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Surviving 2014: The Toughest Year in Healthcare

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The following is a guest blog post by Ben Quirk, CEO of Quirk Healthcare Solutions.
Ben Quirk
How bad is 2014 for the healthcare industry? We’ve all read about ICD-10, EHR incentives, Medicare cuts, and the Affordable Care Act. But the most telling moment for me occurred during this year’s HIMSS conference in Orlando. There was quite a bit of B2B enthusiasm, but among the civilians it was mostly a lot of stunned looks and talk about how to get through the year. Here are some of my observations:

ICD-10. CMS has made it abundantly clear there will be no further delays to the October 1 deadline for ICD-10 implementation. This is possibly the most significant change to the healthcare industry in 35 years, affecting claims payment/billing systems, clearinghouses, and private and public software applications. Anyone who provides or receives healthcare in the US will be touched by this in some way.

In a recent poll of healthcare providers conducted by KPMG, less than half of the respondents said they had performed basic testing on ICD-10, and only a third had completed comprehensive tests. Moreover, about 3 out of 4 said they did not plan to conduct tests of any kind with entities outside their organizations.

Incorrect claims denial will be the most likely result. CMS will not process ICD-9 Medicare/Medicaid claims after October 1, and there is a high potential for faulty ICD-10 coding or bad mapping to ICD-9 codes. Error rates of 6 to 10 percent are anticipated, compared to an average of 3 percent under ICD-9. ICD-10 will result in a 100 to 200 percent increase in denial rates, with a related increase in receivable days of 20 to 40 percent. Cash flow problems could extend up to two years following implementation. This will be a costly issue for providers, and a very visible issue for patients.

We advise our clients to be proactive in their financial planning. This should include preparation for delayed claims adjudication and payments, adjustments to cash reserves, or even arranging for a new/increased line of credit. Having sufficient cash on hand to cover overhead during the final quarter of 2014 could be very important, as could future reserves to cover up to six months of payment delays. Companies not in a position to set aside reserves should consider working with lenders now before any issues arise.

Meaningful Use. As with ICD-10, CMS has stated there will be no delays to MU deadlines in 2014. That means providers who have never attested must do so by September 30, or else be subject to penalties in the form of Medicare payment adjustments starting in 2015. Providers who have attested in the past will have a bit longer (until December 31), but the penalties are the same.

There is much dissatisfaction with the government’s “all or nothing” approach to MU, where even the slightest misstep can invalidate an otherwise accurate attestation. While the ONC has proposed a more lenient model for EHR certification in coming years, everything will be measured against a hard deadline in 2014.  CMS is offering some mitigation through hardship exemptions, based on rules that are somewhat broad at this point. Providers should consider applying for an exemption if no other options are available.

We advise against taking shortcuts or rushing to beat the clock on MU. Up to ten percent of eligible professionals and hospitals will be subject to audit, and large hospitals may have millions of dollars at stake. Being prepared for an audit means more than just making sure an attestation is iron-clad; internal workflow and communication are also important. A mishandled audit notification can result in a late response and automatic failure.  Data security should also not be overlooked. Medical groups have failed audits due to lapsed security risk assessments as required under HIPAA.

Medicare Payment Cuts. Medicare Sustainable Growth Rate (SGR) cuts continue to hover over Medicare providers. Enacted by Congress in 1997, the SGR was intended to control costs by cutting reimbursements to providers based on prior year expenditures. But every year costs continue to rise, as do ever-worse SGR cuts (almost 24% in 2015). And every year Congress prevents the cuts via so-called “doc fix” legislation.

In early 2014 there was surprising bi-partisan agreement on a permanent doc fix, whereby Medicare reimbursements would be based on quality measures rather than overall expenditures. However, the legislation was derailed by linking it to a delay of the ACA’s individual mandate. As of mid-March there is still no permanent or temporary solution. Congress will almost certainly intervene to prevent SGR cuts, but by how much is uncertain.

