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CMS Statistics from AHIMA

At the American Health Information Management Association (AHIMA) conference in San Diego, the Centers for Medicare and Medicaid (CMS) released some interesting statistics.

Up to July 2014 the Medicare and Medicaid incentive programs have jointly paid out $24.87 billion, with roughly $16 billion going to Medicare and $8 billion for Medicaid.

CMS says that 92% of hospitals have received incentive payments. Of the possible eligible professionals (EP) that could have registered, 90% are shown to have done so. That is quite a remarkable adoption rate.

As part of their move towards Meaningful Use, approximately 75% of all EP's implemented electronic health record (EHR) systems to help produce the required reports, and assist with administrative reports, management of claims, and attestation. This expense is clearly justified. To date, more than 400,000 health care providers have received incentive payments.

These EP's have seen that investment in their EHR has paid for itself in the first flush of incentive payments, often covering the entire cost of EHR implementation. Of course, once in place an EHR will continue to operate at high efficiency for years to come. The ongoing savings in human resources and increased operational efficiencies will continue to reduce overheads, making for better margins and bottom-line profits well into the future. 

Specify, For Effective Billing and Reimbursement

Until the move to ICD-10 is globally adopted, many physicians prefer to continue using the ICD-9 coding system.

Section I.B.6. of the ICD-9 manual advises that, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

The key word is "definitive". In practice this means that unconfirmed diagnoses are best avoided as they may later incur denials and / or delays to reimbursement. The presence of doubt is sufficient to introduce delay.

For example, use of words such as Suspected, Probable or Working indicate an uncertain diagnosis. Documentation that shows "Fatigue, query possible anaemia." would be better coded exclusively for the symptoms presented. In this case, "fatigue (780.79 Other malaise and fatigue)". Although this may be less than helpful as a diagnosis, it is a definitive and factually accurate presentation of the symptoms, which has a matching code that cannot be argued with.

Coding in this way allows for any indicated follow-up procedures to be recommended, without at the same time adding doubt into the mix. This factual approach to coding in turn allows for effective and streamlined billing and payment resolution as treatment progresses.

California Leads The Way In Interoperability

A new initiative by leading California insurers Anthem Blue Cross and Blue Shield of California aims to connect almost 9 million patient records in an online system, making health information available on demand by any healthcare provider in California. The two insurers are committing $80 million into seed funding for the Cal Index program, which should launch by end of 2014.

The Cal Index will be a long-term project which will be refined over the next few years. The Index should allow nearly 25% of Californians, healthcare providers, hospitals and emergency rooms easy accessibility to medical records with a few key strokes. The potential is clearly huge - both for success and failure.

Paul Markovich, Chief Executive Officer of San Francisco non-profit Blue Shield, said "We need to bring healthcare into the digital age, and by doing so you can really improve the quality and cost of care. What you ultimately want for every patient is an evidence-based, personalized care plan, and you can only do that if you have real-time digital information." Lofty goals indeed.

The obstacles are large. Security is a primary concern, as is the interoperability of non-aligned computer systems in facilities and practices. Some standardization and shoehorning will be required, making this an ongoing project. Cal Index will allow any patient to opt out of the system, and doctors will only have access to the information of their own patients. This will address the fears of individuals, giving them an out if they want it, though Cal Index organizers hope those patients will form the minority. President of Anthem Blue Cross, Mark Morgan, says "We've spent a lot of time assessing the challenges. We feel, frankly, quite confident we've got a solid foundation."

Anthem Blue Cross and Blue Shield of California are taking an $80 million leap and investing in a long game. California is the first state to step up to the challenge and the rest of us are watching eagerly to see how this initiative unfolds.

NIST Announce Cybersecurity Framework RFI

Six months ago the National Institute of Standards and Technology (NIST) issued its cybersecurity framework. This week, NIST issued a Request for Information (RFI) to gather feedback from stakeholders on their understanding of the cybersecurity framework, and their initial experiences of using the guidelines it contains.

One of the reasons for this RFI is that is has emerged that many stakeholders mistakenly believe that the cybersecurity framework issued by NIST was a rule book which must be followed to the letter. This is not the case.

According to NIST spokesperson Alan Sedgewick, senior IT policy adviser at NIST, “Organizations should use this (cybersecurity framework) as they think about how to manage risk, but they shouldn't treat it like every item is a must-do." Sedgewick confirms, the framework is a series of guidelines around which to build your own secure implementations – it is literally a framework.

This has caused some confusion as well as frustration, with some providers not understanding that the document is not prescriptive. It simply offers recommendations, guidance and best-practices. The implementation is up to the organizations themselves, and how they wish to handle that within their own unique environments and situations.

"There are a lot of organizations that are looking for additional detail. One of the things that is important to us is that we invite that criticism and we want folks to be very honest about how they're using the framework, what they like about it and don't like about it, so the framework itself can improve and NIST can develop those tools as well that can help organizations in their struggle."

If as a stakeholder you wish to participate in the RFI and offer your own feedback, full details are available directly through the NIST web site, here. This RFI will enable the NIST to progress the framework to the next level, using actual real-world experiences from a broad platform of practical implementations. Framework 2.0 should not be far behind, and we can perhaps look forward to seeing it as early as February of next year, in time for the first anniversary of the initiative.

