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A Digital Health Manifesto: the future of healthcare, possible today

A Digital Health Manifesto: the future of healthcare, possible today | EHR and Health IT Consulting |

It’s easy to get excited about the future of healthcare. Thanks to advances in web and mobile technologies there is tremendous potential to create exciting new health services.  Hundreds if not thousands of apps are being developed that touch on practically all aspects of healthcare, targeting patients-consumers, clinicians, administrators, insurance companies, researchers and healthcare authorities.


Something is clearly happening in healthcare, but a more fundamental question is, will technology enable a radical improvement in the quality, productivity and accessibility of healthcare. It’s an important question because the future of healthcare, from a budgeting and staffing perspective, is in fact not looking good. In most developed nations healthcare costs have been increasing rapidly (and faster than GDP) due to the rising costs of drug development and the increasing prevalence of chronic illness (in turn due to ageing populations). Those cost drivers aren’t about to disappear–and this while the world economy itself is suffering from chronic illness.


The future of healthcare may look exciting from a gadget perspective but there is in fact a real danger that healthcare in many countries will first get worse before it gets better. Hence the importance of the question: will technology-driven innovation be the right medicine, radically improving quality and productivity just when we need it?  Unfortunately, the answer to that question isn’t simple. There are technical issues, legal issues, policy issues and business model issues to address.


However, looking at the state of technology and medical science today, we at HealthStartup Europe do imagine a radically different and vastly improved healthcare experience, especially from a consumer-patient perspective. It is a healthcare experience that should, in principle, be possible today if we found a way to deal with the various obstacles more rapidly.


Let’s call this vision of a better healthcare experience a digital health manifesto (feel free to contribute to the manifesto – comment below or via Twitter and Facebook and we’ll update the text).

A Digital Health Manifesto

1. A transparent market for healthcare services, based on cost, outcomes and reputations

We expect access to a transparent market of healthcare services provided by hospitals, clinics, GPs, psychologist, life/health coaches and so on.  With ‘transparent’ we mean knowing who they are, how (cost)effective they are based on objectively gathered costs and outcomes data and how satisfied their customers/patients are. Ideally, we will be using one of several competing recommendation engines that suggest caregivers and healthcare programs relevant to my current health needs and location.

2. Access to remote/mobile health services

We expect many if not most of our interactions with healthcare providers to be done on a remote basis via online tools. This means we reduce the number of face-to-face interactions (and thus reduce travel, time spent in waiting rooms), while simultaneously increasing the total amount of time ‘connected’ to the healthcare system via remote monitoring technology and diagnostic services. An obsolete reimbursement model and regulatory framework should not be the reason why we have to sit in waiting rooms and neither should it prevent us from gaining access to more frequent and/or ongoing services that can be provided efficiently on a remote basis.  Thus, we expect access to a globally competitive market of remote diagnostic services, including genetic testing, tele-consultations and remote monitoring of health indicators (e.g. cardiac, blood pressure, sleep, etc).  We are willing to give these services access to our medical records and data if it improves their diagnostic and predictive power. And if we are chronically ill (or in need of geriatric care) we expect to stay at home for as long as is medically and technologically possible. We are willing to take more responsibility for our care, if we have the (monitoring/tele-health) tools and information to be able to do so.

3. Access to updated/complete electronic health records, medical knowledge and decision support tools

We expect our care givers to have access to the best and most up to date clinical information and medical decision making tools. These include accurate and always-up-to-date medical records, diagnostic tools, treatment guidelines and research results.  As patients we also expect to have access to such information, as a basis for constructive doctor-patient communication.  We do not tolerate medical errors.  We expect data-driven care; and we expect to have access to that data too.

5. Access to certified personal health record services, devices and wellness apps that integrate with electronic medical records and are accepted by clinicians

We expect access to a competitive market of certified and interoperable personal health record systems, devices and wellness services that can help us achieve our personal health and fitness goals.  ‘Certified and interoperable’ in the sense that these services can plug into clinical medical record systems and are accepted by clinicians. We want to take a more proactive and goal-orientated approach to our health, and we expect our general practitioner to help us in that regard.

6. All my anonymous health data available to researchers

We expect medical researchers and scientists to have access to our health records data – it is our data and it should be put to good (and meaningful) use.

The trouble with health data transparency

It’s disconcerting that the vision described above isn’t yet a reality.  It could be and it should be. The data is out there.  Also, there are thousands of developers and entrepreneurs clamoring to create powerful, user friendly health devices and apps.  The trouble is, a lot of the data while ‘out there’ isn’t yet accessible or being used optimally (meaningfully). Medical records are locked up in closed legacy IT systems. Doctors and hospitals have few incentives to share data and invest in open technologies. Current reimbursement models, privacy legislation and security concerns deter investment in new technologies and new ways of working.  A lack of standards and the fact that most new gadgets and apps are single-purpose products means that we’re not yet seeing powerful ‘ecosystems’ of synergistic products and services emerge.

Where are the platforms?

Looking at the history of recent technological progress it is clear that open standards and APIs (e.g. TCP/IP and HTTP for the web, Apple’s iOS for mobile apps, Facebook’s API for social gaming) have been instrumental in unleashing waves of innovation. Something similar is needed in healthcare. Imagine if developers had access to open or partially open data platforms that link up health/medical records, medical research data/results, treatment guidelines, and body-monitoring data.  The resulting boom in clinical informatics, clinical decision making tools, collaborative EHRs and other ‘Dropbox for health‘ type tools will put us on the path to data-driven care and likely lead to radical gains in healthcare quality and productivity. It will make our digital health manifesto a reality as opposed to a dream.

We all have responsibilities

To get there, all stakeholders in the system have responsibilities:

Policy makers need to focus on standards setting, ‘open data’ services and improved reimbursement systems (creating the right incentives).

