Simple Proof that EHR and Meaningful Use are Burdens: A Physican's Point of View

By Daniel Essin, MA, MD from Physicians Practice

The editors of the Journal of the American Medical Association (JAMA) and the BMJ (formerly British Medical Journal) have been proponents of evidence-based medicine (EBM) for some time. Over the years, they have become friendly with the "pioneers" in the field and recently got them together for a retrospective. The video from JAMA and the editorial from BMJ are worthy of your attention. I must admit, that to someone equipped with a scientific frame of mind and a healthy dose of skepticism, it always surprised me that what the EBM people were promoting wasn't the norm.

If there is one thread that unites my approach to EHR it is: Show me the evidence that it is safe, effective (does what you expect and produces beneficial results), and worth the time and money that are devoted to it. Also, what is the opportunity cost? What else could have been done differently or better if not consumed with trying to conquer an EHR. Frankly, and despite our fervent hopes regarding benefits that seem obvious, there is darn little solid evidence as even the people at RAND who make glowing predictions in 2005 were forced to admit [Arthur L. Kellermann and Spencer S. Jones, "What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology," Health Affairs, 32, no.1 (2013):63-68]. Let's look at some evidence related to burden. Wiktionary defines burden as a.) A heavy load; b.) An onus; and/or c.) A cause of worry; that which is grievous, wearisome, or oppressive. Given the definition, one could stop here. EHR is a burden. If it's a burden that is all the more reason that there should be evidence of effectiveness before the burden is imposed. Now let's look at what the government has to say about other burdens, specifically those relating to paperwork. An EHR is intended to be an electronic substitute for paper so, logically, the Paperwork Act and its requirements should apply to any EHR regulation. The Electronic Code of Federal Regulations, Title 5, Part 1320 — Controlling Paperwork Burdens on the Public, §1320.1 says: "The purpose of this part is ... to reduce, minimize, and control burdens and maximize the practical utility and public benefit of the information created, collected, disclosed, maintained, used, shared, and disseminated by or for the Federal government." There is plenty of anecdotal evidence that EHRs promote inefficiency, slow the flow of patients, and cost billions. This can hardly be called "utility." In case you're wondering, I am more willing to accept anecdotal evidence of problems that I am of "success" for one primary reason. In both cases people are straining to make the EHR "work." A success in the face of extraordinary effort cannot simply be attributed to the EHR itself for it was not working to start with, hence the need for extra effort. Failure and dissatisfaction also occur in the face of this same effort, only in these cases, heroic life-sustaining interventions were not enough. The EHR itself was so fraught with problems that even superhuman efforts could not overcome them. So much for utility. How about public benefit? Well ... the claims that EHR and the meaningful use exercise will benefit the public are just that — claims;  a hypothesis. The government is conducting a Phase III clinical trial of a medical modality without going through Phase I and Phase II. It's a crapshoot but maybe it will succeed. The problem is, there is no study design, no protocol, no tracking of things other than attestation and meaningful use reports. Any claim of success will remain as unsupported by evidence as it is now. The requirements under the Affordable Care Act give every evidence of being a burden. They give little conclusive evidence of benefit. There are few criteria for what would constitute success. What is the evidence for that? Chest Physician [vol. 9, no. 1, January 2014] reported that the "earliest that physicians will progress to Stage 3 of the meaningful use requirements will be in January 2017. Officials at CMS are still developing the Stage 3 requirements and expect to issue a proposed rule sometime in the fall of 2014." So, no clear utility and no clear benefit yet an onus and a cause of worry. It certainly violates the spirit, if not the letter, of the Paperwork Reduction Act. If it walks like a burden and talks like a burden, it's a burden.

 Courtesy of Physicians Practice: http://www.physicianspractice.com/blog/simple-proof-ehr-and-meaningful-use-are-burdens?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=11022014

Hospitals, Office Visits of Great Use In the Future, Doctor

By Daniel Essin, MA, MD

 

The headline of a recent Medscape article reads "Topol: Hospitals, Office Visits of Little Use in the Future." Eric J. Topol, MD, has written a book that I have not read called "The Creative Destruction of Medicine" and blogs under the same moniker. He clearly sees himself as a medical futurist, frequently making interesting and challenging assertions about where medicine is going and where it should go. Technology looms large in his view of the future.

