Getting your practice head, Volume 4: Medical Data Backup Essentials for Physicians. Know more about Data Backup and HIPAA Compliant Data Backup here
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While I had heard that almost 400,000 Americans die each year because of medical mistakes, in a recent article Forbes contributor Dan Munro underscored that volume when he asked readers to imagine the largest commercial aircraft -- an Airbus A-380 -- crashing every day for a year: The number of passengers who would perish aboard those imaginary crashes compares to the number of patients really dying annually in our hospitals due to blunders.
People who want nothing to change usually dispute the number of deaths. For the sake of argument, let us assume the actual number could be represented, then, by one crash every four days. Even then, surely it is worthwhile trying to figure out how to prevent these errors.
Certainly, procedural failures or pure accident causes some errors but incomplete or incorrect information about the patient is at the heart of a large percentage of these mistakes.
As Munro points out, a major problem is that the current healthcare industry is incentivized by revenue and profits -- not safety and quality. Therefore, as newly re-elected Florida Governor (and former healthcare CEO) Rick Scottsaid at a recent meeting to discuss cutting costs in healthcare, the industry has been unwilling to voluntarily reduce profits. Since safety and quality using current methods would be expensive and slash profits, perhaps electronic health records (EHRs) and health information technology (HIT) could accomplish the goals of all stakeholders.
EHRs can maintain patients' complete medical histories, along with all known allergies and medications. The record should travel with patients, no matter where they go for treatment. Doctors do not have to rely on the patient's fallible memory at every encounter. The record speaks for patients, even if patients are incapacitated for any reason.
We must recognize that doctors often face points of no return -- and patients get no second chances. Choosing the right medicine or treatment is frequently a game of probabilities. Choose the right medicine and the patient will live. Choose the wrong one and the patient will die. This is why even the most qualified doctors often seek second or third opinions before embarking on a risky treatment plan. Doctors have told me countless stories about their ability to save patients because a complete EHR was available. In these cases multiple doctors were able to view the same information at the same time, often while residing thousands of miles apart. They collaboratively agreed on the best option -- and saved the patient's life.
EHRs also facilitate artificial intelligence. A patient's medical history often is full of reams of data; manually winnowing through that information is a daunting task. Today, teams of top doctors help develop artificial intelligence systems that can quickly determine if a proposed medicine, food, or medical procedure will likely cause the patient greater harm than good. This will reduce a large number of medical mistakes.
There is no cause for concern. Decisions suggested by artificial intelligence systems developed by top-notch doctors likely are more accurate than decisions made solely by humans. Watch Vinod Khosla discuss this fascinating issue. All doctors are not created equal. As Khosla pointed out, studies show that if you give the same data on a patient to a random group of 10 doctors and ask them if surgery is recommended, half will choose surgery while the other half will choose not to perform surgery.
If artificial intelligence systems are built using the medical minds of the doctors that choose the right answers, these technological solutions sift through an incredible amount of data and provide more medically reliable recommendations. Of course, a human doctor still makes the ultimate decision. However, the doctor has the benefit of a large amount of data analysis and is much more likely to make a decision based on complete information, not incomplete data.
Perhaps EHRs plus AI will save many more
lives and dramatically reduce medical errors without increasing costs too much.
Should you implement an EMR or an EHR? Do you know the difference? Is there a difference?
In theory, and by definition, there is a difference and it should play into any provider’s clinical software selection. At the same time, marketing messages and technical terminology have clouded provider’s understanding of the two software definitions.
Recently, National Alliance for Health Information Technology (NAHIT) established definitions for electronic medical records (EMR), electronic health records (EHR) and personal health records (PHR).NAHIT Has Defined EMR and EHR
The NAHIT has produced the following definitions for EMR and EHR:
By these definitions, an EHR is an EMR with interoperability (i.e. integration to other providers’ systems). More on this later…Who Needs Which?
Marc Anderson, CEO of the AC Group, says it comes down to the words “medical” and “health.”
An EHR will provide a more comprehensive view into a patient’s health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives.
Meanwhile, an EMR is a more silo’d record of a single diagnosis or treatment, most likely used by a specialist. If your responsibility is taking care of one unique problem – perhaps an orthopedist setting a bone – then a stand-alone EMR may well be sufficient. Certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates.
EHR interoperability is the name of the game, as healthcare providers and health IT vendors begin to realize the importance of connecting systems and medical devices to better communicate and share data throughout a medical organization.
National Coordinator for Health IT Karen B. DeSalvo has mentioned time and time again the need for EHR interoperability throughout the healthcare sector in order to ensure all physicians and healthcare professionals are able to access key data when making vital clinical decisions. Additionally, payers, patients, and hospitals will need the ability to view necessary health information to create a healthier population around the nation.
The Brookings Institution released a policy brief several months ago calling for fixing some of the issues and challenges within the health IT industry including the need for greater EHR interoperability and data exchange. Redundant testing and duplicative data entry would be solved with an increase in medical data sharing.
The Office of the National Coordinator for Health IT (ONC) has gone forward with addressing the challenges and needs of the healthcare community with regard to improving EHR interoperability. From the ONC Nationwide Interoperability Roadmap to the report to Congressaddressing information blocking, this federal agency has put great efforts toward advancing EHR interoperability throughout the country.
Despite ONC’s efforts, according to Chief Informatics Officer Dr. John D. Halamka, there is an access of policy and political barriers to true health information exchange. Halamka states that the Massachusetts State Health Information Exchange (HIE) creates thousands of connections between hospitals and professionals throughout the nation with the help of Health Information Service Providers (HISPs).
The CIO goes on to say the EHR interoperability has a “positive trajectory” and that there is currently sincere progress taking place in boosting health data exchange. More importantly, Halamka states the importance of continuing efforts, identifying gaps in EHR interoperability, and solving these issues. Moving forward is the only real option.
Analysis from the research market firm Frost & Sullivan shows that interoperability and connecting healthcare tools is not uniform around the globe. In order to fix this issue, stakeholders will need to address connectivity standards and create a “digital healthcare strategy” that can connect vital medical devices in efforts to improve care coordination.
“More than 50 percent of healthcare providers do not have a healthcare IT roadmap, although they acknowledge the role of digital health in enhancing healthcare efficiency,” Frost & Sullivan Healthcare Research Analyst Shruthi Parakkal said in a public statement. “Consequently, even the existing interoperability standards such as HL7, DICOM and Direct Project are not being utilized optimally by many providers.”
Instead of requiring upgrading individual systems and investing funds in updating workflows, it would benefit hospitals and clinics if vendors developed products with guaranteed connectivity even when devices are developed by multiple manufacturers.
Parakkal also mentioned the importance of EHR interoperability in healthcare providers’ quest for successfully attesting to meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs and qualifying for financial incentives for adopting certified EHR technology. As CIO Dr. John D. Halamka mentioned, we must move forward in order to improve EHR interoperability on a national level.
Various stakeholders have begun taking part in sending their public comments to the Centers for Medicare & Medicaid Services (CMS) with regard to the Stage 3 Meaningful Use proposed rule and the proposed modifications to Stage 2 Meaningful Use requirements for the next few years.
The College of Healthcare Information Management Executives (CHIME) released their comments to CMS about the proposed rulings on May 27. CHIME representatives found that Stage 3 Meaningful Use requirements under the proposed rule are “too ambitious” and need some significant revisions, according to a company press release.
Additionally, the organization showed complete support of CMS in reducing the EHR reporting period in 2015 from a full year to a continuous 90-day period. CMS did reduce the number of objectives under the Stage 3 Meaningful Use proposed rule and improved the reporting periods, but the high number of total proposals for the Stage 3 portion was thought “unworkable” by CHIME representatives.
“Were all requirements finalized as proposed, we doubt many providers could participate in 2018 successfully,” CHIME stated in its public comments. “And with so few providers having demonstrated Stage 2 capabilities, we question the underlying feasibility of many requirements and question the logic of building on deficient measures.”
