from connected monitors and integrated directly into the EHR — raise similar doubts. Unless reviewed by the physician, the information may flow into the electronic record without his knowledge. Other uncertainties could include whether the clinician was in fact the one to enter vital signs.

As another example, audit trails may not sufficiently indicate when a physician interacted with the EHR system depending on how time is recorded in that system.

The final example presented by Curtis and Warden centers of differences between the electronic chart and the printed record because of the fact that the latter "rarely looks the same as what they would have seen on a computer screen at the time they were caring for their patient."

That is problematic, they argue. "This potential discrepancy may give the health-care provider — and subsequently the medical malpractice attorney—difficulty in deciphering the options that were even available for the health-care provider to select while caring for a patient," claim Curtis and Warden.

While the legal experts do not offer solutions to any these examples, they draw attention to an obvious for changes in how EHR technology is presented in legal proceedings to ensure that all parties are on the same page, albeit electronic.

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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 |

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 |

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, 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. 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. 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. 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. 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. 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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In the age of the smartphone, physicians should not expect privacy rights

In the age of the smartphone, physicians should not expect privacy rights | EHR and Health IT Consulting |

I have had patients try to snapchat their laceration repairs.  They have utilized FaceTime for discharge instructions with loved ones. I recently had a patient try to put their phone in selfie mode so they could see how their lumbar puncture was going in their back (my nurse quickly prompted them to get back into position and removed their phone).

Smartphones have changed everything.

By now many physicians know of the Bethesda, Maryland anesthesiologist who wassuccessfully sued for hundreds of thousands of dollars by a patient who “accidentally” recorded conversations she was having while he was sedated.

My social media feeds were in overdrive when the final judgement was announced. Even though every physician I know felt the Anesthesiologist’s behavior was not appropriate, most were shocked at the massive amount of the judgement — $500,000. Most also felt it wasn’t appropriate for the patient to be recording the physician team without their knowledge. What if the team started talking about their next patient at the end of the case, and this patient was privy to all that information?

The patient most likely used the iPhone’s native Voice Memo app to record the conversation. The app enables you to record audio as long as you want or until your phone runs out of memory or battery life.

While the Anesthesiologist erred on an epic scale both professionally and with their medical charting — most felt it was still a gross invasion of privacy to do what the patient did. I was surprised by how many physician’s felt they somehow had a legal right to know if they were being recorded. That is definitely not the case.

Patient’s can legally record your interaction with them secretly in almost every state. Further, they can use that recording to sue you as well.

In my lectures on the interplay between social media and medicine, one of my themes is how physicians should expect their interactions with patients to be put in the public domain at any time. I tell my students how patients will be tweeting their doctor’s name if they aren’t happy with their care or uploading videos to Youtube showing how the patient visit went.  If you look at Google reviews of various hospitals, you already see this happening — specific doctors’ names being used and patient’s giving detailed descriptions of their medical record and what happened. What’s interesting is that when this happens for other services, the owner or manager is able to respond to specific complaints in order to give both sides. That’s impossible for hospitals to do due to privacy laws protecting patients.

In a great piece published by JAMA on this issue, the authors summed it up best with their following conclusion:

If physicians embrace this possibility, establish good relationships with their patients, provide compassionate and competent care, and communicate effectively and professionally, the motives of patients and families in recording visits will be irrelevant.

Expect it, embrace it, don’t complain about it.

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Awarding of DoD EHR Modernization Contract Forthcoming

The Department of Defense appears set to name the winner of the Defense Healthcare Management Systems Modernization (DHMSM) contract — its future EHR technology — later this week.

A spokesperson for the DoD told Politico that the decision would be announced at the end of July, which is this Friday. The awardees of the contract will be responsible for replacing and modernizing aspects of the DoD’s current Military Health System (MHS) clinical systems

The contract valued at $11 billion should have serious implications for the interoperability of the DoD and the Department of Veteran Affairs whose joint integrated EHR project was shuttered. Additionally, the contract made headlines as suitors lined up to win the multi-year award.

Last June, Epic Systems and IBM announced that they would team up to make a bid for the DoD EHR contract. To bolster its bid, the Epic-IBM team enlisted Allegany Ballistics Laboratory in West Virginia to test its proposals for the DHMSM contract.

“What we wanted to do was have Epic running and have the opportunity to integrate and test, add new functionality, integrate other pieces of the big package so that there were no surprises,” IBM’s Managing Partner of Federal Services Andy Maner told reporters in January 2015. “We just wanted to make sure we were getting ahead. Obviously Epic is live all over the country, but we wanted to be a step ahead in a DOD-hardened environment.”

The pair also named 17 healthcare executives to an advisory group in their pursuit of the DHMSM contract, including healthcare professionals from Kaiser Permanente, Geisinger Health System, Partners Healthcare, and Mercy Health.

PricewaterhouseCooper had also entered the fray in 2014 with an offering based on combination of open source software — notably the code maintained by Open Source Electronic Health Record Alliance (OSEHRA) — and commercial applications from its partnership with DSS, MedSphere, and General Dynamics Information Technology.  The PwC-led bid, however, fell out of contention earlier this year.

"While DoD cannot comment on the details of the ongoing source selection, the competition is robust and will support DoD’s objective of acquiring a best value solution for the enterprise that meets requirements, including interoperability with the VA and private sector healthcare providers," a DoD

spokesperson told in February 2015. "The Government has completed the evaluation of initial proposals and on February 19, 2015 opened discussions with offerors included in the competitive range."

Other bids include Epic competitors such as Cerner Corporation and Allscripts.

No matter the outcome, the VA is monitoring the situation is set on making its VistA EHR interoperable with the DoD's EHR technology. "We’re making sure no matter what solution they select, interoperability will not be impacted," VA CIO Stephen Warren told reporters in February of this year. “And we’re going to continue working on evolving VISTA and supporting other organizations who’ve chosen this product as the way for them to do health care delivery."

The awarding of the DoD EHR modernization contract should bring an end to the difficulties plaguing the DoD and VA's interoperability efforts.