ONC Report Progress of Safety Plan

In July of 2013 the Office of the National Coordinator (ONC) published the Health IT Safety and Surveillance Plan. The stated goal was to learn, lead, and improve on Health IT Safety.

In this first year since the report was released the Health IT Safety Program has also been implemented, as well as the Office of Clinical Quality and Safety. The feedback to the ONC has given fresh insights into EHR systems, quality of care and IT security.

Statistics show a greater than 10% increase in the number of hospitals that received an incentive payment during the last twelve months, while eligible professional payments rose by 56% between June 2013 and June 2014.

Quoting from a variety of independent sources, the ONC see improvements across the board in Meaningful Use functionalities such as computerized provider order entry (CPOE), clinical decision support, patient access, lists and reminders. The statistics support the argument in favor of EHR use. Those physicians using EHS's are, quote, "...significantly more likely to report safety improvements associated with EHRs than physicians that were not using EHRs." The majority of physicians went on to say that their EHR systems helped to facilitate direct communication with other providers and also helped with referrals. The scheduling and reminder functions of an HER also contribute to more effective interaction and collaboration between providers as well as patient interactions.

The most compelling section of the report covers medication management and medical errors. Three times as many EHR users reported that their EHR prevented a medical error than caused one, eliminating significant human error issues which may otherwise not have been caught. An unrelated 2010 study in Florida corroborates this finding, saying that the Florida hospitals which adopted the five core measures of Meaningful Use to manage medication consistently reported the lowest rate of adverse drug events of all hospitals in the state.

ONC Disputes JASON Report Findings

In April 2014 an independent report commissioned by the Agency for Healthcare Research and Quality (AHRQ) determined that a major brake on successful growth of the national health data infrastructure was the overall lack of interoperability. In fact they found that interoperability was by far the most difficult obstacle needing to be overcome.

The JASON group was formed from independent government science and technology advisers, tasked with identifying current infrastructure challenges. The group worked closely with the Office of the National Coordinator (ONC), which mitigated some of the JASON report yesterday by refuting and dismissing many of the findings contained in the report.

In their review of the JASON report, released September 4, the ONC say that JASON used old data, specifically, that it reached a conclusion on Interoperability eighteen months ago - six months before the Meaningful Use Stage 2 began. The ONC believe that in the intervening months there had been a “positive change in the trajectory of interoperability progress" which had seen dramatic growth in interoperability that was not taken into account. They also say that the JASON report entirely omitted computerized processing order entry (CPOE) and clinical decision support (CDS) from their considerations.

The ONC has seen several changes within its ranks during recent months. This review of the JASON report demonstrates there are now some differences of opinion. The ONC Health IT Policy Committee (HIPTC) has largely dismissed much of the JASON report. Micky Tripathi of the HITPC is quoted as saying “We believe that JASON did not adequately characterize the progress made in interoperability, though we agree that there is considerable room for improvement as will be outlined in these recommendations.” As the chair of the HIPTC Interoperability and Health Information Exchange Workgroup, Tripathi is well placed to speak with authority on the subject.

A final series of recommendations on the future of health data infrastructure is expected to be announced within the week.

Three growth areas for EHR in 2014

Global marketing specialists Frost & Sullivan have analyzed a recent survey which used a catchment of 1835 executives in over 40 countries. From it, they made the following predictions for EHR in 2014.

Their analysis they determined that mobile device applications are going to be the primary growth area next year. mHealth, as they describe it, is growing in areas such as vital signs monitoring and location-aware tele-monitoring, using wireless and Bluetooth applications on dedicated devices as well as regular downloadable apps on mobile phones.

On the practitioner side, patients and health data can be monitored from anywhere, at any time. Frost & Sullivan believe that every hospital will eventually have to acquire a full enterprise level wireless EHR and/or management solution in order to operate effectively, and to keep ahead of their game.

A second prediction for growth lies in Cloud services, or Software as a Service. Enterprise wide cloud based computing offers many benefits, not the least of which is the ability for practitioners and service providers to work on the move, using a range of devices. Moving from your desktop computer to your tablet will allow on-call responders to get immediate access to the information they need, and opens up the opportunity for busy administrators to take the occasional well-earned lunch.

The third area where growth is perceived as highly probable is in regulatory compliance of organizational data. With financial incentives for HIPAA meaningful use, many Medicare and Medicaid registered organizations are finding that use of an effective electronic health record (EHR) system standardizes and streamlines daily operations, and also calculates and produces the reports necessary to support their HIPAA attestation and ONC audits.

unlocked-iphoneOnce considered an unnecessary investment by many practitioners and hospitals, an EHR solution is now a highly desired item which offers a significant return on investment, often paying for itself with the first Meaningful Use incentive payments. Many organizations are coming to realize that this is a smarter way to work and are actively planning to adopt an EHR, with an eye specifically on profit levels and revenue. Accordingly, growth within this area should be significant throughout 2014.

Other areas identified by the survey have similar mobile device dependencies: Patient engagement, video telemedicine and cardiovascular therapeutics to name only a few.

The take-away here is clear. The trend for the rest of the year continues to be toward cloud-based services and systems that can run on portable devices. From the patient wearing a heart monitoring device to the surgeon monitoring it from their car, small and mobile is the way to go.