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Monday, March 31, 2014

KatrinaCare 2.0?

Obamacare Website Fails as Deadline Arrives
People trying to apply and enroll for private health insurance through Obamacare before Monday's midnight deadline discovered the website was "currently unavailable.", the online marketplace bedeviled by bugs since its launch last fall, went down for several hours Monday morning, a statement from the Department of Health and Human Services said. It was back online later in the morning after a short time when it put customers in a "queue," meaning they'd be notified by email when they could proceed with enrollment...
Should be an interesting day for "KatrinaCare."

The day's other main event is the pending Senate vote to kick the SGR and ICD-10 cans down the road yet again, this time past the 2014 mid-term elections. I'll be following that today.
athenahealth Issues Statement on ICD-10 Delay; Government's Willingness to Kick the Can Down the Road on SGR, Meaningful Use

WATERTOWN, Mar 31, 2014 (Menafn - GLOBE NEWSWIRE via COMTEX) --athenahealth, Inc.ATHN, a leading provider of cloud-based services for electronic health record (EHR), practice management, and care coordination, today issued the following statement in reaction to the House vote, and pending vote from the Senate, to patch the Sustainable Growth Rate ("SGR" or "Doc Fix") and delay ICD-10 for another year to October 2015.

Ed Park, executive vice president and chief operating officer, athenahealth, provided the following comment:

"It is unfortunate that the government has once again chosen to delay ICD-10. athenahealth and its clients are/were prepared for the ICD-10 transition, and in fact we have national payer data showing that 78 percent of payers are currently proving readiness in line with the 2014 deadline. The moving goal line is a significant distraction to providers and inappropriately invokes massive additional investments of time and money for all. The issue is even more serious when considered in association with another short-term SGR fix and 2013's Meaningful Use Stage 2 delay. It is alarmingly clear that health care is operating in an environment where there is no penalty for not being able to keep pace with necessary steps and deadlines to move health care forward. Our system is already woefully behind in embracing technology to drive information quality, data exchange, and efficiency, and delays like this only hinder us further."

Why Doctors Are Not Joining ACO’s
March 31, 2014 10:09 am by Dr. Linda Girgis, MD
According to a recent study published on Wiley Online Library, 60% of physician practices have not joined and have no intention of joining an ACO in the future ... Of the 32 medicare pioneer ACO’s : 9 dropped out, 13 had “some” savings, and 2 lost money and had to pay CMS. The ones that had “some” savings did not necessarily have enough to get paid ...

There are many reasons that doctors are not rushing to join ACO’s”

1. As noted above, this is a new venture and may very well fail.  There is no record to study to make a wise investment.

2. We are only allowed to join one. We are not allowed to change once we sign up. What if we choose the wrong one?

3. It is another intrusion into the way we practice. We are now required to meet increasing government regulations, ie meaningful use,  e-prescribing, etc. This is another way for insurers to regulate the way we practice.

4. We can lose money. Most doctors are truly trying to give the best care for our patients. We try to be cost conscious about it. We are the ones on the front lines who know the patient best and can make the best treatment decisions. We do not need an organization to hold us accountable for costs. Some patients are truly sick and require expensive diagnostic work up. I don’t want to have it in the back of my mind that I may get “dinged” for ordering an expensive test that I think a patient needs. For doctors, quality comes first. Sure, we all need to take some responsibility for holding down costs, but I fear the day when we are punished for doing the best for our patients.

5. Most ACO’s are not physician run. The quality measures are being made by non-physicians. Quality metrics can only be determined by someone who has a medical degree. If others are determining what makes up good outcomes, they are basing their decisions on statistics and not medicine. Clearly, a deficiency in my mind.

6 The future is uncertain. With the passage of the ACA, many physicians are concerned about the future of the  healthcare system in this country. Many fear the worst. Many are in a “wait and see” position before making any decisions about changing the way they practice.

7. Doctors have been burned by insurance companies and regulations in the past. Most are not trusting the new ACOs based on past experiences...
Full MedCityNews article here.

How prepared are providers in Indiana for Stage 2 Meaningful Use?

It’s been fascinating to watch Stage 2 unroll as compared to Stage 1. We’re in the same spot where people glance at a lot of the requirements and metrics and think, “That’s not that hard especially after I’ve done Stage 1. This is just a few new things; it’s not going to be that difficult.”
Just as we saw in Stage 1 when people started to dig into the details, they are realizing that it may be a little bit more complicated than what they had anticipated. It’s not surprising but Indiana folks in Indiana are starting to realize that Stage 2 is hard and they’re going to need some help to get there. Obviously, we’re in a good position to do that.

What factors will determine whether an eligible provider is successful or unsuccessful in Stage 2?

The challenge is going to be different based on the size of the organization. In Indiana, we have a significant amount of provider employment, employed by hospital systems specifically, and they have to look at global solutions for transitions of care. They can’t look at one doctor out of 475 doctors — one a provider to provider basis — and just his transitions of care and how to they get to 10 percent. They have to be thinking of some global solutions for that. We are very fortunate to have a very good HIE in the state that has a global solution and for them now it’s a matter of getting in queue. It’s bandwidth from an HIE standpoint for them to get all aligned and integrated.

