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The four key areas of EHR implementation

The four key areas of EHR implementation | EHR and Health IT Consulting |

Failing to adequately plan for and manage change on the scale of an EHR implementation can send the cost of change soaring.


Effective change management starts at the beginning, with a thorough analysis of existing processes, to provide clarity up front about what works and what doesn’t.


This enables informed choices when considering updates to the hardware infrastructure or changes to record-keeping processes. Wisely investing this time up front will help minimize office downtime and implementation costs later.


Given the scope and complexity of an EHR deployment, you’ll need more than a standard IT project plan to ensure a successful rollout. Your project plan should cover every important activity and major milestone.


Give yourself the time to analyze, implement, train, and practice—and then take it step by step. Think through the entire process, articulate your needs to your vendor and build in a thorough follow-up phase to make sure everything is running smoothly.


The four key areas of change management to help your practice ensure a smoother transition are:


 • Assessment: Careful assessment of existing processes and infrastructure is essential to putting your practice in a strong position to support a new EHR system.


• Resources: Managing resources well ensures you’ll build a capable team with a strong leader and responsive vendor.


• Accountability: Clearly assigned roles and responsibilities provide accountability throughout the project and build commitment at every level.


• Logistics: A well-thought-out plan can minimize the risk of missteps in an inherently complicated, time-intensive process.


EHR implementation has the potential to be an arduous, drawnout and expensive process—but it doesn’t have to be. With careful planning and effective change management, your team can make a streamlined transition that will ultimately benefit both your practice and your patients, from back-office operations to quality of care.


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Organisation Capability's curator insight, January 10, 2014 6:24 AM

Brilliant article that highlights common "watch outs" and common mistakes during change management iniatives.

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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Why can't we use ICD-9 and ICD-10 codes after Oct. 1?

Why can't we use ICD-9 and ICD-10 codes after Oct. 1? | EHR and Health IT Consulting |

When the U.S. House Energy & Commerce Subcommittee on Health held its hearing "Examining ICD-10 Implementation" last month, dual coding came up.

No not the kind of dual coding that allows healthcare providers to practice ICD-10 codes until Oct. 1. But politicians kept asking why ICD-9 codes and ICD-10 codes couldn't be used at the same time.

And none of the witnesses could answer the question. You could hear the screaming across town coming from the Department of Health and Human Services (DHHS) building.

I could understand the reluctance of everyone who did not want to speak for the Centers for Medicare and Medicaid Services (CMS). But for Pete's sake, they're already there to sing the praises of ICD-10 coding. Why couldn't someone try to explain that the differences between assigning ICD-9 codes and ICD-10 codes is not the same as choosing between a Blackberry or iPhone?

CMS tried to explain it in a revised guidance statement last week:

"No, CMS will not allow for dual processing of ICD-9 and ICD-10 codes after ICD-10 implementation on October 1, 2015. Many providers and payers, including Medicare have
already coded their systems to only allow ICD-10 codes beginning October 1, 2015. The scope of systems changes and testing needed to allow for dual processing would require significant resources and could not be accomplished by the October 1, 2015, implementation date. "

Except the committee noticed that depending on dates of services, ICD-9 codes will need to be used after Oct. 1. That kind of makes me wonder too. Makes me wonder if healthcare payers are going to be able to handle a few days of ICD-9 codes.

But we get a little closer to the problem here:

"Should CMS allow for dual processing, it would force all entities with which we share data, including our trading partners, to also allow for dual processing. In addition, having a mix of ICD-9 and ICD-10 codes in the same year would have major ramifications for CMS quality, demonstration, and risk adjustment programs."

There's the rub. Things will be crazy enough not being able to compare ICD-9 years to ICD-10 years. But mixing both code sets in the same year will make data analysis about useless.

And if healthcare providers figure out that reimbursement rates are different for an ICD-9 code compared to an ICD-10 code, they're going to choose the higher paying code for medical claims.

Would it be possible for healthcare payers to deny an ICD-10 claim if they can offer lower rates for ICD-9 claims?

No, CMS wants to rip off the bandage quickly Sept. 30. It's may sting Oct. 1. But it's going to hurt worse if they try to pull it off a tiny bit at a time.

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Industry Divided Over Use of Sponsored Alerts in EHR Systems

Industry Divided Over Use of Sponsored Alerts in EHR Systems | EHR and Health IT Consulting |

While electronic health record notifications can be valuable to physicians, some industry experts have raised concerns about the use of sponsored alerts, the Wall Street Journal reports.

Details of Sponsored EHR Alerts

Sponsored alerts are paid for by industry groups and pop up on a patient's EHR when they are due for health services, such as vaccines.

Practice Fusion, an EHR software vendor startup, sells such alerts to drugmakers, insurers and labs. The notifications then are displayed to them through its EHR products, which are available to providers at no cost. The company uses patients' health indicators and medical history to match them with preprogrammed alerts in real time.

Practice Fusion CEO Ryan Howard said there are currently around 112,000 health care professionals using its products in roughly 5.5 million offices visits each month. During a four-month study period, Practice Fusion said the alerts increased vaccinations by 73%, accounting for an additional 25,000 immunizations.

Despite Practice Fusion's reported success, the practice of sponsored EHR alerts is not widespread. Epic Systems delivers non-sponsored alerts in its EHR software, which providers must pay for. Meanwhile, athenahealth includes sponsored alerts in its medical reference mobile application, but not its EHR software.  


Some experts say that sponsored alerts straddle the line between health promotion and marketing.

Joseph Kvedar, Partners HealthCare's vice president of connected health, acknowledged that the alerts could help to improve patient outcomes, but added, "It's a fine line between recommending some kind of guidelines-based care versus recommending something that is marketing or sales-driven."

Robert Wachter, associate chair of University of California-San Francisco's Department of Medicine, said that while anti-kickback laws prohibit drugmakers from directly paying physicians to prescribe their medications, no-cost software subsidized by drugmakers could be viewed as an incentive to physicians.

However, Ramy Fayed, a Medicare fraud expert at the law firm Dentons, noted that Practice Fusion's sponsored alerts do not violate federal anti-kickback laws because receiving the sponsored alerts is not a precondition for a physician to obtain the software at no cost.

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AMA Applauds EHR Attestation Extension, Calls for More Changes

AMA Applauds EHR Attestation Extension, Calls for More Changes | EHR and Health IT Consulting |

While the American Medical Association announced its support for CMS' decision to extend the deadline for eligible professionals to attest to the Medicare meaningful use program, the group warned that participation will remain low without further changes to the program's requirements, Healthcare Informatics reports.

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments.

Last week, CMS pushed back the 2014 reporting deadline for eligible professionals from Feb. 28 to March 20.

CMS said it extended the deadline to "allow providers extra time to submit their meaningful use data," adding that the agency continues to encourage providers to start attesting for the 2014 reporting year as soon as possible. Eligible professionals who do not attest by the new deadline could face a payment adjustment beginning Jan. 1, 2016.

CMS said that deadlines for the Medicaid EHR Incentive Program are not affected by the extension.

However, CMS said that the new March 20 deadline applies to eligible professionals who wish to switch from the Medicare program to the Medicaid program -- or vice versa -- for the 2014 payment year.
AMA Reaction

In a statement, AMA President-Elect Steven Stack said that while AMA is "pleased" with the extension, it "underscores that the meaningful use program is not working."

Stack said that policymakers should:

    Remove the measures of the program that eligible professionals find most difficult to meet; and
    Revamp the EHR certification program to allow vendors to develop patient-focused products.

Specifically, Stack said "policymakers need to act on [AMA's] recommendations" introduced last fall (Walsh, Clinical Innovation & Technology, 2/27). In a blueprint released in October 2014, AMA recommended that CMS and the Office of the National Coordinator for Health IT:

    Expand options for specialists in Stage 3 and require physicians to meet 10 or fewer Stage 3 measures;
    Provide hardship exemptions for all stages of the meaningful use program; and
    Remove the all-or-nothing attestation approach and instead implement a 50% threshold for incurring penalties and a 75% mark for earning Stage 1 and Stage 2 incentives.

Addressing these recommendations would make the program more flexible, Stack said.

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EHRs Improve Mortality Rate and Increase Patient Satisfaction

EHRs Improve Mortality Rate and Increase Patient Satisfaction | EHR and Health IT Consulting |

Electronic health records (EHRs) have been adopted by thousands of hospitals. reported that nine out of 10 of all eligible hospitals achieved meaningful use through December 2014.

Once hospital staff members and physicians became accustomed to EHR technology, they and their patients reaped the many benefits offered by switching from paper to digital health records, including:

  • Patient information being more complete.
  • Diagnoses being more accurate.
  • Better data, leading to quicker and safer decision-making.
  • More convenience for patients with shorter wait times.
  • Integrated data improving the coordination of care.
  • Greater efficiencies leading to significant cost savings.
  • Fewer medical and medication errors.
  • Improved patient outcomes.

The cost savings and convenience delivered through EHRs are certainly valuable, but their positive contributions to patient care are even more noteworthy.

Predicting Mortality Rates
Studies show that EHR use yields significant clinical benefits. In one study conducted from 2010 through 2012, HIMSS Analytics and Healthgrades found that hospitals using advanced EHRs were better at predicting mortality rates.