Healthcare providers and their IT partners need to start opening up their systems and transition from a document management approach toward a patient-relationship/communication approach.

Medical information publishers such as academic journals and medical associations need to take a more innovative approach to IP and content distribution, so that the world’s medical knowledge is made instantly available to those who need it.

Startups need to think beyond single-purpose products and explore how they can plug into the existing healthcare plumbing and link up with other synergistic developers.

Progress certainly is being made. For example, the US government has introduced legislation to encourage the interoperability of health information while other public authorities are building open data service platforms (e.g. Almere Data Capital/the Dutch Health Hub).

Healthcare providers are taking steps to open up their systems (e.g. the US Department of Veterans Affairs’ blue button initiative).  EHR providers too are beginning to open up their datasets to external developers (e.g. EHR company PracticeFusion is working with Prior Knowledge to open up the dataset to developers and entrepreneurs).  And EHR providers like Avado and PatientsKnowBest are trying to build systems that are more patient-doctor collaboration tools than clinical document management or bill-generating tools.

Startups too are beginning to think about APIs.  For example, data storage and file sharing company FolderGrid is not only focused on building a secure (HIPAA-compliant) system but is also trying to create an open platform on which other IT developers can build.  Makers of body-monitoring gadgets like GreenGooseare releasing APIs so that 3rd party developers can build apps on top of their platform.

And the path to data-driven care is being cleared by companies such as Humedica, Archimedes and Predilytics who are developing advanced analytical and decision-making tools for doctors and providers.

Initiatives such as these are exciting but the digital health revolution, from a data integration perspective, is still clearly in the starting blocks. Many challenges around technology, business models, strategy and policy remain.


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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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CHIME, AMA Support Bill to Revise EHR Incentive Programs

CHIME, AMA Support Bill to Revise EHR Incentive Programs | EHR and Health IT Consulting |

The College of Healthcare Information Management Executives (CHIME) and American Medical Association (AMA) recently expressed their support for the Further Flexibility in HIT Reporting and Advancing Interoperability Act (Flex-IT 2 Act).

The Flex-IT 2 Act serves as a revision of the EHR Incentive Programs. The revisions, put forth by Congresswoman Renee Ellmers, would improve the way in which meaningful use requirements affect healthcare professionals.

On July 30, both CHIME and AMA expressed their support for Flex-IT 2. While both organizations stated that they support the principles of meaningful use and want to see it succeed, they both believed that reforms were necessary in order to make the program effective.

Major concerns about the EHR Incentive Programs involve the fast-paced deadlines and the difficulty healthcare professionals have in meeting them. Physicians believe that the arduous tasks to meet the various stages of meaningful use prohibit them from innovating EHR and providing adequately for their patients.

“Our members believe in the intent and promise of Meaningful Use, but providers and hospitals alike have been hamstrung by its often overly prescriptive requirements,” CHIME said in a public statement.

The bill posits that revisions to the program need to be made before Stage 3 Meaningful Use can move forward. According to a posting on Ellmers’ website, only 19 percent of providers and 48 percent of hospitals have managed to meet Stage 2 Meaningful Use. Before the program can continue, it needs to be altered to make it a more practicable feat for providers to accomplish.

Flex-IT 2 would delay the start of Stage 3 Meaningful Use as well as restructure meaningful use requirements for Stage 3, making them more feasible and less redundant. According to Ellmers’ website, Flex-IT 2 would accomplish five goals:

  • delay Stage 3 until 2017 or until 75 percent of healthcare facilities are able to meet the standards in Stage 2
  • standardize the list of requirements for Stage 3 to make them less repetitive
  • create a 90-day reporting period every year
  • bolster EHR interoperability
  • allow for more hardship exemptions

“As a nurse, I can speak to the fact that a patients’ health and safety must be put first,” Ellmers wrote. “This legislation will ensure that hospitals and providers can effectively share information so they can continue to focus their time and attention to caring for patients.”

CHIME believes Rep. Ellmers’ legislation will fix the primary issues of meaningful use and increase its effectiveness going forward.

“We view the Congresswoman’s legislation as an opportunity to reevaluate and reorient this vital program that will provide the digital infrastructure to support at 21st century healthcare system,” the organization added.

AMA, which believed the cumbersome nature of the meaningful use programs hindered EHR use and interoperability, is also pleased that the legislation will improve interoperability. Through the bill, interoperability will be enhanced via increased sending, receiving, and incorporation of patient data amongst EHRs.

“This important bill addresses many of the fundamental shortcomings in government regulations that have made many EHR systems very difficult to use,” said AMA President Steven J. Stack, MD. “We heard loud and clear from physicians at the AMA’s first-ever town hall meeting on EHRs and the Meaningful Use program that the systems they use are cumbersome, poorly designed and unable to ‘talk’ to each other thereby preventing necessary transmission of patient medical information.”

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Maximizing Your EHR: 5 Strategies

Maximizing Your EHR: 5 Strategies | EHR and Health IT Consulting |

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

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

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

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

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

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

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

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

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How Does Your EHR Vendor Solve Challenging Situations?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Senate to Recommend Pausing “Dreaded” Stage 3 Meaningful Use

Senate to Recommend Pausing “Dreaded” Stage 3 Meaningful Use | EHR and Health IT Consulting |

Stage 3 Meaningful Use may be put on hold if recommendations from a hearing today on interoperability and information blocking are brought to HHS Secretary Sylvia Burwell.

The Senate Committee on Health, Education, Labor, and Pensions (HELP), chaired by Senator Lamar Alexander (R-TN), heard comments from several health data experts, including hospital leaders and EHR vendor representatives, who explained the obstacles facing the healthcare industry as it attempts to break down data siloes and integrate electronic health records into a seamless care continuum focused on health information exchange.