For a small provider it’s much more difficult because they probably can’t buy that solution. They’re going to have to do a little more of that detailed work of whom am I referring out to and then they’re going to have to do some more work to determine if those providers are on Stage 2 software or a piece of a HISP somewhere because if they’re not this HISP to HISP thing doesn’t work. That’s the biggest challenge I see for small providers — that physician they are referring to has to also be on a HISP to get that transition of care piece to work.

Is the Purdue REC in communication with these HIEs in order to help providers?

Absolutely, we talk to them if not every week then every other week. Our main HIE in the state also does work with syndromic surveillance messaging to the state’s Department of Health as well as immunizations. We’re fortunate in the state to have several HIEs, and we keep open communications with all of them. The whole transitions of care — that has really just started to crystallize in the last two months as far as what is a real process that can happen to make it work. We’ve been talking about hypothetical HISPs, HIEs, and eHealth partners. Now it’s shifted to workable plans.

Is integrating HIE into clinical workflows going to pose a problem?

It is. For large providers, they’re probably going to make that workflow fairly straightforward for providers or their staff. It’s going to be a concern for small providers and it’s going to depend on the software. On top of that, they’re going to have to configure their software to set up where that referral is going and what their Direct address is and their EHRs need to verify their security key and all those technical components. It’s really going to be tough.
Good stuff. Props to EHR Intelligence.



Medscape Medical News
Senate Votes to Delay SGR, ICD-10 by 1 Year
Mark Crane, March 31, 2014

The US Senate has voted for a 1-year "doc fix" preventing a 24% pay cut for physicians who treat Medicare patients, while also delaying by 1 year the implementation of the nationwide conversion to the International Classification of Diseases, 10th Revision (ICD-10), set of diagnostic and procedural codes that was scheduled to occur on October 1.

The bill now awaits President Obama's signature...
Don't hold your breath for a "signing ceremony."

More to come...

Friday, March 28, 2014

The downloadable ONC Security Risk Assessment Tool

What is the Security Risk Assessment Tool (SRA Tool)?
The Office of the National Coordinator for Health Information Technology (ONC) recognizes that conducting a risk assessment can be a challenging task. That’s why ONC, in collaboration with the HHS Office for Civil Rights (OCR) and the HHS Office of the General Counsel (OGC), developed a downloadable SRA Tool [.exe - 66 MB] to help guide you through the process. This tool is not required by the HIPAA Security Rule, but is meant to assist providers and professionals as they perform a risk assessment.

The SRA Tool is a self-contained, operating system (OS) independent application that can be run on various environments including Windows OS’s for desktop and laptop computers and Apple’s iOS for iPad only. The iOS SRA Tool application for iPad, available at no cost, can be downloaded from Apple’s App Store...
Completing a risk assessment requires a time investment. At any time during the risk assessment process, you can pause to view your current results. The results are available in a color-coded graphic view (Windows version only) or in printable PDF and Excel formats.

For details on how to use the tool, download the SRA Tool User Guide [PDF - 4 MB].

A paper-based version of the tool is also available:

  • Administrative Safeguards [DOCX - 269 KB]
  • Technical Safeguards [DOCX - 240 KB]
  • Physical Safeguards [DOCX - 225 KB]
 OK, let me save you a bit of trouble with respect to the 3 paper-based versions.

I downloaded and merged the three MS Word documents into one PDF, annotated the title page, and posted it here for your convenience.

"Completing a risk assessment requires a time investment." Indeed it does. Do a little back-of-the-bar-napkin math. 436 pages? Round down to 430 to exclude the redundant title pages, etc. Assume one minute per page just initially reviewing the entire document. Roughly one full FTE work day. Don't take my word for it; download it and go through it.

Assume then, say (charitably), 30 minutes per page on average adequately addressing and responding to all aspects of the SRA. ~One month of FTE -- by someone with the requisite 45 CFR 164.308, 310, 312 et seq chops.

No matter how you slice it -- doing it all in-house, or bringing in a credible consultant (keyword "credible") -- you're looking at spending ten grand or so, minimally, first time around.

But, should you be audited and found to be noncompliant, you'll be doing it anyway, under an onerous CAP (Corrective Action Plan), and a good bit lighter in the bank account after the punitive HHS/OCR monetary settlement.

Be advised.

Below, one of my 2011 REC SmartDraw graphics:

See also my December 18th, 2001 REC Blog post regarding the also free downloadable NIST Security Rule Toolkit.


More to come...

Legislative update

OK, now it look like there will be no further action until a Senate vote on Monday. From Modern Healthcare:
Reform Update: Docs irate over ‘doc fix’ patch; fight shifts to Senate

Doctors are trying to stoke a rebellion against the doc fix.

A one-year extension of the doc-fix patch passed the House by voice vote Thursday, and so efforts to derail the measure now move to the Senate, where Senate Majority Leader Harry Reid (D-Nev.) has reportedly scheduled a vote for Monday.