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Approaching an ICD-10 Implementation with Confidence

Approaching an ICD-10 Implementation with Confidence | EHR and Health IT Consulting |

The deadline for implementing ICD-10 is rapidly approaching.  Providers and practices should be preparing for the transition and approaching the implementation with confidence. They should be doing this even with therecent announcement from CMS on creating a one-year grace period, allowing for flexibility in the claims auditing and quality reporting process during the transition.  Addressing the following 11 steps will help assure your practice will be on track for a successful transition on Oct. 1, 2015 and going forward: 


Review the major differences between ICD-9 and ICD-10 and how those differences will affect a clinician’s specialty as well as your organization as a whole. Reviewing the “Official Guidelines for Coding and Reporting” for ICD-10 is a good starting point. 


Include staff from the administrative and clinical sides of your practice and divide up the work that needs to be accomplished. Make sure you communicate the changes required by ICD-10, both from a workflow standpoint as well as clinical documentation.


Consider all the different systems you use, the organizations you exchange data with, as well as what electronic and paper-based workflow processes you use that drive clinical encounters and the billing process.  Make sure all of these are updated and/or modified appropriately for ICD-10 compatibility.


Ask vendors about any needed upgrades to use ICD-10, what training (if any) will be needed, and cost estimates. Don’t forget to ask about the ability to concurrently use ICD-9 and ICD-10 and how long you’ll have the ability to do that.


Make sure you consider software and hardware upgrades, education and training costs, the cost of temporary staff during transition should it be needed, changes to printed materials, additional time for documentation review, and the cost of lost coder, clinical and/or revenue cycle staff productivity.


Ask if all their upgrades to accommodate ICD-10 have been completed and if they haven’t, when they will be. Also ask how they (the clearinghouse and health plans) will help your practice with the transition, when can you test claims and other transitions with ICD-10 codes, and whether they provide a list of any data content changes needed. Don’t forget to ask the health plans when they expect to announce their revised ICD-10-related coverage/payment changes. 


This may be one of the most challenging aspects of ICD-10.  Identify potential documentation issues by beginning to crosswalk ICD-9 codes to ICD-10 codes. The goal should be to identify any gaps in the documentation that prevent a coder from selecting the appropriate ICD-10 code.


Identify your education needs. While everyone will need to be trained, not everyone will need to be trained at the same level. Identify who should be trained on what.  You will also need to identify the best training mode for each group and the timeframe for providing that training. 


Testing is critical to success with implementation.  Plan for both internal and external testing.  This will need to be scheduled, so begin the planning now.


Every practice needs to plan for decreased staff productivity and prepare for the possibilities of other financial challenges during the initial implementation period. You should set aside some cash reserves for the practice. It may also be wise to consider establishing a line of credit. 

Preparing now for the transition to ICD-10 will help ease the burden of compliance on Oct. 1, 2015 and assure you will not have a major disruption in your practice revenue.


Make sure you familiarize yourself with the new grace period rules, including some key points below. CMS also announced the establishment of a communication center and an ICD-10 ombudsman to help receive and triage physician and provider issues. 

  • Medicare contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of ICD-10 codes is used. Moreover, physicians will not be subject to audits as a result of ICD-10 coding mistakes during this one-year period.
  • Physicians will not be penalized under the various CMS quality reporting programs for errors related to the additional specificity of the ICD-10 codes, again as long as a valid ICD-10 code from the right family of codes is used.
  • If Medicare contractors are unable to process claims within established time limits because of ICD-10 administrative problems, such as contractor system malfunction or implementation problems, CMS may in some cases authorize advance payments to physicians. 
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Medical Practice Organizational Structure

Medical Practice Organizational Structure | EHR and Health IT Consulting |

The purpose of an organization chart is to depict the skeletal structure of the practice, including the functional relationships between, among, and within the specific components. An organization chart provides a point of reference and improves the flow and direction of communications. It allows people to see how they fit in the big picture, increases efficiency, and maintains a balance in the practice.

The development of good structure for organizations has been a concern for managers throughout history. Medical practices have both structure and process. The structure refers to the formal organization and the plans, schedules, and procedures that hold it together. Structure is the instrument by which people formally organize themselves to carry out a task. Process represents what actually goes on: what is done, how it is done, and the way individuals or groups behave and carry out their perceptions of the assigned tasks. The structure can be seen as the anatomy of a practice, and the process as the practice's physiology.

There are six key aspects of an organization chart.

1. Division of work.

When too many people share responsibilities, it wastes time and resources. When staff is stretched thin, tasks are not completed on time. By referring to an organization chart, each person in the practice can determine what his or her responsibilities are. Because of this, the medical practice functions more efficiently.

2. Line of authority.

An organization chart is characterized by a rigid, formal structure of authority relationships in which the authority and the responsibility for performing each specialized task in the practice are legitimized. Authority is impersonal, since it is vested in the position rather than in the individual holding that position, and this is reflected in an organization chart.

3. Flow of authority.

Authority flows from top to bottom on an organization chart and defines the hierarchical structure of the medical practice. This accounts for the pyramidal shape of most organization charts.

4. Span of control.

The span of control concept of organization structure refers to the number of subordinates who can effectively be directed and coordinated by one supervisor. As the number of subordinates in each echelon increases, the shape of the organization chart changes from a tall pyramid to a flatter one.

5. Delegation and decentralization.

These are structural concepts that are closely related to the span of control. Delegation is the assignment of responsibility and the transfer of authority for directing and coordinating task performance to one or more subordinates by a supervisor. When this is done, authority is in effect decentralized, or removed from the single central position it once occupied. Continued decentralization has the effect of transferring authority and responsibility relationships to successively lower levels of the organization, widening the span of control at the higher levels.

6. Departmentalization.

This is a natural consequence of specialization and division of labor. As specialization increases, division of labor naturally results in the formation of organizational segments, usually referred to as departments. The larger a medical practice becomes, the more departmentalization it requires to facilitate the specialization of activities. In very large practices, the basis for departmentalization may vary at different levels. Although departmentalization is necessary in every practice to provide specialization, it usually poses problems in coordinating activities.