Senator Alexander, skeptical that the industry can overcome the many barriers to true interoperability, including active information blocking, expressed frustration about the questionable impact of the EHR Incentive Programs on the ability of healthcare organizations to provide safe, quality, effective care.

“If I found myself suddenly at the Vanderbilt University Medical Center emergency room and the doctors there wanted to get my paperwork from the hospital and doctors I usually use —information blocking means that there is some obstacle getting in the way of my personal health information getting sent to them,” Alexander said.

“This could happen a few different ways: My usual hospital refuses to share my information. The electronic systems at both hospitals don’t talk to each other. My usual hospital says it will charge Vanderbilt a huge fee to send my electronic records. My usual hospital says it can’t share them for privacy reasons. Or, my usual hospital won’t send them because they cite concerns about data security.”

While HHS has spent more than $30 billion since 2009 on the meaningful use program, attempting to get providers to adopt EHRs and exchange data between business partners, the results have been less than satisfactory, according to many lawmakers.  After CMS released the proposed Stage 3 Meaningful Use criteria in March, stakeholders across the industry have criticized the framework for being too ambitious for providers to cope with.

“[A] hospital told me that Stage 1 and Stage 2 worked ‘okay,’ but they were ‘terrified’ by Stage 3,” Alexander said during the hearing.  “My instinct is to say to Secretary Burwell, 'Let’s not go backwards on EHRs, but let’s not impose on physicians and hospitals a system that doesn’t work, in which they spend most of their time dreading.’  Half the doctors are now paying penalties rather than participating.  We want something that physicians and hospitals buy into that helps patients, rather than something that they dread.”

During a news conference after the hearing, Alexander said that putting Stage 3 Meaningful Use on hold would be among his recommendations to the administration.  While Alexander stressed that “no one wants to turn back” on EHR adoption, Stage 3 may not be the most effective way to bring better health IT use into the nation’s varied and complex healthcare system.  

Alexander has been one of the most vocal proponents for “rebooting” the meaningful use system and retooling legislation to better meet the needs of providers who are not able to successfully attest to the program.

The Senate HELP Committee has held four hearings on the progress and pitfalls of the EHR Incentive Programs.  Staffers have also been meeting regularly with healthcare experts and representatives from the administration to work on strategies that will help to improve meaningful use for providers.

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Why Not "Meaningful Interoperability" For EMR Vendors?

Why Not "Meaningful Interoperability" For EMR Vendors? | EHR and Health IT Consulting |

At this point, arguably, Meaningful Use has done virtually all of the work that it was designed to do. But as we all know, vendors are behind the curve. If they aren’t forced to guarantee interoperability — or at least meet a standard that satisfies most interconnectivity demands — they’re simply not going to bother.

While there’s obviously a certification process in place for EMR vendors which requires them to meet certain standards, interoperability seemingly didn’t make the cut. And while there’s many ways vendors could have shown they’re on board, none have done anything that really unifies the industry.

PR-driven efforts like the CommonWell Alliance don’t impress me much, as I’m skeptical that they’ll get anywhere. And the only example I can think of where a vendor  is doing something to improve interoperability, Epic’s Care Everywhere, is intended only to connect between Epic implementations. It’s not exactly an efficient solution.

A case in point: One of own my Epic-based providers logged on to Care Everywhere a couple of weeks ago to request my chart from another institution, but as of yet, no chart has arrived. That’s not exactly an effective way to coordinate care! (Of course, Epic in particular only recently dropped its fees for clinical data sharing, which weren’t exactly care coordination-friendly either.)

Increasingly, I’ve begun to think that the next stage of EMR maturation will come from some kind of “Meaningful Interoperability” incentive paid to vendors who really go the extra mile. Yes, this is iffy financially, but I believe it has to be done. As time and experience have shown, EMR vendors have approximately zero compelling reasons to foster universal interoperability, and perhaps a zillion to keep their systems closed.

Of course, the problem with rewarding interoperability is to decide which standards would be the accepted ones. Mandating interoperability would also force regulators to decide whether variations from the core standard were acceptable, and how to define what “acceptable” interoperability was. None of this is trivial.

The feds would also have to decide how to phase in vendor interoperability requirements, a process which would have to run on its own tracks, as provider Meaningful Use concerns itself with entirely different issues. And while ONC might be the first choice that comes to mind in supervising this process, it’s possible a separate entity would be better given the differences in what needs to be accomplished here.

I realize that some readers might believe that I’m dreaming if I believe this will ever happen. After all, given the many billions spent coaxing (or hammering) providers to comply with Meaningful Use, the Congress may prefer to lean on the stick rather than the carrot. Also, vendors aren’t dependent on CMS, whose involvement made it important for providers to get on board. And it may seem more sensible to rejigger certification programs — but if that worked they’d have done it already.

But regardless of how it goes down, the federal government is likely to take action at some point on this issue. The ongoing lack of interoperability between EMRs has become a sore spot with at least some members of Congress, for good reasons. After all, the lack of free and easy sharing of clinical data has arguably limited the return on the $30B spent on Meaningful Use. But throwing the book at vendors isn’t going to cut it, in my view. As reluctant as Congressional leaders may be to throw more money at the problem, it may be the only way to convince recalcitrant EMR vendors to invest significant development resources in creating interoperable systems.

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From ICD-9 To ICD-10

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

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

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

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

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

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

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

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

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


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

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EHR Vendors Lag Behind in EHR Interoperability, Usability

EHR Vendors Lag Behind in EHR Interoperability, Usability | EHR and Health IT Consulting |

The current development approach of most EHR vendors in is unsustainable and warrants a serious reconsideration of the value of application programming interfaces (APIs), according to new research from Chilmark Research.

