Healthcare Talent Transformation

The Billing Codes Merry-go-Round

Jonena Relth

Many of you may have heard that The Centers for Medicare and Medicaid Services and Office of the National Coordinator for Health Information Technology held a “listening session” in Washington on May 3, 2013. The meeting was with stakeholders to discuss EHRs and billing.  Hmmm…I bet many of you weren’t invited.

You may also have heard that The American Health Information Management Association is urging more research on the causes of higher levels of coding and reimbursement through the use of electronic health record. Sue Bowman, Senior Director of coding policy and compliance, has reiterated their view, “The extent to which EHRs have led to improper reimbursement is unclear. EHRs produce more complete and accurate documentation and this could be leading medical providers to seek reimbursement for services they have always been providing, but weren’t properly documenting before. Higher levels of reimbursement do not necessarily equate to fraud.” [Good for AHIMA to share this very important tidbit the government bean counters must have overlooked when they estimated disbursements from their mandated EHRs!]

I’ve written several articles on coding the past year, emphasizing the issues that will and are resulting from too complicated a coding system. Here's one you might like to check out.  IDC-10 Codes, There's Got to Be a BETTER Way!

This latest round about coding is a perfect example of the documentation mess we're in, except in the reverse.  Now physicians are getting accused of seeking higher reimbursements because their EHRs are allowing them to more accurately document all the services they are providing - which are  legally billable, by the way!  Look at this from the physician’s side:  They have expensive EHRs they've been mandated to implement.  Now they have a capability to document and bill for all their services that they probably missed billing in the past due to “user/billing errors.”  Doesn't it make sense that they would bill for all the services they provided - thus helping them pay for their EHRs, employee training, lost productivity, etc?  Wow, if you’re healthcare provider in today’s healthcare world, you’re placed in a position of being “damned if you do and damned if you don’t.”

This reminds of our of complicated tax system.  For those of us lucky enough to hire a good CPA, we can deduct everything coming to us, but those who can’t afford such professional services, you’re left to filing your taxes with only “street” knowledge that you’ve gathered over the years.  And oh yeah, what you’ve learned may or may not be applicable to the newest tax rules, so you’re increasing your chances of being audited by the IRS.

Now back to Ms. Bowman...  She’s recommending the development of a code of ethics for EHR vendors and users to design and use the system appropriately, guidelines to ensure features in an EHR are correctly used, development by CMS of a national set of coding guidelines for hospital reporting of emergency department and clinic visits, and education and training on coding with EHRs.

Forgive me, but on the vendor’s side, shouldn’t this be part of the licensing process for EHR software?  There will always be some unscrupulous people in all professions, but is it necessary to make more laws to make sure docs are coding correctly?  Remember, the new codes have increased from 13,000 to 55,000! Getting all the coding done correctly will be like finding a specific shell on the beach. There's a good chance you'll find the wrong shell? Coding accuracy will be a myth!

I would welcome dialog on the issue.  It’s a big one for me and I’m hoping it gets you riled up a bit to!

Remote Patient Monitoring: The Ideal RPM System

David Scher, MD, DLS Healthcare Consulting

Remote patient monitoring may serve patients who are in the post-acute care phase of recovery from a hospitalization as well as those with chronic diseases.  Monitoring may consist of communication tools or measurements of medication adherence, glucose measurements for diabetics, oxygen saturation measurements for those recovering from pneumonia or who have chronic lung or heart disease, symptom reporting, and vital sign measurements, and other potential parameters. Most important to consider is that these tools must be used in a context of a comprehensive approach to monitoring. A strategy regarding workflow and dedicated human resource support needs to be designed prior to implementation. Once implemented on a small-scale initially, it needs to be reexamined with an eye on identifying pain points in logistics, communication, and outcomes.  The following consist of what I consider five characteristics of an ideal RPM system, however individual needs might vary.