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EHRs and Patient Portals: Key Contract Considerations

EHRs and Patient Portals: Key Contract Considerations | EHR and Health IT Consulting |

Most practices now use EHRs and slightly more than half use patient portals, but a significant percentage is still exploring their options when it comes to acquiring both technologies, according to our 2015 Technology Survey.

If you are a manager or physician at one of these practices, doing your homework upfront may reduce the likelihood that you'll experience common post-implementation challenges, such as interoperability issues or work flow problems.

Here, Jeffery Daigrepont, senior vice president of the Coker Group, a healthcare consulting firm, shares some of his top guidance for practices that are on the hunt for an EHR or patient portal:

If you are looking for an EHR:

Make sure that interoperability (between your EHR and other EHRs, and between your EHR and other practice technologies such as your patient portal) is a key part of your vendor contract, says Daigrepont. "Those that haven't bought [an EHR yet] and want to learn some lessons from those that have already been through this, could actually put a statement of work, or what I call "acceptance criteria" into the contract that basically says, 'I'm accepting this [EHR], but I'm not going to be financially responsible for it until my interoperability expectations are met,'" he says. "That forces the vendor and the practice to have a discussion about what are those expectations and both sides can verify that there's accountability and that will work as expected."

If you are looking for a portal:

Watch out for monthly, recurring subscription fees without cancellation options, says Daigrepont. "If you have three doctors, the portal could be $50 [per month] to anywhere from $150 per month, per provider. So if a practice does decide to use a portal, they should always have the right to deactivate that portal in the future if a doctor left, or maybe the doctor just didn't find it was valuable, or there was no [patient] adoption," he says. "Sometimes people sign up for a three- [or] five-year term on these portals and they're stuck paying that monthly subscription fee whether they're using it or not ... you should always be allowed to activate and deactivate."

DPC Integration's curator insight, July 22, 2015 11:47 AM

This a must, people!  Please see a health care lawyer first, if you need help.!

Windows Server 2003: Mitigating Risks

Windows Server 2003: Mitigating Risks | EHR and Health IT Consulting |

With Microsoft ceasing support for Windows Server 2003 as of July 14, security experts are warning organizations to migrate to a new operating system as quickly as possible and, in the meantime, lock down any servers that continue to use the aging operating system.

Beginning in August, Microsoft will begin releasing Windows updates that attackers can potentially reverse-engineer to design exploits that will compromise every Windows Server 2003 system that remains in use.

"After July 14, Microsoft will no longer issue security updates for any version of Windows Server 2003," according to a Microsoft announcement. "If you are still running Windows Server 2003 in your data center, you need to take steps now to plan and execute a migration strategy to protect your infrastructure."

The company recommends current users upgrade to Windows Server 2012 R2, as well as Microsoft Azure and Office 365 where applicable.

"Computers running the Windows Server 2003 operating system will continue to work after support ends," US-CERT warned in a November 2014 alert. "However, using unsupported software may increase the risks of viruses and other security threats. Negative consequences could include loss of confidentiality, integrity and/or availability of data, system resources and business assets."

To mitigate those risks, organizations that continue to use Windows Server 2003 can pay Microsoft for an extended support contract for the operating system.

Microsoft declined to comment on how much it charges for Windows 2003 extended support contracts, but by some accounts, base pricing starts at $600 per server, per year, with the price doubling every year.

"If you have deep pockets, you could easily follow up with Microsoft and pay for that extended support, though it's not indefinite," says Karl Sigler, threat intelligence manager at security firm Trustwave, tells Information Security Media Group. "Frankly, depending on your architecture, it would probably be far more inexpensive and beneficial to [simply] upgrade."

Still, paying for extended support was the route chosen by some organizations after Microsoft ceased support for Windows XP. Microsoft stopped supporting that operating system in January 2014, although it did subsequently release a security update for a zero-day flaw. Microsoft's Malware Protection Center also promised to continue releasing new signatures and updates for XP's built-in anti-virus software engine until July 14.

Even so, market researcher NetMarketShare reports that Windows XP still accounts for 12 percent of all laptop and desktop operating systems. The U.S. Navy reportedly signed a $9.1 million contract with Microsoft in June to continue support for 100,000 Windows XP devices.

12 Million Servers

Official usage statistics for Windows Server 2003 are difficult to come by, although US-CERT reports that as of July 2014, "there were 12 million physical servers worldwide still running Windows Server 2003."

According to a survey of 1,400 IT professionals released in March by IT firm Spiceworks, 15 percent of firms that used Windows 2003 reported that they had fully migrated away from it, while half of all firms had partially migrated, 28 percent said they were planning to migrate, and 8 percent said they had no plans to migrate.

Sigler says that numerous organizations that are still using Windows Server 2003 are likewise running older versions of SharePoint, the Internet Information Services platform, or Exchange. "Organizations - especially IT - tend to be change-averse," he says. "They're basically under the premise that if it's still working, it isn't broken, so why fix it?"

Some organizations remain stuck on Windows Server 2003 and older software due to tight IT budgets in recent years, says information security expert Brian Honan, who heads Dublin-based BH Consulting and also serves as a cybersecurity adviser to Europol, the European law enforcement agency. "I am aware of a number of organizations that are still running Windows Server 2003 and indeed will be for the foreseeable future," Honan tells ISMG. "This is due, in part, to a lack of investment in IT infrastructure over the past number of years - due to the recession - resulting in systems and hardware not being capable of or suitable to run modern operating systems."

Honan says beyond the cost of the new hardware, organizations are also faced with the cost of new software and training, as well as the challenge of having to test and potentially re-engineer numerous applications and processes that currently work on Windows Server 2003 devices. "Some legacy applications may not yet be tested - or indeed supported - on more modern platforms, therefore forcing organizations to remain on outdated platforms," he says.