 

As you may have gathered, I am no stranger to technology but I am probably less impressed with it than many. This is primarily because, when it comes to technology, we collectively seem to be spending more time rearranging the deck chairs on the Titanic than on understanding and using technology to its full potential. Had the captain of the Titanic been less confident about their "sink-proof" technology, he might have slowed down. Had he known what we know now about the atmospheric science that explains why icebergs become invisible when there is an Arctic inversion layer, he might have slowed down. Had he realized that the rudders have no effect if you throw the engines in reverse and cause cavitation and turbulence in their vicinity making it impossible to steer and that inertia makes it impossible to turn a large vessel on a dime (see Exxon Valdez), he might have slowed down. It was incomplete understanding of science and a misplaced trust in technology that sank the Titanic.

 

Now Topol asks us "Why do we need hospitals in the future? Why do we need to have office visits with physicians in the future? "He says we have the technology we need to do most everything the patient needs by remote monitoring. He also thinks that video chat is equivalent to a face-to-face meeting and I guess he also believes that the high-tech equipment and high bandwidth communication channels needed to support it are available where they are needed most, like poor neighborhoods and rural areas where the population is so sparse that it is not economical to run fiber or high-speed cable for miles just to reach one home.

 

This vision of the future is based on one underlying assumption: The data tell the story, that is, make the diagnosis. I don't agree. I was taught and it has been my experience that the history makes the diagnosis most of the time but that getting the history is difficult and not everyone is equally good at it. I have a whole file of interesting cases that I have resolved as the "expert consultant" simply because I sat down with the patient, gained their trust, and asked one or two simple, obvious questions that no one had asked before. Like when I asked a patient who had supposedly made a suicide attempt, "Why did you take those 14 pills all at once?" The answer: "The doctor told me to take all the medicine. I had a visit scheduled the next day and I had these 14 pills left, so I did what the doctor said and took them." Neither data nor remote monitoring would have helped. I could not have gotten the critical history using video chat. The doctor that failed to ensure that she understood how to use the meds correctly in-person, is unlikely to have done a better job using video chat. It's true, the patient was forced to travel an hour to reach our clinic and waited 45 minutes to see me. Topol would probably label that a waste of time, but as a result of that 105 minutes, she was spared weeks of unnecessary psychiatric care including psychotropic meds and of being permanently and incorrectly labeled as a suicide attempt.

When neonatology was new and the hospital got its first monitors suitable for use on small babies, our lead physician was totally captivated by the new equipment and the data it would produce. There were times when he would sit there glued to the monitor, watching, as a baby's vital signs became unstable. The baby needed attention urgently but the doctor was fixated on the data.

Data never cured anything. In some respects, I wish that Topol was a pediatrician. Pediatricians know that the vital signs alone (temperature, respirations, heart rate, etc), the things you could get by remote monitoring, are poor indicators of whether an illness is serious or not. The same can be said for lab tests. Some can be disturbing, but none "prove" that the child is sick enough to require treatment. You need to observe the child closely, from multiple angles, for a prolonged period of time in order to get a clue as whether what you see is a significant deviation from their normal state. Some of your appreciation of their normal state comes from having spent time with them when they were normal, at those unnecessary office visits.

Cut out the face-to-face contact and the well-visits and you will drive up the number of patients who are incorrectly assumed to be seriously ill by doctors who are seeing them, in the ER, for the first time. The assumption that data, especially the kind of data that has been bent, folded, spindled and mutilated to get it entered into an EHR, is going to eliminate the need for patients to see their doctor represents the same sort of blind trust in technology that was the undoing of the Titanic.

 

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/hospitals-office-visits-great-use-future-doctor?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=30012014

2013 PQRS - Medicare EHR Incentive Pilot: Submit Quality Data by February 28, 2014

The Physician Quality Reporting System (PQRS) Medicare EHR Incentive Pilot allows eligible professionals to meet the clinical quality measure (CQM) reporting requirement for the Medicare EHR Incentive Program through electronic submission while also reporting for the PQRS program. 
Are you an eligible professional  who is participating or wishes to participate in the 2013 PQRS-Medicare EHR Incentive Pilot ? You can now submit your 2013 quality data.

If you would like to participate in the pilot you must submit 12 months of CQM data by February 28, 2014 at 11:59 pm ET.

Steps to Successfully Participate

To successfully participate in the pilot, you must do the following by February 28, 2014:

1. Register for an IACS account (for EHR submission only)
2. Indicate intent to report CQMs using pilot in EHR Registration & Attestation System
3. Generate required reporting files
4. Test data submission
5. Submit quality data

If you cannot submit your CQM data for 12 months electronically through PQRS, you must return to the EHR Attestation System and deselect the electronic reporting option.  Please note: if you do not submit your 2013 quality data or deselect the electronic reporting option in the EHR Attestation System, you will not receive an EHR incentive payment.