There are specific steps CHIME offered that may
improve attestation to Stage 3 Meaningful Use requirements if CMS integrates the suggestions in the final ruling. These steps are:
1) Requiring a 90-day reporting period under Stage 3 Meaningful Use regulations for the first year of attestation
2) Retain the same 90-day period for any eligible healthcare provider participating in the Medicare or Medicaid EHR Incentive Program for the first time
3) Discontinue patient action thresholds under the patient portal objectives
4) Reduce the number of measures in certain encompassing objectives like health information exchange and care coordination
5) In limited circumstances, give providers the opportunity to meet objectives via paper-based means
6) Give providers a 90-day remission in any calendar year for program upgrades, bug fixes, or EHR optimization
CHIME was especially concerned with “unrealistic” health information exchange measures and the ongoing uncertainties around patient action objectives. CMS proposed that modified Stage 2 Meaningful Use requirements would mandate that only one patient among a provider’s consumer base would need to view, download, and transmit their health data. However, under the Stage 3 Meaningful Use proposed rule, this requirement goes up to 25 percent of the patient population among eligible hospitals and professionals. CHIME was also concerned that attesting to Stage 3 by 2018 was too soon and providers would not be ready.
“While we acknowledge policymakers’ intention to make each Stage more difficult than the last, we are concerned with the strategy that envisions Stage 3 serving as both the apex of MU requirements and as a starting point for those providers with no experience at Stage 1 or Stage 2 of the EHR Incentive program,” CHIME said. “We worry some of the objectives pose too great a stretch for seasoned meaningful users, let alone those who have never participated in the program.”
Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.
Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.
Still, Chan was troubled by the lack of quantitative evidence
that electronic reminders actually enable healthcare providers to provide better patient care, as well as by anecdotal evidence that too many electronic reminders may actually have a detrimental effect on care. Indeed, getting a better handle on the efficacy of electronic reminders is crucial as the US healthcare system continues its transition from paper to electronic health records. It’s been estimated that eight in 10 office-based physicians and six in 10 hospitals now use some type of EHR system, and that number continues to grow.
Now an assistant professor at Stanford School of Medicine, Palo Alto, CA and a physician-scientist with Veterans Affairs (VA) Palo Alto Health Care, Chan recently received an NIH Early Independence Award to explore the impact of EHR electronic reminders on the quality of primary care. His research will focus on the Veterans Health Administration (VHA), the country’s largest healthcare delivery system serving about 9 million enrollees at 150 hospitals and 819 community-based outpatient clinics. Because the VHA was among the first healthcare systems to adopt EHRs, it will provide Chan with an excellent window into the real-world experiences of doctors, nurses, and other healthcare professionals accustomed to working with electronic reminders.
Preliminary research by Chan shows that, depending upon the VHA facility, the same type of healthcare provider caring for the same type of patient may have to process as few as 5 or as many as 40 electronic reminders relating to preventive care and disease management. Building upon this work, Chan will study in greater detail how electronic reminders vary not only in number, but in topic breadth, complexity, and comprehensibility. Most importantly, he will analyze the impact of all of these factors upon the productivity and efficiency of healthcare professionals and the quality of care received by patients.
Such work is part of a much larger, ongoing NIH effort to generate the evidence base needed to guide the design, use, and evaluation of an ever-expanding array of health information technologies. For example, the recently announced Precision Medicine Initiative will enable volunteer participants to partner with researchers to develop creative new approaches for the gathering, use, and sharing of genomic, health, and lifestyle information via EHRs, mobile health devices, social media, and other electronic information platforms.
Amazing Charts, a leading developer of Electronic Health Record (EHR) and Practice Management (PM) systems for physician practices, today announced the Amazing Charts Partner Community, an online marketplace of innovative third-party services and solutions seamlessly integrated with the Amazing Charts platform.
The Amazing Charts Partner Community features a broad spectrum of value-added offerings for medical practices, including solutions for document management, patient engagement, care coordination, and revenue cycle management. Users can filter by product category, compare vendor offerings, and submit inquires. A few of the solutions listed, such as NoteSwift and Updox, are already utilized by Amazing Charts’ customer base, while most are new services curated from dozens of applicants.
“Now there is one place where Amazing Charts users can conveniently find trusted partners who have been pre-approved by our rigorous vetting process,” said Matt Pierce, Vice President of Sales and Business Development for Amazing Charts. “We will continue to expand the program as we identify new customer challenges and shifting market trends, forging partnerships with companies that are best positioned to meet those needs.”
EHR implementation has had a variety of goals throughout the healthcare industry including achieving the triple aim of healthcare, which focuses on improving the quality of patient care, reducing healthcare costs, and boosting population health outcomes. Additionally, EHR implementation was meant to improve productivity and reimbursement among medical facilities.
A new study published in the Journal of the American Medical Informatics Association reveals whether EHR implementation brought about improvements in reimbursement and productivity among ambulatory practices.
The results showed that reimbursement rates did rise significantly with the help of EHR implementation. However, ambulatory practice productivity went down across the two years researchers examined. The increased revenue was caused by the uptake in ancillary office procedures like drawing blood, immunizations, ultrasounds and wound care.
Overall, finding that EHR implementation is associated with increasing revenue within the medical sphere is a boost to the industry and may affect the triple aim of healthcare as well. These type of results indicate that investing in health IT systems and certified EHR technology is beneficial for all.
The reason researchers from Drexel University focused on EHR implementation within ambulatory practices is due to the fact that health IT integration has been slow among these medical entities. Even though meaningful use regulations under the Medicare and Medicaid EHR Incentive Programs provide financial assistance to healthcare organizations adopting and implementing certified EHR technology, a smaller percentage of ambulatory practices have digitized patient health records.
One of the key concerns has been that EHR implementation may actually have negative consequences for both reimbursement and productivity within a medical practice. This research, however, indicates that adopting EHR systems should have a beneficial impact on the revenue cycle of ambulatory practices.
The Drexel University researchers looked at the number of patient visits among 30 ambulatory practices before and after EHR implementation and tracked the reimbursement rates associated with each visit. There was a loss of patient visits after implementing EHR systems that seemed to stabilize after a period of time among most of the facilities. However, six ambulatory practices still had productivity losses even after two years’ time.
Despite a potential loss in productivity, the increased revenue stream due to EHR implementation shows a clear benefit of health IT systems for the medical industry. EHR implementation was associated with an uptake in billing more ancillary procedures.
“A major reason for the slow uptake of EHRs—and delayed access to the benefits of EHR—has been financial concerns about the impact of EHR implementation on practice productivity and reimbursements,” the researchers wrote in the published paper. “The bottom line news is good: practice revenues increased during EHR implementation despite persistent productivity losses. EHR implementation in this study increased reimbursements but reduced long-term practice productivity across all specialties. While the productivity losses can be seen in a negative light, these findings also suggest a type of efficiency in which the practices are getting paid more for seeing fewer patients.”
Amazing Charts just announced a new EHR partner program. This isn’t something that’s particularly new for EHR vendors. They all have lots of partners. Some have formalized them into a program like athenahealth has done with their More Disruption Please (MDP) program. Others are much more quiet about the partners they work with and how they work with them.
What’s clear to me in the EHR industry is that an EHR vendor won’t be able to do everything. There are some that like to try (See Epic), but even the largest EHR vendor isn’t going to be able to provide all the services that are needed by a healthcare organization. This is true for ambulatory and hospitals.
Since an EHR vendor won’t be able to do everything, it makes a lot of sense for an EHR vendor to have some sort of partners program. The challenge for an EHR vendor is that a partner program comes with two major expectations. First, the partner has a high quality integration with the EHR software. Second, that the partner is something that the EHR vendor has vetted.
The first challenge is mostly a challenge because most EHR vendors aren’t great at integrating with outside companies. This is a major culture shift for many EHR vendors and it will take time for them to get up to speed on these types of integrations. Plus, these integrations do take some time and investment on the part of the EHR vendor. When there’s time and investment involved, the EHR vendor starts to be much more selective about which companies they want to be working with long term. They don’t want to spend their time and money integrating with a company which none of its users will actually use.
The second challenge is that EHR users assume that an EHR partner is one that’s been vetted by the EHR vendor. Even if the EHR vendor puts all sorts of disclaimers on their partner page, the EHR vendor is still associated with their partners. The written disclaimers might help you avoid legal issues, but working with shady partners can do a lot of damage to your reputation and credibility in the marketplace. I actually think this is probably the biggest reason that EHR vendors have been reluctant to implement partner programs.