Researchers studied 32 different procedures across 4,500 acute-care facilities, and evaluated the associated mortality rate. They then examined the hospitals’ EHR use, and concluded that those using more advanced EHRs were better able to predict mortality rates for most conditions, including stroke, heart attack, COPD, pneumonia, respiratory failure, and stomach and intestinal surgery.

Positive Clinical Outcomes
Through the HIMSS study, researchers also found that hospitals with advanced EHRs captured more patient information. And perhaps most interestingly, the mortality rates of the advanced-EHR hospitals actually improved for heart attack, small intestine surgery and respiratory failure.

How could EHRs lead to positive clinical outcomes? With improved data capture, physicians can better monitor additional patient risk factors, base their decisions on more complete information and manage patient care more effectively.

Healthcare professionals across the country are documenting lives saved thorough EHRs, particularly due to the universal anytime, anywhere access to a patient’s health record.

It’s clear that building improved care models and eliminating errors through missing, delayed or incomplete paper records have been a game-changing outcome of EHR use.

Increased Patient Satisfaction
Although physicians may not always communicate to patients the many benefits they can experience with EHRs, they have proven to be significant:

  • Efficiency is probably the most noticeable advantage, which becomes clear when patients are awaiting test results or diagnoses. Primary care physicians and specialists no longer need to contact each to obtain important information, or wait for a lab to send test results; lab results are now sent electronically to healthcare providers, and often directly to patients, as well.
  • Convenience is achieved through quicker appointment setting, as well as shorter office wait times as result of improved pre-visit communication.
  • Health improvements stem from more frequent reminders of important preventative measures, such as diabetes and cancer screenings.
  • Patient engagement often improves, especially when doctors use EHRs to educate patients about their health.
  • Increased time spent with the physician, as a result of reducing the time spent searching for charts or tracking down patient information.

When patients feel their time is respected, and understand the status of their health, they are more satisfied with the care they receive.

Successful EHR Implementation Yields Important Results
What is more important in healthcare than saving lives? By leveraging the power of EHRs, healthcare providers have the potential to continuously improve patient outcomes and decrease mortality rates, while improving the physician-patient relationship.

Implementing advanced EHRs equals a win for those on both sides of the screen.

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It's not too early to start hating ICD-11 coding

It's not too early to start hating ICD-11 coding | EHR and Health IT Consulting |

Just in case you were wondering, ICD-11 will not be a substitute for ICD-10 implementation. Joyce Frieden reminds us that ICD-11 is expected for release in 2017.

Note that an ICD-11 release doesn't mean it's good to go. Release means healthcare professionals can start reviewing it and learning it.

Since it's supposed to be based upon ICD-10-CM, there will be plenty for U.S. healthcare organizations to complain about. So there will be tweaking.

And of course there will be the campaign to delay ICD-11 implementation because ICD-12 coding will be so much better.

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How can we make the EMR note more legible? Here are some ideas.

How can we make the EMR note more legible? Here are some ideas. | EHR and Health IT Consulting |

Despite the well-known rollout problems for hospitals and clinics across the nation, there are many palpable and welcome advantages to using electronic health records.

Chief among these are the ability to access the chart from anywhere, rapidly search for information needed, and reducing the centuries-old problem of illegible doctors’ handwriting.  But with the good comes the bad, and in these still relatively early stages of health care information technology adoption — the current IT solutions remain slow and cumbersome, ultimately taking time away from doctors and their patients.

I’ve written a lot about these problems and will continue to do so until we get this right. However, another less talked about disadvantage is that if they are not optimized carefully, use of IT significantly reduces the quality of physician documentation in the medical records.

Let’s take the example of a history and physical, which is the core document the physician produces when he or she first sees the patient. In the traditional way of doing things, the doctor would dictate (using a transcription service) the medical history, physical exam findings, and then their overall assessment of what’s wrong with their patient and the treatment plan. The final product is a letter-like record that appears in the chart, carefully sub-headed and in flowing paragraphs that look like they have been written by a human being.

Thankfully this remains the process for lots (if not most) doctors. However, it may not be for much longer. In the new health care IT world, where capturing data is paramount and many EMRs make the doctor into type and click bots — the new up-and-coming way to do a history and physical is to go through a checklist and series of tick boxes on the computer. Typing and use of voice-recognition software are encouraged for the other parts. The end result is a ream of information, often incoherent, and a final assessment that is robotic and frequently lacks clarity of thought. Unfortunately from what I’ve seen, medical students and residents are increasingly adopting this new method of doing things, with the result being a vastly inferior product that is displeasing to the eye and whose content lacks downstream thought. A problem of both style and substance.

I would challenge anybody, including the IT gurus who promote its use so much, to look at a history and physical produced by the two methods and honestly assess which one is more coherent: the traditional one or the new computer generated report? Ditto for progress notes and discharge summaries, where the same problem exists.

So what can be done apart from going back to the bad old days of no information technology? Actually, an awful lot, if we optimize the information technology correctly. Remember IT is not the enemy here — it’s the design and implementation. Here are some solutions:

  • Decide what is and isn’t useful information to put in the main physician documentation sections. Should there be a gold-standard definition from a leading authority?
  • Make the final computerized document more eye-friendly and avoid reams of data in favor of intelligent looking descriptions and paragraphs. If tick boxes must be used, make the output a better one.
  • Seek feedback and guidance from other institutions who already do things better with their own electronic medical records.
  • Put tremendous resources into developing better voice recognition software. The particular one I’ve seen used the most (no name mentioned) is painfully slow and I feel a bit sorry when I watch colleagues talking slower than a 5-year old as they dictate their notes, correcting mistakes every few seconds with the keyboard.
  • Create a national task force to address this issue for the future.

A good start would be for hospitals to establish committees involving senior physicians, IT staff, and administrators. Because every hospital has their own electronic medical record, the work to do will be unique to each institution.

The world of health care needs to quickly correct course before this problem gets too far away from us. With information technology, health care will reap what it sows. If it encourages new doctors to become thoughtless type and click bots — just see what that doctor generation will look like in 10 years time.

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Prepare for the tsunami of patient data with integrated, flexible technology

Prepare for the tsunami of patient data with integrated, flexible technology | EHR and Health IT Consulting |

In 2013, 68 percent of U.S. consumers owned a smartphone and 80 percent owned a personal computer with Internet access, according to a February 2014 report by the Nielsen Company. These ownership rates are expected to increase, especially with mobile devices, and are influencing consumers’ behavior.

“Today’s consumer is more connected than ever, with more access to and deeper engagement with content and brands thanks to the proliferation of digital devices and platforms,” according to Nielsen.

Those brands include healthcare brands, although hospitals and physician practices have been slow to adopt online platforms that allow them to connect with patients at home or on their mobile devices. However, in the coming years, patients will increasingly demand online connections with their providers and will also be electronically submitting large amounts of data to their healthcare organizations.

This changing patient communication and engagement dynamic is why organizations need to be prepared with highly flexible, integrated information technology (IT) systems that, regardless of the source, collect, interpret and manage the information to deliver insight that helps providers better manage populations and individual patients. Organizations that have been reluctant to adopt such technology should avoid further procrastination so their providers can become accustomed to this type of patient interaction, but also to take advantage of financial incentives offered by the Meaningful Use of Electronic Heath Records (EHRs) program from the Centers for Medicare and Medicaid Services.

Wearable monitoring devices will become the norm

The approaching “tsunami of data” arriving at healthcare organizations will, in part, be from patients’ wearable health monitoring devices, according to the PwC Health Research Institute (HRI) (PDF). Although now primarily used for exercise and wellness, these monitoring devices offer “useful, shareable information while gathering valuable consumer health data,” HRI reports, adding that “the opportunity is there” to leverage that data to “deliver more personalized care and experiences.”

Although adoption will be gradual, patients wearing durable biometric sensors wirelessly reporting blood glucose levels, blood pressure, heart rate and other metrics to providers will become the norm in the near future. Providers must be able to efficiently collect and integrate this data into their current workflow so they can monitor patients’ management of chronic illnesses and detect when a potential adverse event is imminent.

This capability will become increasingly significant in the near future given the recent inundation of announcements from technology companies that they will be launching tools and apps that gather and transmit this consumer generated data to physicians directly from patients’ smartphones. Without an effective plan in place, this additional source of data could overburden practices.

With EHRs becoming an essential tool in organizations, providers need to deploy patient-facing technology integrated with EHRs and other existing IT systems to ensure that data collected from these devices and manually entered by patients are normalized and assimilated for clinical analysis and reporting. This data exchange and standardization process is still evolving, but new industry-driven collaborative organizations, such as Carequality, are dedicated to accelerating progress in health data exchange among multi-platform networks, healthcare providers, EHR vendors and health information exchange vendors.

Additionally, organizations will need to establish workflows that leverage allied professionals such as case managers, nurse practitioners and physician assistants, who can review the data delivered from these wearable health-monitoring devices. One such workflow has yielded positive outcomes for Kaiser Permanente Colorado, which used at-home blood pressure monitors and web-based reporting tools that connected clinicians and 348 patients with uncontrolled hypertension, aged 18 to 85 years. Kaiser’s six-month study of these patients showed a significantly improved ability to manage high blood pressure to healthy levels for the home-monitoring group, who were also 50 percent more likely to have their blood pressure controlled to healthy levels compared to the usual care group.

