Archive for the HIT Category

Patient Centered Medical Homes: A New Model for EHR Maximization

Posted in HIT, Uncategorized on May 31, 2013 by Matthew Levy

A growing problem in healthcare today is a shortage of providers available to offer primary care solutions to patients. Most students have extensive debt upon completing their medical education, and the idea of entering a low-paying field that might cause them to spend more of their professional career in debt. The percentage of medical school graduates who opt for some sort of specialist training, either as part of their residency or with a fellowship after completing an internal medicine residency is too high to sustain an acceptable level of access for patients to quality primary care.

The non-profit group National Committee for Quality Assurance has set out a series of criteria for measuring the success of a medical home model in place. One of the fundamental criteria set out is a quality EHR system to guide the interactions and interchange of information, which is among the things that EHR systems were designed to take advantage of. The interactions required to make this model work are central to the features of an EHR, from both quick and more advanced communication to tracking of results and tests amongst multiple providers. Additionally, it allows analytical models within a population. Data from the system can be used to track all sorts of achievements, measuring care levels and seeing which patients have not reached certain levels of care. This makes it easier to manage care, not as isolated encounters, but with the focus on a patients ongoing health and outcome.

It could be argued that the advantages of an EHR, while useful in all systems, are best suited for a Medical Home model. While the popularity of the medical home model is still reasonably new, the ideas behind it are not. Not only has the concept been around since 1967, but it is driven by basic concepts, not limited to many of the requirements set forth as part of Meaningful Use. Whether the model will stick as a common method for managing care is yet to be seen, but the tools are there to make it work, and like many ideas for change, all it will take is people willing to make the effort.

Further Reading:

HHS: What is PCMH

Allscripts case study on the use of PCMH

Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality

Let’s Talk Telehealth!

Posted in HIT on May 16, 2013 by mfisher527

What is telehealth? Healthcare services provided over the web, text, video and remote interacting between patient and their Provider.

What are the benefits of telehealth? Easier access to healthcare and decreased cost for starters! Everyone is busy these days…convenience is what we are all seeking. Most people have been in the position of wanting to schedule a visit with their Healthcare Provider, but simply do not have the time. People in rural areas have little access to convenient healthcare options. With telehealth, they have easier access to proper care. This is ideal if they need a visit with a specialist. If all we had to do was get on our computers to have a healthcare related visit, wouldn’t we be more apt to make that appointment?

Quality of care is the main concern of Healthcare Providers. With telehealth patients can be closely monitored. Patients can transmit blood pressure results, glucose readings, protime results and other in-home tests they perform on a regular basis.

The Veteran’s Association is offering some amazing services via telehealth. These include speech pathology appointments, mental health visits, surgery consults, visits with their family practitioner for medication refills/changes and much more. The VA is making it easy and affordable for our veteran’s to receive the care they need. Read more here http://www.telehealth.va.gov/real-time/index.asp

Many facilities are offering 24/7 web based services. Internet Medical Clinics is based in Texas and offers their patients to “consult with their healthcare providers, receive laboratory services, medications, diagnostic testing, and more. Online access to the Virtual Healthcare Delivery System for appointment requests, prescription refills, “virtual” consultations with healthcare providers, and online medical records”. UC Davis Children’s Hospital has provided telemedicine consultations to over 5,500 children in California. They also offer  specialty services, rural telehealth care, teleradiology and acute care.

Of course the concept of telehealth requires up-to-date technology and training. Thanks to the FCC “The Healthcare Connect Fund” was created. This fund will help cover the costs of equipment, broadband internet, research, education and may even help cover the cost of facilities if it is the most cost-effective option. The annual cap is 4 million dollars.  Facts and criteria can be found here http://www.fcc.gov/document/healthcare-connect-fund-fact-sheet

Will online healthcare be the wave of the future? Time will tell if it is cost-effective and being used properly.

EHR in the Cloud! Is it Right For You?