Gambling with Critical Flaws

But the dangers of continuing to use unsupported operating systems have been well documented. Since Microsoft ceased supporting Windows XP, for example, the operating system has been vulnerable - and remains vulnerable - to numerous flaws that have been patched via updates to more modern Windows operating systems. And every time Microsoft patches a more modern version of Windows with a flaw that also affected Windows XP, it gives attackers the option of reverse-engineering the fix, and then creating malware that can target the flaw to exploit XP systems en masse.

The same goes for Microsoft's server software, Honan warns. "Organizations that will remain on Windows Server 2003 ... should look at additional security controls to reduce their attack profile, such as employing anti-virus software, change monitoring and file integrity monitoring software; ensuring firewalls and [intrusion prevention] systems are updated and operating as expected; restricting traffic to those [servers] by users or by certain IP addresses; implementing additional security monitoring of these systems and also of associated network traffic; and finally ensuring that their incident response plans are up to date," he says.

Trustwave's Sigler says the security risks facing organizations might not be immediately severe once Microsoft stops releasing patches for Windows Server 2003 and starts releasing updates for only more modern versions of its server software. "If it's a public server facing the Internet, then it's going to be a higher risk than if it's a server just facing a small internal team," he says.

Still, the security risks will only increase, going forward. "How risky it's going to be is really dependent on what happens in August, and the months following that," he says.

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Patient Engagement, Security Top the List among Hospitals

Patient Engagement, Security Top the List among Hospitals | EHR and Health IT Consulting |

Today the American Hospital Association (AHA) and the College of Healthcare Information Management Executives (CHIME) released the results of its HealthCare's Most Wired™ Survey, which illustrated that data security and patient engagement are the most important concerns among the country’s hospitals.

This survey focuses on analyzing health IT adoption among hospitals across the country and studies how health IT can be used to improve value-based healthcare metrics. Hospitals are currently taking more aggressive approaches to ensuring patient data remains private and secure.

“With the rising number of patient data breaches and cybersecurity attacks threatening the healthcare industry, protecting patient health information is a top priority for hospital customers,” Frank Nydam, Senior Director of Healthcare at VMware, said in a press release. “Coupled with the incredible technology innovation taking place today, healthcare organizations need to have security as a foundational component of their mobility, cloud and networking strategy and incorporated into the very fabric of the organization.”

Due to the Stage 2 Meaningful Use requirements under the Medicare and Medicaid EHR Incentive Programs, more hospitals have pushed forward patient engagement measures as well. The results from the survey show that 89 percent of Most Wired hospitals offer patient portal capabilities, 67 percent established a method for integrating patient-generated data, and 63 percent include patient tools for managing chronic disease.

“We commend and congratulate this year's Most Wired hospitals and their CIOs for improving care delivery and outcomes in our nation's hospitals through their creative and revolutionary uses of technology,” CHIME CEO and President Russell P. Branzell, FCHIME CHCIO, stated in the release. “These Most Wired organizations represent excellence in IT leadership on the frontlines of healthcare transformation.”

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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 |

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.

“ 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 |

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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Nine Types of Usability Problems with Electronic Health Systems

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

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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Three Common EHR Missteps

Three Common EHR Missteps | EHR and Health IT Consulting |

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 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."


• 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.


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.


• 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.


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.


• 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.


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 |

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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How Does Your EHR Vendor Solve Challenging Situations?

How Does Your EHR Vendor Solve Challenging Situations? | EHR and Health IT Consulting |

Today I was asked if I thought a specific EHR feature (in this case it was cloud hosted) was one area practices should consider looking at to avoid having a short sighted view of their EHR vendor. The specific feature and question are interesting, but I think it’s a short sighted way to look at an EHR vendor.

My immediate response was that when I look at an EHR vendor, I look at how they solve challenging situations and if they’re still solving those problems. I’m more interested in the EHR vendors direction and approach than I am any specific feature or function they offer today.

Let’s take them in the inverse order. Is your EHR vendor still solving your problems? This is a hard one to evaluate since meaningful use and EHR certification has hijacked the EHR development process.

However, when you dig into an EHR vendor you can tell which ones are really investing in improving their platform and which ones are just doing the minimum necessary to retain their customers. It’s a totally different mindset. A forward thinking EHR vendor is trying to push the envelope, is interested in user feedback and is working towards a brighter future. An EHR vendor that’s doing the minimum necessary is just barely meeting the EHR certification and meaningful use requirements and never really responds to customer requests. Sure, they’ll do a bug fix here or there or fix anything major, but there’s no real investment in the future.

One easy way for you to start evaluating which vendors are investing in their future and which aren’t is to talk to their sales people. Does the salesperson have something new to sell you (like RCM or some other service)? If they do, it’s quite possible your EHR vendor has started focusing (and investing) on some new product and not the EHR anymore. Just remember that it’s really hard for a company to focus and invest in more than one area.

Sadly, I think many EHR users know that their EHR vendor has stopped innovating their product. They know this based on the release cycles of the EHR vendor. When was the last time your EHR vendor put out something that made your life as a clinician or a practice easier and it didn’t have to do with MU?

Related to the above is something that’s even more telling when it comes to the future of your EHR. Ask yourself the question, how does my EHR vendor approach solving challenging situations? If you talk to a lot of EHR vendors like I do, you can pretty quickly tell how an EHR vendor approaches problems. Unfortunately, many of them do the minimum work possible to solve the problem. The best EHR vendors dive deeply into the problem and not only solve the problem, but try to think of a better way to optimize everything surrounding the problem.

I still remember sitting down with an EHR vendor for breakfast one day. As they described their ePrescribing solution, they described how they could have implemented ePrescribing really quickly. However, they didn’t just want to have ePrescribing. They wanted to take the time to really understand ePrescribing and ensure that the doctor could ePrescribe with as few clicks as possible. They wanted to make sure that the process was efficient and accurate. It wasn’t enough to just be able to ePrescribe, but they wanted their doctors to be efficient while doing it too.