"Routinely referred to as 'platforms'” EHRs fail to live up to today’s common understanding of the term. Data-sharing within and across organizations is carefully controlled and difficult to implement without vendor approval and support," states the latest Chilmark Research Insight Report. "Consolidating functionality across products or organizations is impossible. Each customer of each EHR vendor develops software that should be usable elsewhere but is not."

EHR vendors have perceptions of their technology that do not match those of their end-users.

"Most of the major vendors regard their core clinical systems as comprehensive and inviolable — few readily admit that provider demands are broader than existing EHR feature sets," the authors of the report go on to explain. "This stance glosses over the functional gaps, disorganized clutter, and general lack of usability in EHRs."

This closed approach to EHR development is beginning to become more and more glaring as healthcare organizations and providers adapt to the shift away from fee-for-service to value-based reimbursement where health information exchange an emerging necessity.

Opening up their systems has some EHR vendors concerned. "A prevailing view in HIT has been that opening applications to developers increases the risk that customers could more readily migrate to a competitor. Many HIT vendors fear that the data in their applications, if made more readily accessible via APIs, will flow to a competitor’s product," the report states.

An obstacle in the way of increasing data liquidity in healthcare is the limited adoption of API-based access to health data.

"Vendors and their customers have had to employ a dizzying array of sanctioned and clandestine methods and technologies to extract data from EHRs," the authors maintain. "There are exceptions, but no major HIT vendor can support anything like the API infrastructure needed to cultivate the third-party application ecosystem that general-purpose B2B and B2C application vendors provide today."

According to the report, the Fast Healthcare Interoperability Resource (FHIR) is the leading candidate for bringing API-based access to data to the healthcare industry:

The main advantages of FHIR are its relative programming simplicity and better support for discrete data access. It promises to be an easier way for programmers to use and consume healthcare data than existing HL7- and CDA-based exchange mechanisms. Every major HIT vendor expresses strong to full-throated enthusiasm for FHIR and its potential benefits. However, FHIR is still a draft standard and does not figure prominently in any HIT vendor’s near-term product plans.

The authors of the report to caution against putting too much stock in FHIR, but they do indicate that there is a "seeming inevitability of adoption" given the number of publicly available FHIR servers

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New Privacy Threats in Healthcare?

New Privacy Threats in Healthcare? | EHR and Health IT Consulting |

Privacy advocate Deborah Peel, M.D., is worried that several ongoing healthcare sector initiatives, including the emphasis on nationwide, interoperable health information exchange, provisions of the21st Century Cures bill, and a push for a national unique patient identifier, could erode patient privacy and individuals' control over their records.

Electronic health records systems, and databases that store massive amounts of data on millions of patients, have "created a situation where our absolutely most sensitive information is at the greatest risk of all personal information," says Peel, founder and chair of advocacy group, Patient Privacy Rights, in an interview with Information Security Media Group.

"And on top of that, as Congress has woken up and found out, your doctors are not getting the information they need [for treatment]. That was the whole purpose of having an electronic health record system, and it's failed miserably. ..."

Peel's concerned that the intensifying focus on improving electronic health records interoperability and nationwide data sharing, in an effort to ease access to treatment information, could lead to more hacker attacks as well as insider breaches.

Plus, she opposes proposed changes to the HIPAA Privacy Rule included in the 21 Century Cures bill, which the House recently passed and sent to the Senate. Those changes would allow healthcare entities to disclose patient data to other healthcare entities or business associates for research purposes without patient authorization.

"The point of the medical record is to help the physician take better care of you," She says. "Who goes to the doctor to join endless numbers of hidden 'research projects'? I don't know anyone who does."

Patients need to have more control over collection and storage of their own health information, she says, and they should be given the opportunity to approve the use of their records in research projects.

Unique Patient IDs

Peel also is concerned about renewed calls by some healthcare industry associations, including the College of Healthcare Information Management Executives, for Congress to re-examine its long ban on the creation of a national unique patient identifier

When Congress passed HIPAA in 1996, the law called for the creation of a unique health identifier for individuals. But in response to privacy concerns, Congress in 1999 passed a law prohibiting federal funding for the identifier. However, some healthcare IT leaders say some sort of ID is more critical than ever in facilitating secure national health information exchange and ensuring patient record accuracy in the wake of mass adoption of electronic health record systems.

But Peel fears a national patient identifier would open the door for more invasions of privacy. "The rationale for a unique patient ID is exactly the same as the rationale of a Social Security number. It was supposed to be used for one purpose. And what happened to the Social Security number? It's used as a national ID for everywhere, and it allows all kinds of people to collect information about you from everywhere."

Peel, a practicing psychiatrist and psychoanalyst, is founder and chair of the advocacy group Patient Privacy Rights. Peel became active in privacy rights at the federal level in 1993. She advocated first as an individual and later on behalf of state and national medical specialty organizations for patient control of access to medical records. She has made multiple presentations at national panels and Congressional briefings.

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Approaching an ICD-10 Implementation with Confidence

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

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


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


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


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


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


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


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


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


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


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


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

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


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

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

Medical Practice Organizational Structure | EHR and Health IT Consulting |

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

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

There are six key aspects of an organization chart.

1. Division of work.

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

2. Line of authority.

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

3. Flow of authority.

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

4. Span of control.

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

5. Delegation and decentralization.

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

6. Departmentalization.

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

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AMA docs fed up with EHR woes

AMA docs fed up with EHR woes | EHR and Health IT Consulting |

When it comes to EHRs, many docs are more frustrated than ever. And they let that be known Monday at an American Medical AssociationTown Hall, bringing their EHR challenges and experiences to the fore.