The ACA. As the cost of insurance has increased over the past decade, high-deductible plans have become more and more common. Due to the Affordable Care Act, this trend has become the norm. Media outlets focus on the impact to consumers, and argue about whether more “skin in the game” leads to better choices or less care. What we’re hearing from the front lines is much more concrete: high deductibles are having a negative impact on revenues.

Very few people understand their liabilities under a typical health insurance plan. Last year George Loewenstein, a health-care economist with Carnegie Mellon University, published a survey showing that only 14 percent of respondents understood the basics of traditional insurance policies. At the same time, hospitals report that about 25 percent of bad debt originates from patients who are currently insured. With millions of new enrollees in high-deductible plans and an ongoing economic slump, the situation can only get worse.

The ACA had a further impact by reducing the amount of Disproportionate Share Hospital (DSH) charity funds available, based on a projected increase in insurance coverage.  But with some states not participating in Medicaid expansion, combined with an increase in patients lacking the knowledge or resources to manage large medical expenditures, the reduction in funds comes at exactly the wrong time.

Providers can cope by adjusting revenue cycle processes. For example, new programs should focus on estimating patient liabilities pre-arrival, educating the patient at check-in, and instituting proactive billing/collection at the point of service. In general, providers must pay more attention to the self-pay process, focusing on patient education and offering transparent, easy-to-use billing and payment methods.

Value Modifier. This program has not been a worry for most providers thus far. Not because it won’t have an impact on revenue, but because they don’t know about it. A little-known provision of the ACA, the Value-Based Payment Modifier mandates adjustments to Medicare reimbursement based on quality and cost measures. The program is being phased in, and so far has applied only to group practices of 100 or more Eligible Professionals (EPs). In 2014, smaller groups of 10 or more EPs will be subject to the legislation. These groups must apply and report to the program by October 1. Otherwise, they will be subject to a 2 percent cut in Medicare reimbursements starting in 2016.

One of the most important aspects of the program is its definition of “eligible professional” when defining the size of a group practice. For the purposes of Value Modifier, eligible professionals include not only physicians but also practitioners and therapists. That means that a practice with 8 physicians, a nurse practitioner, and a physical therapist would qualify as a practice with 10 EPs.

Value Modifier is part of the growing trend toward quality-based reimbursement. Even commercial payers are considering some version of the program. The scoring calculations are complex and poorly understood, so we advise clients to get up-to-speed as soon as possible. Groups with high quality and low cost will receive incentives rather than cuts, with additional upward adjustment for services to high-risk beneficiaries. Groups that are not paying attention may be surprised by an additional hit to revenue in 2016. In addition, quality scores will eventually be published to the general public on the Medicare.gov Physician Compare website.  Sub-par or missing scores could have a negative financial impact on a practice.

Conclusion

These are only the most high-profile impacts to the healthcare industry during the current year. Much else flows from them: changes to workflow, to computer systems, to financial expectations. Tremendous pressures are coming to bear within a limited timeframe.  We’re seeing an industry in the midst of tectonic change, with 2014 as the fault line. It’s unclear whether these disruptions will be for better or worse. But there certainly will be winners and losers, and those who plan ahead are most likely to survive.

______________________

Ben Quirk is CEO of Quirk Healthcare Solutions, a consulting firm specializing in EHR strategic management, workflow optimization, systems development, and training. The company’s clients have enjoyed remarkable success, including award of the Medicare Advantage 5-star rating. Quirk Healthcare presents a weekly webinar series, Insights, to inform clients and the general public about government programs and industry trends. Mr. Quirk is also Executive Director of the Quirk Healthcare Foundation, a learning institution which fosters innovation in the healthcare industry.

March 26, 2014 I Written By

Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

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In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.

Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?

Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.

The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.

None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.

None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.

Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.

Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.

But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.

So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.

1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.

Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.

Consider applying the hardship exemption deadline extension to the incentive program participants.