Reminds me of many of the ICD-10 implementations I’ve seen. I’d describe EHR vendor implementations as ok, better, and best. The “ok” implementation is that they have a search box which can search by word or code. Theoretically, this works. It just means you’re going to have a big book next to you or an app on your phone which lets you really find the code and then all you’re doing is entering the code. Not good!

The “better” implementation is the vendors that group codes so that when you search you can choose the group of codes and then essentially drill down into the group and find the code you need. In most cases, I’ve seen this type of implementation done by integrating a third party vendor. The EHR vendor often passes that third party cost on to the end user (imagine that). I’ll admit that a third party vendor integration for this feels kine of lazy. I’m all for third party integrations, but your EHR vendor won’t ever be able to take coding to the next level if they’re working with a third party. This kind of “grouping” approach is better, but it’s not the best.

The best type of ICD-10 implementation I’ve seen is one that integrates deeply into the EHR documentation. The documentation essentially narrows down the ICD-10 code list for you as you document the visit. Then, when it’s time to do your assessment, the hard work of identifying the right codes is already done for you. Sure, you’ll need to verify that the machine approach to ICD-10 identification is right, but it’s the best approach I’ve seen to ICD-10.

Hopefully this ICD-10 example gives you a view into what I mean when I say that you have to evaluate how an EHR vendor works to solve a problem. Are they just trying to get by or do they take their solution to the next level of automation? I feel sorry for the doctors who are stuck on EHR software that’s no longer investing in their EHR and just take the minimal necessary approach to EHR development.

Going back to the person’s initial question about cloud hosted EHR, it’s easy today to say that every EHR vendor should be on the cloud. The cloud has won in every industry and it will eventually win in healthcare as well. However, cloud or not is not what concerns me. I’d be more interested in hearing an EHR vendors reason for going cloud or not. Not to mention their reasons for moving to cloud or not. That will tell you how an EHR solves a problem and how an EHR works with new technology. Their direction and approach to those challenges is much more important than the specific choice they make.

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From ICD-9 To ICD-10

From ICD-9 To ICD-10 | EHR and Health IT Consulting |

With ICD-10’s mandatory October 1st deadline approaching fast and furiously (I know you think summer just started, but believe me folks, Labor Day is right around the corner), a lot of information remains uncertain.  What are ICD-10 codes?  How will they impact my practice?  What are the differences between ICD-9 and 10?

Fear not, like a safety trampoline for you to jump to from a burning building, ICD-10 ready drchrono has your back.  You’ll want to be working with someone who knows what they are doing because switching to ICD-10 is no laughing matter – its a mandatory requirement passed down by the U.S. Department of Health and Human Services to all those covered by HIPAA regulations, so that means if you own or are supporting a healthcare practice, you are affected (it should be noted that ICD-10 does not affect outpatient CPT coding and physician services). Did we mention that you need to cross over to ICD-10 by October 1st?  As in October 1st 2015?

To ensure you are up and running for ICD-10, please review this 5 step checklist:

1.  Obtain access to ICD-10 codes: Code books, or go here and select “2016 ICD-10-CM and GEMS” to download 2016 Code Tables and Index.

2.  Train your staff: Ensure your staff is well-versed with ICD-10.  There are a wealth of online resources provided for you by CMS.

3.  Be sure to update your processes: Please update any electronic and hard-copy forms (new ICD-10 coding will be from left to right).

4.  Get in contact with your vendors: Please be sure to confirm their ICD-10 readiness, and in some cases, you can ask about testing opportunities.

5.  Once you have completed the above steps: Ensure your ICD-10 system is ready to rock.  The best way to do this is to generate a claim.


You could simply reach out to the drchrono team at, and we’ll get you set up with the right tools so that you really don’t need to worry about steps 1, 3, and 5.  Our EHR system will be prepared to fully support ICD-10 and will provide a full crossover solution to help you and your staff understand what ICD-9 codes translate to ICD-10 codes as you prepare for the transition.  Our system will allow you to generate ICD-10 ready forms in time for the transition in both electronic and print ready format, and last but not least, our solution will be fully tested and definitely ready to rock and support your office’s ability to submit claims against ICD-10 codes by October 1st.

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Managing a Successful EHR Implementation Extension Program

Managing a Successful EHR Implementation Extension Program | EHR and Health IT Consulting |

Extending your healthcare organization's EHR technology to community physicians and hospitals can prove to be life saving for the patients of your community. This, in turn, dramatically increases patient safety and continuity of care. Sharing known allergies, current medications, and saving time on reviewing lab and radiology results are all examples of how a patient’s healthcare can be greatly affected.

Your organization has decided to increase the footprint within the community by offering availability to your EHR technology. Now what?

The first steps in developing the EHR implementation extension program can feel a bit daunting to those involved, seemingly like taking a road trip without a map or a compass or a smart phone. These days many of us would be completely lost without these tools to guide us. In planning a road trip, typically milestones are planned along the way to the final destination. Having a clear vision of the whole picture will help you and your organization to determine the milestones and plan for success.

The healthcare community is a small one within every region. And when things go well, it will be talked about. However, if an EHR implementation go-live turns south, the word spreads like wildfire within the local healthcare community, potentially harming the success of your healthcare organization's EHR implementation extension program.

Here are a few wrong turns to avoid in helping to ensure a successful EHR implementation extension program.

Navigating without a compass: When starting a successful EHR implementation extension program, develop a strong steering committee that knows and is behind the overall strategy. Develop a roadmap of healthcare sites that will be successful and have similar goals to your organization. Determine those sites by considering the following

  • Financial stability – a thriving practice usually reflects the success of the practice.
  • Similar goals and standards to your organization – a practice that aligns similar to your organization will ensure a cleaner patient record.
  • Amount of referrals to and from your organization – the amount of the referrals between your organization and the potential site can indicate a larger common patient base, affecting a greater patient population.