The American Medical Association issued a statement from President Dr. Ardis Dee Hoven saying the association “is extremely disappointed in today's House action to give up on SGR repeal. There was bipartisan, bicameral support for reform this year, yet too many in Congress lacked the courage and wherewithal to permanently fix Medicare to improve care for patients and provide greater certainty for physician practices. Congressional leadership had to resort to trickery to pass an SGR patch that was opposed by physicians.”

Dr. Charles Mick, an orthopedic surgeon from Northampton, Mass., and a past president of the North American Spine Society, expressed disappointment that congressional leaders once again opted for a patch. “All of us had been very optimistic that this was the best chance in many years for a permanent fix to the SGR problem,” he said.

Now that the House has acted, the chances of heading off the deal appear remote. But Mick is not giving up hope. “We will be putting pressure on the Senate to hopefully come up with a proposal,” he said. “Whether that will occur or not we don't know.”...
 Also from Modern Healthcare,
ICD-10 extension in doc-fix bill divides healthcare industry

While powerful healthcare industry groups are lobbying on both sides of a congressional measure that would force a delay in the launch of the complex and voluminous new sets of diagnostic and procedural codes known as ICD-10, providers are divided on whether the delay will help or hurt them.

Their positions depend on how confident they are they will be ready for the switch to ICD-10 scheduled for Oct. 1, 2014.

The bill, which delays implementation until at least October 2015, passed the House on Thursday and a Senate vote is expected Monday.

“We put a ton of effort into preparing for ICD-10,” said Dr. Brian Patty, chief medical information officer at four-hospital HealthEast Care System, St. Paul, Minn. “We've had our ICD-10 steering committee up and running for two years.”

At immediate risk are contracts the system has for extra coders for case review and to convert ICD-9 codes from an ambulatory electronic health record running on ICD-9 that's being phased out and won't be replaced until next year.

“That's literally about a half a million dollars for various contractors to cover us when we go up on ICD-10,” Patty said.

But what may be worse—if the delay goes into effect—is its impact on relationships with affiliated physicians, who comprise about four-fifths of the medical staff.

“We just began training all of our physicians with online training about a month ago,” Patty said. About 200 have completed two to four hours of training, which will have to be repeated next year if the delay goes into effect, he said...
Again, I have to think that the Obama Administration wants to put the ICD-10 rollout on hold (sans fingerprints) until after the 2014 midterm elections, lest there be another KatrinaCare fiasco.

Interesting thoughts from Tom Sullivan:
Latest ICD-10 one-liner is no joke
Senate's turn to vote on ICD-10 delay on Monday

WASHINGTON | March 28, 2014

Whether you’re on that chair edge hoping President Obama gets a chance to sign the provision pushing ICD-10 back within the Sustainable Growth Rate fix into law, or crossing fingers that the Senate kills it come Monday, no matter.

The reality is that a code set conversion simply should not be about politics.

Other than lazily dumping ICD-10 and the SGR process for determining how much to pay doctors who treat Medicare patients under the umbrella term of healthcare reimbursements, the tie between them prior to the now infamous Section 212 bomb within the bill, ICD-10 and SGR have almost nothing to do with each other.

Proponents of ICD-10 have made the case for years that the U.S. needs the modern classification system as a key piece of digitizing the last multi-trillion dollar sector to be industrialized. Opponents, likewise, have been vocal that the immediate benefits are unproven, even by countries such as Canada and Australia that have been using ICD-10 for years, insisting that the ride may not be worth its ticket price for those who actually have to use the codes and pay for that privilege, and questioning just how modern ICD-10 will be when it’s live in production...

More to come...

Thursday, March 27, 2014

ICD-10 update

apropos of Tuesday's post. On the congressional calendar today. We'll see if it passes both houses intact.



From The Incidental Economist this morning:
How much does health care contribute to health? [FAQ]

Read all the linked stuff. It's not a settled question, by any means. The infographic above is arguing a serious, expensive misalignment.

House delays vote on ICD-10, doc pay
Bill would have delayed the ICD-10 deadline to 2015, created a temporary SGR fix

WASHINGTON, March 27, 2014

After a fiery debate on the House floor, the House members pushed back an effort to delay the ICD-10 compliance deadline to 2015, legislation that also aimed to create  a temporary SGR patch.

Rep. John J. Duncan, a Tennesee Republican, declared the bill had the requisite two-thirds majority to pass. However, Rep. Joe Pitts, a Republican from Pennsylvania, objected to the vote, saying that a quorum was not present. The House voted. Duncan said it passed, Pitts objected, and so it was postponed...
And, then, from FierceHealthcare...
House approves temporary SGR fix
Bill also delays ICD-10, two-midnight rule and RAC audits
March 27, 2014, By Ilene MacDonald

The House of Representatives on Thursday approved a temporary fix to the sustainable growth rate (SGR) for one year in a bill that also delays ICD-10 implementation until at least October 2015 and postpones hospital compliance with the controversial "two-midnight rule"and recovery audits of medically unnecessary claims until March 2015.