March 5, 2014 I Written By

Mandi Bishop is a healthcare IT consultant and a hardcore data geek with a Master's in English and a passion for big data analytics, who fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

Meaningful Use Playbook 2014: Overcoming Adversity – Breakaway Thinking

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The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
broncos
I apologize in advance, but I am still mourning the Super Bowl loss of the Denver Broncos. I can’t stop replaying each moment and thinking of alternative scenarios. What if Peyton Manning utilized a quick huddle instead of audibles and hand-signals? What if Denver’s defense had better protected Peyton? What if the Broncos had scored more than eight points?

Regardless of the what-ifs and wounds resulting from the loss, the team has to step up and prepare for the next season, if they want to finish at the top. In the healthcare world, providers must also change their playbook and approach, if they wish to capitalize on the next phase of Meaningful Use.

For the past year, providers have been scrambling to select, implement or optimize a new electronic health record system to meet federal requirements for Meaningful Use Stage 1. Adding to providers’ challenges is the evolving nature of the rules for achieving meaningful use incentives; federal agency Centers for Medicare and Medicaid Services (CMS) is constantly updating the Meaningful Use Playbook. Similar to football players at the end of the season, providers are tired and wounded. However, they must be aware of and prepare to take on the new requirements for 2014. Otherwise, they risk future penalties and foregoing funds. To help healthcare providers prepare for this new season, here is a summary of changes taking effect this year.

  • Three-month reporting period
    All providers are now required, regardless of their stage of meaningful use, to demonstrate meaningful use for a three-month EHR reporting period. Medicare providers may elect to report clinical quality measures (CQM) for the entire year or select an optional, three-month reporting period for CQMs that is identical to their meaningful use reporting.
  • Exclusions and vital sign objectives
    All eligible professionals, eligible hospitals and critical access hospitals are now responsible for adhering to the latest changes in Meaningful Use Stage 1. This includes new requirements for electing exclusions toward menu objectives, age limits for recording and charting changes to vital signs, and new exclusions toward reporting height, weight and blood pressure.
  • View, download and transmit all health information or admissions online
    To better align with the new capabilities of certified EHR technology, CMS is replacing Meaningful Use Stage 1 objectives for accessing information online with the capacity to view, download and transmit this information.
  • Reporting of clinical quality measures
    All providers, regardless of their stage of meaningful use, must report on clinical quality measures to CMS. Eligible hospitals must report 16 of the 29 CQMs and eligible providers must report 9 of the 64 CQMs.(Source)

For providers making the leap to Stage 2 of meaningful use, this is only the beginning. Not only must they abide to the changes mentioned above, but they also need to plan and execute a strategy for integrating diverse IT systems and engaging patients. Neither are simple tasks. However, just as I believe that Peyton can shake this last performance and finish strong next year, I believe in the resiliency of providers too. With the right leadership and planning, they will take patient care to the next level.

Omaha! Omaha! Omaha!
Carrie Yasemin Paykoc
Xerox is a sponsor of the Breakaway Thinking series of blog posts.

February 19, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

A Hospital Perspective on Meaningful Use from Encore Health Resources

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The following is a guest blog post by Karen Knecht in response to the question I posed in my “State of the Meaningful Use” call to action.

If MU were gone (ie. no more EHR incentive money or penalties), which parts of MU would you remove from your EHR immediately and which parts would you keep?

Karen Knecht
Karen Knecht
Chief Innovation Officer at Encore Health Resources

It’s an interesting question you’ve posed on MU, and I think you have generated some great discussion on this topic, such as last week’s response by Dr. Sherling from the perspective of an eligible provider.

My colleagues and I would like to provide an eligible hospital perspective.  The industry is now three-plus years down the path of implementing “certified EHRs.”  There was a need to kick-start the digitization of healthcare in this country and create a common infrastructure to drive change, and MU has done that.  For example, establishing standards for data capture is critical for unified reporting and analysis.  Would the industry establish and adopt these standards without a program like MU?