Fast and furious: Understand the time requirements of the development of the contract and all third-party contracts prior to scheduling your first EHR implementation go-live. Generally, the development of the contract between your organization and your customer can take six to nine months, being generous. Before the finalization of the contract many decisions have to be mad (e.g., what will the package offered include, negation of third-party contracts for additional licensing, service level agreements). Additionally, your legal team will want and need to be involved to fully understand what is being offered, how Stark antikickback laws can affect the contract, and the agreements for allowing users outside of your organization to use the system. Having a plan to potentially separate from a potential client is also a necessity within the contract.

Selecting an EHR system including add-ons, options, and fine print: Developing a solid and clear marketing package will help to set expectations from the beginning. During the initial conversations, it is vital for the package and its contents established. Clearly communicate what is included with the actual implementation of their site and what is a chargeable add-on. For example, custom reports or custom build that can take costly resources can potentially be an add-on package with a set price. Having a clear understanding for both your organization and your potential client will help to provide a solid foundation of the relationship.

Avoid sticker shock. Be clear about what goes into the pricing that is presented in the contract. When developing the pricing portion of the EHR contract, break down what’s included, such as training, go-live support, and help desk for post-go-live process.

The vehicle has all the bells and whistles, but no gas in the tank: There are two parts to this potential blunder to consider. First consider the state of your current health IT infrastructure and setting expectations of what is required for hardware/software/connectivity for your future customer. A full evaluation of your current state of your organization's infrastructure is a valuable tool to help develop the costs and plan to fill any necessary gaps to accommodate the additional usage of the system. This also applies to health IT interfaces that will potentially be used for these sites. Another consideration is setting requirements for hardware and software for the incoming customers.

Giving an inadequately educated driver the keys: There are many options for how to provide education to your in-coming customers, and knowing them may determine the success of your go-live. Some organizations choose web-based training, some classroom training, and some a mixture. Knowing your clientele can help you make this decision. If your organization is looking to bring on smaller ambulatory clinics, they may not have the resources to attend 20+ hours of training. Providing the intro related workflows via the web-based training and offering minimized classroom training may be a good alternative for your organization. If your organization can only offer web-based training, consider providing practice environment an extended go-live support to accommodate the needs of your soon-to-be customer.

Caution about overload: When development of the overall strategy is taking place, consider the amount of resources required to make your strategy a success. Your timeline may include several back-to-back EHR implementations. Consider a team large enough to rotate the discovery, data collection, build, and go-live duties. The question is: to have a separate build team or envelope it into the current build team? The timing of your project plan in conjunction with other organizational initiatives will play a part of how to proceed. If there are other large projects or your organization is new to the system themselves, then it might not be feasible for the current staff to take on. Consider forming a team specific to this project with members being liaisons to the project team. Extending your organization's EMR generally is a long-term initiative and often includes time away from the office for discovery, meetings, go-live prep, and go-live support. 

Being successful is not only important to your organization, but also to your customers and most importantly, the patients. While there are many opportunities for failure, there are also many opportunities for success when it comes to extending your EHR technology. A solid roadmap (clear strategy), a navigation system (project plan), and clear communication will help to build a solid roadmap, guiding your organization to its destination, with the windows down, the radio up, and singing at the top of the lungs.

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Preparing the Nonclinical, Non-Coder for ICD-10

Preparing the Nonclinical, Non-Coder for ICD-10 | EHR and Health IT Consulting |

As the U.S. healthcare system moves closer to the Oct. 1, 2015, ICD-10 implementation deadline, clinicians and coders continue preparing for this immense change in healthcare reimbursement and clinical documentation practices. While medical office operations and management continue to focus on ICD-10 education, it's important to determine the appropriate education levels of non-coding, nonclinical staff needed for ICD-10 education. Determining the details in ICD-10 education is an important consideration that an astute leader will want to eagerly identify according to their practice needs.

A practice leader's focus on educating the nonclinical, non-coding staff might include reviewing the following positions: scheduling, registration, accounts payable and accounts receivable, laboratory, revenue cycle specialists, and file clerks. For the ICD-10 transition to flow as smoothly as possible, it is imperative that all staff have knowledge of the new coding system and understand how it will impact their current positions.

In order to determine the correct level of education, analyzing current job positions should commence. This includes the review of policies and procedures, specific job aides and toolkits, work flow, and finally, transparent communication with the team. Furthermore, the revenue cycle process should be reviewed to ensure all staff with revenue cycle interactions are appropriately educated in ICD-10.

Here are some suggested processes a practice leader may follow in order to establish appropriate training in ICD-10 according to job position, including giving a brief refresher on the revenue cycle processes, and common positions that normally interact with the cycle and its specific stage. While every effort is made to cover all non-coding, nonclinical staff, it is up to the practice leader to review all positions and determine the best way to proceed with ICD-10 education for their team.

Revenue Cycle

A healthy revenue cycle is a key to a successful physician practice. A practice leader should review his current revenue cycle processes and take into consideration where the individual practice's revenue cycle starts and stops, as well as determine each staff position's interaction with the cycle.

Before education can be delivered, and staff positions are analyzed, it is crucial to remember the flow of the revenue cycle from the initial intake of patient information to zeroing out the balance in the patient's account. This will ensure a successful ICD-10 training for practice staff.

The process of a medical office revenue cycle usually resembles the following:

1. The patient calls to schedule an appointment.

2. Registration obtains prior authorization from insurance for the patient visit, if appropriate.

3. The patient presents for her scheduled appointment and signs required paperwork.

4. The physician examines the patient and documents the visit on the patient's chart.

5. The coder receives the chart and assigns the codes according to the physician's documentation.

6. The claim is sent to the payer.

7. Reimbursement is issued for the visit, if appropriate, according to the patient plan and contract.

8. Accounts receivable processes the payment and a statement is sent to the patient if monies are owed.

9. The patient pays the balance on her account.

10. The patient's account for that date of service is at zero balance.

The revenue cycle process is complete for that patient encounter.

In order to understand how a staff member interacts in the revenue cycle at each level, analyzing positions is a must. Below is a sample of how this process might look and which staff member might interact at each level:

1. The patient calls to schedule an appointment and speaks with a scheduler. The scheduler will need to do a quick intake on the patient's insurance, reason for visit, if the patient is new or established, or if he has a referral. Appropriate steps must be addressed to obtain authorization for the visit. In order for this to occur, the scheduler will need to give the patient's insurance payer an appropriate ICD code.

