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Saturday, September 22, 2012

Weekend Updates

My quick Photoshop response to the "VDT' push. Shot the USB drive on my kitchen counter, imported it, and did the overlays. Plenty to say about this concept coming up. Some of you might recall the quickie iMovie/YouTube I did a while back.

And, yeah, I know, a PHR <--> Patient Portal is the significantly better way to go long-term, but, whatever works, and flash drives are way more convenient than burning stuff to CDs.

UPDATE: Quick news item:

10 EHR Vendors Pledge Patient Records Access Within Months
Joseph Goedert, SEP 21, 2012 11:51am ET

The Office of the National Coordinator for Health Information Technology recently challenged electronic health records vendors to have their systems support patients viewing, downloading and transmitting their health information by the 2013 HIMSS Conference in March.

View/download/transmit is an EHR functional requirement under Stage 2 of the meaningful use program. Four vendors initially took the pledge and the count now is up to 10. They are: Alere Wellogic, Allscripts, athenahealth, AZZLY, Cerner, eClinicalWorks, Greenway Medical Technologies, Intellicure, NextGen and SOAPware.

Vendors taking the challenge can Tweet their pledge to #VDTnow.


Again, After October 3rd, there will be some criteria regarding which you will be unable to make up any ground (i.e., once the doc has closed the note, she can't go back in and change any encounter-related data, including those needed for MU attestation).

On the Medicare side, having to attest in 2013 (no, it does not traverse the calendar year) will cost you $5,000 per EP, $3,000 of that in year one.


First three weeks of September are cookin'. I don't pay a whole lot of attention to my traffic numbers, as this is a non-commercial personal blog I use just to reflect upon my interests since I began my REC work. But, I gotta say, this is pretty nice to see. Probably has something to do with my getting the HIMSS12 and Health 2.0 Conference press passes.

If you're attending and have any topics/views you'd like to have me write about, give me an email shout and we'll hook up. BobbyG "at" BGladd "dot" com. Also, tweet me, @BobbyGvegas

This is pretty curious, my top traffic countries:

Norway? Norway?

Tusen takk, mine norske venner, og si hei til Ole Børud for meg!


Saw this linked in a tweet. Jeez...
Medicare Bills Rise as Records Turn Electronic

When the federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records, the goal was not only to improve efficiency and patient safety, but also to reduce health care costs.

But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.

Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well.

The most aggressive billing — by just 1,700 of the more than 440,000 doctors in the country — cost Medicare as much as $100 million in 2010 alone, federal regulators said in a recent report, noting that the largest share of those doctors specialized in family practice, internal medicine and emergency care...
Over all, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.

The higher coding has captured the attention of federal and state regulators and private insurers like Aetna and Cigna. This spring, the Office of Inspector General for the federal Health and Human Services Department warned that the coding of evaluation services had been “vulnerable to fraud and abuse.”

Some experts blame a substantial share of the higher payments on the increasingly widespread use of electronic health record systems. Some of these programs can automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients — a practice called cloning — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams than, perhaps, they did.

Critics say the abuses are widespread. “It’s like doping and bicycling,” said Dr. Donald W. Simborg, who was the chairman of federal panels examining the potential for fraud with electronic systems. “Everybody knows it’s going on.”...

Many hospitals and doctors say that the new systems allow them to better document the care they provide, justifying the higher payments they are receiving. Many doctors and hospitals were actually underbilling before they began keeping electronic records, said Dr. David J. Brailer, an early federal proponent of digitizing records and an official in the George W. Bush administration. But Dr. Brailer, who invests in health care companies, acknowledged that the use of electronic records “makes it faster and easier to be fraudulent.”

Both the Bush and Obama administrations have encouraged electronic records, arguing that they help doctors track patient care. When used properly, the records can help avoid duplicate tests and remind doctors about a possible diagnosis or treatment they had not considered. As part of the economic stimulus program in 2009, the Obama administration put into effect a Bush-era incentive program that provides tens of billions of dollars for physicians and hospitals that make the switch...

Some contractors handling Medicare claims have already alerted doctors to their concerns about billing practices. One contractor, National Government Services, recently warned doctors that it would refuse to pay them if they submitted “cloned documentation,” while another, TrailBlazer Health Enterprises, found that 45 out of 100 claims from Texas and Oklahoma emergency-department doctors were paid in error. “Patterns of overcoding E.D. services were found with template-generated records,” it said.