Posted in HIT on April 17, 2013 by mfisher527

Among the more popular advancements in technology in recent years has been the promotion of a style known as “cloud computing.” Developments such as Apple’s iCloud, Google Apps and Microsoft Office were designed to take advantage of the on the go atmosphere of today. Workers and students alike have migrated to a world in which they might need information or data at any time and being away from home or the office is not a reasonable excuse. Cloud computing offers users storage and access to their information, including contacts, calendars, e-mail. The result is a lack of need to store these items on a home computer, which allows them to be quickly accessed from another computer or a smartphone or tablet. It provides two major abilities: to quickly access necessary information while away from home, and eliminating the need to undergo a time wasting data transfer when acquiring new equipment.

It comes as little surprise, then, that Healthcare organizations are getting in on this trend. EHR’s such as AthenaHealth, Practice Fusion, and e-MDs exist as cloud based systems. This means that practices and providers do not need to host servers or storage units in the office to run all the necessary programs and store all records, both old and new. At the same time, providers can access their EHR from anywhere, and all it can require is quickly signing on from any web browser, meaning all doctors can complete their work at home if they need to, or quickly respond to a task, review a lab, or authorize a prescription, even if they happen to be away for the day.

It sounds too good to be true, and in some cases it is. While downside is probably too strong, there are some concerns that keep cloud-based EHRs from being the obvious solution. Foremost, because of the ease of access, these systems need to strongly address security. HIPAA is a major concern. If a provider can easily access  their EHR from any computer, what is to keep them from accidentally leaving it open when others use the same computer? Luckily most cloud-based EHR’s use bank level security in ensuring that patient records stay secure. The other major concern is one of storage. While the biggest advantage to a cloud system is that storage is off site, and offices are not required to buy expensive new equipment, which makes it a good investment for a small practice with a limited number of providers. But in the case of larger practices and hospital systems, sometimes the amount of data needed to be stored in the form of past patient records and images are very large. So the organization needs to determine that the system they are considering does not have a either a limit to storage space or the potential for higher usage fees for practices that need more data space.

If a practice determines that a cloud-based EHR is both secure and cost effective given the size of their practice and their data needs, they should consider cloud-based technology. It is easier to implement, easier to set up access for all providers, and easier to share information. Whether ones system is cloud or server based, it is proper implementation and motivated use which will best allow the provider to reap the benefits.

Further Reading:

“5 Advantages of A Cloud-Based EHR for Small Practices”

AthenaHealth

PracticeFusion

EHR Interoperability

Posted in HIT on April 1, 2013 by mfisher527

What does “interoperability” mean?  ” The ability of two or more systems or components to exchange information and to use the information that has been exchanged accurately, securely, and verifiable, when and where needed.”

http://www.ehealthinitiative.org/

Electronic Healthcare Records are not a one size fits all. With the variety of healthcare facilities, it is a given that each EHR option is not created equally. EHR interoperability is a work in progress. With that being said, the goal is for them all to be able to communicate with each other, making healthcare for the patient and the providers much more efficient, safe and transitional. Exchange of documents between EHR’s is also a big part of meaningful use stage 2. Several states have started to mandate EHR Interoperability.

Cerner, McKesson, Allscripts, Athenahealth, Greenway and RelayHealth, a McKesson subsidiary make up about 40% of the EHR market. These vendors announced the launch of CommonWell Health Alliance at a recent conference (HIMSS). Allscripts signed on last minute, while EPIC has yet to jump on board. The goal of the alliance is to make sharing data a possibility and to enable  interoperability.

EHR/HIE Interoperability Work Group  includes 19 EHR suppliers, as well as  18 vendors of health information exchange software. Similar concept as CommonWell Health Alliance, only smaller EHR systems. Their goal is to have interfaces between EHRs and HIEs be compatible.

What are the advantages to EHR interoperability? There is no wait time for transferring charts between specialties, up-to-date information will be easily accessible.  Avoiding keying information in manually or scanning it in will save valuable time and money. Patient care and safety will greatly increase with EHR interoperability.

Why are there so many challenges with EHR interoperability?  Technical barriers, time and the expense of setting up interfaces are the major  challenges.