Once these industry stakeholders finalize a standards-based interoperability framework that enables information exchange between and among networks, expect the wearable health-device technology market, as well as health-monitoring apps for mobile devices, to rapidly expand.

Capturing and leveraging data efficiently

Before health data exchange with patients intensifies, organizations can set the stage for the data influx by establishing the necessary IT infrastructure and introducing digital communication into staff and provider workflows.

For example, by 2014, most organizations should have implemented a patient portal with functions for secure health information exchange and provider messaging that are required to successfully attest for Stage 2 of the Meaningful Use program. To make this investment truly worthwhile, the portal should also be able to perform routine administrative tasks such as appointment scheduling, reminders and prescription renewal requests.

Once staff and providers have become accustomed to those basic functions, they can start to add more interactive functionality, such as performing online visits and sending text message reminders to patients’ mobile devices that encourage the patients to engage in their care, such as confirming a scheduled appointment or approving a prescription refill.

If an organization has implemented a patient portal only to attest to Meaningful Use, then it should check with its vendor to ensure that the technology contains this more advanced patient-interactive functionality and that it is fully integrated with existing IT systems. This portal must also include integration with an app for mobile devices since patients will increasingly demand that type of access, as well.

Sustained engagement through integration

If consumers can access their healthcare data via a patient portal as easily as they can online shop on their tablets or buy movie tickets on their mobile phones, the organizations implementing the solution will reap the benefits. These benefits are not just financial either. A patient who is more interactive with his or her providers and health information is likely to be more engaged in his or her own care and have better outcomes.

With integrated, easy-to-use patient-facing technology, organizations can ensure that these activated patients who are communicating with and supplying information to their providers will continue to be engaged for years to come.

ChemaCepeda's curator insight, March 3, 12:58 PM

Llega un tsunami de datos en salud ¿Estamos preparados para captarlos e integrarlos de forma natural en nuestros servicios?!

Electronic Health Record Vendors Take Patient Data Hostage: What Should We Do?

Electronic Health Record Vendors Take Patient Data Hostage: What Should We Do? | EHR and Health IT Consulting |

In today’s interconnected world it seems intuitively true that instant access to comprehensive medical patient histories will help physicians to provide better care at a lower cost. This simple argument was persuasive enough for the federal government to spend $26 billion to incent medical providers to adopt electronic health records (EHR) systems so that they can electronically share medical records. The initial investment appeared to be large, but it was an economically sound solution to control the rising healthcare expenditure. The resulting HITECH act is one of the few healthcare laws that maintains bipartisan support. To establish a nationwide health information exchange network, officials designed a two-stage plan. First, incent every medical provider to create an electronic archive of their patients’ medical records. Second, connect these electronic archives together so that the providers can share their patients’ records. The $26 billion in federal incentives was a lucrative source of revenue for hundreds of different software vendors to develop and aggressively market their own type of EHR products in a medical market that knew little about information technology. According to the Office of National Coordinator for Health IT, in 2008, less than 10 percent of hospitals had basic EHR systems, and a mere five years after, 94 percent of the hospitals use a certified EHR system.

The next step forward is to connect these electronic silos together so that physicians can share their patients’ records. The billions of dollars in federal spending will only have any tangible benefit if this is done successfully. EHR vendors have taken patient data hostage and are not willing to release it unless they receive a big ransom. They typically claim that technical problems limit the interoperability of their products. This prevents physicians from sharing their patient records with other doctors. This is like T-Mobile claiming that its users cannot make calls to AT&T customers. The claimed interoperability limitation does not end here. The vendors are proposing hefty charges to allow data sharing between their own customers.

As I have discussed in detail before, this a hole that the government has dug for itself. A nationwide health information exchange network sounds great, but it is not possible to achieve this goal without the proper alignment of economic benefits for every player in the healthcare market. In the face of this problem, the government has three choices:

  1. Pay EHR vendors the ransom that they are asking to release their hostage and allow sharing of the patient data among medical providers.
  2. Regulate the industry and force the EHR vendors to allow sharing of patient data among medical providers.
  3. Do nothing.

The government appears to be following the first plan. Officials had not anticipated interoperability challenges and assumed that all of the providers with EHR systems would have the capacity to exchange records. Based on this assumption, the third stage of the EHR incentives program was designed to encourage physicians to actively engage in the exchange of medical records. Today nearly every physician has an EHR system and although many of them also want to exchange information, the EHR vendors do not allow them. The incentives, which were initially planned to encourage physicians, will end up with EHR vendors and help drive future profits. As Rep. Phil Gingrey (R-GA) put it, "we have been subsidizing systems that block information instead of allowing for information transfers, which was never the intent of the [HITECH] statute.”

Regulating the industry seems like the only feasible solution to this problem. Rep. Michael Burgess (R-TX), the leader of the House Energy and Commerce trade subcommittee is drawing up a bill to enforce data sharing. The benefits of regulating the EHR industry, if any, will take a very long time to become tangible. The EHR vendors will furiously push back against any kind of regulation and will insist that technical challenges are a real barrier to interoperability. Congress is poorly situated to adjudicate this claim. Time is a critical factor in the long term success of HITECH plans, which threatens the viability of this strategy.

The best solution for the government is to do nothing. The new pay for performance payment methods in which the medical providers are being paid a fixed amount for treating patients would drive them to become more efficient and increase their profit margin by seeking solutions such as health information exchange to cut costs. Because the market for new EHR products is now saturated, the only revenue source for EHR vendors are charges for data exchange. Currently, they can get away with outlandish charges because they know the incentives from the federal government allow doctors to cover their costs. But if the free money from the government were to stop, then EHR vendors would have to persuade the physicians to pay for the exchange fees. Just like any other service, the highest price that the medical providers would pay is equal to the value of the service for them. If the electronic exchange of information helps medical providers to cut back on their costs and save some money they will be willing to pay a fair price for it. EHR vendors will end up lowering their fees to a reasonable level or will eventually go out of business.

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Survey Shows Many Unprepared for ICD-10 Implementation

Survey Shows Many Unprepared for ICD-10 Implementation | EHR and Health IT Consulting |

Is your physician practice ready for ICD-10 implementation? The latest survey commissioned by Navicure and conducted by Porter Research found that ICD-10 preparedness varies tremendously among US healthcare providers. The survey takers included practice administrators, billing managers, practice executives, coders, and billers.

With the prior delays of the ICD-10 implementation date, it would stand to reason that there may be another postponement. However, 67 percent of respondents trust that the ICD-10 transition will take place on its newly scheduled date of October 1, 2015.

A major challenge of the ICD-10 transition that 41 percent of respondents cited is lack of payer readiness. One of the issues associated with the prior ICD-10 delays is that many providers paused the preparations for the transition until the date was closer. Only 23 percent continued with their efforts after the delay took place.

Some of the top concerns survey respondents commented on include the impact on staff productivity, lack of staff training, and the possibility of the ICD-10 transition deadline being pushed back yet again. However, only 5 percent feel that their technology won’t be ready in time for the implementation.

When it comes to being prepared for ICD-10 integration, only 21 percent of survey takers claimed they were “on track for implementation.” A total of 15 percent have not started preparing for the implementation at all while 11 percent developed a plan.

Those who have not started preparing for the ICD-10 transition cite five major reasons:

(1) Waiting on EHR vendor to provide ICD-10 software updates

(2) Waiting to implement a few months before the October 1 deadline

(3) Lack of staff, time, and training resources

(4) Belief that the ICD-10 transition date will be further delayed

(5) Lack of knowledge on where to begin

Despite some of these issues, out of all polled, 81 percent are at least somewhat confident that they will be ready to implement ICD-10 coding by the October 1, 2015 deadline. While these numbers are high, they have actually dropped from the 87 percent vote of confidence from a survey taken in the fall of 2013. Clearly, with only 21 percent of respondents feeling they are on track, providers may not be completely prepared for the ICD-10 transition as of yet.

“Since 2013, Navicure has been conducting ICD-10 readiness surveys, which have allowed us to gain broad perspective on how we can best help healthcare organizations prepare for the transition,” Jim Denny, founder and CEO of Navicure, said in a public statement.

The majority of respondents expect staff productivity loss of one to 40 percent. Providers may need assistance with improving productivity and efficiency when the ICD-10 integration takes place. Additionally, 49 percent of survey takers are either planning to conduct end-to-end testing or are already in the midst of this process. Unfortunately, this is a decline of 7 percent when compared to the fall 2013 survey.

The report goes on to explain the importance of beginning ICD-10 preparations such as staff training and clinical documentation practices even if waiting on new software updates. End-to-end testing is also vital to incorporate in order to address any risks with payer collaboration before the October 1 deadline.

Additionally, providers should prepare for a dip in staff productivity for the first three to six months after ICD-10 integration. It is important to develop a plan to manage these potential issues. Transitioning to ICD-10 will not be an easy road, but with thoughtful strategies in mind, it will be more manageable over the long-term.

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EHR Vendors Will Lower Data Exchange Prices or Close

EHR Vendors Will Lower Data Exchange Prices or Close | EHR and Health IT Consulting |

In an opinion piece for the Brookings Institution's "TechTank" blog, Niam Yaraghi, a fellow at the Brookings Institution's Center for Technology Innovation, writes that the best way for the federal government to address "outlandish" health data exchange fees charged by vendors is to focus on new pay-for-performance efforts.