I think over time we’ll see the first problem solved as EHR vendors work to standardize their APIs for partner companies. As those APIs become more mature, we’ll see much deeper EHR integrations and the costs to an EHR vendor will drop dramatically when it comes to new partner integrations.
The second problem is much harder to solve. My best suggestion for EHR vendors is to create a platform which allows your users to help you vet potential partners. Not only can they participate in the vetting process, but it can also help you know which partners would be useful to your users. Is there anything more valuable than user driven partnerships? It also puts you in a good position with potential partners if you already have users interested in the integration.
However, an EHR vendor shouldn’t just leave potential partnership requests to their users. Many of their users don’t know of all the potential partner companies. Users are so busy dealing with their day jobs that they often don’t know of all the potential companies that could benefit their practice or hospital. Certainly you should accept user input on potential partnerships, but an EHR vendor should also seed the potential partner feedback platform with a list of potential partners as well. The mix of an EHR vendor created list together with user generated partner lists is much more powerful than one or the other.
We’re just at the beginning of companies partnering and integrating with EHR vendors. I expect that over the next 5 years an EHR vendor will be defined as much by the organizations it chooses to partner with as the features and functions it chooses to develop itself.
Increasingly hospitals are recognizing the value of interoperabilitybetween electronic health records and automated dispensing cabinets, or ADCs. In addition to eliminating redundancies during the medication ordering process, linking them helps to reduce medication errors at the point-of-care.
Now nurses are able to easily interface with the complete medication management system within one application at the patient's bedside, said Nilesh Desai, director of pharmacy at HackensackUMC.
"With the addition of the interoperability piece, it is now embedded directly into Epic and as you open a patient's chart, automatically you can launch and schedule the medications and view if the medication has been delivered by pharmacy or not," said Desai.
With this interoperability, he said, that there's not a separate login and the nurse doesn't have to remember another password: It's connected to the EHR and it directly opens up to the patient's chart.
Normally when there is a medication that has to be delivered from the pharmacy, the nurse has to go back to the cabinet or look into the cabinet to see if pharmacy delivered it or not.
"If the medication is not delivered the medication is grayed out and the nurse will be unable to remove it," said Desai. "As soon as a pharmacy technician delivers a medication, it lights up. As a nurse, you don't have to go to the cabinet to find out if the medication has been delivered. A nurse can do it directly from a computer from anywhere in the nursing unit. It saves quite a few steps and time."
Shafiq Rab, MD, vice president and chief information officer at HackensackUMC, points out that there are other benefits of interoperability between EHRs and ADCs. One is that while the drug is being procured from the pharmacy system, it also checks for allergies, drug-to-drug interaction, and drug-to-food interaction.
Clinical inefficiencies raise red flag for hospitals
A benefit analysis extrapolated from a 2013 white paper prepared by Cerner, "The Clinical Benefits of CareAware Enhanced Dispensing," revealed that prior to interoperability between EHRs and ADCs, nurses at Penn State Milton Hershey Medical Center were spending on average of 8.5 minutes on a single patient's medication pass resulting in clinical inefficiencies within the medication administration and reconciliation process. Post-implementation they spend on average 5.8 minutes, a 32 percent improvement.
To address the inefficiencies due to disparate clinical information systems, Penn State Hershey partnered with CareAware, Cerner's device connectivity architecture that provides interoperability between CareFusion's Pyxis MedStation ADC and Cerner's Millennium EHR.
According to the white paper, CareAware "allows clinical information to be shared seamlessly between the two systems improving workflow and patient safety," while allowing the nurse to view the same information in both systems.
Flip Groves, vice president of business development in the Medication Management Solutions Group at CareFusion/Pyxis, said such interoperability extends not only to the EHRs, but also into the entire, end-to-end, medication-management process.
"Interoperability means connecting the automated dispensing cabinets into enterprise-wide pharmaceutical resource inventory management system, to IV prep check systems, to microbial surveillance systems, bringing together oversight and optimization of the end-to-end management of medication processes and resources," said Groves.
He added that interoperability also enhances patient safety and clinical workflow by eliminating opportunities to introduce errors, and by providing the users with the right information, through the right application, in the right place, at the right time.
Dan Pettus, vice president for IT in the Medication Management Solutions group at CareFusion/Pyxis, said that interoperability is significant not only for EHRs and ADCs but also for other devices including IV pumps and ventilators.
That capability, said Pettus, is the tie-in to all of the necessary connections that you need to make these applications from products interoperable.
"It's beneficial to our customers to have one-stop shopping when it comes to those technology platforms," said Pettus. "Less interfaces, less complexity, it reduces to maintain these things over time."
Point-of-care medication errors averted
Mark Neuenschwander says that for years he has tried to draw attention to the gap between the point-of-dispensing and the point of administering medications.
"It is possible for nurses to get the right medications for the right patients at dispensing cabinets and then to administer them to the wrong patients," said Neuenschwander, a Bellevue, Wash.-based consultant on bar code-enabled medication dispensing, preparation and administration.
Bar code medication administration, Neuenschwander says, has matured and become commonplace in today's hospitals to verify patients and medications to address this problem, but be noted that in addition to verification, a sound medication use process requires information.
"In addition to verifying that they have the correct medications for a particular patient, they also need to have access to information about medications both when they come from dispensing cabinets and when they are at the point-of-care."
Neuenschwander, cofounder of the unSUMMIT for Bedside Barcoding, asserted that nurses must document what is administered and that this must occur at the point of care, not at the point of dispensing.
"It is critical that what the nurse sees at any point is up to date. I am thrilled with the ongoing efforts and success in integration information with information systems, dispensing cabinets, and point of care technologies," he said.
One of the key issues that some healthcare providers have found with the Medicare and Medicaid EHR Incentive Programs is the mere financial impact of EHR implementation. In Minnesota, small medical practices – particularly solo practitioners – will no longer have to invest in costly EHR implementation plans due to a bill that was passed by Minnesota lawmakers in both the House and Senate.
Under the Minnesota Department of Human Services policy omnibus bill, there are various healthcare reform objectives including exempting solo practitioners and cash providers from having to invest in health IT systems and EHR implementation.
While this may benefit these providers financially and allow them to run their practice without monetary disadvantages, paper-based patient records could potentially lead to safety issues and additional medical errors that impact population health outcomes across underserved regions within the state.
Nonetheless, Minnesota seems to be the only state in the nation where an EHR mandate required all healthcare providers and hospitals to install and implement EHR systems by January 1 of this year.
The bill’s amendment on EHR implementation is now in place and providers will have to comply with it starting in January 2015, according to a press release from the Citizen’s Council for Health Freedom (CCHF), a Minnesota-based organization aimed at protecting patient privacy and rights.
CCHF feels the EHR mandate that required all providers to participate in EHR implementation was too costly and had patient privacy implications the organization does not support. Essentially, Minessota was the only state that did not have an opt-out option. Other providers across the country could take the payment penalty hit from the Centers for Medicare & Medicaid Services (CMS) instead of being required to adopt certified EHR technology.
In particular, providers in Minnesota were required to implement an interoperable EHR system that was connected to a state government-approved Health Information Organization, which is a costly endeavor.
“We’re pleased that lawmakers have included this important amendment in Rep. Tara Mack’s bill that will allow small clinics and practices to continue to serve patients in Minnesota,” stated CCHF president and co-founder Twila Brase. “Many small clinics and practices cannot afford the cost of the EHR system, and many practices do not want to make their patients’ data accessible online.”
“This amended bill will allow small clinics to thrive in smaller communities,” Brase continued. “And it will allow single doctor’s offices to keep their doors open, rather than be forced to join a big practice.
Patients would be able to search for practitioners who hold their medical data truly confidential and for doctors that look them in the eye rather than turning their back on them and typing into a computer. Minnesota is the only state that, until now, did not allow healthcare providers to opt out of expensive, intrusive online-accessible EHRs. The federal HITECH Act mandates EHRs, but allows any provider to opt out. This amendment begins to give Minnesota the level of freedom and privacy available to doctors and patients in the rest of the nation.”