But working with many large healthcare organizations representing several hundred individual hospitals in their MU programs, there are clearly many lessons learned and opportunities to improve for the future, even if the MU program were to go away.

Overall, there are no MU objectives that we would discount as having no value.  However, there are some that have served their time and others that are ahead of their time.

For the parts to continue, we see a high level of value in the CPOE, Barcoded Medication Administration, Medication Reconciliation and Clinical Decision Support objectives, as they are making tangible contributions to patient care.  However, we would recommend timeline delay due to additional capital outlay as well as complexity of workflow.  This would give more time for deeper and broader adoption.

For the parts to no longer measure in the same way, we would start by simplifying and removing the objectives that are topped out: the ones that are already hardwired in most organizations such as Vital Signs, Demographics, and Smoking Status.  This is no different than the current process for removing quality measures from reporting requirements once they have been well adopted — and HITPC is in agreement about this.  In their meeting last week where they discussed proposed Stage 3 measures, they were saying much the same thing.  Even if you stop measuring these things explicitly, they will continue to be electronically documented.

Second, we could see removing objectives that are now standard for “certified” EHRs.  For example, the time and effort to document the Drug Formulary, Drug-Drug, and Drug-Allergy checking functionality, for the sole purpose of meeting the MU objective, is not well spent.  Another example is the lab results stored as discrete values, which are part and parcel of any lab system in existence.

Other objectives that are causing great concern among many hospitals are the ones dealing with providing and exchanging information electronically.  It would be helpful to reconsider the expectations for these objectives, since many are finding out that implementing a patient portal without a sound patient engagement strategy is not going to be enough to ensure that 5% of patients will actually access their records.  Hospitals should have a portal and secure messaging capability, but it doesn’t seem realistic to put thresholds on patient utilization.  As the old saying goes, “You can lead a horse to water, but you can’t make it drink.”

Additionally, the requirement for Direct exchange to transmit summary of care is cumbersome and actually a step backwards for those entities who are part of an HIE and are currently exchanging data among members.  For most others, it is really only practical to implement with a physician ambulatory partner.  The sad fact is that nursing homes, SNF’s, and other entities where hospitals commonly transfer patients are not included in the EHR incentive program and do not have the technology necessary to participate in a direct exchange in a meaningful way.

And finally, we think all aspects of electronic quality measures should be rethought.  We love the idea of calculating these measures electronically, but they need to be appropriately validated and re-addressed in the context of the poor data collection that is occurring.  Perhaps CMS should consider another voluntary incentive program for facilities that have fully implemented all their clinical documentation.  Given the change that is proposed to the physician quality reporting programs as a result of the SGR fix, perhaps a similar refinement of the IQR and VBP programs along with MU should be considered.

See other responses to this question here and please reach out to us if you’re interested in providing a response to the question.

February 18, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Did Meaningful Use Try to Do Too Much?

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When I was reading Michael Brozino’s post on EMR and EHR about the Value of Meaningful Use, I was hooked in by his comment that meaningful use standards only went halfway. I’m not sure if this was the intent of his comment, but I couldn’t help but sick back and consider if meaningful use missed the mark because it only went half way.

When I think about all of the various features of meaningful use, it really feels to me like ONC and CMS tried to bite off more than they could chew. They tried to be all things to everyone and they ended up being nothing to no one. Ok, that’s not perfectly correct, but is likely pretty close.

Think about all of the meaningful use measures. Which ones go deep enough to really have a deep and lasting impact on healthcare? By having so many measures, they had to water them all down so it wasn’t too much for an organization to adopt. I’m afraid these watered down measures and standards render meaningful use generally meaningless.

Certainly the EHR incentive money has stimulated EHR adoption. However, could this EHR adoption have had even more impact if it would have just focused on two or three major areas instead of dozens of measures with good intentions but little impact?