According to Yaraghi, the federal government has spent billions of dollars "to incent medical providers to adopt electronic health record systems so that they can electronically share medical records."

However, Yaraghi writes that EHR vendors "have taken patient data hostage and are not willing to release it unless they receive a big ransom." He notes, "They typically claim that technical problems limit the interoperability of their products" and charge significant fees to allow providers to exchange data.

To address the issue, Yaraghi argues that the federal government has three choices:

  1. Pay EHR vendors' prices to release data and allow sharing between medical providers;
  2. Regulate the industry and make EHR vendors allow such data sharing; or
  3. Take no action.

He writes that the "government appears to be following the first plan" noting, "The [EHR] incentives, which were initially planned to encourage physicians, will end up with EHR vendors and help drive future profits."

In regard to the second plan, Yaraghi writes, "The benefits of regulating the EHR industry, if any, will take a very long time to become tangible."

Therefore, he argues that the "best solution for the government is to do nothing." According to Yaraghi, "The new pay-for-performance payment methods in which the medical providers are being paid a fixed amount for treating patients would drive them to become more efficient and increase their profit margin by seeking solutions such as health information exchange to cut costs."

Further, he notes that because of market saturation, EHR vendors' only source of revenue is data exchange charges and that currently they can charge "outlandish" prices "because they know the incentives from the federal government allow doctors to cover their costs." However, Yaraghi writes that "if the free money from the government were to stop, then EHR vendors would have to persuade the physicians to pay for the exchange fees." He concludes, "EHR vendors will end up lowering their fees to a reasonable level or will eventually go out of business".

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Vendor Fees Harm EHR Interoperability, Other Goals

Vendor Fees Harm EHR Interoperability, Other Goals | EHR and Health IT Consulting |

Stakeholders say that fees charged by electronic health record vendors to transmit and receive data between different EHR systems are hindering the progress of the meaningful use program and harming efforts to achieve interoperability, Politico reports.

Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments.

Details of EHR Vendor Fees

Lawmakers did not anticipate the EHR vendor fees when creating the meaningful use program, Politico reports.

According to more than a dozen sources interviewed by Politico, providers generally pay between $5,000 and $50,000 to transmit information between their organizations and other entities, such as:

  • Blood and pathology laboratories;
  • Health information exchanges; and
  • Government agencies.

In addition, EHR vendors sometimes levy additional fees every time a physician receives or sends data.

Stakeholder Reaction

Former National Coordinator for Health IT Farzad Mostashari said that the vendor fees to share data are "not because of technical standards, but because of business practices," adding, "The vendors don't have the same incentives as the providers do."

According to Politico, EHR vendors have become increasingly reliant on such fees as sales of new software decline. For example, NextGen Healthcare and its parent company had sales revenue decline from $149 million in 2012 to $87 million in 2014. Meanwhile, revenues from interchange fees increased from $49 million in 2012 to $67 million last year.

Some stakeholders contend that such fees are making health data sharing prohibitively costly.

Lance Donkerbrook, COO of Commonwealth Primary Care accountable care organization, said, "The No. 1 factor hindering the exchange of information between health care stakeholders is the exorbitant fees that most EHRs are charging for integration, connectivity and reporting." He said that many of the 250 independent physicians in the ACO are not able to share data with one another because they have a total of 30 EHRs among the doctors, with vendor fees ranging from $7,500 to $40,000.

According to Politico, the problems associated with EHR vendor fees have become particularly acute in the past year as providers have attempted to attest to Stage 2 of the meaningful use program, which requires providers to share data.

Meanwhile, Sarah Corley -- vice chair of the Electronic Health Records Association, which represents the majority of EHR vendors, and CMO of NextGen -- said, "As with other areas of health care, variability increases costs, and all stakeholders in health care need to work together to reduce this variability and the factors that drive it."

Potential for Legislative, ONC Action

National Coordinator for Health IT Karen DeSalvo at a meeting earlier this month described concerns about of EHR vendor fees as a "common refrain" that "Congress has asked us to do something about."

The Office of the National Coordinator for Health IT's certification program requires EHR vendors to demonstrate that their EHR software will allow providers to demonstrate meaningful use of EHRs, including data sharing. However, ONC does not have the power to regulate vendor fees, according to Politico.

Meanwhile, some Republican lawmakers are considering potential legislative solutions. Rep. Michael Burgess (R-Texas), chair of the House Energy and Commerce Trade subcommittee, is drafting a bill to enforce data sharing among providers, Politico reports. He said, "Interoperability is what makes an EHR useful. It's unfair that practitioners have to spend money on connections they thought were part of the EHR when they bought it." Although he acknowledged that vendor fees are an issue that "should be resolved in the marketplace," he noted that "you can't just drop your EHR like a used car and get another one." He said that lawmakers are "very closely" examining what legislation would "look like" if the market does not fix the problem on its own.

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Behavioral Health EHR Adoption Shows Promise in Survey

Behavioral Health EHR Adoption Shows Promise in Survey | EHR and Health IT Consulting |

In today’s healthcare sector, implementing EHR systems has become a way of life. It is nearly impossible for a medical office to avoid EHR adoption, said Jennifer D’Angelo, Chair of the new HIMSS Long Term Care and Behavioral Health Task Force and Vice President of Information Services for Christian Health Care Center.

“From an interoperability standpoint, and from a reimbursement standpoint, it’s being required,” D’Angelo told Behavioral Healthcare. “All levels of care will need to have an EHR for care coordination among all providers.”

A survey of Behavioral Healthcare readers shows that most of the respondents find their EHR systems satisfactory and are using them extensively. Only a small percentage (9.1%) are “very unsatisfied” with their current EHR technology. In fact, 72.5 percent feel neutral or satisfied with their EHR system.

The survey points toward the majority of behavioral health specialists viewing EHRs as technology that enhances patient care. While most have adopted EHR systems, some have yet to make the transfer often due to low funding for this particular expenditure. Some of the common reasons for not adopting an EHR are: financial (41.3%), no need for it (32.5%), haven’t found the right one (13.8%), and staff resistance (5.0%).

Others may continue to shop for better health IT technology, especially if their current systems do not line up with meaningful use requirements. Physicians are more likely to adopt EHR technology with features that achieve meaningful use in order to receive financial incentives from the Centers for Medicare & Medicaid Services (CMS). For example, some vendor’s health IT systems may be capable of meeting Stage 1 Meaningful Use requirements but not Stage 2.

Other potential disadvantages of EHRs that the survey highlighted are:

(1)   time consuming

(2)  causes confusing

(3)  difficulty getting data reports

(4)  costly

D’Angelo recommends that hospitals and clinics have support onsite during the first couple of weeks during EHR implementation in order to resolve any potential end-user issues quickly and efficiently. Despite the potential problems associated with EHR technology, there are significant benefits that physicians are seeing. Survey respondents reported a number of benefits including:

(1) improving patient care

(2) reducing paper-based records

(3) boosting staff efficiency

(4) helping guarantee reimbursement

The best EHRs offer a more streamlined workflow process for a variety of tasks including pulling up patient files, recording new visitor data, and finding key information quickly.

EHR consultant Eileen Casella Rider explains that EHR technology that is developed with the input of healthcare staff members tends to work better in a care setting than those built solely from a technical standpoint. Rider goes on to say that some clinicians may not have superior computer skills, which may lead to confusion and emphasizes the need for extensive training on EHR systems.

A final aspect of the survey finds that, out of all respondents who knew their EHR server choice, 34 percent use the software-as-a-service (SaaS) option. Experts claim that SaaS is the server of the future and will only increase in popularity. This type of feature allows clinicians to run their EHR system through the cloud.

These survey results display the tangible benefits of EHR technology in the medical care setting.

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EHR Integration Assists Lean Production Design

EHR Integration Assists Lean Production Design | EHR and Health IT Consulting |

The healthcare industry has emphasized “Lean Production” – a term coined by MIT researchers meaning the elimination of waste – in recent years, as it continues EHR integration initiatives and the adoption of electronic prescribing along with other health IT technology.

According to a report from the Agency for Healthcare Research and Quality (AHRQ), lean production refers to subtracting waste that eats up resources (funds, staff, time, or room) without increasing value or quality.

The report covers six case studies in which healthcare organizations incorporated lean initiatives such as improving the recording of outpatient data, bed flow, and outpatient EHRs. Lakeview Healthcare adopted these programs among others and interviews were conducted with physicians, nurses, and both clinical and nonclinical staff.

Many of the interviewees reported that Lakeview Healthcare experienced enhanced efficiency, employee satisfaction, and a more organized environment. Additionally, top executives stated the focus on lean production led to a $29 million return on investment over the last 14 years.

The organization also focused on quality improvements and increasing patient satisfaction. EHRs were introduced through group training in outpatient medical offices. Some physicians learned how to effectively use EHR technology in one-on-one training sessions.

EHR systems assisted greatly in improving patient flow in the ambulatory care setting. In order to reduce potential issues during EHR implementation, senior leadership incorporated process improvement work before adopting the health IT systems.