The volume of telemedicine visits is growing at a staggering pace, and they seem to have nowhere to go but up. In fact, a study released by Deloitte last August predicted that there would be 75 million virtual visits in 2014 and that there was room for 300 million visits a year going forward.
These telemedicine visits are generating a flood of medical data, some in familiar text formats and some in voice and video form. But since the entire encounter takes place outside of any EMR environment, huge volumes of such data are being left on the table.
Given the growing importance of telemedicine, the time has come for telemedicine providers to begin integrating virtual visit results into EMRs. This might involve adopting specialized EMRs designed to capture video and voice, or EMR vendors might go with the times and develop ways of categorizing and integrating the full spectrum of telemedical contacts.
And as virtual visit data becomes increasingly important, providers and health plans will begin to demand that they get copies of telemedical encounter data. It may not be clear yet how a provider or payer can effectively leverage video or voice content, which they’ve never had to do before, but if enough care is taking place in virtual environments they’ll have to figure out how to do so.
Ultimately, both enterprise and ambulatory EMRs will include technology allowing providers to search video, voice and text records from virtual consults. These newest-gen EMRs may include software which can identify critical words spoken during a telemedical visit, such as “pain,” or “chest” which could be correlated with specific conditions.
It may be years before data gathered during virtual visits will stand on equal footing with traditional text-based EMR data and digital laboratory results. As things stand today, telemedicine consults are used as a cheaper form of urgent care, and like an urgent care visit, the results are not usually considered a critical part of the patient’s long-term history.
But the more time patients spend getting their treatment from digital doctors on a screen, the more important the mass of medical data generated becomes. Now is the time to develop data structures and tools allowing clinicians and facilities to mine virtual visit data. We’re entering a new era of medicine, one in which patients get better even when they can’t make it to a doctor’s office, so it’s critical that we develop the tools to learn from such encounters.
It seems pretty obvious: You do the work, you get paid. But unfortunately for many in the healthcare business, it’s not always that black and white.
There are so many obstacles to proper payment, including: complex and confusing billing systems; patients unable to pay their office copay, co-insurance, or deductibles; high outstanding accounts receivable; improper coding vs. documentation; etc. All this and more can lead to outstanding bills and ultimately low cash flow for the practice.
Here are some tips to make sure your practice gets the compensation it deserves:
The Right Code: ICD-10
With the new ICD-10 rules taking effect Oct. 1, it’s imperative that your practice management software and EHR are up to date and that the billers in your practice are trained and ready to go. Improper documentation at some point in the chain of work can lead to a deficit in your bottom line. Make sure that your software is ICD-10-ready.
Ignorance Is Not Bliss: Pay Attention to the Details
Doctors, office managers, and certain staff should be able to access at-a-glance details and have the ability to generate reports if they are employing an efficient billing system. Every doctor should be able to easily access the following data:
• Average daily and monthly revenue categorized by HCPCs and insurance
• Number of outstanding accounts receivable
• Cash value of outstanding accounts receivable
• Number of audits paid/failed status
• Payment and claim status
• Outstanding revenue by HCPCs and insurance
• Monthly adjustment reports
If you are a doctor in a private practice and can’t access this critical information, then at a minimum, you should require a weekly billing report from billing staff or your outsourced billing service. This weekly report should cover the items listed above and will allow you great insight into the "health" of your practice.
Verify Patients’ Benefits Before Their Visit
At the very least, verify patient's benefits before they leave your office. It sounds fairly obvious, but many practices don’t get the patients’ copay before they see the doctor. This could be rectified as easily as keeping patients’ credit cards on file, so it can be the default if the patient fails to bring cash to their visit. Better yet, utilize a practice management system that seamlessly updates you with this information so that you can easily charge in the office. You’d be surprised how something so simple can increase practice cash flow.
Claim Denied? Don’t Let It Go
Make sure your billing staff is diligent about following up on denied claims. Making sure your billing staff or billing service has the right codes can significantly improve this denial rate, but when it does happen, don’t let it go. There should always be follow up on denied claims, but ideally, your billing staff or service should try to catch coding errors before they’re made. Catching coding errors is often better handled by a sophisticated, outsourced billing service — just make sure it offers a transparent view into billing success.
As we’ve reported in the past, hospitals are throwing their weight behind the use of wearables at a growing clip. Perhaps the most recent major deal connecting hospital EMRs with wearables data came late last month, when Cedars-Sinai Medical Center announced that it would be running Apple’s HealthKit platform. Cedars-Sinai, one of many leading hospitals piloting this technology, is building an architecture that will ultimately tie 80,000 patients to its Epic system via HealthKit.
But it’s not just software vendors that are jumping into the wearables data market with both feet. No, as important as the marriage of Epic and HealthKit will be to the future of wearables data, the increasing participation of medical device giants in this market is perhaps even more so.
Sure, when fitness bands and health tracking smartphone apps first came onto the market, they were created by smaller firms with a vision, such as the inventors who scored so impressively when they crowdfunded the Pebble smartwatch. (As is now legendary, Pebble scooped up more than $20M in Kickstarter funding despite shooting for only $500,000.)
The time is coming rapidly, however, when hospitals and doctors will want medical-grade data from monitoring devices. Fairly or not, I’ve heard many a clinician dismiss the current generation of wearables — smartwatches, health apps and fitness monitoring bands alike — as little more than toys. In other words, while many hospitals are willing to pilot-test HealthKit and other tools that gather wearables data, eventually that data will have to be gathered by sophisticated tools to meet the clinical demands over the long-term.
Thus, it’s no surprise that medical device manufacturing giants like Philips are positioning themselves to leapfrog over existing wearables makers. Why else would Jeroen Tas, CEO of Philips’ healthcare informatics solutions, make a big point of citing the healthcare benefits of wearables over time?
In a recent interview, Tas told the Times of India that the use of wearables combined with cloud-based monitoring approaches are cutting hospital admissions and care costs sharply. In one case, Tas noted, digital monitoring of heart failure patients by six Dutch hospitals over a four-year period led to a 57% cut in the number of nursing days, 52% decrease in hospital admissions and an average 26% savings in cost of care per patient.
In an effort to foster similar results for other hospitals, Philips is building an open digital platform capable of linking to a wide range of wearables, feeds doctors information on their patients, connects patients, relatives and doctors and enables high-end analytics. That puts it in competition, to one degree or another, with Microsoft, Qualcomm, Samsung, Google and Apple, just for starters.
But that’s not the fun part. When things will get really interesting is when Philips, and fellow giants GE Healthcare and Siemens, start creating devices that doctors and hospitals will see as delivering medical grade data, offering secure data transmission and integrating intelligently with data produced by other hospital medical devices.
While it’s hard to imagine Apple moving in that direction, Siemens must do so, and it will, without a doubt. I look forward to the transformation of the whole wearables “thing” from some high-end experimentation to a firmly-welded approach built by medical device leaders. When Siemens and its colleagues admit that they have to own this market, everything about digital health and remote monitoring will change.
Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone.
Much of the literature on EHRs fails to support the primary rationales for using them.
AFTER EXTOLLING THE virtues of the electronic health record (EHR) in his 2004 State of the Union Address, President George W. Bush established the Office of the National Health Information Technology Coordinator (ONCHIT) and charged it with developing a “health information technology infrastructure” that “reduces health care costs resulting from inefficiency, medical errors, inappropriate care and incomplete information.” This charge includes the adoption of EHR systems that can “reduce health-care costs by up to 20% per year.” Retail sales, financial services, 0and telecommunications are examples of industries using information technology (IT) to achieve quality and savings. Accordingly, the same lesson can be applied to U.S. health care.
Or can it? A considerable body of evidence suggests that widespread adoption of the EHR increases health care costs. Although the focus of this paper is on the limitations of the EHR in ambulatory care, ample research shows that this might likewise apply to inpatient settings.
EHR definition and uptake.
The Healthcare Information and Management Systems Society (HIMSS) defines the EHR as a “longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.” It does more than store information: It “supports other care-related activities directly or indirectly, including evidence-based decision support, quality management and outcomes
reporting.” According to the National Health Care Survey, EHRs were in use in 17 percent of physicians’ offices, 31 percent of emergency rooms, and 29 percent of hospital outpatient departments in 2003. In office settings, the 17 percent figure has not changed since 2001.