For More Information
For further guidance on the 2013 PQRS-Medicare EHR Incentive Pilot, please read the Participation Guide  and Quick-Reference Guide .

If you have additional questions, please contact QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or via qnetsupport@sdps.org. The Held Desk is available Monday through Friday from 7 a.m.-7 p.m. CST.

Source: CMSLISTS Email Update dated January 15, 2014

Last Updated Jan 16, 2014

Why Cloud Services are Ready for Prime Time in Healthcare

By Marion K. Jenkins, PhD, FHIMSS from Physician's Practice

Chances are, you've heard about cloud computing but may not know much about it and how it relates to HIPAA. Here, we answer a few key questions about cloud services.

Cloud hosting — what is it?Cloud hosting has many variants and goes by many names, but it generally refers to the IT model where a medical practice uses computer servers and data-storage systems located in a service provider's data center rather than onsite at the practice. Some people think that since the word "cloud" is used, there is somehow magically no more hardware issues to worry about. On the contrary, a typical cloud-hosting facility has massive amounts of hardware and software systems.  Cloud is so new, is it right for healthcare?Cloud hosting is actually not a new concept. In fact, versions of cloud hosting under different names have been around for nearly 30 years. In the early days of massive mainframes, such companies as Boeing Computer Services and Computer Science Corporation offered these services under the terms "timeshare" and "service bureau." Over the years many other labels have been used, including application service provider (ASP), software-as-a-service (SaaS),infrastructure as a service (IaaS), utility computing, and hosting. Finally about five years ago, the label "cloud" finally took hold, and although some of the terms above are still relevant in specialized circumstances, cloud hosting covers the overall concept.


What has made it an attractive solution for healthcare? Recent advances in several areas, including server and storage virtualization, and increased bandwidth of broadband services, have made cloud hosting much more attractive. In addition, server architecture — including both processing horsepower and processing (CPUs) — have become massively scalable. And improvements in management software have significantly added to both performance and reliability. These advances in technology have prompted significant changes in the way cloud services can be configured and delivered. What about the cloud and HIPAA?Cloud services are not automatically HPAA compliant. In fact,not only are many cloud providers not HIPAA compliant, they are wholly ignorant of HIPAA principles. The new HIPAA Omnibus rule released earlier in 2013 required all service providers to undergo a HIPAA compliance and remediation program by September 23, 2013.

 (If you are using a cloud provider, you should contact them and request a copy of their HIPAA compliance program documents, and also request that they sign a Business Associate Agreement. If they cannot produce them, or they are reluctant to execute a BAA, you have a major problem.)
 Cloud-hosting services can be made HIPAA compliant, provided proper HIPAA security is built into the platform, along with HIPAA-compliant processes and procedures for its operation.  Note: There are some common "cloud services" that you may be familiar with or are already using that are definitely not HIPAA compliant.  These include common web mail services from many Internet Service Providers (ISPs) such as AOL, Gmail, Hotmail, etc. These are not — nor can they be made to be — HIPAA compliant. In addition, most of them specifically prohibit any kind of business use, so in using them in conjunction with a medical practice typically violates their "Terms of Use" policies. 
What are the big advantages of cloud over onsite servers, storage, etc.? Perhaps the biggest advantages are in the ability to grow as the practice’s needs grow, and to avoid the costly and disruptive effects of repeated computer upgrades every few years. Most people understand that new computer systems are obsolete within a few months after they are installed.  So system designers have to anticipate future needs and buy more capacity than they really need, based on anticipated requirements of a few years down the road. Eventually the needs increase and even the "new" equipment becomes underpowered. So in a computer system "lifecycle," for the first few years there is too much capacity, and for the last few years there is too little capacity. Therefore for most of the time, the system is either too big or too small.  Cloud services allow the computing horsepower — CPU, memory and hard drive space — to be "dialed-up" as needs increase, so it can keep pace with the needs of the practice. And generally that upgrade can be done without the downtime typically associated with a computer system "forklift upgrade."
And a good cloud provider is generally able to offer access to hardware and software tools that would be unaffordable to a typical practice.

