Healthcare

Not too many organizations seem to be unduly concerned about the impending conversion which is now less than two and a half year away for 5010. Or so it seems at least by the actions being taken in the industry. Though I have been hearing a lot about how worried they are regarding the lack of time they might have for changing such a complex network of application portfolio, but not many seem to be taking actions commiserate with their concerns.
We have seen quite a lot of semi-structured exercises taking place, either using internal staff or leveraging high-end consulting organizations but they are primarily limited to very high level analysis of what is going to be impacted. While the initial high level assessment is not a bad idea at all, in my opinion we should be way past that stage by now. A seventy page power-point deck highlighting the twenty core areas that are going to be impacted would have been a good idea in March’2009 but may not be sufficient in October’2009.

Let’s try to see the things in perspective:

1) First of all the mandate date of 1st Jan, 2012 is actually a misnomer. The actual date that one needs to be concerned about is really 1st Jan, 2011. The latter is the date when organizations are supposed to be ready to test their compatibility with their trading partners and the year after that is supposed to be focused more on testing rather than real first-time implementation. So basically all we have is around 15 months and in some cases (such as the Blues) that time is even more restricted because the association’s requirement of being prepared by 1st July, 2010. Barely 9 months away.

2) Second, the tactical approach that most of the organizations are thinking about (i.e., using a step down conversion on the inbound 5010 docs and then propagate the resultant 4010 doc all the way through the downstream applications w/o making any change to them) is not a bad idea at all but definitely has its limitations. The most glaring one being the fact that the shelf life of this solution is not much beyond 1st October, 2013, i.e. when ICD10 mandates take hold. Why I say so is because 4010 can not support ICD10 and if we keep on down-converting the inbound 5010s, the propagated 4010s will need to incorporate the down-converted ICD9 and that defeats the whole purpose of going the ICD10 route. Bye, bye granularity. Bye, bye reduced payouts. Bye, bye increased quality of care. After that it might as well be a mandate being pushed down the throat courtesy CMS.

3) Third, the step-down approach itself is not as simple as some people are assuming it to be. Obviously it is relatively easy to down-convert a 5010 to 4010 (notice the use of word ‘relative’. The conversion is not entirely straight-forward, just simpler than up-conversion) but what happens to the attributes that are new in 5010 and are expected to be used for some decision making process in the downstream applications. By ignoring them during down-conversion (as 4010 will not support them) and hence not using them in the decision making process downstream, is the organization still in compliance with the mandate? Or even if one stores that deleted information in some kind of interim repository, what will be the performance impact on core transaction processes if the applications now have to access the interim repository to get the additional data? In any case, even if one makes simple modification to the core application to fetch the addition data from the interim repository, wouldn’t that call for all sort of regression testing and wouldn’t that defeat the whole concept of not touching the downstream applications? Also, how does one handle the 3rd party apps? The vendors will have either a 4010 compliant app or a 5010 compliant app. They are not going to have an in-between app that will allow the end users to configure an interim repository as the source of additional information while maintaining compliance with 4010 standards.

So, the bottom-line is that even if one is thinking about using the interim tactical approach (that of down-conversion variety), one must not be complacent in terms of time frames. There are many considerations even to implement the interim solution and it is definitely not going to be the final game. So my recommendation is start work on the interim solution immediately and when I say ‘work’, I mean a heck of a lot more than the power points. I mean, identification of required attributes to support 5010 specific mandates in the downstream apps. I mean, identifying the code sets that are going to require the additional data and to design an approach for those code sets to get the new data elements. I mean, designing a fool-proof store-and-forward methodology that can support batch as well as real-time transaction processing and is not a resource hog to eat up all your spare processing time. By the way, does anybody have any spare processing time in any case? I did not think so.

Posted by Rajiv Sabharwal at 04:10 AM | Permalink | Comments (1) | TrackBacks (0)

Information retrieval & timely communication is becoming the lifeline of hospitals where a staggering amount of information is exchanged each day. In a healthcare setup where miscommunication or delay can have disastrous results, it is imperative that the quality and efficiency of communication be maintained at all times. Unfortunately, even the most modern hospitals continue to rely on outdated modes of communication, using a combination of pagers, paper records, walkie-talkies and public address systems.