Initially, EHR implementation led to a dip in productivity due to the learning curve of adopting new technology. However, this trend reversed and a management engineer reported that chart filing time decreased by 70 minutes once the implementation was finished. This reduced wait times for patients as well, thereby improving patient satisfaction. The incorporation of technology also ensured patient safety.

“The use of technology meant integrated and improved patient safety processes,” the report stated. “The management engineer reported that, as part of the larger value stream of projects that included the Surgeons’ Preference Cards, patient safety improved as a result of checklists that were built into the computer system that could be used as a communication and debriefing tool.”

The results show enhanced routinization and organizational culture. In fact, the interviewees indicated a rise in teamwork and encouragement to gain better outcomes for patients. The focus on “Lean Production” has led to higher reported employee satisfaction and a low nursing vacancy rate.

Another case study came from Central Hospital where both improvement of emergency cardiac care and management of surgical procedure cards were incorporated into the lean strategy. The top leadership at this organization has used lean initiatives to enhance care and efficiency as well as transform the work culture.

A third case study from the academic medical facility Grand Hospital Center incorporated cardiology follow-up appointment scheduling as part of its lean program. Both EHR and scheduling systems were used to collect the necessary data to track progress of the lean initiatives.

The team at the Grand Hospital Center also aimed to decrease the costs of supplies, implants, and other resources. Some of the benefits the program achieved are the reduction of discharge time by three and a half hours and assigned rehabilitation therapists to specific floors to cut down on travel time.

Essentially, EHR integration could play a significant role in medical facilities’ aims to reduce waste and adopt the “Lean Production” style.

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IOM Panel Recommends Addition to Stage 3 Meaningful Use

IOM Panel Recommends Addition to Stage 3 Meaningful Use | EHR and Health IT Consulting |

A committee from the Institute of Medicine (IOM) has released recommended guidelines urging the federal government to include patient socioeconomic status and behavioral health data in Stage 3 Meaningful Use regulations. The IOM report was published in the New England Journal of Medicine last month.

The committee suggests incorporating a number of social determinants into EHRs and asking patients 12 questions about their socioeconomic status and behavioral health. Out of these 12 measures, four are currently being evaluated within the healthcare industry while eight are original questions. This process may cut costs in the healthcare industry as well as provide patient-centered accountable care.

Using such data could lead to improved diagnoses and treatments as well as strengthened decision making among providers. Clinicians would be able to identify risk factors more quickly by learning about a patient’s social background.

In addition to basic healthcare services, physicians would be able to refer patients to community organizations or public health departments when different issues arise such as domestic abuse. Along with these benefits, this kind of questionnaire would broaden the amount of patient data available and aid population health management strategies.

The recommendations stem from an IOM report released in November that attempted to uncover social and behavioral domains that are directly related to health outcomes, Politico reports. The panel in charge of the paper analyzed the ways to capture this data in EHR systems.

Some criticism from the American Medical Informatics Association claims that adopting this questionnaire will cause physician workflow issues as well as patient privacy complications. Additionally, some experts wondered if patients would provide honest answers to the questions.

The authors of the IOM report, however, hold a different opinion. The authors stated that by having data on socioeconomic status, employment status, and personal relationships, doctors would be able to “better partner with the patient to make informed and realistic medication choices.”

“Any new diagnostic technology or mode of therapy creates added demands and necessitates changes in practice,” William Stead of Vanderbilt University and Nancy Adler of the University of California, San Francisco, wrote in the report. “We believe that the benefits of adopting and using the measurement panel will outweigh these costs.”

Nonetheless, providers would need to take patient privacy and security into account when implementing a socioeconomic and behavioral health questionnaire in their practice. The change in workflow, however, will be minor, as much of the data can be self-reported or recorded during initial medical visits.

The most recent report hopes to expand the number of organizations involved in considering the implementation of this socioeconomic and behavioral health questionnaire. In particular, it asks the U.S. Department of Health & Human Services (HHS) to take part in including the survey within Stage 3 Meaningful Use requirements.

To qualify for the EHR incentive program under Stage 3 Meaningful Use regulations, the panel calls for behavioral health and socioeconomic data to be stored in EHR systems. Time will tell whether the federal government decides to include a behavioral health and socioeconomic survey as part of Stage 3 Meaningful Use.

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EHR Interoperability Issues Challenge Primary Care Teams

EHR Interoperability Issues Challenge Primary Care Teams | EHR and Health IT Consulting |

What are some of the most substantial health IT issues that are hindering the healthcare field? A study published in the Journal of the American Medical Informatics Association found that EHR functionalities that lacked integrated care management software and care plans, weak practice registry and EHR interoperability, and meager capabilities for patient tracking have all led to significant challenges for primary care teams.

Researchers from Mathematica Policy Research in Cambridge, Mass., came together to determine how EHR systems are affecting teamwork among primary care practices. The study analyzed data from patient-centered medical homes (PCMHs) that were part of the National Committee for Quality Assurance (NCQA) 2011 program.

Throughout the last decade, the federal government has placed more regulations on healthcare organizations and providers to improve patient-centric care, population health management, and patient data documentation. Both policymakers and providers have put more focus on sharing test results and patient records among medical facilities and improving health information exchange. Health IT initiatives can play a significant role in enhancing teamwork among primary care practices, which is why this study focused on the experiences of primary care teams from 27 PCMHs  among 17 states.

Representatives from NCQA assisted by reaching out to physicians located at the PCMHs. A total of 63 professionals were interviewed, ranging from front-desk staff to physicians among different size and geographical location of medical practices.

A few of the basic questions that the researchers asked among primary care teams included:

1) How does health IT assist in building teamwork at your practice?

2) How did health IT pose challenges to your practice? How did you solve these issues?

3) Has the way certain staff members used the EHR changed once teamwork became more structured?

Some of the benefits that EHR systems showed include improved communication and task delegation with the help of instant messaging and task management software as well as the capability for nurses and medical assistants to collect symptom-related data. Additionally, primary care teams found that EHRs led to improved access to patient information along with the ability to include notes within patient schedules. Most of the practices were utilizing commercial EHR systems while two practices implemented customized EHRs.

The study uncovered that primary care teams could improve services by incorporating population health management software, such as a registry that includes an electronic list of patients with certain conditions that may need extra monitoring.

“I don’t have an aggregate way of looking at my patient panel so I can’t make large decisions about management,” a doctor from Indiana told the researchers.

The researchers found that adopting care management tools and standardized EHR data entry are some other ways to improve teamwork at primary care practices. For some of the bigger issues like patient tracking challenges and poor EHR interoperability, physicians and healthcare professionals are calling for greater solutions from vendors and federal agencies.

The authors of the study suggest that health IT vendors may be able to develop more effective EHR systems if they work alongside primary care teams and incorporate care plans, assimilated care management software, and greater functionality for data tracking.

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Preparing for Integrating Patient-Generated Data into an EHR

Preparing for Integrating Patient-Generated Data into an EHR | EHR and Health IT Consulting |

Patient portals, mobile apps, secure text messaging, and email are increasing collaboration between providers and patients in new ways. Meaningful Use Stage 3 proposed requirements will likely be a driving force in determining how patient generated data (PGD) will be interpreted, used, and integrated into electronic health records (EHRs). Considering that 70 to 90 percent of diagnoses can be determined by a health history alone, innovations that encourage use of PGD will continue to emerge as organizations focus on achieving high quality care outcomes to obtain reimbursement.

In addition, more than 60 percent of patients want to communicate with their providers electronically now, according to an Office of the National Coordinator for Health Information Technology report. Although mobile devices, wearable technology, telemedicine, and mobile applications offer promise for increasing patient engagement and providing a more comprehensive picture of a patient’s health outside of a provider visit, organizations need to establish workflows, stakeholder accountability, patient education programs, and expectations to use the data effectively, securely, and safely.

Where Do You Start?

Using a team approach, below are six essential steps to establish an organization’s readiness to incorporate PGD into the EHR:

  1. Conduct an IT inventory and workflow assessment. Understanding the organization’s IT system bandwidth and determining which apps can be integrated into the EHR is the first step. Managing data storage, provider notification of PGD data entries or requests, IT workflows, as well as establishing interoperability with current systems and apps needs to be in place to efficiently, effectively, and securely use resources to manage data.
  2. Evaluate patient Internet access, mobile app usability, and health literacy to customize education programs. An assessment of Internet access, mobile app usability, health literacy, among other factors that may influence generation of PGD, can determine gaps, areas of remediation, and opportunities. In addition to posting an evaluation tool on the patient portal, patients can be assessed using a survey during the registration process. After survey data is analyzed, education programs can be tailored for different populations (e.g., adolescents, seniors, etc.) to enable patients to record, organize, store, and share data that can influence change.
  3. Create an information governance structure to manage PGD. Identifying what data is needed and how it will be aggregated, stored, interpreted, used, and shared in the EHR involves a multi-disciplinary approach. While the information governance infrastructure can drive the vision of how PGD should and will be used, creating a business intelligence (BI) competency center — which is a cross-functional team that supports and promotes the effective use of BI across an organization — can tactically collect, aggregate, archive, and share data for use. The expertise of clinical, health information management (HIM), informatics, risk management, and library professionals can be valuable in managing PGD.
  4. Adjust workflows and roles to manage information flows. As patients continue to collect and record an increasing amount of information, managing data will involve delegation, as well as require new roles and responsibilities. Technicians, medical assistants, or medical scribes may be well-suited to take on an information management role – such as collecting and summarizing PGD for clinicians – during the intake process so providers can maintain efficient office practices.
  5. Set expectations about use of solicited and unsolicited PGD. Managing information overload is a common challenge for many healthcare providers. Clinicians need to determine what types of data will be useful in informing diagnosis and treatment decisions. Setting limits with other practice providers, organizational leadership, and patients about clinical information use is also needed to consistently and effectively measure, collect, record, and share specific types of data. Expectations should be set with patients regarding the reasonable receipt and review of unsolicited information.
  6. Create resource lists of “certified” apps to prescribe to patients. Providers and healthcare organizations that want to recommend apps to their patients should create a standard list of those that they find useful and that can support their patients.  While this is best managed with an internal team, external sources, such as the HIMSS recommended evaluation sources Happtique (which was recently acquired by SocialWellth) and, can help clinicians select apps that might be useful to patients.