"We know there are many frustrations with electronic health records," began AMA President Steven J. Stack, MD, in a July 20 AMA Town Hall in Atlanta. "They have so much potential to improve healthcare, improve quality, improve our efficiency, improve patient engagement, and yet that's not the current state of reality," he added. "Our experience as physicians is often falling far short of the promise that I think we all hope we eventually reach."

Stack called on participating AMA Town Hall members to bring their stories – the good, the bad and the ugly – of their EHR experiences, so they could send a "clear message" to policymakers on Capitol Hill regarding what's working and what needs serious re-working.

The physician voices in the room were overwhelmingly negative, with many docs citing decreased efficiency, less time with the patient and considerable ongoing expenses as a big part of the problem.

One physician, Melissa Rose, a pulmonary critical care and sleep practitioner, was among those sharing their experiences. Rose, who works in a three-physician practice, was an early adopter of EHRs in 2006. And since then, the challenges have been overwhelming. It's "very costly," she said. "I am still paying a huge amount.

"It's slowed our productivity dramatically," she explained. "Every time they have more regulations, more things I have to answer takes time away from the patient."

Rose then detailed an account of what it's like when the Internet goes out at the practice, which is not altogether uncommon. When the Internet goes down, "you're stuck," she said. Even switching to Comcast didn't help Rose and her team. "You have a slight blip in the Internet connection, and you have to sign back in" to the system, she said. And because they're a small medical practice, they've outsourced their IT department, making it difficult to deal immediately with server issues.

Despite the crux of her woes being attributed to EHRs, they're not all bad news, she acknowledged. "The e-prescribing is awesome," she said, easily the "best part" of electronic health records.

Vinaya K. Puppala, MD, an Atlanta-based anesthesiologist, also spoke at the Town Hall Monday. Puppala, who works at Alliance Spine and Pain Centers, a 17-doc practice, says his biggest problem with EHRs is that they were not designed for the patient. "Most systems being designed today are not designed (for clinical care)," he said. "It's set to comply with the federal regulations as opposed to actual physician patient care."

Puppala's concern is that with meaningful use and EHRs, there's been a shift in medicine away from physicians acting as clinical decision makers toward being "data miners." And with that, is the accompanying decrease in efficiency which ultimately detracts from patient care. 

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EHRs and Patient Portals: Key Contract Considerations

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

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

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

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

If you are looking for an EHR:

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

If you are looking for a portal:

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

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

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

Key Big Data Challenges Providers Must Face

Key Big Data Challenges Providers Must Face | EHR and Health IT Consulting |

Everybody likes to talk about the promise of big data, but managing it is another story. Taming big data will take new strategies and new IT skills, neither of which are a no-brainer, according to new research by the BPI Network.

While BPI Network has identified seven big data pain points, I’d argue that they boil down to just a few key issues:

Data storage and management:  While providers may prefer to host their massive data stores in-house, this approach is beginning to wear out, at least as the only strategy in town. Over time, hospitals have begun moving to cloud-based solutions, at least in hybrid models offloading some of their data. As they cautiously explore outsourcing some of their data management and storage, meanwhile, they have to make sure that they have security locked down well enough to comply with HIPAA and repel hackers.

Staffing:  Health IT leaders may need to look for a new breed of IT hire, as the skills associated with running datacenters have shifted to the application level rather than data transmission and security levels. And this has changed hiring patterns in many IT shops. When BPI queried IT leaders, 41% said they’d be looking for application development pros, compared with 24% seeking security skills. Ultimately, health IT departments will need staffers with a different mindset than those who maintained datasets over the long term, as these days providers need IT teams that solve emerging problems.

Data and application availability: Health IT execs may finally be comfortable moving at least some of their data into the cloud, probably because they’ve come to believe that their cloud vendor offers good enough security to meet regulatory requirements. But that’s only a part of what they need to consider. Whether their data is based in the cloud or in a data center, health IT departments need to be sure they can offer high data availability, even if a datacenter is destroyed. What’s more, they also need to offer very high availability to EMRs and other clinical data-wrangling apps, something that gets even more complicated if the app is hosted in the cloud.

Now, the reality is that these problems aren’t big issues for every provider just yet. In fact, according to an analysis by KPMG, only 10% of providers are currently using big data to its fullest potential. The 271 healthcare professionals surveyed by KPMG said that there were several major barriers to leveraging big data in their organization, including having unstandardized data in silos (37%), lacking the right technology infrastructure (17%) and failing to have data and analytics experts on board (15%).  Perhaps due to these roadblocks, a full 21% of healthcare respondents had no data analytics initiatives in place yet, though they were at the planning stages.

Still, it’s good to look at the obstacles health IT departments will face when they do take on more advanced data management and analytics efforts. After all, while ensuring high data and app availability, stocking the IT department with the right skillsets and implementing a wise data management strategy aren’t trivial, they’re doable for CIOs that plan ahead. And it’s not as if health leaders have a choice. Going from maintaining an enterprise data warehouse to leveraging health data analytics may be challenging, but it’s critical to make it happen.

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Avoid Inadequate Use of Patient Portals

Avoid Inadequate Use of Patient Portals | EHR and Health IT Consulting |

An area where many physicians stumble with technology, says osteopathic physician Saroj Misra, is not using the patient portal to its fullest capacity; a feature which is built right into the EHR in most cases. Aside from being a meaningful-use requirement (patients must engage with their physicians through the patient portal) a portal can offload a good portion of the front-end work for staff and physicians — such as direct messaging with the physician and staff, prescription refill requests, scheduling and canceling appointments, and viewing lab and imaging results. 