The last-minute voice vote, arranged under special rules that provided for no amendments and limited debate, needed only a two-thirds majority (290) votes.

The bill still needs approval of the Senate before Congress' deadline of midnight on Monday, March 31...

More to come...

Wednesday, March 26, 2014

Aye, robot

How Environment and Technology Can Improve Health Care
Putting comfort of patients first yields surprising results

More than 800 robots now rove the halls of U.S. hospitals, increasing doctors' efficiency by letting them be in two places at once. And these stand-ins for people are taking on other duties, too. At the UCSF Medical Center, a robot packages 13,000 doses of medication, including IV solutions, every day, "virtually eliminating the opportunity for human error," says Michael Blum, a cardiologist and chief medical information officer at the center. Each dose gets a bar code that a nurse must match to a patient's wrist band before the medication is administered.

The number of robot-assisted surgeries – for everything from gall bladder removal to hysterectomy – has soared, though critics say there's still little evidence that the method produces better results than comparable minimally invasive procedures. (The FDA has been looking into robotic surgery in response to growing reports of problems, such as the arms moving improperly.) Other robots emit beams of ultraviolet light to kill potentially deadly bugs. A recent MD Anderson Cancer Center study found that a unit from a company called Xenex killed 95 percent of C. difficile bacteria – six times more than bleach, the standard disinfectant.
Change is also coming to the ICU, which faces a daunting challenge. In any given hospital, as many as 15 medical devices, including monitors, ventilators and infusion pumps, are connected to an ICU patient, but because they are made by different companies, they don't "talk" with one another. Patient-controlled analgesic pumps that deliver powerful narcotics, where a known side effect is respiratory depression, aren't linked to devices that monitor breathing, for example. "Today's ICU is arguably more dangerous than ever," says Peter Pronovost, senior vice president for patient safety and quality at the Johns Hopkins Medical Center in Baltimore...
To address the need for "interoperability," health care and industry executives convened the first Patient Safety, Science and Technology Summit in January, and nine of the largest medical device companies pledged to share data and standardize device interfaces. According to a new report from West Health Institute, a research organization focused on reducing health care costs, true interoperability could save $30 billion by avoiding mistakes.
Meanwhile, design plays a role in intensive care, too. At Memorial Sloan-Kettering Cancer Center's 20-bed unit in New York, sliding glass doors are glazed with LCD privacy glass, which transitions from clear to opaque at the touch of a button and can be cleaned far more effectively than curtains. Monitors, medication pumps, oxygen, suction and power outlets reside in ceiling mounted mobile columns rather than in headboards, and no cables snake across the floor. "That allows us latitude and freedom that we would never have in standard rooms," says Neil Halpern, chief of the hospital's critical care medicine service. Seattle Children's similarly puts access to power and gases into movable booms so the medical team can quickly and easily get to the patient.

Wachter is cautiously optimistic that all this innovation will lead to better, safer care. But the smartest of technologies still leave no room for complacency. "We've learned how amazingly complicated it is," he says, "to reliably deliver care to sick people."
Props to the THCB article "How a Washing Machine Inspired Me to See the Future of a Safer ICU" for turning me on to this.

Also, see

The Robot Will See You Now

IBM's Watson—the same machine that beat Ken Jennings at Jeopardy—is now churning through case histories at Memorial Sloan-Kettering, learning to make diagnoses and treatment recommendations. This is one in a series of developments suggesting that technology may be about to disrupt health care in the same way it has disrupted so many other industries. Are doctors necessary? Just how far might the automation of medicine go?

...Information technology that helps doctors and patients make decisions has been around for a long time. Crude online tools like WebMD get millions of visitors a day. But Watson is a different beast. According to IBM, it can digest information and make recommendations much more quickly, and more intelligently, than perhaps any machine before it—processing up to 60 million pages of text per second, even when that text is in the form of plain old prose, or what scientists call “natural language.”

That’s no small thing, because something like 80 percent of all information is “unstructured.” In medicine, it consists of physician notes dictated into medical records, long-winded sentences published in academic journals, and raw numbers stored online by public-health departments. At least in theory, Watson can make sense of it all. It can sit in on patient examinations, silently listening. And over time, it can learn. Just as Watson got better at Jeopardy the longer it played, so it gets better at figuring out medical problems and ways of treating them the more it interacts with real cases. Watson even has the ability to convey doubt. When it makes diagnoses and recommends treatments, it usually issues a series of possibilities, each with its own level of confidence attached...
Great article. I'm a hardcopy Atlantic subscriber, so I read this when it first came out.


I just put a new linked graphic in my right hand links column.

YouTube link
Not ever gonna win a Grammy with that one... :)

JUST IN (11:20 a.m., March 26th)
LinkedIn Groups
Group: AHIMA

Subject: Urgent Possible ICD-10 Delay: Announcement from AHIMA

A new bill has been quietly introduced into the US House and Senate that features a section calling for the delay of ICD-10-CM/PCS implementation until 2015. This bill is expected to go to the House floor tomorrow, Thursday, March 27 for a vote.