Seeking New Benefits within an EHR

Posted in HIT on April 1, 2013 by Matthew Levy

It is known that screening for colon polyps with colonoscopy can decrease the rate of colon cancer, the second leading cause of cancer death in both men and women. And yet, many people are never appropriately screened. This was highlighted by the recent “Love your Butt” campaign designed to encourage people to be screened.  While putting “Love your Patooty” signs in the metro is one attempt to increase screening rates, a recent article published in the Annals of Internal Medicine described a more focused approach using EHR’s to identify candidates for focused interventions. The study observed 4 methods for tracking this approach, each adding one additional element to the care provided. These included a “usual care” control group, an EHR-based addition that automated reminders and selected the patients that needed mailings sent, a further group that received mailings plus “assisted” telephone calls from an MA to follow up and schedule screenings, and a final group that received “navigated” assistance from an RN to help them with more complicated decision making.

The results of this study were interesting. On top of the “usual care” group, patients in the EHR-automated group were twice as likely to be current for CRC screenings within 2 years. The more advanced groups received notable steps up from there, but not as impressive as the automated group. This can be very useful. It shows that a system set up to fully automate the process, with the EHR handling everything except requiring staff to put messages out with regular mail. If the office wants to go further, it can, through phone calls and expert advice.

EHR’s have been criticized for being expensive and time consuming, but in this study, the ability to use structured data to identify patients who were eligible for, but had not yet received, colonoscopy allowed the investigators to target just these people for more aggressive, and ultimately often successful, interventions. The fact that the vast majority of the task could be done without provider oversight is more interesting. This same type of structured data and related processes could also be used to identify other groups of patients such as those who need vaccines or other tests. A good system can be set up to allow providers to easily check both the dates and results of screening but also prompt users if screening is overdue. Structured data can also be used to identify patients who have received prescriptions which might have had warnings issued, such as the recent one regarding Ambien in women. These types of uses for an EHR are just beginning to be investigated and utilized and everyone should look forward to seeing more such investigations.

Further Readings:

“’Love Your Butt’ Ads Try To Conquer Colonoscopy Fears”

Study Abstract

Overcoding vs. Proper Coding

Posted in HIT on March 13, 2013 by Matthew Levy

During a speech at last weeks Federation of American hospitals conference, acting CMS administrator Marilyn Tavenner discussed the CMS concern about the practice of upcoding, in which providers consistently code at a higher level of service than justified by the service actually provided. It has been argued that EHR usage makes this activity easier, because providers can copy old data from notes and document alarge amount of the physical exam with a single click. Many EHRs have a function that can keep track of what was documented within a single visit and calculate the appropriate billing level. CMS and others are concerned that EHR’s are partly responsible for a dramatic increase in the number of higher-level visits being billed by providers. Between 2001 and 2008, hospitals increased billing by about a billion dollars for emergency room visits. A similar increase has been seen with billing of outpatient office care. CMS has announced that they will be instructing healthcare organizations about Electronic Health Records and conducting small, targeted audits to ensure electronic billing is done properly.

But is the CMS concern entirely warranted? The advantage to an EHR is that the documentation is clearer than the potentially illegible handwritten note, making it easier for coders and providers to quickly review what they’ve covered and realize that they can bill for a higher level of services. With paper records, if a provider wanted to safely bill at a higher level, they needed to ensure that all the proper documentation (often repetition from a previous visit) was re-documented. Often this leads a provider to simply consider billing at a slightly lower level, given the time commitment needed to fully document a visit from a very complex patient. With EHR’s, however, not only are some systems built with technology capable of capturing and measuring an estimated billing level, but the ability to quickly import past histories and document that a system was reviewed without major changes enables a provider with a very complex patient worthy of a higher level of service to document that service without spending an overly excessive amount of time doing so.

At the same time, some providers are undoubtedly using these advantages to code at a higher level than is appropriate. The ability to clone an old note means that a less honest provider could simply assume that a patient in for one problem is fine in every other system and document a full review without actually spending the time doing so.  There is likely a mix. Many providers have used the advantages of an EHR to move billing to an appropriate level of service. Others, however, have taken this a step too far and taken even the simple visits a level up, expecting that nobody will notice. But this is exactly how payers identify practices worth auditing. If a doctor codes frequently enough at a level outside the normal range of distribution, that is the sort of activity that will draw the attention of payers to investigate further. If EHR usage is bringing coding to an appropriate level and reducing under coding, this activity should hold true through all providers, forming a sort of bell curve.