Also, interacting with the patient portal module of an EHR allows physicians to incrementally add in new technical capabilities, says Tom Giannulli, chief medical information officer for EHR vendor Kareo, helping them to take a step-wise approach to EHR use and implementation. "Physicians can incrementally add new capabilities to their clinical automation effort by learning and applying new functional modules that are available in any modern EHR," he says.

Despite the advantages of using a patient portal, medical practices say they struggle with encouraging patients to engage with their physicians online. In the 2015 Physicians Practice Technology Survey, 53percent of respondents said their practice has a patient portal, yet of that group, 63 percent said their greatest challenge was "getting patients to sign-up/use the portal."

Marissa Rogers, a family medicine residency program director at Genesys Regional Medical Center in Burton, Mich., says her clinic has an additional challenge when it comes to the portal: a large, inner-city patient population that doesn't have consistent access to computers. 

"The hardest part [of portal implementation] is getting patients engaged with the portal. ... We can get the right percentage signed up and get them active in the portal. But keeping them engaged in it, relooking at things, or making sure they are checking on … labs or sending a message, that part is hard."

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Impact of DoD EHR Modernization Contract on EHR Vendors

Impact of DoD EHR Modernization Contract on EHR Vendors | EHR and Health IT Consulting |

Prime contractor Leidos and its partners Cerner and Accenture are the big winners of the DoD Healthcare Management System Modernization (DHMSM) contract — the DoD EHR modernization project — but they are not the only ones to benefit from the award.

According to Black Book Managing Partner Doug Brown, the DoD's contract award also has positive implications for EHR vendors not named Epic Systems. Allscripts is one such example.

"The biggest upside will definitely be for Allscripts on the announcement.  Allscripts may have been the underdog in the bid against Cerner and Epic, but Allscripts has the experience of large system clients, complex system implementations, internal resources, and satisfied customers," Brown maintains. "Most importantly, Allscripts also has earned a reputation as an interoperability leader and acquired strategic companies to support population health and revenue cycle management."

Moreover, Cerner's preoccupation with the DoD EHR modernization and Epic's need to rebound from the loss should give Allscripts a leg up in competing with the two EHR vendors on future contracts,

"The spoils of Cerner being consumed with DoD, and Epic losing credibility with the contract loss will undoubtedly go to Allscripts," claims Brown. "That would put Allscripts on the radar screen of some large hospitals and multispecialty physician clinics in current replacement mode."

Brown also sees opportunity for McKesson as a result of the federal agency's decision. "McKesson also stands to gain share back, as it emerges back on the scene from recent EHR system make-overs for its efforts that augment EHR much like Allscripts in interoperability, population health and revenue cycle," he adds.

As for the negative impact of the DHMSM award, Brown foresees difficulties for EHR vendors not aligned with the CommonWell Health Alliance:

Any EHR vendor or support system that does not participate in the CommonWell alliance is likely going to be assessed as outside the innovative interoperability ramp up and lack opportunities in the replacement market.  Epic has rejected the invitation of CommonWell which consequently decreased the satisfaction scores of its own Epic users in Black Book polls over the past 2 years. 

In fact, all the Cerner’s alliance partners in the CommonWell consortium intensely focused on interoperability all stand to gain inclusion in sales opportunities dominating by Epic and Cerner of late.  This includes the current decision making statuses of many Siemens and NextGen clients struggling with vendor replacement choices.

The cross-vendor CommonWell initiative, in which only 24% of providers put only little stock in a year ago, has experienced an upsurge in credibility and reliability as 84% of CommonWell members report last month success rates with highly complex data sharing overall, and 94% report success with common interfaces.  Epic Systems and NextGen faired far less (below 50%) successful record transactions across different platforms.

As for the rationale behind the DoD awarding the EHR modernization project to Leidos et al., Brown argues that it all came down to interoperability. "Cerner’s demonstration of wide-ranging provider interoperability on multiple, different platforms were the huge differentiator over Epic’s garden-walled methodology to system user data sharing," he states.

What also didn't help Epic were its customer satisfaction compare to Cerner and its reliance on consultants for large-scale EHR implementations.

"Cerner is known to their new clients as dedicated their best minds and internal staff into complex implementations, so report clients, with firm control of how Cerner orchestrates their bigger projects. Epic have also failed to convince the provider community outside full Epic regional networks that wide-spread connectivity is achievable," says Brown.

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Senate Committee Tackles EHR Interoperability, Data Blocking

Senate Committee Tackles EHR Interoperability, Data Blocking | EHR and Health IT Consulting |

The Senate Committee on Health, Education, Labor & Pensions continues probing into the obstacles in the way of achieving the promise of health IT with a focus on EHR interoperability and information sharing during hearing Thursday.

In his opening remarks, Chairman Lamar Alexander (R-TN) highlighted a variety of reasons in his own experience as a patient why health information exchange (HIE) is limited between providers — ranging from competitive and technical reasons to concerns about health data privacy and security.

This remains the cases despite the tens of billions of dollars disburse to eligible professionals and hospitals participating in the EHR Incentive Programs and demonstrating meaningful use of certified EHR technology (CEHRT).

"But interoperability—this communication between systems that is so critical to the success of electronic health records—has been difficult to achieve," Alexander explained. "Information blocking is one obstacle to interoperability, and I’m interested in hearing today from the witnesses the extent to which this is a problem – and the extent to which the government may share in the blame."

Alexander also referred to a health information blocking report to Congress prepared by the Office of the National Coordinator for Health Information Technology as its conclusion that Congressional intervention is required to ensure the exchange of health information — although he conceded the difficulties associated with this task.

"But this is not the only view of the practice -- some view information blocking as rational competitive practice by for-profit businesses in a competitive health care industry," he maintained. "In other words, why would a hospital and physician network make it easy for a patient to go out of their network when that is against their business interests?"