1. Single vendor for all technologies.  There are currently vendors which can furnish multiple technologies and even some with more than an organization or healthcare system might want. Be careful about a one size fits all proposal. Consider whether it would be of benefit to have the technology provided by a wireless carrier or not.
2. Easily implemented and unobtrusive to the user.  Anyone who has experienced difficulties with setting up a new TV or smartphone understands frustrations with technology implementation. Considerations for assisting the healthcare system, Senior living facility, and the individual user are an important point of an RPM business plan.  If the tool is difficult to set up or significantly gets in the way of daily activities of living, it will not be utilized. Involving a caregiver with instructions is crucial in this regard as well.
3. Must have optimized population alerts and superimposed personalized alerts.  Optimized alerts are those determined from evidenced based medicine, professional societies, or physicians associated with the customer.  In addition, these alerts should be customizable for the individual patient whose baseline measurements or variations might be atypical.  Both of the above should result in alerts to non-physician healthcare providers which are actionable only. What this means is that measurements which do not prompt a provider to recommend a change in course of treatment or other action should be stored but not transmitted. There might even be different levels of alerts which, after verified, are conveyed to the physician or other provider which ideally via an algorithm, would prompt different actions.  The aim is to minimize false positive alerts while maintaining a high degree of specificity.
4. It needs to be a closed loop system.  This refers to every alert being addressed with an interaction. This might be a human interaction (phone call) or algorithmically determined digital message with instructions. It also refers to a follow-up afterwards to determine adherence to the instructions.  This system must be bidirectional to work. There also needs to be a human component to discuss symptoms and interact with patients with limited capabilities.
5. There must be seamless integration with PHR and EHR.  The incorporation of data into the PHR and EHR is imperative. This is a logical progression of collection of data. It must be filtered so as not to clutter an electronic file with endless unimportant data points. It must be in an easily identifiable part of the electronic record.  It must be able to be shared with the caregiver and all designated providers in an interoperable fashion.

Hopefully the Telehealth Promotions Act of 2012 will be approved in this Congressional session and pave the way for widespread adoption of these technologies which are sorely needed.  It is up to both industry and adopters to optimize implementation and utilization and to create outcomes measures which might translate to health and financial ROIs.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

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Health Wonk Review: Health Wonks Tackle New Questions in Healthcare Reform

Thanks to Louise Norris at Colorado Health Insurance Insider for hosting this week's edition of Health Wonks Tackle New Questions in Healthcare Reform.

Be sure to read Peggy's post this week. In her post, Cost, Compliance and Safety: Are They Mutually Exclusive?, Peggy compares the aviation industry and the healthcare industry, and wonders if we might be heading down the path towards over-regulation in healthcare. 

Transparent Healthcare – It’s Here: Get on the Bus or Get Runover

Jonena Relth, TBD Consulting

I’ve done some “unscientific” surveying of the issue of Transparency in Healthcare and was surprised by what I found. While we often blame the older docs of being inflexible and holding back in the transparency arena, I run across docs of all ages who know that healthcare delivery must change. There are the gutsy docs willing to put their heads above the fray and open themselves up to scrutiny by their peers and patients. They ask the hard questions, pressing for why we’re still teaching and practicing medicine the same way. They ask the question of why we don’t review our standard procedures using Lean methodologies to see how medical professionals can save time and money and improve patient care.

As with any change, there are those individuals that still need to be brought over to the “light side.”  Forgive my Star Wars analogy… There are still MANY doctors, old and young, who still have the “I went to medical school and thus know more than anyone else in the room. I like what I do now and don’t want healthcare to change – or at least don’t want my work to change.”

I don't have much advice for how to change the attitudes of the second group, except to:

• Keep the drums pounding…in a nice way of course. 
• Allow naysayers to stand back and watch the changes happening around them but not too long.  At some point, they will need to get on the bus, or the changes will pass them by.

Medical School Experiences that Show Leadership Transparency

Medical students experience both types of leadership: Transparent and Autocratic.  They see firsthand transparent leadership from some docs’ autocratic leadership from those docs unwilling to open up and flex, even a little, to allow the students learn from the docs’ personal experiences that would bring the subjects to life.  Yes, students are taught to memorize, assess quick, make quick decisions, but that's a different topic to address later.

As a trainer and teacher, I love to hear of times when professors share the good, the bad and the ugly with their students.  It’s from these real-life experiences that the “light bulbs” turn on around the room. These professors show a transparency that shows they are “real people” working at a complex job with many variables. It helps give the students a better idea of what practicing medicine will be like from them after their LONG training journey.

Don’t jump to conclusions here, I’m not suggesting breaking HIPAA laws, just doctors showing a bit of vulnerability.

Unfortunately, in medical school, the time is so short to teach the students all the theory and science needed to practice medicine, instructors in the classroom and hospital use an autocratic teaching style to get through as much of the content they can. There isn’t time to allow for much “self-discovery” or independent thinking. That will come later when they have more experience under their belts.