2. The patient arrives for the visit and checks in at the front desk. The registration specialist will confirm the patient's information and insurance, as well as collect any copays due at that time. He may also take the original requisition slip if referred by another physician. Depending on work flow and practice size, the scheduler may have to select an ICD code (the reason for the visit) for pre-authorization purposes and/or to place on the patient's superbill.

3. The patient is seen by the physician. The physician documents the patient complaint and proposed treatment, if any, in the medical record. Diagnoses and any procedures are added to the superbill. The patient checks out, the chart is completed by physician, and routed to the coder.

4. The coder reviews the chart and assigns ICD codes according to the physician documentation. The encounter is sent electronically at midnight and routes to the insurance payer.

5. The payer issues payment to the physician. Your accounts receivable or billing department processes the payment. Any monies owed are sent by the patient to the billing department. Once the patient account is zero, the claim is closed.

The ICD-10 planning phase begins with determining each staff's interaction with the revenue cycle. This can occur by reviewing processes and work flow as well as policies and procedures. Scheduling, registration, filing, billing, accounts payable and receivable, release of information, revenue cycle specialists, and privacy and security staff should be asked for the tools they use every day with current ICD-9 codes, so they can be updated to ICD-10 codes.

Structuring Training

Once the quantity of existing ICD-10 knowledge is determined, training can be disseminated to staff through a variety of delivery methods. Face-to-face, written, electronic, or a combination of two or more can be used. Four hours to eight hours of training could be sufficient, but will be determined according to the needs of each staff member. This training should be completed at least one month prior to Oct. 1, 2015.

A detailed four-hour ICD-10 training agenda may look similar to the following, starting with the morning session:

• An overview of the healthcare system and why it is expanding from ICD-9 to ICD-10.

• The differences between the two classification systems.

• The impact on various physicians and healthcare positions.

• How the medical practice is preparing for ICD-10, to include

timelines, parallel testing, upgrades, and go-live date.

• A question-and-answer session.

The afternoon agenda can be customized according to position, need, size of practice, etc. For a registration specialist, the training may look similar to the following:

• An overview of current work flow practices and where ICD-9 codes appear.

• An overview of any current daily job tools, such as coding, billing, or insurance software or interfaces.

• Updated policies and procedures to include the communication protocol with physicians regarding specific coding questions.

• Process flow changes, if any.

• ICD-9 to ICD-10 crosswalks, if available, pertaining to the practice and job title.

• Updated fee tickets with ICD-10 codes.

• Available resources: coding books, anatomy toolkits based on staff position, designated coder-of-the-day team member who can be contacted should a question arise, etc.

Additional spot training can occur after the initial training as a refresher for staff members who encounter ICD codes in their positions, followed by regular education meetings following the implementation date. The practice leader may also wish to monitor claim denials, and map back to specific steps in the process in order to further fine tune ICD-10 training with all staff (clinical and nonclinical). Lastly, updating policies and procedures, process flow charts, coding tools, and reference cards will help ensure a smooth transition for a practice.

When implementing ICD-10 in a medical practice, it's critical for a practice leader to review all nonclinical and non-coder positions, and to assess the ideal amount of training for each position. Understanding the revenue cycle and what each department contributes to the cycle will be useful in determining appropriate training methodologies for ICD-10.

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Latest ICD-10 Developments and What Physicians Should Know

Latest ICD-10 Developments and What Physicians Should Know | EHR and Health IT Consulting |

With October less than three months away, physicians need to be prepared for the ICD-10 conversion.

By now, everyone in the healthcare industry knows that the effective date for ICD-10 implementation is Oct. 1, 2015. Moreover, because of the multiple delays of the effective date of the transition, there is no excuse for physicians not to be ready to change coding systems. Some larger institutions have already been utilizing the more specific standards of the U.S. version of ICD-10. Specifically, ICD-10 in the U.S. has two categories – ICD-CM and ICD-PCS.

ICD-10 CM is “[t]he International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States,”  according to Tech Target. Funded by the U.S. Centers for Medicare and Medicaid, ICD-10–PCS is specific to the United States and is utilized for procedural codes. The biggest obstacle for most physicians and coders is the increased specificity, which translates into a cash-gap increase. If the condition or procedure is not correctly coded, the claim will be denied and have to be re-filed utilizing one of approximately 69,000 ICD-10 CM codes compared to approximately 14,000 ICD-9 CM codes.

On July 6, 2015, the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA) issued a joint statement. “ICD 10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD.  “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to  physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs.  The actions CMS is initiating today can help to mitigate potential problems.  We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

Simultaneously, Representative Marsha Blackburn (R-TN), introduced H.R. 3018, Coding Flexibility in Healthcare Act of 2015. The purpose of the act was to provide a six-month safe harbor period for the transition to ICD-10 for submitted claims. The bill is still in Committee and has not been voted on by either the House or the Senate.

The takeaways for physicians include:

• Utilize the resources available through the AMA and CMS;

• Coordinate with all insurance companies to make sure that their systems are compatible and see if a “test run” can be done on submission claims;

• Review the contracts of EHR providers and see if there is a provision for a subscriber to recover for lost revenue in the event of a delay, glitch or system error in the claims submission process with ICD-10; and

• Be as specific as possible in medical documentation.

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Using Philosophy, Not Data, To Chart Better in the EHR

Using Philosophy, Not Data, To Chart Better in the EHR | EHR and Health IT Consulting |

Technology is so great, so captivating, and so compelling, it has spawned a kind of irrational exuberance which blinds people to the enduring principles and values that really matter. It’s a phenomenon that’s not unique to computer technology.

Alan Greenspan coined the term irrational exuberance during the dot-com bubble of the 1990s and Robert Shiller wrote a book, “Irrational Exuberance,” that analyzed the phenomenon. In terms of data and information, our current enthusiasm for data in healthcare displays all the features of a speculative bubble.