The Office of Inspector General is studying the link between electronic records and billing...
Wow. Read the entire article, along with the 140+ comments (linked in the title). The touting of HIT is not going to get any easier. Add to the foregoing the pending conversion to ICD-10... May we live in interesting times.

We were cheerleading the notion of legit and defensible "upcoding" via EHRs all the way back during the DOQ-IT program (all part of the endless "ROI" pitch). I knew back then it was only a matter of time before there'd be major pushback on the payor side.

Expect the claims adjudication fighting to get ever more intense.


Center investigation suggests costs from upcoding and other abuses likely top $11 billion
by Fred Schulte
Thousands of doctors and other medical professionals have steadily billed higher rates for treating elderly patients on Medicare over the last decade — adding $11 billion or more to their fees and signaling a possible rise in medical billing abuse, an investigation by the Center for Public Integrity has found.

Medical groups argue that the fee hikes are justified because treating seniors has grown more complex and time-consuming, both due to new technology and declining health status. The rise in fees may also be a reaction, they say, to years of under-charging, and reflect more accurate billing. The fees are based on a system of billing codes that is structured to make higher payments for treatments that take more time and effort...

Among the investigation’s key findings:
  • Doctors steadily billed Medicare for longer and more complex office visits between 2001 and the end of the decade even though there’s little hard evidence they spent more time with patients or that their patients were sicker and required more complicated — and time-consuming — care.  The higher codes for routine office visits alone cost taxpayers an estimated $6.6 billion over the decade.
  • More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.
  • The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.
  • Medicare administrators have struggled for more than a decade to crack down on medical coding errors and abuses, often in the face of opposition from medical groups including the American Medical Association, which helped design, and now controls the codes. Whether they make honest mistakes or engage in willful misconduct, there’s little chance doctors who pad their charges will face any serious penalties.
...Medicare officials deny the AMA and other medical groups have outsized influence over the payment system. But they concede that the system has been left in place for years because they could not reach an agreement on ways to improve it.

Most patients have no idea doctor pay scales exist because Medicare and other insurers don’t typically help people decipher them. As owner of the copyrights on the codes and their definitions, the AMA controls their publication and aggressively enforces its copyright.

Princeton University Professor Uwe E. Reinhardt, a prominent health care economist, said government officials could have paid the AMA a lump sum to develop the codes, simplified them and retained their ownership for taxpayers. Doing so would have opened up the process to public scrutiny and given patients a better understanding of health care finances. Other critics note that millions of seniors might help the government check on the veracity of medical bills if they knew the lingo and how to crack the codes.

“I wish I had some way to check up on the billing process,” said Judy Ryden, a retired community college teacher who is on Medicare and lives in Grants Pass, Ore. “Unless I had a degree in medical coding I have no idea what all that means. I can’t tell whether a charge is legitimate or not,” she said...
Again, read all of this. I found it here on THCB: Kill The Codes. Excerpt:
...Not long ago I asked readers what my time is worth on a per-hour basis.  Collectively and independently, they settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.

But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

It depends on who’s looking.  Since every medical test and order is tied to a doctor’s name, then of course it looks like doctors are the problem.  And yet it’s the government who has mandated the codes, the requirements for chart completion, and the electronic records to which our electronic signatures are attached...


And, Mr. No Life is digging into May 2011 update of DURSA. Pretty interesting, actually. My recommendation to HealtHIE Nevada brass is that we leverage the experiences of those who've already gone down this path. No sense re-inventing wheels. HIPAA (and related) compliance gets you a good bit of the way to being a successful DURSA signer, but there are also a lot of technical testing specs to engage and document to demonstrate Trusted Secure Messaging.

Consistent weaknesses in sections of the Millenium clinical information System (CIS) are revealed in the combined study of the ERD, logical schema and the data tables. PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation. There is evidence that keys are managed by software within the application rather than by the in-built functions available in the database management system leading to less confidence in data integrity.

Health reform is pressuring hospitals, health systems, and physician groups to demonstrate value, not just generate volume and that IT improvement has to be seen as part of that drive. To meet this challenge, all members of the care team will need to break down silos and collaborate more closely than ever before. Building trust with IT services is essential, but at the same time this will not occur without IT staff becoming committed to primarily clinical objectives. Success will require the enthusiastic engagement of physicians through the use of sophisticated CIS in quality improvement — and not just on isolated projects. This next level of interdependence and collaboration — known as clinical integration — is vital to any enterprise seeking improved quality, patient safety, and value. This study analyses the deployment of Firstnet in Emergency Departments from the viewpoints of ED Directors, systems analysts and software engineers and observes that the support needed by the EDs comes up well short of what is needed and that the shortfall is attributable to both the Health Support Services of NSW Health and the technology itself. If this situation is not rectified then the promise of the gains of the IT Age for clinical care will be well and truly squandered.

