Healthcare

This year marks the 40th anniversary of the release of The Rock Opera, Tommy and a song contained within it titled “The Pin Ball Wizard”, composed by Peter Townsend and Performed by “The Who”. Within that Rock Opera is the song and a key phrase, “See me, Feel me, Touch me, Heal me”, a simple phrase that represents a complex human need to be recognized, understood, interacted with and satisfied. It represents the challenges of the key character, Tommy, a blind boy who is a champion pinball player.

Borrowing that phrase, translate that same human condition to our challenges world wide with providing healthcare;

1. See Me – Give me access to healthcare when needed in a timely fashion;
2. Feel Me – Understand my need/condition;
3. Touch me – Spend time with me to examine my needs and diagnose my condition(s);
4. Heal Me – Create a successful care plan for my treatment and follow through using the care necessary in my world.

Given the full continuum of care that this represents, document all of the above in an Electronic Medical Record (EMR), make it accessible to the continuum of Physicians and Clinicians through an Electronic Health Record (EHR), and let the patient access it as necessary through a Personalized Health Record (PHR). This is not an easy task when you consider the competitive nature of healthcare in the U S with competing Business Groups all vying for the same patient market.

The financial impact of doing this can be a rocky road to navigate. Creating access to data through market connectivity while trying to reduce the cost for the patient requires leveraging existing technology investments where the data resides to create viewable, actionable records that allow pro-active monitoring of patient conditions. Identifying problem areas where patient safety, quality of care and cost effectiveness can be improved through the use of Utilization tools with Enterprise Performance Measurement (EPM) is a necessary component as well.

The development of The Interoperability Platform solution and its associated front end engines that allow for multiple functional applications can be the answer for achieving this complex set of challenges. Yet, it is not a simple thing to accomplish from a healthcare enterprise or community perspective.

The political and technical accessibility challenges need to be explored and consensus built for any environment to develop a strategy that is acceptable to the majority of the user community. This will allow change that is transformative and actionable from a clinical and financial perspective.

Posted by Gary O. Claytor at 05:39 AM | Permalink | Comments (13) | TrackBacks (0)

The most prominent model of disease management today is the payor-driven disease management which aims to reduce costs of high risk patients. Other models are pharma-sponsored disease management which promotes usage of drugs from that pharma or employer-sponsored wellness program targeting improvement in productivity and higher employee satisfaction. None of these models have primary objective of making a significant difference in the quality of life of chronic patients through disease management services.

The success of payor-driven disease management programs is mostly measured with cost indicators and outcomes. The strategy for managing a chronic disease revolves around defining clinical protocols, patient education and continuous monitoring. This model of disease management is focused on short-term management of high-risk patients rather than long-term enablement of patients to lead a better quality of life. Consequently, these programs have limited success.

Patient-centric disease management programs need to be modeled as a service designed for patient. The singular most important objective of this program would be to make a positive difference in quality of life of chronic care patients and their family. The parameters for measuring success of the disease management program will be driven by this objective. Organizations like payors, providers, employers and pharmas who have an interest in managing disease of the patient can sponsor or contribute in subsidizing the service costs for patients. 

Like any disease management program, patient-centric disease management requires an active participation from physicians. Patient-centric disease management services can be offered by:
1. Provider organizations
2. A disease management organization having a network of physicians to support this program. Physicians get incentives for their participation.
3. A disease management organization, aligned with payors who will influence physician participation in program. 

This program will involve complete commitment from patient themselves and their families as well. Motivational programs designed to increase adherence to the program will be an essential component of the program. Skilled care managers with emotional sensitivity are critical for the success of program. Personalized care will be core to the patient-centric disease management. Apart from services providing ready access to care, to improve the quality of life of chronic patients, a plethora of support services designed to make tasks of daily living convenient need to be incorporated into the disease management program. There should be a lot of emphasis on community forums and networking events between patients with similar backgrounds where they can share experiences, support and encourage each other. This program needs to extend much beyond improved care coordination and outcomes. Ultimately, it needs to create an experience for patients and their families where they feel much comfortable and confident in coping with the disease.