In the race to provide better care at lower cost, we have been assured that data will win by a head and distracted physicians won't harm anyone in the process. We are collectively gambling billions on this race in which the patients are the guinea pigs, being experimented on without their informed consent. Unknown to most people in healthcare and the government is the troubling lack of credibility in the quality of research being done on the computer science behind medical information and medical records. And this says nothing of the clarity and accuracy with which it is communicated to the public. Shiller said: "Some of this so-called research often seems no more rigorous than the reading of tea leaves." This comment would be relevant to healthcare if a lot of research was actually being done.

Shiller continues, to paraphrase: The answers to these questions are critically important to private and public interests alike. How we value data, now and in the future, influences major economic and social policy decisions that affect not only doctors and patients, but also society at large. If we exaggerate the value of data, then as a society we may invest too much in collecting and storing it, and too little in education, patient care, and other forms of human capital. We might deplete those resources that will be needed to devise new solutions to those conditions that influence the health of the world's population such as Ebola, Dengue and Chikungunya.

The buzz that surrounds technology is not conducive to thinking about principles and values. These are topics that concern ethicists and philosophers and that should help us to remember that:

• Data alone never saved a life. It takes people to do that. Data may help them but knowledge and experience are more important.

• One should not take any risk that is out of proportion to the potential benefit. Whenever possible let the patient decide which risks they prefer.

• One way to avoid doing harm is to be aware of what has happened and what was done before. Remember, insanity is doing the same thing over and over, while expecting a different result. Quality medical records, not data elements, are necessary if physicians are to be adequately informed about the patient's course.

EHRs have drawn the physicians’ focus away from the patient and the task of creating quality medical records, forcing them instead to function as data entry clerks and coders. This creates an ethical dilemma for physicians. Time pressures increase the likelihood that chart notes will be skimpy and uninformative. Both templates and copy/paste increase the chance that the notes will "document" things that were not done or not true, while failing to document things that were done (because it was too difficult to include them). People lose the potential to be informative because the context in which the data arose has been stripped away. It has either been discarded, or scattered in multiple, generally inaccessible locations. Without the relevant context the meaning, the information physicians need to understand their patient's cannot be reconstructed.

This is why the emphasis should be placed not on data, but on the faithful and complete recording of the information that physicians glean from their interactions with patients. In this regard, there is a branch of philosophy called “Pragmatics.” HP Grice (1913-1988), a British philosopher of language proposed the Cooperative Principle that he believed governed linguistic communication. His maxims provide a template, of sorts, that can guide physicians in creating informative, meaningful entries in the medical record. They are:

Maxim of Cooperation. Contribute what is required by the accepted purpose of the conversation.

Maxim of QualityMake your contribution true; do not convey what you believe false or unjustified.

Maxim of QuantityBe as informative as required.

Maxim of RelationBe relevant.

Maxim of MannerBe perspicuous; avoid obscurity and ambiguity, and strive for brevity and order.

To which should be added the calculability assumption:

Calculability Assumption: Whatever an utterance or narrative implies (though not stated explicitly) must be capable of being worked out.

Unfortunately, people apparently believe that technology can insure that a medical record will be accurate, complete and informative and that, if it isn't, big data will come to the rescue. I wouldn't bet on it.

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EHR Replacement Market May See 7% Annual Growth Rate

EHR Replacement Market May See 7% Annual Growth Rate | EHR and Health IT Consulting |

As computer systems continue to evolve and stronger certified EHR technology is developed, the EHR replacement market will see significant growth over the coming years. Once more healthcare providers begin to implement strategies for Stage 3 Meaningful Use attestation, their respective medical facilities will begin to upgrade their EHR systems in order to improve the quality of patient care as well as population health outcomes.

Kalorama report called EMR 2015: The Market for Electronic Medical Records shows that there will continue to be an annual growth rate of 7 or 8 percent over the next five years for the EHR replacement market. This positions EHR vendors and developers in a strong spot for sector growth.

Whether it is EHR system upgrades or training and consulting, vendors will still see a steady increase in the EHR replacement market, according to a Kalorama Information press release.

"There might be a thought now that everyone has their EMR now so the market won't grow, but I'd argue against that," Bruce Carlson, Publisher of Kalorama Information, stated in the press release.  "There are upgrades, vendor switches, and still untapped physician markets for web-based products.  That being said, it's like any other software market now that the direct incentives are over and as such, vendors need to sell on value."    

As the requirements of the meaningful use stages continue to roll out over the coming years, more physicians and facilities are attempting to avoid the financial penalties under the Medicare and Medicaid EHR Incentive Programs. As such, more providers are switching over from paper records to certified EHR technology and others are upgrading their systems to reflect meaningful use attestation. All of this is stimulating the EHR replacement market to steadily rise.

Medical facilities that don’t implement certified EHR technology by 2015 will face a 1 percent reduction in their Medicare-based claims, which will rise to 2 percent in 2016 and 3 percent for years beyond. This cut in payment from the Centers for Medicare & Medicaid Services (CMS) could damage the financial future of certain hospitals and clinics.

Due to these potential meaningful use penalties, more providers are focused on upgrading and adopting certified EHR technology, which will continue to boost the EHR replacement market.

Vendor replacement contracts are also likely to affect the healthcare industry over the coming years, which will include new implementation of EHR systems, training and consulting fees.

Within the EHR replacement market, the reasoning behind many providers’ choice to upgrade their systems may be due to the need for an integrated EHR and practice management solution, according to

“Revenue Cycle management and integrated EHR vendor loyalty among small practice EHR physician practices is still on a significant upward trajectory,” Doug Brown, Black Book's Managing Partner, said in a public statement. “The EHR/practice billing vendor's abilities to meet the evolving demands of interoperability, networking, mobile devices, accountable care, patient accessibility, customization for specialty workflow, and reimbursement are the main factors that the replacement mentality and late adoption remain volatile especially among solo and small practices.”

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