Given the inflationary $1.9 trillion cost of U.S. health care, 20 percent savings is significant. A RAND analysis estimated that national adoption of the EHR could lead to “more than $81 billion” in annual savings, while Jan Walker and colleagues estimated that information exchange across providers, hospitals, public health, and payers could save $77.8 billion per year.
The Case For The EHR
As noted, the EHR’s potential is based on its ability to introduce new efficiencies to health care delivery. Each is examined below.
Worker productivity gains.
One analysis showed that the EHR increased documentation time among physicians by approximately 17 percent, while computerized provider order entry (CPOE) increased it by 98 percent.8 In a separate study, EHR implementation at Kaiser Permanente resulted in a 5–9 percent decrease in office visits replaced by telephone contacts.9 Even if future “smart texts” or automated physician orders correct these inefficiencies, it is unclear whether the EHR enables gains in provider-to-patient ratios. Rather, these studies suggest that a possible outcome is that the same providers would serve the same patients, with fewer office visits, more remote communication, and more documentation.
However, the EHR can enable clerical staff reductions amounting to $13,000 per physician per year.10 For these savings to be realized, staff employment would need to be completely terminated. Although this is likely in outpatient settings, anecdotes of health care systems (where EHRs are prevalent) offering displaced workers other employment opportunities (including in IT departments) are commonplace enough to dilute these savings.
Ultimately, if the EHR consistently reduced labor costs, lower staffing ratios should enable insurers—representing the “front line” in managing health care costs—to reduce their fee schedules among EHR-enabled providers. The same should be true for participants in consumer-directed health plans. There is little evidence that this is occurring among the 17 percent of practices possessing an EHR.
Not only are the EHR’s labor savings questionable, but increased billings are another likely outcome. Thanks to underlying decision logic previously only available to large institutions, the EHR can “auto-populate” or scour the record to justify a greater intensity of service. Accordingly, “increased coding levels” account for the return on investment.11 Alternatively, better “capture of charges” and fewer “billing errors” can lead to a five-year $86,400 “benefit” per provider.12
Although additional detail may warrant increased payment, the “content” might be unchanged from the point of view of the patient (the end user). Physicians are prone to under-documentation, but these EHR enhancements, appropriate or not, arguably increase health care costs without any corresponding increase in quality.
Medical mistake avoidance.
EHR advocates point to “decision support” that reduces errors of omission and commission at the point of care as a critical safety advantage.13 The Agency for Healthcare Research and Quality (AHRQ) has endorsed several IT interventions that promote patient safety (such as error tracking and alerts about the timing of tests); however, mention of the EHR is conspicuously absent. In fact, AHRQ’s “20 tips to help prevent medical errors” also fail to mention the EHR, versus interventions such as hand washing or relying on large-volume hospitals for complicated surgeries. The EHR’s failure to pass muster with AHRQ’s evidence-based approach to translating research into practice might explain the necessity of funding a large number of projects to better evaluate the EHR’s role in patient safety.
Indeed, the available evidence is decidedly mixed. Examples of omission-type error reductions include alerts about vaccination status among children cared for in the emergency department; inpatient vaccination and anticoagulation reminders; diabetes, hypertension, vitamin B12 deficiency, thyroid and anemia screening in the elderly; health maintenance and counseling in a pediatric practice; and hypertension identification and control.
However, EHR decision support has no effect on adherence to primary care guidelines for asthma or angina management; it leads to “variable” and “limited” adherence to diabetes and coronary artery disease reminders; it has no effect on evidence-based interventions for heart disease and heart failure; it causes no change in the care of patients with depression; it leads to “unwieldy” tracking and monitoring of preventive health and chronic illness; and it has no impact on diabetic glucose control.
Why such inconsistency? Physicians might resent the loss of professional autonomy or have limited tolerance for on-screen prompts. In one survey, 75 percent of physician respondents admitted ignoring reminder icons, and more than half seldom or never acted on the information. The EHR also impedes addressing other immediate patient needs in a time-limited office visit.
EHR advocates also point to errors of commission. For example, important information might be missing from paper records, including radiology or laboratory tests. Accordingly, if inaccessible records are responsible for costly retesting, reductions should be readily achievable. This was not the case at Kaiser Permanente, where “use of clinical laboratory and radiology services did not change conclusively” over a two-year transition to the EHR.
Excessive testing could be more a function of defensive medicine, ease, or fear of uncertainty. EHR decision support tools—including peer management, guideline promotion, and alerts about cost or redundancy—might reduce this. However, an EHR-based decision support system that is cost-saving, generalizable, and sustainable remains elusive. Finally, ancillary testing is an important source of revenue. “Profit center” laboratory or radiology departments will not necessarily welcome EHR-based interventions that lead to fewer tests and less revenue.
Storage of other encounter data.
Medical records are notoriously vulnerable to damage or disappearance. Hurricane Katrina’s destruction of Gulf Coast physician office practices has been cited as an example of the need for electronic medical information storage. Yet Hurricane Katrina’s cost was not factored into any of the previous savings estimates; in fact, the president’s endorsement of the EHR predated this disaster by more than a year. Furthermore, the history remains a time-honored and reimbursable feature of every physician-patient encounter. Aside from the few situations in which patients are too ill to communicate, patients’ recall of past medical facts is accurate across a wide range of conditions.27 It is also far cheaper than remote storage.
In my recent EHR workshop in Dubai I talked with them about the many changing EHR business models that I’ve seen over the last 10 years. I was really trying to highlight how these new business models have generally been good for healthcare since it’s caused EHR prices to drop to a much more reasonable price point.
Take for example the Free EHR model. Whether you love it or hate it, one thing is certain: Free EHR has caused all the other EHR vendors to lower their price. I’ve seen this over and over again with EHR vendors. It’s hard to compete with an overpriced product against free. So, they had to lower their price so that the price of their EHR didn’t look as bad against free.
One model that I mentioned to those who attended my workshop was that some EHR vendors charge a percentage of billing in order to use their EHR software. athenahealth is the most famous for this approach. Their business model has worked pretty well for them because they’re able to say that not only will the practice get the EHR software for free, but athenahealth also can make the case that by having them assist with the practices billing, then they can help to better optimize the practices billing as well. So, the practice is getting more effective billing and a free EHR. This is why athenahealth could charge such a high percentage of an organization’s billing.
Turns out that there are a lot of billing companies that make a similar business case. Pay me 4-6% of your billing and we’ll optimize your billing which will actually make you more money than you’re paying us. Most of the billing management companies work off of this approach. Of course, this approach works best when you’re talking about practices that aren’t doing a good job managing their billing. This actually seems to apply to most practices.
What I’ve started to wonder is what’s going to happen once all of these practices’ billing is basically optimized? Now the percentage of billing starts to feel really expensive. Practices won’t be good at realizing the optimization that’s occurred and I’m sure that many will choose to take on the billing again. As they take on the billing, they’ll head back to a less than optimized state and then they’ll be ripe pickings for a billing company again.
I can see this cycle happening over and over again. Plus, if you’re a billing company or a company like athenahealth that makes your money off of a percentage of billing, then there’s always new practices that are at every stage of the cycle. So, there’s new business all over the place. The key for these organizations is to find the practices that are at the right place in the cycle.
Will anything happen to stop this cycle?
Ever since the HITECH Act was passed and the Medicare and Medicaid EHR Incentive Programs were established, more than $29 billion was put toward expanding EHR implementation and health information exchange. Eligible physicians and hospitals were encouraged to adopt EHR systems and health IT platforms by offering financial incentives to those that do. Additionally, under the EHR Incentive Programs, reimbursement penalties would be given to those that have not met meaningful use requirements by a certain period. Despite the clear pathway toward medical data exchange, various stakeholders have participated in health information blocking, which impedes the goals of the healthcare IT industry for improved access to key data.
The New York Times reported that administration officials have found hospitals and laboratories along with EHR vendors participating in health information blocking in order to keep their consumer base from jumping toward a competing healthcare provider.