What about support?This is critical, and it is important to make sure you understand what is being provided to the practice by a cloud provider. With onsite servers and other infrastructure, you have to have staff (or contract with an IT provider) to maintain your servers and take care of things like data backups, operating system patches, etc.  With cloud hosting, those services are still necessary, and in most cases they can be provided more efficiently than with an onsite model. However not all cloud providers deliver those services automatically, so you need to check and make sure. Are cloud services foolproof?No, since there is still hardware, software — and people — involved, there is still the potential for outages and downtime, so you need to do your homework and make sure you understand the risks as well as the advantages

My EHR is hosted —does that mean I’m good to go as far as HIPAA is concerned?

Not at all. There has never been a reported HIPAA breach from an EHR — either hosted or onsite. The main culprits have been e-mail, files stored locally, and the theft of portable devices like laptops and USB drives. So you need to consider your non-EHR applications, and make sure they are properly secured. This is true whether those applications are running locally or with a cloud provider. One advantage of properly designed cloud services is that they tend to not allow healthcare data to be stored on local devices.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/why-cloud-services-are-ready-prime-time-healthcare?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=12122013

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice http://www.physicianspractice.com/physician-compensation/new-measures-pay-performance-programs?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=31102013

How Practices Can Recover From a Bad EHR Implementation

By Erica Sprey from Physicians Practice

You and your management team have practiced due diligence throughout the selection and implementation of your new EHR. You've done everything by the book. So what's wrong?

Melding technology and people is a complex process, involving many moving parts.

Is your clinical team talking to your IT support team? Is it responding in an appropriate way? Do you have a strong project leader?

Carolyn Hartley is president and CEO of Physicians EHR, Inc., a Cary, N.C.-based consultancy that assists practices in EHR selection through
detailed implementation and preparedness for quality incentives.  Hartley also serves as consultant to the 62 Regional Extension Centers operated under HHS.

Physicians Practice recently spoke with Hartley about her Medical Group Management Association Annual Conference presentation, "Seven Symptoms of a Troubled EHR Implementation and What to Do About It." Her session is scheduled for Monday, Oct. 7.

Q: Why is it that so many practices have troubles with EHR implementation?

A: We don't get calls from practices that say, "Boy, I love my EHR." We get calls from people who are so angry, that their practice is just about ready to implode. One of [our] physicians said, "Purchasing a system is like having a car delivered to you in a box. There's a car in there if you can figure out how to put together the pieces, but we forgot to include the manual."

Q: There's a lot written about interoperability as many systems don't work together. For example, hospitals are using one system and practices are using another. Do you feel that this is part of the problem?

A: You know, the message from the vendors changes almost every year, on why [practices] should purchase systems. Two years ago, the message was, "You have to buy our system if you want to be interoperable with all the other people in your community." Now the message is "Guess what? We are willing to work with anybody." The problem is you have to have a middle-ware. And by that I mean an algorithm or list of components — first name, last name — [that] when combined creates the patient's identity. We don't have a standard for that yet.

Q: So, practices have bought a system and they are not particularly happy with it — what are the signs of a bad implementation?

A: No.1 in our book is finger pointing. [We hear] "The vendor didn't tell us that," or, "We have one EHR system and one [practice management] system from the same company, and I'm telling you, there are things that are dropping, and we don't know where to go for help."

Another is finger pointing from within, and that is the most dangerous one. We try to get into these as quickly as possible, when the physicians are just mad at each other. If they are mad at each other, then the practice is ripe for getting sold. It's ripe for having key people leave the practice.

Q: What are some things that people can do to recover from this?

A: Well, the good news is that an EHR can be stabilized. There are best practices and they provide a pathway for stability and profitability. We're kind of the bee that's pollinating the forest. We're saying, "Guess what? This worked with these guys in nephrology with this particular system." But we need to take a look at what's best in that practice. Because one of those physicians has figured it out.

Q: Can you talk to me about stabilizing the practice/vendor relationship?

A: Vendors generally know how the system works. …There's a huge rush to get so much market share during meaningful use incentives. So we have this massive market acquisition to say, "Get my system in place." But there wasn't enough backup to support those installs. The vendors know, going forward, they've got to stabilize their clients. Because they are facing anywhere from 35 percent to 75 percent of users at risk of going to a different system.

I coach the regional extension centers [RECs]. They've tried to be consistent in selecting the [EHR] systems. They tried to vet the systems for their primary-care providers. They also responded to the vendors saying, "We're good for primary care." But those vendors are also kind of costly. So, if those primary-care physicians had to go outside of the REC recommendation, and many of them did [because of cost constraints], they go outside and purchase something that is more affordable for them. Now, as we are going into Stage 2 [requirements] of meaningful use and [some] certified vendors cannot meet [requirements for Stage 2] … You have to be a pretty ambitious vendor in order to meet those requirements. So, some of them have huge user databases, [and] they are going to continue. But those that don't have a huge database have to figure out, "What am I going to do in 2014?"