The key challenge involved in patient-centric disease management business model would be the ability to demonstrate value in terms of improved quality of life and better clinical outcomes. Most of the benefits accrued to patients will be intangible benefits which are hard to quantify. A discernible improvement in disease state definitely cannot be assured for all the chronic patients. Under the circumstances, convincing patients to enroll for a program and then continue with the program requires much innovation in designing programs. Another critical success factor is making it lucrative for physicians to invest time for contributing to this program. If all the necessary ingredients for a patient-centric disease management program are brought together, this program will certainly see unprecedented success as it will make an impact where it matters most: it will help patients and their families lead a better life!

Posted by Seema Pandey at 09:23 AM | Permalink | Comments (0) | TrackBacks (0)

In the ICD-9 era, the ICD Codes were small in number, though not highly organized as ICD-10 is. Given that the ICD-10 codes bring in the granularity and accuracy to the diagnostic and procedure coding, not to mention decades of familiarity of the coders in ICD-9, how does a provider ensure that these codes are coded correctly?

In my view there are two ways to tackle this. First, train the two major stakeholders i.e physicians and the coders, rigorously in ICD-10 terminology / granularity. With this, the doctors could write/dictate elaborate discharge summaries, procedure/diagnosis notes, taking care of what is required for ICD-10 coding.  While this is an option for long term, in short term the coders and physicians will struggle to get the coding right.

 Secondly, providers can adopt technology assisted coding of ICD-10, which basically involves software aides for the coder to navigate the ICD-10 Procedure and Diagnosis hierarchy, find and narrow down to the right ICD-10 Code. If the information at hand (Discharge summaries, procedure/diagnosis notes) are not sufficient for ICD-10 coding, the case is sent back to the physician for additional information. In this, huge training period can be avoided for the physicians and coders, however cases will be shuttling between coder and physician will be higher, at least in the initial period.

 Third is an hybrid approach, the training of the physicians and coders is reduced to more to an awareness, and with this at least the coder will be provided with the software tools, if not both coder and Physician, will be enable to put together the right pieces of the ICD-10 code into place. The process of collecting the right information required for ICD-10 can start much before the ICD-10 cutover date, so that the transition is smooth when ICD-10 is actually implemented.
 Given this, from a physician’s point of view, Superbill will have 4-5 pages of annexure for listing the ICD 10 codes. It will be difficult to sift through and to select the right codes.  Does this mean will paper based Superbill be a thing of past? This may not be the case.

A mechanism or an approach is required for generating Superbill specific to a context.  How can we do this ?  A Office Assistant has the information about patients visit based on the appointment, based on the past history of visits. Since usually the medical records of patients are pulled up on the previous day of appointment, the specific superbills can be printed along with it.  If not, they could be printed just-in-time based on the patients answering informal question ‘Why are we here today ?’ by the office assistant. In-any case the generated Superbill will be very specific and customized to the patient visit and will have very small number of codes to choose from.

There will be cases where the context-specific Superbill cannot be generated, or generated Superbill will not be useful. However, the above approach serves the purpose by reducing the physician’s time, the inconvenience of selecting the right codes from a large number of ICD-10 codes, not to mention the implicit benefit of printing shorter Superbill and saving the paper.

Posted by Rajesh Patrao at 05:16 AM | Permalink | Comments (0) | TrackBacks (0)

As US Healthcare industry races to comply with HIPAA 5010 and ICD10 regulations by Jan’2012 and Oct’2013, these two changes remain as the biggest challenges the US healthcare industry has faced in decades. Processes and IT systems will need to be remediated and people retrained to ensure business continuity and avoid penalties. These two changes are being termed as the “Y2K of the healthcare industry” and are expected to cost the industry close to USD 20 billion for remediation.

Given the magnitude of the impact based on high level assessments, it is really important to breakdown the problem statement and detail it out. The mandate as a whole can be broken into two separate problems in a very simplistic way – viz., HIPAA 5010 transformation and ICD 10 Migration. But in my opinion, tackling of these two separately would be prohibitive in terms of implementation (though you might be ok, in terms of impact assessment).

 An alternative and more practical approach would be to run the whole program as a Transformation Exercise (both ICD10 and HIPAA5010) put together, but careful enough not to overload this program with other miscellaneous enhancements. The problem can be attacked by looking at it from different viewpoints (Ref: Fig 1)

Compliance Remediation Viewpoint:  One can look at the whole ICD 10 and HIPAA 5010 simply as compliance need and treat it accordingly. While this is not a bad idea, one would not reap the actual benefits of new regulations immediately.
 A healthcare firm looking at the challenge from a compliance perspective would analyze the business processes and application portfolios try and make them compliant with the regulations.