In many ways, this is just a variation on my wish that EHR incentive money would have focused on EHR interoeprability. As meaningful use stands today, we’ve made steps towards interoperability, but we’re still not there. Could we have achieved interoperability of health records if it had been our sole focus? Instead, we’re collecting smoking status and vital signs which get stored in an EHR and never used by anyone outside of that EHR (and some would argue rarely inside of the EHR).

The good news is we could remedy this situation. ONC and CMS have something called meaningful use stage 3. How amazing would it be if they essentially through out the previous stages and built MU stage 3 on 2-3 major goals? The foundation is there for MU stage 3 to have an enormous impact for good on healthcare, but I don’t think it will have that impact if we keep down the path we’re currently on.

Yes, I realize that a change like this won’t be easy. Yes, I realize that this means that someone’s pet project (or should I say pet measure) is going to get cut. However, wouldn’t we rather have 2-3 really powerful, healthcare changing things implemented than 24 measures that have no little lasting impact? I know I would.

Side Note: Think how we could simplify EHR Certification if there were only 2-3 measures.

February 12, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Meaningful Use Audits and Appeals

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Meaningful Use Expert, Jim Tate, has a really interesting post up on his Meaningful Use Audits website that shares some of the details CMS offered on the EHR incentive audits and appeals process. I know many of my readers are worried about the meaningful use audits and are interested in these details.

You can go and read Jim’s full post for all the details, but I wanted to highlight a few of the items he mentions.

First, CMS said that 5-10% of providers will be subject to pre/post-payment EHR incentive audits. Jim calls this casting a “wide net” for the MU audits. Considering meaningful use stage 1, it makes some sense why the MU audit net would be cast wide. I’m sure many who read this have a friend who’s been through the audit.

I was really intrigued that CMS said “If a provider continues to exhibit suspicious/anomalous data, could be subject to successive audits.” This reminded me of something my brother said about the military. He said that if you got your uniform inspection right the first couple times, then the officers would stop looking at you quite as much. However, if you had something wrong at first, be ready to be scrutinized. It seems like CMS is taking a similar approach. As in most things in life, it’s just better to be honest and accurate. Then, you don’t have to look over your shoulder.

Jim also notes that CMS said that no risk profile will be made public. Basically, we aren’t going to get any clue into how they chose who to audit. Plus, Jim notes that the only next step if you fail an meaningful use audit is to file an appeal.

As long as we have meaningful use tied to EHR incentive money and payment adjustments, I don’t see these MU audits going anywhere. So, if you’re attesting to meaningful use, make sure you’re prepared for an MU audit if it comes.

February 11, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Of Meaningful Use – I wouldn’t remove anything!

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The following is a guest blog post by Joel Kanick in response to the question I posed in my “State of the Meaningful Use” call to action.

If MU were gone (ie. no more EHR incentive money or penalties), which parts of MU would you remove from your EHR immediately and which parts would you keep?

Joel Kanick
Joel Kanick
President and CEO of Kanick And Company and Lead Developer and Chief Architect of interfaceMD

In fact, the pursuit of Meaningful Use (MU) certification has given our company many new ideas that allowed us to go above and beyond the bar MU already set.

Initially, doctors bought into EMRs for the financial incentive. Now that they are educated consumers, they want everything that was promised to them to work for them. Doctors have learned that EMRs are only one small part of the Healthcare Information Technology (HIT) puzzle. They need help putting the rest of the puzzle together.

No one is complaining about MU regarding the direction it is taking healthcare or HIT industries.

Any complaining that comes from a vendor is usually because their technology is outdated and behind the technology curve. They are angry because MU is calling them out. So, shame on vendors for becoming rich, fat and lazy, and not keeping with current technology.

Of the complaints I hear from providers, there are two scenarios:

First scenario: the providers who resent the government telling them how to practice medicine. However and upon deeper review, these providers already ask and track most of all these data points. They just don’t like the way it has been required and thus crammed into their current systems. I understand their anger, they were not consulted as to how to fit all this into their workflow and so it is cumbersome to use.