The bill, which would adjust the Sustainable Growth Rate (SGR) and amend the Social Security Act to extend Medicare payments to physicians and change other provisions of the Medicare and Medicaid programs, also includes a seven line section that would delay ICD-10 to October 1, 2015.

This bill was negotiated at the leadership level in the House and Senate, and it is expected that there will be no debate before calling the bill to vote...
That's pretty interesting.The Obama Administration is back on its heels these days over the continuing judicial challenges to the PPACA, and the just-now announced delay in the HIX individual mandate deadline. Having been seriously burned by the rollout, I could see where they would love to avoid a similar CusterFluck over the ICD-10 transition deadline, and push it out past the mid-term elections. So, while this is a congressional action, its one I could see Obama signing should it reach his desk.

More to come...

Tuesday, March 25, 2014

People get ready, there's a train a-comin'... ICD-10

Apologies for the mixed metaphor (do trains have odometers?). Six months and seven days. That time will evaporate quickly.

I now subscribe to Health Affairs. Recent paper excerpt below.

On October 1, 2014, all health plans, health data clearinghouses, and health care providers that transmit health information electronically must use a new, significantly broader, coding system, called ICD-10, for diagnoses and inpatient procedures. The new system has the potential of improving the health care system, but its costs and complications have caused some to question whether the costs outweigh the benefits.

ICD is the acronym for the International Classification of Diseases. The ICD is maintained by the World Health Organization (WHO) to classify diseases and other health problems recorded on many types of health and vital records such as death certificates. It is used to monitor the incidence and prevalence of diseases and other health problems. The ICD is periodically revised to incorporate changes in the practice of medicine. In 1990 WHO adopted the 10th revision (ICD-10).

In the United States, ICD-10 has been used since 1999 to code and classify mortality data from death certificates. However, a modification of the 9th revision (ICD-9) is still used to assign codes to diagnoses associated with inpatient, outpatient, and physician office use and for inpatient procedures. Currently, the United States is the only G7 nation (the other G7 nations are Canada, France, Germany, Great Britain, Italy, and Japan) continuing to use ICD-9...

...In January 2009 HHS published final regulations calling for a transition to ICD-10 and set October 1, 2013 as the compliance date. However, in late 2011 and early 2012 three is- sues emerged that led the secretary to reconsider the compliance date for ICD-10: 1) The industry transition to the version 5010 electronic operating system necessary to accommodate ICD-10 did not proceed as effectively as expected; 2) providers expressed concerns that other statutory initiatives were stretching their resources; and 3) surveys and polls of affected parties revealed a lack of readiness for the ICD-10 transition. As a result, in August 2012, HHS announced a delay of the implementation date for ICD-10 to October 1, 2014. This means that ICD-10 codes must be used for services provided on or after October 1, 2014. ICD-9 codes may only be used for services provided before that date.

Conversion from ICD-9 to ICD-10 is complicated and costly, causing some affected parties to question whether the benefits of the con- version outweigh the costs. Experts say the new code set will have an impact on not only claims submissions but also such processes as patient eligibility verification, preauthorization for services, documentation of patient visits, research activities, and public health and quality reporting. Not only must new software be installed and tested, but training for physicians, staff members, and administrators is required. New practice policies and guidelines must be developed, and paperwork and forms updated.

Proponents of the transition to ICD-10, including the federal agencies that developed the system, say the codes will provide a more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment strategies and care guidelines. Codes describing the circumstances of injuries are important for public health researchers to track how people get hurt and try to prevent injuries...

Opposition to implementation of the ICD-10 transition in 2014 comes primarily from medical associations, including the American Medical Association (AMA). They believe that the transition will be overly burdensome on providers who are already engaged in efforts to comply with new systems and requirements such as meaningful use, e-prescribing, and quality data reporting.

They cite costs as a major problem. Estimates regarding the additional costs of the implementation of ICD-10 have varied, but one study in 2008 sponsored by the AMA, the Medical Group Management Association, and other provider associations has pegged the adoption costs for a small practice at $83,000, ranging up to $2.7 million for a typical large practice. The study identified costs in six key areas: staff education and training, business process analysis, new claims form software, IT system changes, increased documentation costs, and cash flow disruption...

Given the political fallout from the data system problems encountered with implementation of the health insurance exchanges, the Obama administration will likely be extremely sensitive to any potential problems with claims processing due to the ICD-10 conversion. Extensive testing, both of the system’s connectivity and of coding accuracy, is needed to ascertain readiness for the conversion. As the implementation date approaches, CMS will have to decide if there has been sufficient progress to keep to the deadline. Since CMS has concluded that concurrent use of both ICD-9 and ICD-10 (at user discretion) would be overly complicated, confusing, and costly, likely action in case of significant unreadiness would be to again delay the implementation date.
From Medcity News:
Where Doctors Should Be In The Onward March Of ICD-10
March 25, 2014 by Dr. Linda Girgis, MD

There is much fear and concern among doctors and other healthcare workers surrounding the implementation of ICD-10. Many are predicting a delay in reimbursements in October when ICD-10 is made mandatory for insurance reimbursement. Surely those who wait to near the deadline will have problems. Doctors should be preparing from now, if not sooner.