Most of Healthcare organization are already having plethora of information systems to manage various processes and functions. Whether the need is to admit a patient, diagnose a disorder, access medical reference material or manage equipment, there is an appropriate application for each function. So there are systems in place where information is getting stored in structured manner for future retrieval. While these applications may be available on the hospitals' local area network, by leveraging intelligent middleware solutions, they can be delivered on to a mobile phone, PDA and various other emerging channels like IPTV/hospital kiosks. This enables anytime anywhere access to these information systems and will ensure timely retrieval of critical stored information. The middleware approach is quite unique in the sense it can aggregate existing information systems across various heterogeneous sources and present it appropriately on various communication channels while ensuring optimal user experience. This has the potential to revolutionize the way hospitals, doctors, nurses and other care givers exchange information, communicate with staff and patients, and manage workflows and processes.

Thus Information mobilization can help systematize regular communication and also greatly improve the way hospitals respond to emergencies. For example, push data delivery ensures that physicians, nurses and other staff are promptly notified in the event of medical crises or urgent situations. Another factor in favor of multi-channel enablement is that it can impact 360 degree communication at one go - between the various hospital personnel and also with their patients, external partners, suppliers, regulators etc. - which is an efficient alternative to piecemeal communications improvement initiatives. In short, multi-channel information mobilization finds vast application within the healthcare environment.

Posted by Anant Kulkarni at 03:58 AM | Permalink | Comments (1) | TrackBacks (0)

With the frequencies of pandemic diseases increasing, governments, world over should look at effective tools that can enable them manage the diseases more effectively. Mobile phones even the most basic ones can aid governments across key pandemic management activities. This is truer in developing countries where the mobile penetration has been more rapid than traditional telephony. For example over 40% of Indian population including people in the remote rural areas has access to mobile phones.

So, what can a mobile do?

Managing a pandemic covers 3 main facets - precaution, treatment and prevention.
 1.Precaution to avoid spreading,
 2.Treatment covers early identification, isolation and treatment of the affected and
 3.Finally Prevention ensures the right vaccination to be delivered in an effective time-bound manner  across the country.

The main challenges for effective management of the above activities are:
 •Creating awareness and enabling public to take the necessary precautions at a national level within a  short span of time
 •In case of affliction ensuring that help is on-hand whenever and wherever a person requires it
 •Ensuring that vaccinations are effectively done covering the entire population

Mobile phones can be an effective delivery aid for all the above:
 •Government in partnership with mobile service providers can effectively and continuously reach out to the  entire population through SMS (text and voice)
 •Help desks and multi-lingual IVR (Interactive Voice Response) systems can deliver much needed advisories  to the public.
 •A central pandemic management system can enable real-time update and delivery of disease specific  information to the entire population.
 •Location awareness of callers can be used to direct people to the nearest health center capable of  diagnosing and treating the disease.
 •Service provider infrastructure can be leveraged to effectively identify help desks at the nearest health  center and route help calls appropriately.
 •Information on vaccination clinics can be delivered in a guaranteed manner significantly increasing the  reach and awareness of the government's vaccination program.
 •Feedback via SMS and IVR can effectively close the loop - enabling the central pandemic management  committee to track the progress of the initiative and identify bottlenecks early in the cycle. This also  cuts the tapes and enables public to directly voice their concerns and viewpoints to powers that matter.

All the technologies and infrastructure required to do the above currently exist and can be rolled out rapidly. It is important for governments to include the above as part of their disaster management planning. Regulations along the lines of E911/CALEA can ensure compliance and readiness of communication and healthcare service providers to support such scenarios.

Posted by Karthik Srinivasan at 09:09 AM | Permalink | Comments (0) | TrackBacks (0)

Yogi Berra's second claim to fame is for being one of the most quoted figures in the sports world. He is credited with coining the deceptively simplistic observation, "It ain't over till it's over." But he's also known for his flubs. Yogi takes his experiences as one of baseballs' all-time heroes and turns them into funny, appealing, and moving essays on the game of life. His philosophy is plainspoken and down-to-earth, honest through more than 50 years of reflecting on the game of baseball. Keep trying. Stay humble, Trust your instincts. Most importantly, act. When you come to a fork in the road, take it.

Americans are at “the fork in the road” now with Healthcare Reform or Insurance Reform or what the take (spin) for selling the legislation to the American Public will be for tomorrow’s speeches, press conferences and headlines. Each one will proclaim “Somebody is lying and it is not me!” “Read the legislation!” or “There is no legislation”, how can we read it?”