Second scenario, the providers’ office is still using fax machines, some required by their EMR vendor. They are still dictating (PCs, iPhone apps, phone recorders) all their exam data and still relying on paper charts. In practices of all sizes, providers complain of MU because they don’t want to change how they operate their business. After all, they have been doing it this way for many years, successfully. They complain of this change because they fear the unknown.

They are doctors; highly skilled and highly educated in medicine but not in business or technology. I see so many doctors closing their privately held medical practices to join a group practice or a hospital setting. Most will freely admit that it’s because they don’t want to address the fear and go through the anticipated pain of migrating to a paperless environment. They don’t know how to choose or maintain the system, with or without MU.

What I know MU is positively doing:

  • Setting a standard language (ie: XML)
  • Setting a standard format (ie: HL7)
  • Setting a secure communication channel (ie: Direct Protocol)
  • Requiring patient portals to potentially aid in convenience to the patient and lower the workload on office staff
  • Creating a standard method to share data electronically (ie: CCDA)
  • Demanding security and encryption and planning for emergency scenarios
  • Utilizing eRx to reduce fraud, abuse and increase safety in drugs that are prescribed
  • Reducing paperwork (eg: lab requests), speeding-up information delivery (eg: lab results electronically instead of by paper delivery)
  • Promoting communication to educate patients
  • Demanding reconciliation of data when exchanged between two organizations to make certain correct information is gained

Selfishly, from my point of view, the largest complaint regarding MU2 is that it requires all pertinent health information be exported and imported in a standard format allowing providers to easily change EMR vendors. This MU requirement should scare some EMR vendors!

Effectually, MU is pushing change and as a result it is getting a bad rap.

See other responses to this question here.

February 5, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Meaningful Use Program a Success…Depending on How You Measure Success

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The new National Coordinator of Health IT, Karen Desalvo, MD, published a blog post on The Health Care blog that proclaims that the “EHR Incentive Program Is on Track.” Of course, many would argue that it’s her job to be a cheerleader for healthcare IT, but I think this post is an important look at the measures that ONC and HHS have of what they consider a success.

If the goal of the EHR incentive money is just to get doctors and hospitals using EHR software, then indeed it’s been a big success. EHR adoption is through the roof at every level (although, I think they’d like it higher in the ambulatory space). This can’t be argued. The $36 billion in EHR incentive money got healthcare on board with EHR software.

If EHR use is your measure of success, then the HITECH act was a success. However, the goal of the HITECH act wasn’t just EHR adoption. If it was, then we wouldn’t have meaningful use. The goal was for doctors to adopt an EHR and then meaningfully use it. Of course, the jury is still out on whether doctors will follow through on meaningful use stage 2. I’m personally predicting a major fall out from those who attested to MU stage 1 and those that choose to sit out MU stage 2. Certainly Dr. Desalvo argues that this won’t be the case.

Either way, let’s assume that the majority of doctors do attest to meaningful use stage 2. Should we call the HITECH act a success? More pointedly, does meaningful use produce the results we want?

As someone who follows the EHR industry day in and day out, I think the jury’s still out on this. I’ve said many times that I fear the EHR incentive money might have incentivized doctors to adopt the wrong EHR software. The current and future EHR switching will likely prove this out. Although, we’ll see if organizations can get it right the second time.

However, choosing the right EHR is only half of the battle. Even the best tool used inappropriately won’t yield the desired results. There’s a strong case to make that meaningful use forces a doctor to use an EHR inappropriately. Every person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work and does little to improve care.

I recently heard someone argue that they had “no sympathy for doctors having to accurately, legibly, and cohesively document what is happening.” I think it’s a real challenge to say that meaningful use equates the more accurate, legible, and cohesive documentation. In fact, many of the meaningful use hoops serve to make the documentation more illegible and difficult to read. Not to mention the issue of making the physician less efficient and therefore more likely to cut corners.