Article by Erica Sprey, courtesy of: http://www.physicianspractice.com/mgma13/how-practices-can-recover-bad-ehr-implementation?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=04102013

EHR Data Interface Issues for the Third Party Biller

 

Is the Industry Moving Away From Your Billing Model?

An article by Ron Sterling taken from the May/June issue of HBMA Billing.

Third party billers face a variety of business and technical challenges in interfacing with electronic health records (EHR) and other systems. Indeed, some of the initiatives in the healthcare industry will continue to complicate the establishment and maintenance of data interfaces for the foreseeable future.

Business Challenges

If you go back a few years before Meaningful Use, there were over 1,200 practice management system (PMS) vendors and a couple of hundred EHR vendors. During that time, the third party billers and/or practice management system vendors had the access to, and the attention of, physicians who needed to get their claims out of the door and paid. Consequently, it was the EHR vendors that would offer to accommodate interfaces with medical billing systems. Indeed, a variety of PMS vendors touted their systems as a gateway to a variety of EHR options for their physician clients.
Today, newly introduced integrated PMS/EHR products and EHR acquisitions by PMS vendors and vice versa have led to fewer, if any, billing system options for many EHR buyers. From integrated systems (that by design and business model do not interface with other products), to vendors that will not interface with other options, many vendors have established themselves as one stop shops for medical billing, EHR solutions, and, in some cases, RCM services. Indeed, some vendors have exclusive or "preferred" clearinghouse relationships for the handling of standard HIPAA transactions. In essence, more and more vendors want to position themselves as the only source for healthcare software solutions and services.

That is not to say that there are not EHR vendors who are eager to interface with a variety of practice management systems. However, the industry is moving to fewer interfaced solutions and more integrated offerings. Indeed, the majority of "new" solutions are integrated PMS/EHR offerings.

Healthcare Industry Changes

Related to the business challenges, the Meaningful Use initiative will affect interface strategies for all PMS and EHR products. For example, Stage 2 Meaningful Use core (required) measures include secure messaging with patients and providing electronic access to patient medical information. In most cases, this requires the use of a patient portal.

Patient portals can provide both medical billing and clinical interactions with patients. As importantly, most patient portals are designed to interface with one product line of medical billing and EHR products (such as Centricity PMS/EHR or NextGen EPM/EHR). Patient portals are not typically designed to interface with one vendor's practice management software containing billing data and a different vendor's EHR that houses clinical information. If the patient portal is separately interfaced with a PMS from one vendor and an EHR from a different vendor, the patient portal may not "know" how to properly route the message. In practice, however, patients may exchange secured messages with the practice on both billing and clinical issues.

A strategy that may include a separate patient portal for clinical issues and one for medical billing purposes presents a variety of operational challenges, including coordinating patient access and even accurately routing information. As importantly, separate patient portals will undermine support for the Patient Centered Medical Home and Accountable Care Organizations. For example, a patient who accesses the medical billing patient portal may not be reminded about a clinically-driven patient service issue.

Technical Challenges

Most interfaces are based on the Health Level 7 (HL7) structure. However, various aspects of HL7 are open to interpretation by vendors. Indeed, a variety of PMS and EHR vendors do not strictly support the HL7 standard. For example, some vendors use general HL7 messages instead of designated HL7 messages to send information. In other instances, the information in a message is not placed in the expected place but in a comment or supplemental area. Indeed, some vendors do not use the standard code sets, and instead use text fragments. In each case, the effort to establish the interface may require a painstaking evaluation of the vendor's "HL7" implementation.

Even after achieving success, the interface may have to change to address evolving coordination of information requirements between the medical billing and clinical record functions. For example:

• The Meaningful Use Stage 1 measures require ethnicity and race information that is commonly captured in the PM systems but is needed by the EHR to track provider performance and qualify for the EHR incentive payments from Medicare or Medicaid.
• Meaningful Use Stage 2 will require sharing of contact information and email addresses.
• The HIPAA omnibus rules will affect the information needed to track HIPAA Privacy and Disclosure as well as support exchanges with patients. As a practical matter, most medical billing and EHR interfaces do a poor job of coordinating HIPAA privacy and disclosure status for patients.