Just for the sake of trying to understand one piece of the debate, consider the number 47,000,000. That seems small compared to the trillions we have been hearing about over and over but 47,000,000 is the number that those clamoring for the current legislation that has been put before the congress is using to describe “Un-insured Americans”. When broken down to its roots and components, what is in that number?

1. Un documented Americans or Illegal Immigrants (20,000,000);
2. Individuals who have healthcare insurance available but chose not to have it (10,000,000);
3. Those who are without employment and either cannot afford individual policies or are uninsurable (17,000,000).

That 17,000,000 represents a much more manageable number then the spun number, 47,000,000. In fact, it makes the debate seem ridiculously one sided and expensive. So we are considering in Washington that our entire system needs to be thrown out and overhauled for 17,000,000 uninsured citizens thus disrupting the way healthcare is accessed, diagnosed, treated and reimbursed?

Please don’t take this in the wrong light. Those 17,000,000 citizens need attention and deserve to be cared for in a country with the greatest healthcare capabilities in the world but not by “Throwing the Baby out with the Bathwater.” We do not need to “Boil the Ocean” to do this. (Have I included enough clichés?) But we do understand this, especially the professionals, clinicians, physicians and technology specialists that make our healthcare system quality, safety and access what it is today.

Let us consider then addressing the real issues;

Make healthcare affordable for the 17,000,000 that need to be provide the same care by:

1.Addressing Torte Reform;
2.Elimination of Fraud and Abuse in those programs already in place like Medicare, Medicaid, CHIP, WIC, American Disabilities Act, Veteran Administration, others;
3.Concentrating on massive campaigns to address illegal immigration in a civil and humane way;
4 Creating additional efforts for signing that percentage of eligible Americans up for Medicaid, available plans;
5.Changing the laws that allow individuals to have portable insurance that is owned and managed individually.

Mostly, for the 85% of Americans who are happy with their current healthcare plans and flexibilities to choose, leave them alone!!  Government interventions and management of our health is a dangerous option and tears at the fabric of American culture and rights we have preserved for 233 years.

Posted by Gary O. Claytor at 10:19 AM | Permalink | Comments (4) | TrackBacks (0)

Is there too less time for ICD-10 transition? Or is there plenty of time? Will my vendor ensure that we’re compliant, or should we engage a consultant to do a thorough gap assessment? These are questions that should be and probably are on every program manager’s mind that’s been entrusted with the ICD-10 implementation in his organization.

ICD-10 transition is not straightforward at all. Through the years, complex processing logic has been built that depends on ICD codes and other codes that are derived from ICD codes.  Without a deep dive, it’s difficult to project the scale of impact, and the effort and time required to remediate the impact. And you don’t have the ICD-8 to ICD-9 transition experience to leverage here (which you have in case of HIPAA 4010). Moreover, given the difference in usage and implementation, experience from ICD-10 implementation in other countries can help to a very limited extent.

Being conservative is your best bet. When there are too many unknowns, it is common sense to build as much margin into your timelines as you can – which means that you should set the ball rolling immediately. Once you’ve done a detailed assessment, you’ll know the scale of the impact better – you can then slow down or speed up your implementation. Making that call based on knowledge of things at 25K feet level is a huge mistake.

It’s amazing that some that pushed back on the initial compliance date as too aggressive are sitting on things, now that the date has been pushed out. It is wishful thinking that the date will be pushed out further. And the argument that any work done now will become throwaway if the compliance date is pushed out or if the legislation is modified holds no water either.

Posted by Vijay Kumar B at 10:10 AM | Permalink | Comments (0) | TrackBacks (0)

Cheapest option to compliance – who wouldn’t be interested? Especially in an industry that potentially spends more than a quarter trillion dollars per year on regulations. In the case of HIPAA 5010, developing just the ability to send and receive 5010 transactions will achieve basic compliance and is arguably the cheapest option. I wouldn’t be too hasty to call the organizations that plan for basic compliance as short-sighted, but at the same time I’d recommend that organizations at the very least perform an assessment before heading that path.

Converters are one option to achieve basic compliance. Implementing a step-down converter for inbound files and step-up converter for outbound files, right at the gateway will allow you to keep your internal processes unchanged and achieve compliance.

Updating the front end systems to map the new 5010 files to the as-is database schemas is a little more strategic than converters, but still not strategic enough to realize the benefits of 5010.

These tactical options sound appealing at the first glance, but the devil lies in the detail. Either option can’t guarantee that your backend systems won’t need any change at all. You’ll need to analyze each change in 5010 closely to find out if you can do without any backend change. After an assessment, you might just find out that the tactical solutions are nearly as expensive as the strategic solution.