In this post, I’m not trying to make the case for or against EHR software. I’ve done a whole series on the benefits of EHR and so I believe that they can provide an amazing benefit to healthcare when implemented properly. My point with this post is that if our government is going to spend $36 billion on EHR software, then I wish they’d spend a little more time making sure that it’s not only implemented, but implemented well.

If they did this, then maybe we could call the HITECH act a real success. As it stands now, we’re using the only metrics we have available: EHR incentive spent and meaningful use attestation. I’d suggest there’s so much more value (both gained and lost) in an EHR implementation than either of those two things measures.

How about we track ways EHR use reduced costs, improved patient care, and saved lives? Maybe they don’t want to track that data because if they do, they won’t like the results. What would they do with meaningful use if they found out it raised costs, hurt patient care and did nothing to save lives? Would anyone want to make the case for why meaningful use should be scraped for something better? I wouldn’t want to as the new ONC chair either.

January 22, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Interview with Barry Haitoff, CEO of Medical Management Corporation of America

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The following is an interview with Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff

Tell us about Medical Management Corporation of America (MMCOA).
MMCOA helps physicians and physician groups increase collections, assure compliance, manage overhead and navigate the maze of EMR/EHR, Meaninful Use, PQRS and other Government incentive programs and regulations. With a focus on revenue cycle management, MMCOA helps our clients stay ahead of the curve with things like the transition to ICD-10.

What are the keys to running a good medical billing company?
Like any successful business, I believe the 2 most important assets are people and systems. We hire, retain and cultivate quality individuals and empower them with state of the art systems and technology. We never settle for status quo and continue to look for better ways of doing things. My style of leadership is one of servitude. It is my goal to provide all staff members a great work environment, financial incentives and proper tools to perform their functions.

What’s your take on the economics of outsourcing medical billing? Where’s the ROI for an office that’s considering going with an outside medical billing company like yours?
I tell physicians, “do what you do best and outsource the rest”. Your tax work is handled by a professional accountant, your legal work is handled by a professional attorney, who is handling your billing? Outsourcing your billing can sometimes be more expensive than keeping it in-house, however, the return should far outweigh the added cost.

Most practices do not have adequate resources in their billing department to do the right job. A great deal of money winds up being left on the table. There is a reason that the tallest buildings in most metropolitan cities are owned by insurance companies. A quality billing company will increase your collections at a rate that will far exceed the fee.

In addition, because the typical fee structure is based on a percentage of collections, not only does the billing company have “skin in the game” to do a good job, the billing overhead of the practice is better managed. If one or more physicians are out of the office on vacation resulting in lower charges, that eventually results in lower collections. With billing in-house the practice still pays salaries, benefits, software licenses etc. All the fixed costs remain in place regardless of collections that month. With outsourced billing company, the practice’s cost for billing is directly in proportion to the amount collected that month.

What are some of the biggest changes to medical billing that have happened over the past couple years?
EMR/EHR, PQRS, ePrescribing, HIPAA, Meaningful Use, Accountable Care Organizations, Value/Quality based reimbursement, Bundling, Health Insurance Exchanges, added governmental regulations, OIG compliance and soon…..ICD-10, ICD-10, ICD-10. ICD-10 will prove to be the biggest challenge to date. We’re ready!

How is medical billing going to be impacted by things like ACOs (Accountable Care Organizations) and value based reimbursement?
Someone will still need to make sure that services rendered are reimbursed properly. More challenging, someone will need to distribute funds appropriately to the myriad of providers involved. There will be a greater need for revenue cycle management as payments are bundled.

Is healthcare ready for ICD-10? What are you doing to make sure you’re ready?
Our research to date says no. Providers and staff are not yet trained. Insurance carriers and software vendors have not yet successfully tested.

We have established an ICD-10 committee headed by our Director of Healthcare Informatics. We have begun informing and educating our clients and staff, researching tools, attending training sessions, initiating dialogue with our software vendors and staying up to date.