Where Should Doctors Be in the ICD-10 Conversion?

  1. All doctors should know coding. Ultimately, we are the ones responsible for any billing or coding mistakes. We cannot pass the blame on someone else. The buck stops at us. The best way to protect ourselves from coding and billing mistakes is to be proficient in it. While many rely on others for this task, we still need basic knowledge and oversight of our billing practices, despite who is actually doing the coding.
  2. Doctors should be learning ICD-10 coding. There are many seminars, webinars, on-line materials and many sources available to teach us. We need to start utilizing some of these references now. If we wait to September to start, we will be learning in crunch time and this is the way mistakes seep in. Better learn from now when we have the leisure to make and learn from mistakes.
  3. Doctors and practices should have already or currently be mapping their codes. What this means is that the most commonly used codes should be mapped out into their ICD-10 equivalents.  It will no longer be acceptable to just code for knee pain. Now, the code needs to show the cause and exact location. What could have been only coded with only one ICD-9 code in the past, now has many more detailed ICD-10 codes to choose from.
  4. Some insurances are allowing codes to me submitted in the ICD-10 format from next month. What I am planning to do in my practice is to make a trial run with one insurance at a time.  In this way, I will not have a major delay in reimbursements and I have time to work out any flaws in the implementation process. This also gives me a more ample way to become proficient in ICD-10 coding.
  5. We need to ask for help. There are many people available to help. Many of our state and national medical societies have help available for us. We need to search out these resources and use them...
Item number 5: REC opportunity?

One thing a lot of people are unaware of is that the ICD-9 to ICD-10 crosswalk mapping is not unilateral. There are some ICD-10 codes for which there is no ICD-9 antecedent, and, in some cases the ICD-10 code is less granular than the ICD-9.

From the AMA guidance:
A critical issue associated with the transition to ICD-10 involves the matter of crosswalking between the ICD-9 and ICD-10 code sets. The term “crosswalking” is generally defined as the act of mapping or translating a code in one code set to a code or codes in another code set. (The terms “crosswalking” and “mapping” are sometimes used interchangeably.) There has been much discussion about how crosswalks will be used in the industry during the transition from ICD-9 to ICD-10. Understanding crosswalking will be important to physicians during the transition phase when learning which new ICD-10 code to use in place of an ICD-9 code, since there is not always a one to one match.

Were the crosswalk unidirectional, you can envision an EHR drop-down menu subpanel wherein you'd simply pick the more granular ICD-10 code from your former usual ICD-9 code choice. A few seconds more** per chart, perhaps.
** Even so, assume an average additional 3 seconds per chart, processing 5,000 patient visits per year, 15,000 seconds, or 4.16 hours, at $240 per hour (see my "Case for EHR scribes?" post), that's an additional $1,000 annual labor cost. Then there would also be the inevitable rejected claims re-processing costs, at least in the early going.
Not gonna be that simple. 1.2% of ICD-10s have no ICD-9 antecedent. 3% of ICD-9s have no ICD-10 match at all.

Below, an example of reduced ICD-9-to-10 granuarity.


About that mixed metaphor. :)


The Note Taker's Dilemma
Saurabh Jha, MD
The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.

The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.

Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping...

Read on.


More to come...

Monday, March 24, 2014

More on the socioeconomic determinants of health

Above, the German sculpture "Politicians discussing global warming."

Climate Change Dangers Here Now, Will Worsen Many Human Ills, UN Panel Warns

...If climate change continues, the [Intergovernmental Panel on Climate Change] panel's larger report predicts these harms:
  • VIOLENCE: For the first time, the panel is emphasizing the nuanced link between conflict and warming temperatures. Participating scientists say warming won't cause wars, but it will add a destabilizing factor that will make existing threats worse.
  • FOOD: Global food prices will rise between 3 and 84 percent by 2050 because of warmer temperatures and changes in rain patterns. Hotspots of hunger may emerge in cities.
  • WATER: About one-third of the world's population will see groundwater supplies drop by more than 10 percent by 2080, when compared with 1980 levels. For every degree of warming, more of the world will have significantly less water available.
  • HEALTH: Major increases in health problems are likely, with more illnesses and injury from heat waves and fires and more food and water-borne diseases. But the report also notes that warming's effects on health is relatively small compared with other problems, like poverty.
  • WEALTH: Many of the poor will get poorer. Economic growth and poverty reduction will slow down. If temperatures rise high enough, the world's overall income may start to go down, by as much as 2 percent, but that's difficult to forecast.
Bullet point 4 in particular relates inextricably and significantly to bullet point 5 (they're all materially interrelated, really). Recall my post When it comes to health, your zip code matters more than your genetic code.” See also another blog of mine, "Boiling the Frogs Slowly." And, one more: "0.0143%"
From the EPA: 
Climate Impacts on Human health
Weather and climate play a significant role in people's health. Changes in climate affect the average weather conditions that we are accustomed to. Warmer average temperatures will likely lead to hotter days and more frequent and longer heat waves. This could increase the number of heat-related illnesses and deaths. Increases in the frequency or severity of extreme weather events such as storms could increase the risk of dangerous flooding, high winds, and other direct threats to people and property. Warmer temperatures could increase the concentrations of unhealthy air and water pollutants. Changes in temperature, precipitation patterns, and extreme events could enhance the spread of some diseases.
The impacts of climate change on health will depend on many factors. These factors include the effectiveness of a community's public health and safety systems to address or prepare for the risk and the behavior, age, gender, and economic status of individuals affected. Impacts will likely vary by region, the sensitivity of populations, the extent and length of exposure to climate change impacts, and society's ability to adapt to change.