Combining PGD and telehealth innovations can increase patient engagement, accelerate time to arrive at a diagnosis by providing a comprehensive view of patients’ daily activity, and improve treatment compliance. Yet a significant multi-disciplinary undertaking is involved in developing infrastructure, expectations, and education to support how information is collected, shared, analyzed, and used.

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CMS Extends Physician Quality Reporting System Deadline

CMS Extends Physician Quality Reporting System Deadline | EHR and Health IT Consulting |

Recently, the Centers for Medicare & Medicaid Services (CMS) extended the meaningful use attestation deadline for the Medicare EHR Incentive Program for the 2014 reporting year to March 20, 2015. This was implemented in order to give providers more time to submit meaningful use data. In addition to this extension, CMS also prolonged the deadline for Physician Quality Reporting System (PQRS) participation.

The new date for submitting PQRS reporting processes has also been moved to Friday, March 20, 2015 at 8:00 PM. The Healthcare Information and Management Systems Society (HIMSS) explains that the deadline is set specifically for the submission methods certified EHR direct or data submission vendor and the qualified clinical data registries (QCDRs).

The clinical data registries are needed for reporting the clinical quality measurement element of meaningful use as part of the Medicare EHR Incentive Program. Eligible professionals and physician practices receive an incentive payment from CMS if they sufficiently participate and report quality measures information. This is conducted under Medicare Physician Fee Schedule (PFS) services.

PQRS is essentially a program that promotes the reporting of quality data by eligible physicians through incentive payments and payment adjustments. Providers who are looking to begin participating in the PQRS reporting program should first determine whether they are eligible to take part, CMS explains.

The next step to take is to define which reporting method is best for your physician practice. The options available for submitting data to CMS include qualified EHR, claims-based, registry-based, Group Practice Reporting Option (GPRO), and Qualified Clinical Data Registry (QCDR). Additionally, providers should consider each method’s reporting criteria and ensure that they are capable of meeting the requirements.

If a provider chooses qualified registry-based reporting, he or she will need to determine among the reporting options of either individual measures or measures group. Eligible professionals that are using 2014 PQRS individual measures will need to submit nine or more clinically appropriate measures among three National Quality Strategy (NQS) domains. This will allow the participants to qualify for PQRS incentive payments.

Additionally, providers should be aware of the timeframe or reporting frequency requirements for each measure among every eligible patient. The instructions section of each measure specification will include an explanation of the reporting frequency. Staff members will need some training to ensure that they are properly able to capture the data needed for PQRS participation.

Also, it is useful to review information related to the PQRS payment adjustment. It is important to note that eligible physicians who do not meet 2014 PQRS reporting provisions will be subject to a payment adjustment on Medicare Part B PFS services completed in 2016. Those looking to avoid the PQRS payment adjustment should be sure to meet the requirements for satisfactory reporting in the 2014 PQRS or report at least one individual measure through one National Quality Strategy (NQS) domain for a minimum of 50 percent of eligible Medicare Part B FFS patients.

Additionally, providers should be aware that all other PQRS reporting deadlines have not changed and will stay the same.

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Current Solutions to EHR Interoperability Issues

Current Solutions to EHR Interoperability Issues | EHR and Health IT Consulting |

Errors in electronic records, especially those that lead to mistaken identity, as well as EHR interoperability roadblocks can lead to serious risks.

An article in the Journal of AHIMA an incidence that Julie Dooling, RHIA, CHDA,  Director of Health Information Management Practice Excellence at AHIMA, encountered when she went to a doctor’s appointment with her 89-year-old mother to replace a ureteral stent.

The nurse mistook her mother and called her “sister,” as if addressing a nun and then asked if Dooling’s mother ever had knee surgery. While looking at the computer, the nurse had mistaken the patient’s identity.

Dooling figures that it is a copy/paste problem because the nurse showed her the computer screen and the wrong information had disappeared. The healthcare worker deleted the erroneous data.

While EHR systems are improving healthcare delivery across the board, health information management professionals explain that there are still glitches and errors to fix before health IT software runs perfectly in a medical facility. Many fear that implementing EHRs too quickly in an effort to gain meaningful use incentives can lead to more errors in patient data.

Some common causes of these EHR issues are the lack of testing and training available for healthcare staff during the EHR implementation process. Some common problems include copy/paste errors, a lack of EHR interoperability when it comes to information exchange, and other documentation issues.

Another major roadblock is that often physicians within the same practice utilize EHR systems differently due to a lack of training and standardization. Additionally, while many EHRs are able to reach Stage 1 Meaningful Use requirements, many vendors have not set up EHR systems to meet the more complex Stage 2 Meaningful Use regulations, especially those related to patient portals and transition of care conditions.

“If utilization means pushing complex systems into healthcare organizations, then I think we achieved this goal,” said Anna Orlova, PhD, AHIMA’s Senior Director for Standards. “If the goal was using that to support health practices in a meaningful way, we definitely didn’t achieve that goal.”

The health IT industry will need to improve interoperability and information exchange processes in order to allow medical professionals to utilize EHR systems in a meaningful way. From the original example, it is clear that one of the biggest issues with EHRs is the copy and paste function, which – while allowing physicians and nurses to save time by carrying over data from a prior visit – often leads to the wrong information being entered from another patient’s file.

Due to this, it may be more beneficial for patient safety to disable the copy and paste function in EHR systems. While EHR adoption rates have risen quickly, federal government officials find that lack of interoperability is hindering health information exchange (HIE).

Last month, the Office of the National Coordinator of Health IT (ONC) released an Interoperability Roadmap report that may stimulate the improvement of EHR interoperability across the healthcare spectrum. Another solution comes from the nonprofit Commonwealth Health Alliance where a group including EHR vendors, retail pharmacies, and health IT companies are attempting to promote the patient data exchange and ensure easy access to necessary information.

One way to improve data sharing between provider to provider or patient to provider is to develop a standardized way to identify patients. Some options being introduced include the National Patient Identifier tool and the “Innovators in Residence” program to address patient identification and identity matching.

The AHIMA publication concludes by urging the healthcare industry to focus on training staff and enhancing use of EHR systems instead of solely concentrating on technology. Once greater interoperability is achieved, EHRs will bring more concrete benefits to the medical sector.

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Secrets to EMR Success

Secrets to EMR Success | EHR and Health IT Consulting |

Aging services providers generally lag behind hospitals and medical practices when it comes to purchasing and using electronic medical records (EMR) systems, in part because government incentives—and penalties—weren’t implemented with them in mind. As the government and other health system sectors increasingly recognize the vital role that entities traditionally serving seniors play in the care continuum, however, the necessity of EMRs in long-term care settings is becoming a reality. One continuing care retirement community recently shared its EMR selection and implementation experience with those attending a Long-Term Living webinar.

The Jewish Association on Aging (JAA) realized that an EMR system could bring benefits to its CCRC, said Deborah Winn-Horvitz, MS, president and CEO. Among the advantages: enhanced coordination of care thanks to a seamless flow of patient/resident information across its service lines; improved availability, accuracy and reliability of data to enable decision-making and reporting; and enhanced efficiencies leading to cost savings—all resulting in improved quality of life for patients/residents and job satisfaction for staff members. The changing healthcare landscape and requirements related to ICD-10, the IMPACT Act, healthcare information exchange, new payment models, an increased focus on length-of-stay rates and rehospitalizations and other factors converged to convince the CCRC that the time had come to select and implement a system, she added. (Click on the “Go Live” image, upper left, to discover the motivations and information sources of webinar participants implementing an EMR.)

Four main challenges

“Funding was a big challenge for us,” Winn-Horvitz said. The Pittsburgh-area CCRC is a nonprofit, faith-based organization that includes a 159-bed skilled nursing facility; an outpatient rehabilitation center; two personal care facilities with a combined 120 units and including independent living; hospice, palliative care, home health and adult day services; and Meals on Wheels and other community resources.

JAA sought grants from local foundations and contributions from individuals to cover some of the cost of system selection, purchase and implementation, Winn-Horvitz said, and operations will cover some of the cost. Support from the organization’s board was critical, however, she added.

“It’s going to be very important from the beginning to have board participation, so when it comes time for you to be in front of your board asking for support for the EMR, they will have a vested interest in this and have an understanding as to why it’s so important,” she told webinar attendees. Because the JAA board was involved in planning from the beginning and had been educated about the project, she added, members permitted funds from its endowment to cover much of its costs.