Signals that Change is Not Easy for MANY

In our EMR/EHR consultancy, we see the flexible doctors willing to attend training whenever it is convenient for the organization.  The inflexible doctors are the ones that still want to be trained one-on-one. My opinion is that these physicians don’t want "transparency" because they don't want others to know what they don’t know. It would bump them off their know-it-all pedestal and down with mortal men.  You can’t blame them.  I’m not being flip – honest.  No one wants to be treated by a doctor who they think doesn’t have all the answers and thus can’t cure them. Patients choose to be treated by docs they perceive to be “the” experts. What’s sad is that these same docs and patients are kidding themselves.  No one can know everything about every topic – even in their particular specialty.  A very skilled doctor may know more than the next 20 people, but new information is found every day and no one has the time to learn everything new every day and keep up with their patient load.

I have the utmost admiration for those who choose the medical field as their choice of profession. It is often a lonely, selfless job that keeps practitioners away from their families and forces them to trade “personal time” for being on call at night, weekends and holidays.  It is, however, time for all healthcare professionals to take a good look and accept that our world, our patients and healthcare delivery are changing. Hopefully more healthcare professionals will choose improved, transparent, care delivery by involving others, especially holding patients ultimately mutually accountable for our own care. 

It’s not a one-way street – patients need to change, as well.

The time is now that patients must start taking responsibility for how we treat our bodies and learn how they work. Ok, so in a perfect world, patients would know that "we are what we eat" and also know that we all need exercise and a will power to avoid things that harm our health.  If we do this, doctors will have a much easier time treating our illnesses and helping to make us healthier. Sounds logical to those of us "A" type personalities, but we have a long way to go to get here!

Please share your experiences with us about doctors – young and not so young – who are modeling transparent healthcare.  I know they are out there.  If you are a champion of transparent healthcare, please let us hear from you so we can learn from you!

Here’s a short list of my current transparent healthcare heroes. These docs are in the trenches speaking out for reforming healthcare delivery. They have all earned the right to be heard.

And folks, leadership is where it has to begin! 

• Dr. Michael Koriwchak; Read one of Michael's blog posts: MD – Techy Doc Who Puts Patients’ Needs First
• Dr. Stephen C. Schimpff; Read one of Stephen's blog posts: Innovative Technologies Can Markedly Enhance Safety or check out his book: The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You
• Dr. John Toussaint

Then there are the holdouts… but we’re working on ‘em! 

Jonena

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Health Wonk Review: Why Hasn't Spring Sprung?

Thanks to Julie Ferguson at Workers Comp Insider for hosting this week's edition of Health Wonk Review: Why Hasn't Spring Sprung? 

Be sure to read Jonena's post this week.  Shethinks there's untapped potential in technology. She asks why EMRs aren't making use of existing technologies to improve care delivery in her post How come Spock's computer was so far advanced beyond today's EMRs?

Health Wonk Review: A Lot to Chew

Thanks to David Williams at Health Business Blog for hosting this week's edition of Health Wonk Review: A Lot to Chew. 

Don't miss Peggy Salvatore's addition to the HWR on the HIMSS13.  Peggy encourages us to stay patient on cost savings from health IT adoption.

“Technology usually brings with it a falling cost curve. But the reality is, for now, we are still undergoing the transformation stage and the transition is rocky and costly.”

Read the entire post.

HIMSS 13: Progress on uptake and interoperability, so when do we see the cost benefit?

Peggy Salvatore, MBA

Last week I was reminded about how far we’ve come in electronic patient records in just three years, when the annual signature event in health IT, the Health Information Management Systems Society conference known as HIMSS (pronounced HIM-Z), was held. Three years ago I spent the week at HIMSS10, and at that time we hadn’t even started up the Meaningful Use hill, let alone crested MU2.

Since then, we also have seen uptake rates for electronic patient records and CPOE topping 50% in most provider venues without even breaking a sweat. And, in my humble opinion, the leading news out of HIMSS13 was the fact that six leading electronic patient record systems will be working together on establishing standards to advance interoperability. Whew! Never thought we’d see that in the first half of the 21^st century…

The progress is commendable. And as a long-time observer and analyst in this field, while the cynic in me often says, “We wrote white papers about that 20 years ago…it’s about time!”, the realist knows that fully integrated electronic patient records requires a kind of sea change in the way we provide service to patients – and that will only come over time with changes in culture, which is why I have been talking about change management and training as absolutely essential for a smooth transition – something that studies are bearing out (see my Healthcare Talent Transformation blog post from last month).

But probably the biggest single factor in moving the needle on uptake is the more than $10 billion we spent in incentives over the last few years  to encourage doctors and hospitals to purchase the software systems. Unfortunately, after those billions have been spent, only now are the top vendors getting together on establishing standards for interoperability. I haven’t read the fine print, but I will guess that those are probably not going to be free upgrades to those systems the tax payers already bought and paid for. I would love somebody who knows about the interoperability effort to post here with more details since time to publish does not allow me to do the research. In the meantime, I might do a little looking and report back in a few weeks, so stay tuned.