In light of these increasingly complex business and technical challenges to interfacing medical billing and EHR products, third party billers may need to establish their own preferred relationships with EHR vendors. However, such relationships will be under increasing competitive pressure and user demands to provide a more coordinated approach to patient service and provider relationships.

Right, wrong, or indifferent, the healthcare industry is moving towards comprehensive solutions to meet patient service challenges and optimize provider performance. Consequentially, the PMS/EHR vendors are addressing those needs. A myriad of changes that affect physician relationships with patients and the expectations of patients and payors will complicate the use of interfaces with EHR products and inhibit the efficiencies needed to manage patient care and service. As importantly, interfaced systems may complicate reporting for quality, operational, and management purposes.

Therefore, interfacing between PMS and EHR systems may present a tactical solution to meet physician needs in these relatively early stages of the transition to EHRs, but present a strategic challenge to address evolving healthcare business and patient service models. Third party billing organizations need to recognize these business and service issues in order to provide a clear strategic path for how your services and products will evolve to meet the new demands that your clients are facing.

Courtesy of: http://www.hbma.org/news/public-news/n_ehr-data-interface-issues-for-the-third-party-biller

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

From Volume to Value: Minimizing a Major Healthcare Shift

Nearly everyone, including me, has written on the fact that reimbursement for medical care will move from "volume" (do more, get more) to "value" (do less, keep more). The assumption is that this shift is an irresistible force and, over the years ahead, population management including substantial incentives tied to quality metrics will replace the classic fee-for-service environment. Large health systems are investing heavily in data systems that can track patients across the continuum of care and have begun to add clinical staff providing the needed care coordination. Essentially they are placing fairly expensive bets on the inevitability of the value evolution.

So, what should private physicians do? Should they add staff that can track patients to see if they showed up at the specialist, took their medications, and received the diagnostic study? Should practices begin to rethink how they pay providers? Should you expect a visit from the dominant insurance carriers with a "take it or leave it" imperative to move to value? Maybe not.While I still have confidence that there will be significant financial incentives tied to better management of chronic diseases, avoidance of high-end diagnostics when alternatives are appropriate, providing care in the least costly settings, and reporting quality indicators, I believe that many practices can benefit from these incentives without reinventing what they do.  What then should a practice do? • Medications: Many insurance plans provide incentives to practices that utilize generic medications when appropriate and the government already has bonuses for e-prescribing. This may change the way that physicians select therapeutics but the shift will not have any additional cost or require more staff.• Site of Service: Using an freestanding imaging center, an ambulatory surgery center, or a post-acute care environment may result in bonus payments from some carriers. While there is discussion about the elimination of the reimbursement differences between performing these services in a freestanding setting versus a hospital, this isn’t going to change quickly.• Patient Management: Practices that using an EHR may already have the capability to monitor chronic patients against care protocols that are developed within the practice or adopted from organizations such as the Centers for Disease Control or specialty academies. EHRs can highlight children that are overdue for immunizations, diabetics due for routine lab work, and patients that have skipped preventive care. All of these can ultimately result in cost reductions but add little effort to the practice. In many cases, care recalls can actually increase practice revenue. I recently discussed the lack of dramatic cost savings from the early population management efforts. CMS reported in July that during the first year of operations the Pioneer accountable care organizations (ACOs) were able to reduce costs by 0.5 percent when compared against non-ACO patients. There was still a 0.3 percent increase in overall costs but better than the 0.8 percent in unmanaged care. Only 13 of the 32 Pioneer programs actually reduced costs. Results like this may provide support for more focused programs. Some cost management efforts have produced reliable successes. Co-management arrangements where physicians and hospitals partner around high-cost procedures with the goal of assuring good outcomes while making the care process more efficient are good example. Physicians continue to do what they have but have financial incentives for standardizing care. Generic prescription initiatives produce millions in savings. These programs may be more likely to be the kind of initiatives that will be experienced by the bulk of physicians. The shift from volume to value isn’t going to go away but it might take a much more conservative pathway than the model reflected in ACOs and other population management initiatives. Starting to examine prescriptive patterns, develop care protocols, identify your referral patterns and see if less expensive options are available, and reaching out to your two or three major payers and see if they have an incentive program that might match the steps that you can accomplish.If none are available, then it’s business as usual for your medical practice.

 Article By: Greg Mertz- See more at: http://www.physicianspractice.com/blog/volume-value-minimizing-major-healthcare-shift?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=20082013#sthash.toH5dZCs.dpuf