A second challenge, Winn-Horvitz said, was ensuring sufficient information technology (IT) support. Before implementation, JAA had outsourced its help desk function to one person. “We really needed to put some type of infrastructure in place,” she said.

At the beginning of the project, the CCRC hired a full-time project manager who had an IT background. As implementation loomed, JAA hired an EMR nurse clinician. “One of the looking-back lessons learned is, I would have hired that EMR nurse clinician earlier in the selection process as opposed to waiting until implementation,” Winn-Horvitz said. The Pittsburgh Regional Health Initiative and Pennsylvania REACH West, a federally funded regional extension center (REC), provided assistance as well, she added. (JAA was one of the first long-term care providers to benefit from REC services, Winn-Horvitz said. Find out how a REC can help you by listening to the webinar, “Transform Your Organization with Information Technology: 5 Steps to Success,” available on-demand through Jan. 22, 2016.)

A third challenge related to JAA’s EMR journey, she said, was upgrading the CCRC’s hardware and networks. What JAA had was “bare-bones minimal and clearly not adequate to support the implementation of an EMR,” Winn-Horvitz said. “And so we ultimately rolled that cost up into the entire implementation.”

Actually selecting the system was a fourth challenge. “We knew what our core components were of our IT strategy,” the CEO said. “We had an idea of what we were looking for—there are, of course, a number of systems out there on the marketplace—but we really didn’t know where to begin in terms of the selection process.”

The LeadingAge Center for Aging Services Technologies (CAST) electronic health records system selection tool also was a “tremendous resource” for discovering systems and analyzing their capabilities, she said. JAA also contracted with a consulting company that specializes in EMR selection. “For the spend that was associated with their assistance, it was very, very insignificant compared with the spend for the whole EMR system,” Winn-Horvitz said. “It was a very, very worthwhile investment for us.”

JAA sought a system that was sustainable, high-performing and compliant with the Health Insurance Portability and Accountability Act. The system had to have mobile accessibility, too, since “physicians prefer to access information either on-the-go or from their offices when they’re not here physically rounding in our facilities,” Winn-Horitz said.

The CCRC narrowed its choices to six, then three, then two products, aided by the LeadingAge CAST tool and information gathered by the consultants. “We did very, very detailed site visits for both of those vendors,” visiting providers that were using the systems, Winn-Horvitz said. The scrutiny also included calls to additional facilities geographically less convenient to visit as well as examination of responses to a request for information.

The consultants calculated the five-year total cost of ownership for the two finalists, including software, hardware, incremental staffing and consulting costs for the implementation, the cost of keeping the CCRC’s current system operating during the change, costs for training the project team during the selection process and training all system users during implementation, costs to convert existing patient data into the new system and costs for interfaces to systems not being replaced.

“Some of these are things that we would not have thought of,” Winn-Horvitz said, “so they were able to put together a very, very comprehensive picture for us of what that total cost of ownership would be for the systems that we were considering.”

Ultimately, JAA chose the HealthMEDX EMR. The company “had a really great track record in terms of a rollout that was pretty standardized at this point in their life cycle, and that really made it much easier for us,” Winn-Horvitz said.

Overseeing the project

At the beginning of the project, she said, JAA and its board established guiding principles and goals for the project as well as committees to see it through. The executive steering had oversight at the highest level and included some board members with IT or project management experience as well as the president/CEO, the chief financial officer and the project manager. The system selection committee included heads of all of the lines of business as well as staff members from the front lines.

“We included CNAs, and we included some LPNs and RNs, because we knew that they were going to be critical not only to helping us understand their challenges on a day-to-day basis but also critical in terms of adoption,” Winn-Horvitz said. “If we were to select a system without them and then kind of force it on them, then that clearly would not go over well.”

Remember to include the medical director in the process as well, she advised.

JAA began implementing the EMR in the first quarter of 2014, and the system went live in the skilled nursing, personal care and independent living areas in July. “It was really a very efficient six-month implementation process, and we were able to go live on time,” Winn-Horvitz said. “We’re scheduled to go live with our home- and community-based services by the end of this calendar year.”

The implementation phase has included several forms of oversight: an executive committee of senior managers; the initial oversight committee from the selection process, which included some board members; an implementation team, including representatives from all levels of the organization; an administrative work group that included staff members in business functions such as billing and collections; a project team, led by the project manager, which addressed technical issues; and clinical work groups.

“We formed the clinical work groups at the time of go-live and have continued them in those areas where we’ve gone live,” Winn-Horvitz said. “They meet on a biweekly basis right now to continue to refine workflows, make changes to the system and work with our vendor partner to continue to refine.”

The clinical work groups also identify where retraining is needed. “It’s not enough to train everyone just once,” Winn-Horvitz said. “You have to tell them, and then tell them again and again.”

As the rollout was set to begin, JAA tried to create a sense of excitement and enthusiasm among all staff members, making it “more than just an IT project,” Winn-Horvitz said. “We actually gave a name to the project. We called it J Care, and we were counting down the days to the launch of J Care at the organization. We had signs up. Everyone knew it was coming.”

The organization identified ‘super users’ who could troubleshoot issues and help their co-workers learn the new system, and everyone knew in advance who the super users were. On the go-live date, those super users wore bright green T-shirts so that they were easily identifiable. “We asked them to wear the T-shirts for the first week of go live so that if anyone had a problem anywhere, they knew where they could find a super user,” Winn-Horvitz said. “All shifts, all over the organization.”

The contingency planning the CCRC had completed ended up being useful during implementation, she added. “When you’re going live with an EMR, everyone knows there’s a chance that something could happen, and as fate would have it, we actually ended up having some issues with our power. We had a number of unplanned power outages probably two weeks into our go live.”

But one of the most important lessons JAA learned in the entire EMR selection and implementation process was the importance of communication, Winn-Horvitz said. “You cannot over-communicate,” she said. “It’s so important to include individuals from all levels of the organization. It makes everyone’s job much easier if everyone really knows what’s going on.”

The CCRC already is reaping rewards from its implementation to date: improvements in quality measure scores; access to real-time information; improved workflows in admissions, finance and nursing; and accelerated cash flow due to full electronic claims submission and payment processing.

Noel Pinero's curator insight, March 3, 11:57 AM

Interesting look at EMR implementation in an ever-widening landscape of healthcare organizations. Several nice references to the role of nurses in this piece as well as a link to a webinar.!

Mobile EHRs forge a patient journey platform

Mobile EHRs forge a patient journey platform | EHR and Health IT Consulting |

As last year wound down, Practice Fusion optimized its electronic health record service for Apple and Android tablets — and, in so doing, joined the growing number of vendors making mobile EHRs.

In addition to the obvious benefits of cutting the proverbial cord and arming clinicians with software tuned to specific devices, mobile-optimized EHRs lay a foundation for providers.

On tap for 2015? Patient check-in.

“Very soon the front office staff will no longer have to get out paper forms,” Practice Fusion CEO Ryan Howard says, stressing that this upcoming Practice Fusion feature would finally cover “every step of the patient journey.” 

Indeed, Practice Fusion revealed online check-in earlier this month and explained that patients will be able to submit insurance information, prescription status, and the reason for their upcoming visit before they even set foot in the doctor’s office. 

The company claimed that its new service will eliminate a quarter-billion pieces of paper this year by replacing the average 3-7 page forms patients complete at the doctor’s office.

Beyond check-in, Practice Fusion will also be looking to gear its cloud-based offering toward medical specialists.

“We’re pretty focused on flow sheets this year and really delivering a lot of functionality for subspecialties,” Howard revealed. 

As far as legislation and regulation go, ICD-10 and telemedicine mandates will be huge in 2015 and key at HIMSS15, Howard says. Meaningful Use Stage 3 will also be entering the fold this year, a fact the industry is hard-pressed to heed given the difficulties currently unfurling with Stage 2.

And EHRs optimized for mobile use will be underlying all of the above, Howard explains.

That’s because patients want mobility as much as doctors do.

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RNs are Choosing Where to Work Based on Hospital EHR

RNs are Choosing Where to Work Based on Hospital EHR | EHR and Health IT Consulting |

I came across this tweet and it made me stop and realize how important the selection and more important the implementation of your EHR will be for your organization. In many areas there’s already a nurse shortage, so it would become even more of an issue if your hospital comes to be known as the hospital with the cumbersome EHR.

Here’s some insight into the survey results from the article linked above:

79% of job seeking registered nurses reported that the reputation of the hospital’s EHR system is a top three consideration in their choice of where they will work. Nurses in the 22 largest metropolitan statistical areas are most satisfied with the usability of Cerner, McKesson, NextGen and Epic Systems. Those EHRs receiving the lowest satisfaction scores by nurses include Meditech, Allscripts, eClinicalWorks and HCare.

The article did also quote someone as saying that a well done EHR implementation can be a recruiting benefit. So, like most things it’s a double edge sword. A great EHR can be a benefit to you when recruiting nurses to your organization, but a poorly done, complex EHR could drive nurses away.

I’m pretty sure this side affect wasn’t discussed when evaluating how to implement the EHR and what kind of resources to commit to ensuring a successful and well done EHR implementation. They’re paying the price now.

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Is your medical practice ready for dual coding?