Compliance Remediation viewpoint would result in fairly simple identification of application set that needs to be remediated to be externally compliant, i.e. be compliant with regulations with the government agencies (CMS) and partners.

Business Transformation Viewpoint:  Business transformation viewpoint would involve a thorough analysis of the new standards, their customization and impact assessment on the business, if the changes were applied in their true sense. This would typically reveal a much larger impact (compared to Compliance Impact Viewpoint) and would require much more diligent planning and execution.
 This would involve (I have listed some findings of the viewpoint):
1. How to accommodate and utilize of new HIPAA 5010 messages and on the business processes.
2. How to accommodate and utilize of new segments and fields of 5010 on applications and business processes.
3. Impact of deprecated and changed segments and fields of 5010 on applications and business processes.
4. How the well ordered and much more granular ICD (version 10) codes can be utilized in bringing about the claim processing efficiency and decrease healthcare costs.
5. How the ICD 10 codes can be used to increase accuracy in identifying the diseases from the claims and medical management perspective to better the healthcare provided.
6. How the historical data (ICD 9) can be used to generate required information for rating and pricing.

Execution Viewpoint: This viewpoint puts a concrete roadmap to the transformation program, be it Compliance Remediation or the Business Transformation.  Both of these would have many commonalities, but the magnitudes of these two efforts could be largely varying in size and timeline. 
 Few items that would be considered in the execution viewpoint are:
1. How a given impact analysis can be broken down into a phased implementation approach.
2. What are the critical areas and priority application that need to be remediated based on the business benefit and ease of implementation.
3. What are the business process / workflow changes that need consideration / training.
4. How the additional activities are (potentially during the transition) are handled – these could be the manual edits in the workflow.
5. Last but not the least, what is the most efficient way (in terms of cost and time-line) to bring about the transformation.

As shown in the figure 1, there are different paths that can be taken to execute the program.

1. Compliance Only Remediation (marked as 1) caters to changing minimal set of applications and interfaces, to be compliant. This would typically mean skin deep impact on the whole application portfolio, typically at the interfaces.
2. Business Transformation Remediation (marked as 2, followed by 3) identifies business transformation needs of the organization (along with compliance needs) and executes the program.

I will try and blog more on the different viewpoints with respect to domain areas of a given organization in the future blogs.

Posted by Rajesh Patrao at 08:43 AM | Permalink | Comments (0) | TrackBacks (0)

Few industry experts have called ICD 10 “the Y2K of the healthcare industry” and some organizations are taking it too literally – and they couldn’t be more wrong. In my view, the only thing that these two changes have in common is “the extent of their impact on the enterprise landscape”, and the similarity pretty much ends there.

If you thought that ICD 10 is like Y2K and tools would be able to “get you there”, I want to draw your attention to just a few of the key impacts of ICD 10:

• ICD 10 is impacting the fundamentals of how claims are being paid today and the last I heard “claims” was still the most critical and complex process
• Dual storage and processing systems to support old and adjusted claims
• Contracts need to be renegotiated at new levels of ICD/DRG codes – now, reviewing and revising hundreds of legal documents is not cake walk by any means
• Existing health product offerings need to be aligned to the new ICD/DRG codes
• Medical management modules need to be updated to recognize and use the new ICD codes

The list goes on… but most items you’ll see on the impact list are not simple “if… then… else…” patterns that toolsets would be able to recognize and remediate. Unlike the technical impacts of Y2K, you’ll notice that these are business impacts - that’s why a judicious mix of tools and manual services is a must for successful remediation. And on top of that there is this pressure of the magic phrase “opportunities with ICD 10” - that are supposedly going to give you an edge over your competition.

So the next time, a pure-play technology vendor with little understanding of the healthcare business tries to sell you a 100% automated transition solution, you might as well ask if their tool is ideal for eradicating poverty and world hunger!

Posted by Vijay Kumar B at 08:30 AM | Permalink | Comments (0) | TrackBacks (0)