In what ways has the Accountable Care Act (Obamacare) and the health insurance exchanges impacted your clients?
I’d say that it’s caused a whirlwind of confusion. Providers must take the time to determine which HIX plan networks they’re in, so as not to provide care outside of a contracted relationship with the HIX plans, which predominantly lack out-of-network coverage. We expect our clients to become busier. We expect the additional covered lives to find their way into our clients’ offices. We have helped our clients figure out if they are participants in the Exchanges in their area.

A number of EHR companies have started doing medical billing. How do you differentiate the services you offer versus an EHR vendor?
Most of the EHR vendors that have just started doing medical billing, just started doing medical billing. MMCOA has been in business for 18 years, growing primarily by word of mouth. Some of the EHR vendors are publicly held companies whose most important stake holder is their shareholders. Our most important stakeholder is our clients. We have had clients leave us for those solutions and have since come back. We will continue to provide quality service on a consistent basis and will never sacrifice integrity for growth.

What are the biggest revenue cycle management issues you see in organizations?
Not enough staff. Outdated or inadequate technology. Lack of leadership. Lack of ongoing training. Lack of incentive.

Where do you see revenue cycle management going in the future?
My crystal ball is broken right now. Seriously though, there is a lot of consolidation in our industry and the smaller billing companies will likely go out of business or be acquired. Physicians and physician groups will continue to need assistance with their reimbursements. Unless all healthcare providers wind up employed by an ACO, Hospital System or other Healthcare entity with adequate revenue cycle management expertise, there will be a need for continued navigation of the maze we know as healthcare revenue cycle management.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

January 20, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

More Honest Perspective on Meaningful Use Stage 2

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There’s been a really strong reaction to this post on One EHR Vendor’s Experience with MU Stage 2 certification. Although, Gabriel Perna pointed out that there was a lot of “I dislike” in the article and not enough like. Of course, part of that was because it wasn’t intended as a journalistic effort to cover both angles, but was a private response turned public. However, I was intrigued by the question of what Michael Archuleta, Founder and CEO of ArcSys, might “like” about meaningful use.

Here’s Michael’s response:

I REALLY like Context Aware Information.

I do like the idea that doctors have to be more timely on providing completed documentation.

I do like the notion that meeting MU provides a sense of continuity and expectations between doctors with different systems.

I do like the fact that documentation standards need to be lived up to within a practice.

I do like the fact that MU has already helped alert real patients to real problems.

I do like the fact that MU provides additional tools to help the doctor provide more information to their patients.

Wish my list were longer.

I recognize my “dislike” list comes across as a lot of whining. But, if there is no leadership or anyone willing to respond to my concerns, then the EMR community will struggle.

Plus, Michael added some more perspective to his previous comments:

Part of the frustration is that I spent 20 years of my life dealing with inconsistencies of the “standards” associated with electronic claims. Each insurance carrier would read the same rules differently and we, the vendors, had to code for zillions of contingencies.

Then the same thing happens with HL7 lab results.

Then we get MU and a whole set of “standards” and “rules”. It sounds like the same old song but on a different radio station.

What are we going to do when the SNOMED advocates feel their codes should trump Rxnorm or LOINC or ICD-10? When I talk with doctors about their understanding of these various coding systems, they are mostly clueless. If they balk at implementing ICD-10, wait until they meet SNOMED. Has anyone laid out the rules with respect to certification of when to use atomic-ids rather than concept-ids? These are but a few of the unknowns that people will encounter.

If I could have implemented and coded all the rules for MU2 before the final rules were published, then I could have asked real questions. But, there was no time, so now I live with the consequences. It is akin to the famous Pelosi statement, “You have to pass the law in order to know what’s in it.”

There is definitely a challenge in the rule making process. I really think that ONC takes the public comments very seriously. The challenging question is whether the right people are making the comments and whether the comments are informed or not.

January 8, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.