The federal government is currently attempting to create an environment across the healthcare industry in which medical information will flow freely from one facility to the next. The Obama Administration continues to make it a priority for hospitals and clinics to adopt EHRs and computerize patient records.
President Obama signed a stimulus bill upon taking office that gives hospitals and doctors incentives for implementing certified EHR technology. While large numbers of healthcare providers have adopted electronic records systems, the problem at hand is that few are able to share patient data across platforms designed by different vendors. Essentially, health information blocking delays the progress of EHR interoperability.
“We have electronic records at our clinic, but the hospital, which I can see from my window, has a separate system from a different vendor,” Dr. Reid B. Blackwelder, chairman of the American Academy of Family Physicians, told the news source. “The two don’t communicate. When I admit patients to the hospital, I have to print out my notes and send a copy to the hospital so they can be incorporated into the hospital’s electronic records.”
Another pediatrician from Massachusetts also lamented that he has tried and failed to connect medical records with a hospital’s EHR system in order to better coordinate care with his patients. Not long ago, the Office of the National Coordinator for Health IT (ONC) sent a report to Congress expressing the need to put an end to health information blocking.
Additionally, the costs of sharing data among medical practices are creating barriers and essentially showing that various providers decline to share key data that is needed to treat a patient regardless of their condition.
Certain companiesare also making it more difficult for hospitals to connect to multiple laboratories and technology services while others have customers sign strict contracts that prohibit them from easily choosing a different EHR platform.
Recently, a House Committee passed a bill that states health information blocking is a federal offense. It is also against the law for doctors and hospitals to deliberately take part in health information blocking if they are receiving federal incentives from the Centers for Medicare & Medicaid Services (CMS) for adopting certified EHR technology, according to a bill passed in Congress last month.
Through federal regulations, it is possible that health information blocking could become a problem of the past.
It’s the sad state of interoperability. This week when I was teaching an EHR workshop I asked for those attending to define what an Electronic Health Record was in their own words. I’d say 90% of them said something about making the healthcare data available to be shared or some variation on that idea. This wasn’t surprising for me since I’ve heard hundreds and possibly thousands of doctors say the same thing. EHR is suppose to make it so we can share data.
While people pay lip service to this idea and just assume that somehow EHR would make data sharing possible, that’s far from the reality today. This is true even in some organizations where they own both the hospital and the ambulatory provider. How sad is this? Extremely sad in my book.
I’ve often wondered what would change the tide. I’ve been long hopeful that ACOs and value based care would help to push the data sharing forward, but that’s going to be a long process. The private HIEs are working the best of any HIEs I’ve seen, so maybe the trend of hospitals acquiring small practices and hospital systems acquiring hospital systems will get us to EHR data sharing nirvana. Although, I don’t think it’s going to make it there in most communities. Instead it’s just going to have a number of large organizations not wanting to share data as opposed to some large and some small ones.
Do people really have much hope for true EHR data sharing? Does FHIR give you this hope? I’m personally not all that optimistic. We all know it’s the right thing to do, but there are some powerful forces fighting against us.
March 2015 saw the 3rd stage of Meaningful Use incentives come into effect. We take a look at what is included and how it will affect your organization’s efforts to seek these incentives.
As part of the HITECH Act passed by the Obama administration in 2009, electronic health records (EHR) were mandated for health care providers to provide a superior health experience with an electronic records system delivered more efficiently. Eligible providers (EP) are required to meet certification for each EHR stage in order to qualify for Centers of Medicare and Medicaid Services (CMS) Incentive Programs. The last stage of this Act was implemented in March 2015 as the Stage 3 Meaningful Use (MU) portion.What is Stage 3 Meaningful Use?
Stage 3 Meaningful Use is the final implementation program to ensure that all direct care health providers are utilizing EHRs to effectively improve their delivery of health services. Within this stage there is greater flexibility and simplification for health care providers easing late adopters into HITECH and making those already apart of HITECH the ability to further develop their EHR programs. Requirements to meet the incentives given by the government as part of this program include several specific targets to be met in order to receive the incentives for joining the program.
The purpose of stage 3 is no longer just data capture, EHR adoption or improved information processes but focuses on improved outcomes. 25% of patients must be engaged in secure private messaging with their provider, 25% must be able to view or transmit data from their own records, 60% of lab work requests including imaging must be sent electronically, 80% of drug prescriptions must be sent electronically and lastly 15% of patients must generate health data using applications or health devices. These requirements differ depending on your health care institution’s choices for menu set objectives as opposed to core objectives.Differences between Stages 1,2,3
Stage 3 Meaningful Use focuses on taking the benefits from Stage 1 and 2 in order to improve safety, quality, efficiency of processes and information to affect an improved health outcome for patients.Bottom Line for Your Health Organization
Although there is not a legislated mandatory adoption of EHRs for EPs, there are still consequences. The two most relevant are the loss of sizable incentives for developing your EHR program from the government. These incentives depend on whether you apply under Medicare or Medicaid. If you do not implement EHRs and certify under the MU program, you will lose 1% of the reimbursement under Medicare and Medicaid physician fee schedule covered amount per year to a maximum of 5% after five years.
Remember that your EHR programs still need to be HIPAA compliant for secure data collection, storage and transmission and require that a risk analysis assessment has been conducted for the MU programs.
Due to the legislative motions and prior delays to the ICD-10 compliance deadline, there are many healthcare organizations across the country that may not have made as much progress in preparing for the new medical coding set scheduled to begin on October 1, 2015. Even over the last few weeks, Representative Ted Poe (R-TX) introduced a bill into the House that called for putting an end to the ICD-10 transition altogether.
There has been a fair amount of speculation as to the need for the new medical codes throughout the political spectrum and the delays from the last two years have also brought many medical facilities to doubt whether the current ICD-10 compliance deadline will stand still.
The Journal of AHIMA reports that the ICD-10 delays have set back some organizations financially and led them to lose their momentum. Janis Leonard, RHIT, CCS, director of HIM at Albany Medical Center, told the source that any more pushback against the ICD-10 compliance deadline including a postponement would cause severe disruption and a monetary hit due to all of the funds the medical system invested in ICD-10 training among their staff.
Leonard said that if another delay to the ICD-10 compliance deadline were to occur, it “would be tough to re-engage.” The Albany Medical Center is working toward ensuring that ICD-10 conversion on October 1 is a go and that another postponement does not take place.
“Even the director of patient financial services sent a letter to our Congressmen recently again saying ‘do not delay,’ so we have our financial people as well as our coders engaged in that initiative,” Leonard told the news source.
Additionally, physicians at this particular organization have been supporting the transition toward ICD-10 coding from the beginning and are conducting ongoing documentation improvement initiatives.
Online modules are also being used to offer more training opportunities for medical coders to ensure they are prepared for the ICD-10 transition. In particular, more training information on medical terminology, pharmacology, anatomy, and physiology is being offered at Albany Medical Center to ensure coders will be able to handle the increased specificity of the ICD-10 diagnostic codes.
For more than a year, Leonard and her team focused on dual coding throughout the organization requiring coders to use both ICD-9 and ICD-10 for coding 10 percent of a workday’s cases. Additionally, weekly training sessions are offered where coders can use ICD-10 to code scenarios and review their work with an instructor.
When it comes to retaining a strong workforce of medical coders within a healthcare facility, Albany Medical Center focused on restructuring the career ladder and offering more incentives.
“When we did this, we based [the job positions] on new qualifications, credentials and experience, and we swaddled people into their new roles,” stated Leonard. “And more than half of coders received an increase in pay. We also provided a recruitment and a retention bonus that was paid out over two years with a work commitment of two years to incentivize our coders to stick around after ICD-10 [transition].”
The healthcare industry is changing every day and new, revolutionary processes are continuing to affect patient care and population health outcomes. Whether it’s through patient-centered medical homes, accountable care organizations (ACOs), EHR adoption, or general improved care coordination, the medical sector is making some significant modifications toward better care. However, physician EHR use and implementation of health IT systems will likely depend upon the needs of each disparate medical facility.
Meaningful use requirements, for instance, will need to be flexible enough to ensure health IT platforms are useful and beneficial for differing healthcare providers. When integrating public comments into theStage 3 Meaningful Use final rules and the Stage 2 Meaningful Use modified rules, the Centers for Medicare & Medicaid Services (CMS) should consider the need for adaptable and flexible requirements that providers could customize to their interests.