But the bottom line on the advantages of electronic patient records boil down to a few major points, and at HIMSS13 it is clear we have finally started to move the needle on some of these:

• Uptake rates for physicians, hospitals and computerized order entry (pharmacy, radiology, etc)
• National (international would be *really* nice) standards for interoperability
• Fully integrated patient record including dental, vision, mental health (we’re a looooong way from this one, but it is critical to getting a good end-to-end snapshot of the patient in front of us. Only ONE booth at HIMSS10 even offered software for mental health providers and, no, it wasn’t integrated into the major software packages)
• Ability to pull aggregated, de-identified data for research for full population studies and post-approval FDA studies

The Falling Cost of Technology – Except in Healthcare

As envisioned by the planners, when we can capture the full picture of a patient, and all providers have access to it, theoretically the cost of healthcare should fall quite a bit. No more duplicate tests, the cardiologist will know what the psychiatrist prescribed so we won’t have the drug-drug interaction issues that currently cost us at least hundreds of millions a year in adverse events and the attendant morbidity and mortality rates, we won’t be writing and re-writing scores of sheets of repetitive patient documents for each provider and patient encounter and having to physically store and transfer them. And, the icing on the cake, when we have valid, comprehensive data on full populations, we should know what works in which patients which will narrow our treatment options  to the ones most likely to succeed the first time.

Technology usually brings with it a falling cost curve. But the reality is, for now, we are still undergoing the transformation stage and the transition is rocky and costly. The culture is still changing, the records are still isolated in single offices or hospital systems, and we haven’t completely solved how to interact with patients using an electronic interface in the room, and especially, we haven’t solved how to take and capture complex notes in an electronic record.

We aren’t there yet. But reports out of HIMSS13 suggest we are getting there.

If you were at HIMSS13, we’d love to hear from you in the comments section. And if, like me, you missed it, let me shamelessly hustle what sounds like a great deal which is a three-hour debrief today, Wednesday March 13 from 11 a.m. to 2 p.m. CST and access to full sessions online until June, Here’s the link: HIMSS13 Online Sessions

And, what’s more, the online sessions are eligible for CE credits.

Let me know what you think about HIMSS13, and I’ll be reporting back when I learn more.

 

Health IT Summit in San Francisco March 26-27

Jonena Relth, TBD Consulting

I think many of our readers will want to check this upcoming IT conference to be held in San Francisco.  If nothing else, perhaps many of us can get out of the snowy east and midwest. Seriously, the presenters and topics look great!

  Reposted from Health IT Summit March 26-27 

"The 2013 iHT2 Health IT Summit is less than 30 Days away! Don't Miss this opportunity to join over 200 CIOs, VPs, and Directors of IT from hospitals, health systems, and larger physician practices.

Program Highlights:

• Data Analytics in Healthcare - Featuring Kaiser Permanente, Catholic Health Partners & More
• Evolution of Clinical Decision Support - Featuring Mayo Clinic, Dignity Health, Lucile Packard
• Meaningful Use Stage 2 - Featuring CalHIPSO, Department of Public Health - San Francisco & More
• mHealth Apps & Patient Engagement - Featuring Aetna, West Health, UCSF School of Medicine & More

How will the 2013 iHT2 Health IT Summit in San Francisco benefit you?

1. Learn best practices for leveraging data at the point of care, and how to get the most out of your EHR data
2. Discuss strategies for securing mobile devices and understand how to assess responsibility for PHI
3. Address best practices for improving performance & outcomes and understand how you can use Clinical Decision Support to meet new standards of care
4. Understand how Meaningful Use standards impact ACO operations and success, and the role the new ICD-10 will play in providers understanding their practices and outcomes
5. Discover mHealth tools that reinforce the provider-patient relationship, and best practices for integrating mHealth data into existing EHR and system infrastructure

Still Looking for Reasons to Attend?

We understand your time is valuable. Now more than ever, iHT2 is committed to providing programs which promote improvements in the quality, safety, and efficiency of healthcare through information and information technology.

Interested in attending or just learning more about the iHT2 Health IT Summit in San Francisco or upcoming Summits in Atlanta, Boston, and Fort Lauderdale? Please contact Matthew Raynor at matt@ihealthtran.com or call 561-748-6281.

iHT2 HIT Connect Interview:

Davin Lundquist, MD CMIO Dignity Health Medical Foundation How has Dignity Health Medical Foundation benefited from using CDS (Clinical Decision Support) systems?