Although the United States has well-developed public health systems (compared with those of many developing countries), climate change will still likely affect many Americans. In addition, the impacts of climate change on public health around the globe could have important consequences for the United States. For example, more frequent and intense storms may require more disaster relief and declines in agriculture may increase food shortages...

Impacts from Climate-Sensitive Diseases
Changes in climate may enhance the spread of some diseases. Disease-causing agents, called pathogens, can be transmitted through food, water, and animals such as deer, birds, mice, and insects. Climate change could affect all of these transmitters.

Food-borne Diseases
Higher air temperatures can increase cases of salmonella and other bacteria-related food poisoning because bacteria grow more rapidly in warm environments. These diseases can cause gastrointestinal distress and, in severe cases, death.

Flooding and heavy rainfall can cause overflows from sewage treatment plants into fresh water sources. Overflows could contaminate certain food crops with pathogen-containing feces.

Water-borne Diseases
Heavy rainfall or flooding can increase water-borne parasites such as Cryptosporidium and Giardia that are sometimes found in drinking water. These parasites can cause gastrointestinal distress and in severe cases, death.

Heavy rainfall events cause storm water runoff that may contaminate water bodies used for recreation (such as lakes and beaches) with other bacteria. The most common illness contracted from contamination at beaches is gastroenteritis, an inflammation of the stomach and the intestines that can cause symptoms such as vomiting, headaches, and fever. Other minor illnesses include ear, eye, nose, and throat infections.

Animal-borne Diseases
Mosquitoes favor warm, wet climates and can spread diseases such as West Nile virus.

The geographic range of ticks that carry Lyme disease is limited by temperature. As air temperatures rise, the range of these ticks is likely to continue to expand northward. Typical symptoms of Lyme disease include fever, headache, fatigue, and a characteristic skin rash.

In 2002, a new strain of West Nile virus, which can cause serious, life-altering disease, emerged in the United States. Higher temperatures are favorable to the survival of this new strain.

The spread of climate-sensitive diseases will depend on both climate and non-climate factors. The United States has public health infrastructure and programs to monitor, manage, and prevent the spread of many diseases. The risks for climate-sensitive diseases can be much higher in poorer countries that have less capacity to prevent and treat illness...

More to come...

The case for EHR scribes?

Ran across an interesting Medscape paper.
Hate Dealing With an EHR? Use a Scribe and Profits Increase
Neil Chesanow, February 27, 2014

Like many doctors, you may have resigned yourself to life with an electronic health record (EHR): the torturous clicking, the precious minutes ticking away, the patients squirming in their seats as you squint at the screen, and the hour or two it takes you at the end of each day to catch up on your charts.

It doesn't need to be this way.

A growing number of doctors are saying, "Enough!" They are hiring medical scribes to enter notes, test results, and other data into the software while the doctors devote their full attention to their patients. When the visit is done, so is the patient chart, ready for doctor review.

Patients love it. When scribes are used, patient satisfaction scores increase, often dramatically, studies show. Doctors love it too. Documentation is so thorough that a higher-level Current Procedural Terminology (CPT) code is often earned. The scribe suggests which codes to use, sends electronic prescriptions to the patient's pharmacy on the doctor's behalf, and generates referral letters to specialists.

Between patients, the doctor reviews the scribe's work in the EHR and does whatever tweaking is necessary. A few moments and it's done.

Asfer Shariff, MD, an ENT surgeon in Toledo, Ohio, as well as Founder and Chief Medical Officer of a scribe service called Physicians Angels, says he is now able to review 15-20 scribe-produced charts in as many minutes in his practice. Without a scribe, he was spending up to 2 hours at the end of each day updating charts in the EHR. "I got my family back," he says.

Physicians who work with scribes see, on average, one additional patient an hour, experts maintain. Despite this greater productivity, at the end of the day, all the charts are done. This is true even for high-volume specialists who may generate 50-75 charts per day. The doctors are free to go home at 5 or 6 PM.

Scribe Boom Sparked by Dissatisfied EHR Users
That doctors are seeking help with their patient records isn't a new phenomenon. Transcription services have been around since the 1960s. In the 1990s, a few doctors hired stenographers to follow them from exam room to exam room, taking dictation and later typing up a transcript of what was said to file in paper charts. They were known as scribes. But the idea never caught on...