The American Hospital Association’s President and CEO Rich Umbdenstock wrote in a brief the importance of removing obstacles and developing federal regulations that meet the needs of the healthcare industry. Both care coordination, reducing costs, and investing in physician EHR use are key objectives throughout the medical care market.
“It’s time for regulators to recognize the changing healthcare landscape and remove obstacles on the road to collaboration,” wrote AHA President Rick Umbdenstock. “Healthcare is changing; hospitals are changing; and regulations that block progress toward meeting patient demands and community expectations must change, too.”
Two areas within the healthcare industry that may need health IT customization are public health reporting and chronic disease management. The Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) along with the National Opinion Research Center (NORC) at the University of Chicago released a report titledPublic Health IT to Support Chronic Disease Control.
In efforts to focus more attention on the triple aim of healthcare, NORC determined that chronic diseases are the major medical cost drivers and most common conditions found among patients across the country. The report went over population health interventions and physician EHR use to exchange data with public health agencies in efforts to curb the further deterioration of chronic conditions.
In particular, physician EHR use can be applied toward addressing case management, social services, behavioral health, and public health services. Incorporating EHR systems will also lead to better collaboration and communication among multiple medical facilities and public health agencies.
“The capacity to collaborate and share data across health care, public health and other partners becomes important in the context of supporting public health core functions,” the report stated. “We see great potential for using electronic data shared between health care providers, governmental public health agencies and other community partners. However, our discussion and earlier research points to important barriers to effective coordination and data sharing to promote population health. These challenges range from the limited mandate for governmental public health agencies in relation to chronic disease, limited public health IT infrastructure and historic lack of coordination between governmental public health agencies and health care providers.”
There was a very bad practice that was started thanks in large part to EHR software implementations. That practice is called documentation by exception and it’s employed by many (most?) EHR vendors. For those not familiar with documentation by exception, here’s a definition:
In the US, we all know why this type of documentation was implemented. By documenting all of the normal finding along with the exceptions, then the doctor is able to bill the insurance company at a higher level. I totally understand why doctors want to bill at a higher level. In fact, it was the argument that most EHR vendors would make when they were selling their product to doctors. The EHR was able to help doctors bill at a higher level and get paid more.
While this is going to be hard to change for this reason, there are so many unintended consequences associated with using documentation by exception in these practices. I know so many doctors that are literally embarrassed to share their chart notes with their colleagues because their chart notes are these long, cumbersome notes that are filled with normal findings that provide no value to anyone. Many of these doctors have resorted to creating a separate “short” note that only has the relevant “exceptions” detailed when they send their chart notes to another doctor.
Every doctor knows what I’m talking about, because they’ve found these long lengthy notes that are totally unusable. Plus, in many ways it puts a doctor at some risk if they documented a long list of “normal” items when in fact they didn’t actually check to see if everything was normal or not. However, more important than this is that the doctor can’t even read their own historical notes because they’re so cluttered with all these “normal” findings that it takes real work and effort (Translation: Wasted physician time) trying to search through these awful notes.
If somehow all of these normal findings that were being documented could add some value down the road, then I might change my mind about documentation by exception. However, I can’t imagine any useful clinical benefit to documenting a bunch of normal findings that weren’t actually checked or that were only casually observed. If you didn’t document something was wrong, then we can assume that everything else was normal or at least the patient didn’t complain of anything else. Why do we need to document it clinically? The answer is we don’t and we shouldn’t (except for the getting paid comments above).
We need to find a way to abolish these documentation by exception notes from healthcare. In the US this will be hard since it’s so tied to the payment system, but I’m sure smart minds can figure out a way to fix it. Every doctors I’ve ever talked to wants this solved. It almost makes the EHR notes useless to document this way. This is one more driver in the US system towards concierge and direct primary care models. In these cases, the doctors aren’t worried about reimbursement and so I can’t imaging they’d even consider documenting a patient visit in such an awful manner.
A part of me wonders if EHR vendors will work to solve this problem as well. They could have the beautiful note and the crappy, mess of a note. They’ll use less vulgar terms like the “clinical note” and the “billing note” or something like that, but maybe that’s a small step in the right direction to satisfying the clinical needs (short, concise, relevant notes) together with meeting the billing requirements note. It’s sad that EHR vendors need to do something like this, but it would be better than the current state of EHR notes.
After the HITECH Act was passed and the Medicare and Medicaid EHR Incentive Programs were established, healthcare providers began computerizing their patient records and adopting certified EHR technology in an effort to promote care. However, integrating electronic records into the physician workflow has led to a variety of issues, according to the Agency for Healthcare Research and Quality (AHRQ).
While certified EHR technology has been considered a surefire way to improve patient safety, there are many examples proving the opposite and finding that these health IT systems may lead to medical errors that threaten patients’ lives.
The majority of medical technologies – whether infusion pumps, cardiac monitoring devices, or certified EHR technology – have warnings that tell physicians when an action is unsafe for the patient. Through these alerts, clinicians are expected to stop a prescription or a medical procedure deemed dangerous for a particular patient. In particular, some important alerts are meant to notify a doctor whether a patient will have an allergy or negative drug reaction.
However, the widespread computerization throughout the clinical setting has brought an enormous number of alerts among different medical devices, which physicians manage every day. A study conducted last year shows that monitoring devices across 66 patient beds in an academic hospital generated at least 2 million alerts throughout a single month.
In another study surrounding ambulatory care, computerized provider order entry (CPOE) systems generated alerts for as much as 6 percent of all orders entered, which means doctors dealt with dozens of warnings per day.
When it comes to managing these large amounts of warnings, many clinicians experience alert fatigue and become desensitized to the safety alerts. This could be a major problem for the healthcare sector, as physicians may ignore some warnings due to alert fatigue and cause serious medical errors within the clinical setting. The results show that many physicians override most CPOE warnings.
With more exposure to these warnings and additional use of health IT systems, physicians become even more prone to alert fatigue. This problem is also due to the mere fact that many of these alerts generated via CPOE systems are often “clinically inconsequential,” AHRQ reports. The problem with ignoring certain alerts that do not pose harm is that clinicians will also bypass any warnings that could lead to a serious safety issue for a patient.
Essentially, alert fatigue and the high number of warnings may be leading to additional medical errors and patient safety issues throughout the healthcare industry. The widespread use of certified EHR technology may not have the intended consequences once hoped for with regard to quality care improvements.
In fact, a Boston Globe investigation from 2011 shows that alert fatigue and the failure to respond to critical warnings via medical devices led to more than 200 fatalities across a five-year period.
AHRQ gave some recommendations to prevent some of the issues associated with alert fatigue. Increasing alert specificity and eliminating inconsequential alerts, customizing alerts to each individual patient, providing tiers for alerts with regard to severity, and using human factors strategies when designing the warning systems may all lead to greater patient safety and a reduction in medical errors associated with alert fatigue.
Many hospitals, and some larger medical practices, have been using scribes to capture medical documentation within EMRs — leaving the provider free to make old-fashioned eye contact with patients.
Using the scribe might sound like a crude workaround to techies, but it’s been a hit with emergency department doctors, who prefer to focus on their brief, critical encounters with patients rather than the hospital’s expensive toy.
While it was clear from the outset that doctors loved having a scribe to support them, there’s been scant evidence that the scribe was anything other than an added cost.
A recent study, however, has concluded that at least from a Case Mix Index standpoint, scribes can have a meaningful impact on a hospital’s revenue. The study, which evaluated the use of scribes between 2012 and 2014 across a group of hospitals, concluded thatthe scribes save money and boost patient-doctor communication.
The study, which was designed to capture the impact of medical scribes on a hospital’s CMI, linked Best Practices Inpatient Care Ltd. with Advocate Good Shepherd Hospital, Advocate Condell Medical Center and hospitalist-specific medical scribes from ScribeAmerica LLC.
Kicking things off to a good start, ScribeAmerica and Best Practices put scribes through a jointly-developed course that emphasized workflow, productivity and accurate inpatient documentation. The researchers then tallied the results of using trained scribes over a two-year period in the two hospitals.