Is your medical practice ready for dual coding? | EHR and Health IT Consulting |

Although medical practices cannot submit medical claims with ICD-10 codes until Oct. 1, there are a few good reasons to start using them sooner.

Those reasons support dual coding — when healthcare organizations assign ICD-10 and ICD-9 codes simultaneously to medical records.

The advantages include:

  • Medical coders can practice their ICD-10 knowledge
  • Clinical documentation deficiencies are exposed
  • Extensive internal and external testing can be done

This won't be cheap. Systems need to be designed for dual coding. And no matter what your vendor promises, dual coding is extra work. That means there will be a productivity loss. Maybe computer assisted coding (CAC) will help. Costs would be associated with:

  • Added time
  • Maintaining data collection
  • Analyzing data

Medical practices likely will need to assign extra coding resources. Extra medical coders can be hired to cover the dual coders. Healthcare providers need to do a cost-benefit analysis to determine if it's better to hire personnel or accept longer reimbursement cycles.

To get dual coding started, the Centers for Medicare and Medicaid Services (CMS) recommends answering the following questions:

  • Can the practice management system (PMS) or electronic health record (EHR) can capture ICD-9 codes and ICD-10 codes in the same patient encounter?
  • How much dual coding will be done?
    • How often?
    • How many encounters will be processed?
    • Are all diagnoses or just the top X percent of diagnoses are represented?
  • Will the ICD-10 codes be captured in the PMS or EHR system or on paper?

Before dual coding can start, a medical practice should:

  • Upgrade systems so they are ICD-10 compliant.
  • Make sure clinical documentation can support ICD-10 coding.
  • Start ICD-10 training and education.
  • Test with healthcare vendors or payers.

Then start practicing ICD-10 coding on real cases in the medical practice. Chances are that all this time and money will be investments that payoff after Oct. 1.

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EHR Usability Challenges for Clinical Decision Support

EHR Usability Challenges for Clinical Decision Support | EHR and Health IT Consulting |

To live up to its potential, clinical decision support tools should be able to assist clinician EHR users to make the most appropriate evidence-based decisions when treating their patients. Current EHR technology, however, still exhibits signs of growing pains in terms of how clinicians receive these support services.

“That companion, support tool is absolutely appropriate, but there are certain instances where it needs to be a little more forceful,” says Harvard Vanguard urgent physician Erin Jospe, MD, who also serves as Associate Chief Medical Officer at PatientKeeper.

“That is why there should be a range of different types of alerts that a physician gets,” she explains. “There are certain things where it is fine for them to be in line; there are other things where you need a hard stop.”

The fine line is between prescriptive medicine and physician autonomy. EHR developers need to be mindful of the various and varying needs of clinicians when determining how clinical decision support tools and services impact their EHR workflows.

“Understanding the different applications of clinical decision support will allow them to shine,” Jospe maintains. “It’s not going to be a one-size-fits-all approach. In certain areas, just offering evidence links is sufficient — not everybody needs to see it and will go with the recommendation being presented. Other times you think your patient might be the exception.”

According to Jospe, that latter notion is more often than not a common one among clinicians and likely a source of their frustration when clinical decision support becomes implemented into their care delivery.

“We all think that our patients are special and we want to value and respect the individual human person in front of us, she continues. “When we then try to plug that into a rules-based engine, there is a dissonance between those two imperatives — there is a rule and my patient is exceptional. Trying to understand that and allowing for both as appropriate is what EHRs should be striving to do.”

Connecting filtering with EHR usability

A patient’s EHR comprises numerous fields of data, notes, and other bits of information, but in order for a clinician EHR user to be most effective in her care delivery she must be able to identify the most relevant pieces of clinical data.

“The ability to dive into the specific area of information you’re looking for is crucial,” says Jospe. ” You have to be able to find just what you’re looking for either based on what you’re seeing with the patient or idea that you had. Being able to navigate quickly and efficiently to the information you think you need but still be to trace your way back to broader pools of information is the key or at least one of the primary tenets of a good EHR.”

Historically, this kind of EHR functionality has not featured in EHR design. As a former primary care physician, Jospe claims it created struggles for her earlier in her career and still does for others today.

“That was one of my struggles with primary care and the EHR system that I had to be in,” she reveals. “I was responsible for all of the information that I was seeing but understood the context for maybe five percent of it. I wasn’t the ordering provider — there were specialists, things done in the past, etc. — so how to make sense of that is a real burden and it keeps a lot of docs up.”

Echoing EHR usability sentiments recently expressed by Micky Tripathi, PhD, MPP, of the Massachusetts eHealth Collaborative (MAeHC), Jospe foresees future EHR design that enables EHR end-users to filter clinical data based on their needs.

“You have to be able to find just what you’re looking for either based on what you’re seeing with the patient or idea that you had,” she maintains. “Being able to navigate quickly and efficiently to the information you think you need but still be to trace your way back to broader pools of information is the key or at least one of the primary tenets of a good EHR.”

In the context of a physician, that’s the ability to parse the notes of particular colleagues separately or together. “That ability to give control over finding and communicating information — that’s the secret sauce,” adds Jospe.

It’s so exciting that there is data that can be used to predict the direction and trajectory of your patient’s health. Having that brought to your attention as things are changing is really important and that deserves to be moved and flowed up to the top instead of presented as an option to go in that direction.

Returning to clinical decision support, the road ahead for EHR developers is to ensure this technology is a useful touchstone for clinicians of varying types. “It’s a hard balance. There is a fine line between forcing a particular thought pattern and offering some guidance,” says Jospe.

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Why Are So Many Big Health IT Companies from Small Cities?

Why Are So Many Big Health IT Companies from Small Cities? | EHR and Health IT Consulting |

I was reading over something on HIStalk the other day that talked about how many major healthcare IT and EHR companies have come out of small cities. In fact, when you think about the EHR world, there are only a handful of EHR companies that have come out of the tech hub of the world, Silicon Valley, and they’ve all been started within the past 10 years.

In the article HIStalk mentioned the town Malvern, Pennsylvania. I hadn’t even heard of the town, but a look at Wikipedia has Siemens Healthcare, Ricoh Americas, and Cerner as among the companies based in Malvern. I think the Cerner mention in the list must be because Cerner just purchases Siemens Healthcare, so they are now claiming them. However, Cerner is definitely a Kansas City based company. Either way though, Kansas City is not a HUGE city either and certainly hasn’t been the hub of technology (although, I know they have some cool tech things happening now, like most cities).

The healthcare IT behemoth, Epic was founded in Madison, Wisconsin and now has headquarters in Verona, Wisconsin. If you aren’t in healthcare IT, my guess is that you’ve probably never even heard of Verona.

Those are just a few examples and I’m sure there are many more. Why is it that so many of the large healthcare IT companies have come from small cities? Will that trend continue or will large cities like San Francisco, Boston, New York, and LA start to dominate?

I’m a bit of a young buck in this regard. So, I don’t have the answer. Hopefully some of my readers do. I look forward to hearing your thoughts. Is there an advantage to being from a small town when going into healthcare? It’s exciting to me that healthcare innovation can come from anywhere. I hope that trend continues.

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Free iOS App from ADP AdvancedMD Allows Any Physician Practice to Assess ICD-10 Preparedness

Free iOS App from ADP AdvancedMD Allows Any Physician Practice to Assess ICD-10 Preparedness | EHR and Health IT Consulting |

South Jordan, Utah – February 24, 2015– ADP® AdvancedMD, a leader in all-in-one, cloud electronic health record (EHR), practice management, medical scheduling, medical billing services as well as a pioneer of big data reporting and business intelligence for smaller medical practices, today announced the release and availability of AdvancedMD ICD-10 Toolkit, a free app that gives private practices a suite of ICD-10 preparation tools. Now anyone with an iPhone or iPad running iOS8 can easily test their readiness and train staff for the October 1deadline, free of charge. Customers of AdvancedMD practice management software can also leverage the app to add ICD-10 codes to their charge slip templates.

“ADP AdvancedMD has been a leader in the ICD-10 transition process and a champion of independent physicians and small practices, with such tools as, a website aimed at helping medical practices prepare for the ICD-10 transition, featuring a timeline and a wealth of tools, training and tips to help practices prepare for the change,” said Raul Villar, president, ADP AdvancedMD. “With less than half of all practices ready for the change, we saw a need for a tool that would aid the entire community of independent physicians in their progress.”

The app was created as part of the ADP AdvancedMD iCommit program, which offers incentives to engineers for independently pursuing innovations in addition to their regular jobs.

“We decided that there should be a tool to help everyone prepare for the change to ICD-10 and give our community the ability to gauge their readiness,” said Barlow Tucker, software engineer, ADP AdvancedMD. “A free app was the clear choice because it’s easy to access and use, plus it allows people to get an ICD-10 ‘checkup’ at any time.”

The AdvancedMD ICD-10 Toolkit allows users to:

– Track preparedness for ICD-10
– Compare ICD-9 codes with the ICD-10 equivalents, including risk of increased specificity
– View potential high-risk areas
– Search for ICD-10 codes and sub codes
– View articles and action plans to guide a specific transition

Download the new AdvancedMD ICD-10 Toolkit app for iPad®, iPhone®, and iPod Touch® available for free on the Apple app store.

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