"Research shows a physician using an EHR sees, on average, 11.2 patients fewer per week -- a potential revenue loss of up to $3800 per month -- than before adoption of an EHR," Toth says.

EHRs also cost a bundle in inefficient use of physician time.

"A doctor's cost runs up to $4 a minute or $240 an hour," Shariff observes. "Would you pay $240 an hour to have someone type and click information into an electronic medical record? Would you take your most expensive employees and make them data entry staff? That's what has been happening."...

What Is a Medical Scribe?
The Joint Commission defines a medical scribe as an unlicensed individual hired to enter information into the EHR or chart at the direction of a physician or licensed independent practitioner. Physician practices, hospitals, emergency departments (EDs), long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers all use scribes. Scribes can be employed by a healthcare organization, physician, or licensed independent practitioner. They can also be subcontracted from a scribe service...

"A medical assistant or nurse takes the patient's weight and vital signs and accompanies the patient to an exam room," Toth explains. "The scribe accompanies the physician when he or she enters the exam room and records the history, examination, treatment plan, and other clinical data in real time, while the physician interacts with the patient.

"The scribe does additional typing and other documentation while the physician moves on to the next room," she continues. "At the end of the clinic session, the physician reviews the documentation and makes any corrections to the scribe's documentation and signs off."
"Scribing is not merely listening to a doctor dictate a note and typing it into the EHR," adds Shariff. "It is interpreting the physician-patient interaction and converting it into a concise document with relevant information, then doing appropriate coding to send to the coders/billers, while also creating the letter to the referring physician and doing all the associated tasks."

"The physician-scribe relationship goes beyond transcription," Toth agrees. "For example, scribes remind physicians of treatment plans and other recommendations from previous visit notes and provide a check-and-balance system to ensure visit documentation requirements are met, test results are received, and prescriptions are refilled."

Scribes aren't licensed coders or otherwise licensed, but they do receive from 3 weeks to 3 months of training, depending on the vendor, during which they learn, among other things, clinical terminology and common CPT codes for the specialties for which they are being groomed as well as compliance with Health Insurance Portability and Accountability Act (HIPAA) patient privacy mandates...

"Patients love this," he says. "Even though it's just bread-and-butter medicine, the physicians sound smarter, and patients love the physician's display of intellect. As a result, we've seen patient satisfaction scores go dramatically up."
How dramatically?

"We've had orthopedic surgeons consistently in the 20th percentile in patient satisfaction over 20 years of practice who suddenly leap to the 85th percentile because they do a narrative physical exam while working with a scribe," Murphy says. "Patients like that interaction, the doctors are happier, and they are able to focus on the patients even more."
Physician satisfaction scores, if anything, are even higher.

"It's amazing when you see the difference between a dictated note and one that's generated by a computer," marvels William A. Rivell, MD, a family physician in North Augusta, South Carolina, who began using a scribe for the first time last September. "Even if you're using the templates, it just sounds terrible; whereas I can just tell the scribe what's going on, and it comes out much more fluid."

"Scribes create comprehensive, nuanced documentation that might improve reimbursement by allowing a physician to bill a higher level evaluation and management (E&M) code than he or she would have without this level of documentation," Toth explains. "Many physicians gain a sense of security, knowing that their documentation was completed thoroughly and according to regulations and guidelines."

Ironically, this more comprehensive, nuanced documentation results from spending more time with patients and less time with the EHR...
It's a fairly lengthy, extensively documented paper. It's free, but is firewalled via (the also free) registration.

It seems to me that there is a huge untapped resource out there for EHR scribe deployment. Medical students. it could be (and perhaps should be) part of the curriculum.

"Internships," in the broader business sense.

Liability concerns could be mitigated via some sort of standardized competency testing. Maybe lay that off onto the vendors as part if their ONC certifications. Back during the 2005-2007 DOQ-IT era my company (HealthInsight) sent me to eClinicalWorks HQ for four days of computer-based classroom/hands-on training, the culmination of which was having to do an entire patient chart, soup to nuts, all the way from intake demographics through FH, SH, PMH, Active Rx, Active probs, HPI, CC, ROS, etc, and a full SOAP, and finally coding for dropping the bill, all under time pressure.

I recall making one readily resolved coding error. Four days of group training.

This is doable.

What do you think?

Med schools add EHR training to the curricula
Training reflects hope that young doctors will embrace EHRs in medical settings
11:29 AM - March 25, 2014

Some medical schools are incorporating training on electronic health records (EHRs) into their curricula because exposure to the IT systems is increasingly considered a crucial element of the medical education experience, Politico Pro reports.

The move reflects the medical schools' hope that young, technology-savvy doctors will help integrate EHRs into medical settings. Medical educators note that doctors-in-training do not appear to struggle with EHRs like some of their older colleagues do.

Already, most medical schools include some EHR requirement, and more institutions are expected to follow suit, especially given the growing national investment in health IT. The training can take many forms, including tutorials at the beginning of students' first year, units during pre-clinical courses, and components of patient simulations...

OK, how about scribe duty as a curricular component?

More to come...