We have some basic CDS tools in place within our EMR, most related to medication ordering as well some meaningful use reminder alerts. We also use templates in our documentation to help prompt providers with what questions to ask patients who come in for particular types of visits or with particular problems. We have some order sets and a few care guides related to wellness visits. I would categorize all of these as “First Generation” Decision Support tools. We are actively pursuing technologies that will help us get to what I would call “Second Generation” Decision Support tools that are much smarter and actually incorporate patient specific information and prior results to prompt physicians with more point of care and contextual support for managing patients and their diseases.

Hear from Davin Lundquist, MD and more than 35 other C-Suite Health IT Leaders at the iHT2 Health IT Summit in San Francisco, March 26-27th at the Hyatt Regency San Francisco Airport Click Here to View the Agenda Click Here to Read the Interview in its Entirety Share This Article"

How come Spock's computer was so far advanced beyond today's EMRs?

 

Jonena Relth, TBD Consulting

I read an excellent article on Natural Language Processing (NLP) being, The Next Generation Medical Record.

While the author talks about the system and how it will process information, I'd suggest that the EMR systems of the future must go way beyond being a sophisticated database with natural language query.  With millions of data point of knowledge growing with every discovery and new drug treatment, we will need our computers to go well beyond "holding and processing data".  Undoubtedly, it will need NLP, but in addition, the software will need to contain ALL current, up-to-date information and be able to logically guide providers' clinical decisions.  Think of the space movies of the past. 

For you Star Trek fans, I bet if you listen, you'll quickly the remember the onboard computer. The sounds you heard were that of Majel Barrett-Roddenberry's voice.  Remember how Captain Kirk and his crew simply asked the computer questions and it instantly offered suggested solutions to their problems? "She" even provided the probability of success for each option.  Our computers need to do that same thing plus much more. 

And on a side note, wasn't the voice recognition a nice touch? Today we have iPhones that correct our spelling and the Siri application, a natural language, intelligent personal assistant, that is able to process data and verbally answer our most obscure questions.  This technology is no longer out of reach.  Why aren't EMRs using these options to improve care delivery?  Not to appear ungrateful for the IT programming to date, but our current EMRs are simply VERY expensive data storage tools.

If our iPhones use the latest technology, why don't our healthcare systems?  Think about it, Siri adapts to the user's individual preferences over time and personalizes results.  It performs tasks such as finding recommendations for nearby restaurants, or getting directions.  Wouldn't similar technology be helpful for providers to have at their fingertips?  Not the restaurant look ups...but you know what I mean!

While it's nice for Siri to be able to tell me every turn I should make on my drive across country, a robust computer system that guides healthcare delivery decisions on the spot would certainly be more earth-shattering that a woman's voice telling us how to find the local eatery.

So Mr./Ms. IT professional, please tell us what you're working on now to improve/upgrade our current EMRs.  We truly depend on your expertise and believe that you can build the computers of the future that will revolutionize healthcare delivery and improve patient care!

Exciting stuff for sure!

Please let me and our readers here from you -- I truly welcome comments! Conversation is the best way for us to learn from each other.

Jonena

TBD Consulting has a proven track record for ensuring staff and physician adoption of EMR/EHR system implementations as well as Lean Healthcare. Whether you need assistance to create a training department or organizational change department, help your existing training organization meet the needs of the ongoing changes, or simply need "extra hands" to meet your deadlines or ROI goals, please contact Jonena. She and her qualified staff are here to assist you with your organizational development, coaching and training initiatives.

Drop by our EMR/EHR Clinical Transformation Group in LinkedIn to learn the latest news and opinions on electronic health records. 

Or feel free to call our office today 602-263-1961. We'd love to hear from you!

Health Wonk Review - Insightful Nuggets

Another great edition of Health Wonk Review: Thanks to the Disease Management Care Blog for hosting.

Don't miss Jonena's addition to the HWR. Gone are the days when American medicine was ranked head and shoulders above ALL other healthcare systems around the world. One only needs to watch the up-tick on medical tourism to see that there is a plethora of qualified healthcare providers beyond our borders.  EMRs and EHRs are the US healthcare system’s way of dipping their toes into 2013. We MUST go beyond getting our toes wet. We need to implement change methodologies and Lean tools and processes that will guide all healthcare employees - clinical and non-clinical alike - to participate in and take responsibility for continuous process improvements within their spear of influence. Read the entire post.

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