From 2012 to 2014, researchers found that for both Advocate Condell Medical Center and Advocate Good Shepherd Hospital, CMI values climbed after medical scribes came on board. Advocate Good Shepherd’s CMI grew by .26 and Condell Medical’s CMI rose .28. These are pretty significant numbers given that a CMI growth of 0.1% typically translates to a gain of about $4,500 per patient. In this case, the hospitals gained roughly $12,000 per patient.
These findings make sense when you consider that using scribes seems to have served its purpose, which is to be extenders for providers who’d otherwise be hunched over an EMR screen.
Researchers found that inpatient physicians at the two hospitals studied were able to cut time spent on chart updates by about 10 minutes per patient on average. This profit-building effect is enhanced by the fact that scribes often get discharge summaries prepared immediately, rather than within 72 hours as is often the case in other hospitals.
That being said, it should be noted that the study we’ve summarized here was co-written by the CEO of Best Practices, which clearly invested a lot of time and effort training the scribes for the specific tasks important to the study.
Still, the study does suggest, at minimum, that scribes need not necessarily be written off as an expense, given their capacity for freeing providers for billable clinical activity. Ideally, IT vendors will develop an EMR that doctors actually want to use and don’t need an intermediary to work with effectively. But until that happy day arrives, scribes seem like they can make a difference.
Over the last two decades, the medical industry has changed drastically in terms of patient care and access to medical records. It was nearly impossible to obtain one’s own health record 20 years ago. Forbes reports that patients had little choice but to press legal action if they wished to access their own medical data.
In 1996, however, the Health Insurance Portability and Accountability Act (HIPAA) was passed, which did offer legal protections to patients who needed to see their health records. Nonetheless, there was still significant difficulty in accessing this information and most people never went through the challenging process.
Today, these problems are slowly disappearing, as patients have more ability to readily view their medical history and test results via patient portals and through other electronic means.
A study published earlier this year shows that after three hospital systems in separate states offered their patients the ability to view their health records and physician notes, nearly 70 percent of patients reported understanding their conditions better and taking better care of themselves including remaining vigilant about taking their medications on time. The results from the study also showed that providing patients with this ability did not majorly impact the physician workflow.
The design and evolution of certified EHR technology and health IT systems that held medical data are now changing toward a more cloud-based and mobile platform. This leads to more digitizing of medical records and providing more flexible solutions for healthcare professionals within the clinical setting.
Both mobile health and wearables are also impacting the design of certified EHR technology. The Apple watch, for instance, could potentially hold relevant medical data for physicians to view and patients to access. Additionally, mobile apps on smartphones or tablets could be used by patients to request drug refills and securely message doctors or nurse practitioners.
In a new report from market research firm IDC, Judy Hanover, Research Director at IDC, explains, “The new concept of flexible, mobile, cloud-based acute care EHR supports digitizing paper workflow and reengineering processes … There’s a huge appetite for getting better workflows into healthcare, looking at department specific and mobile apps. I would see an environment where hospitals and health systems would perhaps rip out and replace in some cases.”
According to the report, it is expected that over the next few years, providers will begin to replace their current certified EHR technology with cloud-based solutions instead. Greater investment will continue to be poured into the health IT industry as providers move onto meeting Stage 3 Meaningful Use requirements under the Medicare and Medicaid EHR Incentive Programs.
Additionally, the future of EHRs will continue to depend on EHR interoperability and the ready access of medical data across the healthcare industry. Forbes states that many within the medical sector believe EHR interoperability will be the “biggest game changer.” However, it may take longer than expected for interoperability and medical data exchange to expand across multiple healthcare settings, as this industry “moves slowly.”
The ICD-10 compliance deadline will be here momentarily. Healthcare providers have little more than four months left before October 1, which means their ICD-10 preparation efforts must move forward quickly in order to be ready for the transition and avoid any reimbursement delays from the Centers for Medicare & Medicaid Services (CMS) as well as other health insurers.
EHRIntelligence.com: “Where should a healthcare organization be in terms of ICD-10 preparations right now?”
Pam Jodock: “Ideally, they will have already gone through making sure all their systems are remediated, their documentation has been updated, and hopefully they’ve trained their physicians on documentation. The need for the more detailed elements of documentation on ICD-10, they’ll have trained their coding staff.”
“If they have 3rd party vendors, they’ll have received confirmation from their vendors that they’re ICD-10 ready and that their clearinghouse has tested with their payers. Larger organizations, especially, will have completed testing with CMS both on the end-to-end and acknowledgement testing. That’s the ideal situation.”
“For those entities who are that far along the path, who have continued their implementation efforts despite the delay, they should be in pretty good shape. What they can be focusing on in the next few months before October 1 is looking at their reports. They need to make sure they’re ready to make the transition to ICD-10 and can account for any abnormalities that may occur because of the differences in coding.”
“The more detailed information might alter their numbers slightly on pay-for-performance. If they’re tracking patient activity related to diabetes, they may see those numbers go up slightly or go down slightly because of individuals they might not have captured under the ICD-9 coding. Those individuals may show up under ICD-10 because of additional detail. Looking at the reports and making they’re prepared for that [is important].”
EHRIntelligence.com: “What health IT solutions and services are working for providers with regard to ICD-10?”
Pam Jodock: “HIMSS is not in the position of endorsing specific vendors. We’ve been hearing a lot of positive reports from individual practices that are using vendors and clearinghouses for their solutions. We even saw in testimonies before Congress a few months ago where there was a solo practitioner who talked about the solutions in his office where the vendor essentially said, ‘On this day, you can code on ICD-9 and on this day, we may need to practice coding in ICD-10,’ and this was working.”
“We’re hearing a lot of end-to-end testing results are demonstrating that preparations organizations have made are working well for them. We’re hearing there is not a substantial increase in rejected claims under the testing area for ICD-10 than there were under the existing ICD-9. CMS had projected there might be one to two percent increase, but what we’re seeing is that it remains pretty stable. Regardless of the solution that’s being offered, they’re all working well.”
EHRIntelligence.com: “What testing plans should providers have for the months ahead especially providers that are behind in their ICD-10 preparation?”
Pam Jodock: “We do know that there are some solo and small practitioners out there who have not been able to dedicate as many resources to preparation because they’ve been hit with many other demands for their resources. They’re just now starting their preparation.”
“Testing with commercial carriers, you may have a very limited window left. A lot of commercial carriers will be ending their testing in June or July to focus on completing their transition. If there is still an opportunity to test with external partners, we would strongly encourage organizations to do so.”
“What we would recommend that they look at, is identify those ICD-9 codes they bill most frequently, identify the ICD-10 codes that they would bill for those procedures going forward, and also to look at those ICD-9 codes that generate the greatest percentage of their revenue and make sure they know what ICD-10 codes they will billing for those services going forward. They should create test scenarios using those codes and, if they can find a payer for end-to-end testing, use 25 to 30 scenarios. They can also use those same scenarios for acknowledgement testing with CMS all the way up until September 30.”
EHRIntelligence.com: “What is your viewpoint on Representative Diane Black’s ICD-10 bill?”
Pam Jodock: “This is a conversation we’ve had before. It would essentially require a period of dual coding. She has language in there about penalties. What I would note is that there is no penalty stage, technically, for ICD-10. If you’re not prepared to do ICD-10, if all you’re prepared to do is ICD-9, it may be viewed as a penalty in that there is no allowance for submitting ICD-9 claims.”
“The default penalty is that your claims will not be accepted. If you code in ICD-9 for services after October 1, your claim would automatically be rejected because it’s not coded properly. That is not considered a penalty phase. It’s just considered noncompliance.”
“She’s suggesting that we offer dual coding so that we can ease providers into the ICD-10 world. The challenge with that is that systems have been remediated across the industry based on date of service. For claims that are processed prior to October 1, there’s a whole different set of business rules and payment methodology that are applied to them. If you get to the fork in the road in the claims processing system and your date of service is before October 1, you go to the left. If your date of service is after October 1, you go to the right because the systems are not coded the same.”
“If you were to do dual coding, that would require an additional period of time for payers to again remediate their system and it would essentially result in a defacto delay.”