An EHR is never responsible for fraudulent billing. The provider is ultimately responsible for an accurate assessment of the level of service provided. In this regard, it is important to remember that detail of documentation is only one factor that is considered in evaluating the level of service. Severity and complexity of the problem(s) addressed at the visit is also critical.  Providers should look to EHR’s to facilitate documentation and improve patient care, but not primarily to allow them to increase level of service.

Further Readings:

CMS Audit Program Guidelines

AAFP: Data Show Upward Trend in Medicare CPT Codes Key to Primary Care

Dallas/Fort Worth Healthcare Daily: Cracking Down on Overcoding and Upcoding in the ED

Thoughts on the Cost of EHR Implementation

Posted in HIT on March 8, 2013 by Matthew Levy

There are many healthcare-changing initiatives being talked up these days. These include promotion of technology through HITECH and changing the way medical doctors code for problems through ICD-10. In selling these efforts to hospitals and providers, the people responsible will couch their arguments in benefits to the providers and the patients: EHR’s are supposed to make keeping track of patients records more efficient and enhance quality initiatives, e-prescribing is beneficial because it allows for automated interaction checks, ICD-10 allows description of medical conditions and procedures to be more thorough.

In the latest issue of Health Affairs, there is a study from Julia Adler-Milstein, Carol E. Green, and David W. Bates that explores the effect that implementing a new EHR has on profits for medical offices and practices. In “A Survey Analysis Suggests Electronic Health Records Will Yield Revenue Gains For Some Practices And Losses For Many” the authors reveal a mixed result that in theory (and in the title of the article) seems to confirm some of the worst assumptions about EHR use that physicians may hold.

But EHR implementation, despite the way it is presented in Health Affairs, is not meant to increase profits to hospitals and providers. It is primarily about improving quality of care and office efficiency. This is not to imply money plays no role in the process. Healthcare is, after all, a business. But the changes to the system have not been designed with increasing profits as a primary goal.

The amount of money being spent as part of Medicare and Medicaid has skyrocketed as healthcare has gotten better at keeping people alive and treatments have gotten more complicated. All payers, both private and public, are looking for ways to reduce payments, which has providers and hospitals left scrambling for ways to control their own costs. The Centers for Medicare and Medicaid Services (CMS), which oversees the Meaningful Use attestation program, is pushing ICD-10 implementation for various reasons, but admits that the primary goal is enabling it to have greater data on what treatments providers are billing.

We have always been aware of the costs to effectively implement EHR’s. This is why Meaningful Use incentives exist. Essentially, CMS believes that it will do better in the long run if providers keep and use electronic records and is willing to pay providers, after the fact, if they make that change.  The other problematic element within the study is that EHR implementation isn’t just failing to result in a profit, but that in practices with fewer than 6 providers, money loss is occurring. In essence, the cost to implement the new technology is not outstripped by gains in productivity over the long haul.  The study noted possible reasons for this. Almost half of offices were still maintaining paper records. Others will still maintaining and paying for staff to handle tasks that were rendered obsolete by new technologies, including transcriptionists and staff to maintain the aforementioned paper records. On the other hand, some practices increased efficiency and were able to see more patients; others improved billing and had fewer rejected claims. Larger practices (with more than 5 providers) were more likely to recoup costs than smaller ones.

This study was not designed to look at improvements in patient care, but does confirm that some, but not all, practices may benefit financially from the adoption of EHR’s, especially larger practices and those that use the change to improve efficiency in their offices. The final result of the article, despite a misleading title, is to point out a few important things. Practices who commit fully to using an EHR can see more effective billing practices leading to higher coding levels and fewer rejected claims. On the other side, those groups not interested in breaking from the past will end up wasting most of these potential advantages. In our experience, commitment to a successful implementation process should lead practices to not only improve their business model, but do a better job with their original mission: helping their patients.