DirectTrust President and CEO David C. Kibbe, MD MBA, was one of four witnesses called to testify before the Senate committee. He supported the ONC's conclusion while at the same time recognizing the role of the private sector in advancing EHR interoperability and HIE.

“While the responsibility for assuring secure interoperable exchange resides primarily with the health care provider organizations, and not with the EHR (electronic health record) vendors nor the government, I strongly believe there is a role for government to encourage and incentivize collaborative and interoperable health information exchange,” he testified.

Kibbe's testimony included four activities that the federal government could undertake to promote information sharing:

• Continue to shed light on these problems, and work with trade groups, standards and policies organizations, and others to set expectations for interoperability of EHRs and other applications certified as interoperable, especially those that have been federally subsidized within the Meaningful Use programs.

• Bring better and improved EHR certification processes forward beyond the testing laboratory so that the utility and usability of interoperability features of ONC certified EHR products in the field becomes part of the public record, and can be used in purchasing decisions.  Collaboration and partnership with non-profit trade groups to achieve this goal would be advisable.

• Accelerate federal agency use of and demand for open, standards-based interoperable HIE (health information exchange) with private sector providers and provider organizations, thereby removing reliance on paper-based mail, fax, efax and courier for these federal programs. 

Examples include Veterans Health Administration referrals to and from private sector medical practices and hospitals; Veterans Benefits Administration health information exchanges with private sector medical practices and hospitals; the use by Medicare, Medicaid, and state agencies of interoperable HIE for communications with private sector providers and provider organizations for limitation of fraud, payment adjudication, claims attachments requests, and other administrative transactions now done via fax and mail.

• Continue to tie more robust ONC EHR certification and use of certified EHR technology to participation in Value Based Purchasing programs, wherein interoperability and collaboration across multiple organizations in multiple-vendor environments is financially rewarding to providers and their health IT vendors.  Demand for collaboration and interoperability is best driven by underlying business models and business cases supported by regulation and oversight.

According to Kibbe, at the heart of the issue of information blocking is an inherent unwillingness to exchange health data that came about as a result of fee-for-service and similar reimbursement models that reward information hoarding.

"Changes to these payment incentives could do much to reward business models where collaboration and interoperability are highly valued, and where the technological capabilities, standards, and infrastructure for interoperable health information exchange now in place would be put to much better use,” he concluded.

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

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

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

Smartphones have changed everything.

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

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

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

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

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

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

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

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

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

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Is the DoD EHR Modernization Project Destined for Failure?

Is the DoD EHR Modernization Project Destined for Failure? | EHR and Health IT Consulting |

The Department of Defense is approaching nearer a decision for $11-billion EHR modernization project. A spokesperson for the DoD told Politico that the decision would be announced at the end of July, which is this Friday.

With the decision looming, it provides an opportunity to recall a criticism of the project made earlier this year by Lexington Institute's COO Loren Thompson, PhD.

In a March contribution to Forbes, Thompson deplored the language used by proponents of the DoD Healthcare Management System Modernization (DHMSM) to justify the $11-billion project, which the federal agency is poised to award later this month.

According to Thompson, the DoD's EHR modernization project will not resolve the federal agency's difficulties with EHR integration, interoperability, and information sharing.

"No doubt about it, the project managers understand how to speak the language of acquisition reform," wrote Thompson. "However, a close look at what their site proposes to do for the 9.6 million active-duty warfighters and dependents in the military healthcare system reveals that this effort is going to fail. It will probably be better than what it replaces, but it will lag far, far behind the kind of performance that users of internet-based technologies have come to expect."

According to Thompson, the DoD EHR modernization is likely to fail because of its aim to implement a "state-of-the-market" and "off-the-shelf" EHR technology. "In other words, it is seeking to acquire an electronic health record system that already exists in an industry noted for its antiquated approach to the movement of information," he adds.

The experience meaningful use–eligible professionals and hospitals have encountered in adopting certified EHR technology was proof-positive to Thompson that the DoD's commercial EHR implementation will be similarly mired in EHR integration quagmires:

"Some major medical complexes have paid over a billion dollars to install their enterprise systems, and yet still have to pay high fees to move information beyond the boundaries of their in-house information systems. Thus, the Obama-era incentives have promoted digitization in healthcare without promoting integration. In some ways, the system is more balkanized now than it used to be, because the cost and complexity of the installed technology deters sharing."

Another stumbling block, claimed Thompson, is the duration of the EHR modernization project.

"The business model the program is pursuing resembles a proprietary enterprise software system of the sort that many major hospitals have installed," he explains. "Sounds like vendor lock to me."

Whatever the decision by the DoD, its repercussions will be felt throughout not only the federal agency and its partners in the federal government but also the EHR and health IT marketplace. The winner of this highly coveted contract can likely hang his hat on being at the top of the food chain from a health IT perspective.

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UMass Memorial Chooses Epic Systems for EHR Replacement

UMass Memorial Chooses Epic Systems for EHR Replacement | EHR and Health IT Consulting |

In a July 20 blog post, the President and CEO of UMass Memorial Healthcare Dr. Eric Dickson announced that the hospital will be changing their electronic heath record (EHR) systems software to Epic. The decision, Dr. Dickson wrote, came after an extensive survey of various EHR systems performed by an expansive taskforce at the hospital.

“We can’t expect you to make UMass Memorial Health Care the best place to give care and the best place to get care if we don’t give you the best electronic health record (EHR) system available and so you will have it – Epic is coming,” he wrote in his post.

The taskforce, led by Drs. Bill Corbett and Matthias Walz, set out to determine which EHR system would be best at UMass Memorial Healthcare. According to the blog post, Dr. Dickson was looking for one that was “more dependable, user friendly and better integrates all the information our caregivers need to provide the highest quality care possible for our patients,” he wrote.