This document consists of a study, in 9 sections, into the deployment of the Firstnet software in the Departments of Emergency Medicine in New South Wales, Australia. The first section was published in October 2009 and later reissued in November 2009 (Part 1). Seven sections (Parts 2-8) cover work completed in the second half of 2010 and are published here. The ninth and final section captures the context in which this study was completed. It is a summary of five years research into the design and construction of clinical information systems and was published as a conference paper in November 2010.

The titles of the 9 sections are: 
  1. A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck? 
  2. Discussions with ED Directors: Are we on the right track? 
  3. Discussions with Software Performance Experts. 
  4. Conceptual Data Modeling. 
  5. Database Relational Schema and Data Tables. 
  6. Coalescing the Analyses of the ER Diagrams, Relational Schemata and Data Tables. 
  7. The Integrated Assessment.
  8. Future HIT Regulation Proposals.
  9. Ockham’s Razor of Design: An Heuristic for Guiding Design and Development of a Clinical Information Systems Generator.
This kind of stuff is red meat for people like me.

I've post all of the unzipped PDF sections here.  

"PK values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation."

Ya think?

(btw, "PK" means "Primary Key," a continuing bane of tight software development.)

It's not pretty. e.g.,

Compilation of Weaknesses
A complete study of each table and our observations about their weaknesses are presented in Appendix 1. A compilation of the principal weaknesses identified in the available schema and data tables has been collated in Table 2. The results show that there is no schema or table without a weakness of some kind. The most persistent weaknesses across the data set are non-integer PKs and non-declared FKs. Issues that would represent the highest risk for user sites would be: doubtful PKs, misnamed PKs, and overloading attributes as these potentially can interfere with more fundamental aspects of data management and hence veracity. Other weaknesses if they create disturbance to data will tend to be isolated to single items such as a single patient or pharmacy record.

Weaknesses in CIS implementation suggest a lack of attention to detail, particularly specific testing to validate schema designs and index/FK and PK selection. If the yellow key icon is truly an FK indicator then the apparent use of FKs for creating indices rather than their purpose of maintaining referential integrity is a misapplication of this functionality.
Identified weaknesses could reasonably be expected to produce faulty processing of user data manifesting as problems such as, missing parts of patient records, missing information about pharmacy products. Particularly, these occurrences will appear occasionally without any apparent systematic behaviour as they will not be triggered by each and every patient record but rather only where a particular record uses a combination of information that requires the correct data relationships. Hence any one clinical user will observe a fault on occasions so far apart in time they will not connect a set of failings as being related to an underlying systematic weakness.

That last paragraph is very important. Complete Part 5 PDF document here. Pretty cool; full of tables and screen shots of the various schema relational dictionary tables.

I know just a thing or two about RDBMS architecture, dated as my experience may be in some ways. While data types and functionalities have changed and grown (along with code bloat), the core, necessary logical / linkage concepts have not.

I can't believe we're still extending so much scut-work effort on de-duping stuff in our Microsoft CRM at the office.


Margalit never disappoints.
The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.

The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?...

...There are ... administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

It'll be interesting to read the comments in response to her post as they accrue.


Payers are making mistakes on roughly 1-in-5 claims they receive. Even the most meticulous coding can't protect your practice from payer errors. (Read more here.)

Those mistakes are wasting an estimated $17 billion annually in needless administrative cost -- not to mention delaying payments for your practice. It seems that payers are making it almost impossible for you to get promptly paid in full.

Who has the time and resources to compare each payment, denial and underpayment with changing rules and contracted rates to ensure complete compensation?

With CareCloud Concierge, you do. Our comprehensive revenue cycle management service features:

  • Automated claims-contract reconciliation
  • Proactive compliance
  • Daily aging of receivables
  • Instant rules updates
  • Highly effective internal controls
  • Vigorous denial management protocols
  • Expert support and guidance
Take the headache out of getting paid with CareCloud Concierge.
An obvious marketing response to the recent stories of upcoding and other billing controversies. I now have a REC client using CareCloud. They recently dropped Alteer, in the wake of persistent, maddeningly poor support, and migrated over. I'll be paying a Meaningful Use support visit to them this week to assess how well things are progressing.


That's funny. Sort of.

More to come...

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