Throughout the post, Dr. Dickson emphasized that his staff and the members of the task force were instrumental in selecting the new EHR systems, stating that the decision to sign a contract with Epic came down to the task force’s preferences.

“Why Epic? It basically came down to one thing: hundreds of our caregivers tested the options available to us and they resoundingly selected Epic as the best system,” the post reads. “More importantly,” he continues,” when surveyed, a majority of our caregivers strongly preferred Epic to its competitor and during our demonstration sessions attendees indicated a strong preference for Epic.”

Dr. Dickson continued his post to boast the many accolades Epic has accumulated, including a Best in KLAS recognition for Software Suite and Physician Practice Vendor. He also expressed that it was unequivocally the task force’s top choice for the hospital’s new software system.

Being that quality patient care is the primary concern of UMass Memorial Healthcare, Dr. Dickson expresses his excitement that their new EHR systems will allow the hospital to provide that quality care with greater ease by providing an integrated system that “enables enhances coordination of care across the entire continuum; enhances communication among all care providers and their patients; offers complete and accurate information for each care provider and their patients; improves patient experience and patient privacy controls; provides population health management tools,” the post reads.

Signing a contract with Epic, which Dr. Dickson refers to as “one of the most important contracts [he has] signed since becoming CEO two-and-a-half years ago,” allows UMass Memorial Healthcare give the best care to its patients, he writes in his post.

Dr. Dickson concludes by thanking those who participated in the taskforce which led him to choosing Epic, providing a list of their names at the bottom of the post.

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Awarding of DoD EHR Modernization Contract Forthcoming

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

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

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

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

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

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

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

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

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

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

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

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

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Managing a Successful EHR Implementation Extension Program

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Preparing the Nonclinical, Non-Coder for ICD-10

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

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

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

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

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

Revenue Cycle

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

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

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

1. The patient calls to schedule an appointment.

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

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

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

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

6. The claim is sent to the payer.

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

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

9. The patient pays the balance on her account.

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

The revenue cycle process is complete for that patient encounter.

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

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

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

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

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

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

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

Structuring Training

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

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

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

• The differences between the two classification systems.

• The impact on various physicians and healthcare positions.

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

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

• A question-and-answer session.

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

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

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

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

• Process flow changes, if any.

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

• Updated fee tickets with ICD-10 codes.

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

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

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

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Latest ICD-10 Developments and What Physicians Should Know

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

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

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

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

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

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

The takeaways for physicians include:

• Utilize the resources available through the AMA and CMS;

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

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

• Be as specific as possible in medical documentation.

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Frustration with Stage 3 Meaningful Use Continues to Build

The long wait for the publication of the final rule for Stage 3 Meaningful Use is allowing for frustration to build before these meaningful use requirements are ultimately enacted.

According to Brookings Institution Fellow Niam Yaraghi, the proposed objectives for this next phase of the EHR Incentive Programs will made success unachievable for eligible professionals and hospitals because the onus is not on these providers alone.

"That is, if other providers do not send electronic summaries, the medical provider who was supposed to receive them will fail to meet the second and third requirement," he writes.

"This scenario is very likely to happen," Yaraghi continues, "Roughly a quarter of physicians have attested to the second stage of the program. This tech-savvy minority is already sharing a large portion of their patients with other providers who were not able to meet the second stage of meaningful use, and thus are likely unable to send electronic care summaries."

Yaraghi contends that another significant problem is working against the EHR Incentive Programs, which is the lack of meaningful exchange of health information:

The main advantage of electronic exchange over paper exchange is that complete patient information will be available to medical providers whenever they need it. Completeness of records and timeliness of access are the two key advantages of the electronic exchange; the objectives defined in stage three of this program fail to address both of them. Instead, after implementing the proposed rules, the completeness of the records depends on patients' ability to recall their previous providers and the willingness of other providers to send care summaries. The timeliness of access to such records depends on other providers' availability and responsiveness.

Researchers are not the only individuals becoming frustrated with the direction and progress of meaningful use. The American Medical Association (AMA) in conjunction with the Medical Association of Georgia (MAH) held a town hall on Monday evening, calling on physicians to demand a reboot of the program.

"Government requirements have twisted EHR technology so it interferes with face-to-face discussions with patients, requires physicians to spend too much time performing clerical work and creates new costs that divert resources away from patient care improvements," the associations said in a joint statement prior to the event. "Meanwhile, the much anticipated benefits of being able to share important patient health care information electronically among providers in different settings have gone unfulfilled."

The town hall coincides with AMA's launch of a new campaign with the purpose of postponing the finalizing of Stage 3 Meaningful Use requirements, dubbed Break the Red Tape.

The campaign's website highlights physician EHR dissatisfaction a prime motivator behind championing for delaying Stage 3.

"Physicians are frequently trailblazers when it comes to using new medical technology," it reads. "Yet, there is one area of technology that many physicians do not love — their electronic health record (EHR). While most (80%) physicians have an EHR, the vast majority of physicians are extremely dissatisfied with their systems."

As part of the initiative, AMA is calling on physicians to share their experiences with AMA and its members as well as write to Congress in order to garner support for a delay.

"It appears that the federal government will finalize MU Stage 3 without realigning the other programs. The current direction of the MU program is bad for patients and physicians," the campaign's website also states. "If finalized this fall, MU Stage 3 regulations will determine what EHRs and the practice of medicine will look like in years to come."

Break the Red Tape also includes a question and answer component that provides further details about the AMA's views of EHR technology and meaningful use.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Maxim of QuantityBe as informative as required.

Maxim of RelationBe relevant.

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

To which should be added the calculability assumption:

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

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

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