The strategic solution would entail assessment and remediation of the impact on all the frontend and backend systems. This option will be expensive, but will also avoid applying short-term band aids that eventually make the systems inflexible and expensive to maintain. 

All in all, a detailed assessment should be performed to find out which option is better for your organization. Even if you choose to implement a tactical solution, the detailed assessment report will help your testing phase and will serve as a reference if you decide to update your backend systems at some point in the future.

Posted by Vijay Kumar B at 04:35 AM | Permalink | Comments (0) | TrackBacks (0)

The implementation of ICD-10 will be daunting to say the least.  Estimates regarding what this will take to implement are anywhere from 12,029M – 30,480M; with the bulk of the cost needed for system upgrades, conversion and crosswalks.  A simple question to this massive undertaking is what the return will be to the health care industry and likewise for everyone who participates in the health care system.

It is the general consensus across the industry that ICD-10 will allow for:

1. Better disease management and case management programs
2. Pay-for-Performance and Reimbursement Methodology
3. Underwriting

However, the question then becomes how to implement programs which will support improvements in these and other areas.

First, let’s take a look at the where health care dollars go:

Clearly hospital cost account for at least 1/3 of all health care dollars spent by Private Insurance (in fact according to the Kaiser Foundation, hospital cost are reported at 36.5% and Physician costs are reported as 28.8% in terms of overall cost for the same reporting year of 2004).

Next, looking at the “as-is” inpatient environment, Kaiser Foundation and the AHA Trendwatch Chart Book 2008 provide the following details:

From an inpatient hospital perspective on overall healthcare dollars, while it seems that admissions are in a static state, and days are actually decreasing, the costs associated with inpatient days are increasing. 

Assuming that this trend is happening similarly across the board for most large private payers and that the reason why days are decreasing is due to strong utilization and case management, the question becomes how to reduce cost given with more than just standard utilization/case management techniques?  

This is where using ICD-10 and drilling down to more specific reasons as to why there was an admission in the first place will be valuable.  An example of this could be tracking drug related instances due to an adverse event and the associated cost.  In 1995 there was a study conducted by Johnson and Bootman estimating the cost of drug-related instances in the ambulatory setting in the United States at more than $76.6 billion.  In 2001, Ernst and Grizzle published in the Journal of American Pharmacists Association that in updating Johnson and Bootman’s model, they found that by 2000 the cost of drug related morbidity and mortality exceeded $177.4 billion.  The majority of these costs were accounted for by hospital admissions at $121.5 billion.  By using ICD10 to identify those cases specific adverse drug events while hospitalized, there is potential to help drive down the cost associated with hospital admission due to adverse drug events, thereby improving the quality of care and at the same time reducing costs.

Other examples of where drill downs on cost reduction could be better evaluated are:
1. Emergency Room Visits;
2. Morbidity and mortality;
3. Further investigation of studies provided by WHO and other international organizations based on ICD10.

These are just a few examples of how ICD-10 can be used to help evaluate cost expenditures, while at the same time evaluating quality of care initatives.

Posted by Alison Schambach at 10:17 AM | Permalink | Comments (0) | TrackBacks (0)

As the debate continues and the American People become more educated on the true impact of “Healthcare Reform” the question that begs for an answer is, “What is Healthcare Reform”? Read any article, tune into any top news organization and as soon as you think you understand the meaning from one of the political pundits or news anchors it will change as soon as you listen to another source. Even the politicians responsible for the legislation are confused!

The American people are speaking out like never before in gatherings and town hall meetings across the U S during the congressional August recess. The reactions have been astonishing but even more astonishing has been the opposite views from both sides of the issue with opposing explanations on whether the traditional town hall meetings really represent the true feelings and will of the American people. New political explanations and themes are beginning to emerge. Instead of “Healthcare Reform” we now have “Insurance Reform”. The debate seems to be to identify bad guys. Is it Insurance Organizations, Physicians, Pharmaceutical Companies or Government? Where is the “Bogey Man” in this?
 
Most of us in the technology market space will agree that this has caused a delay in the commitments to move technology forward. It has been a lean year for major providers of healthcare solutions and services to implement anything because healthcare provider organizations are confused over government mandates, stimulus and what that entails. It is apparent, however, that which ever way the debated moves, whatever is or not passed for healthcare reform, the resulting environment will require innovative technology solutions that can support access to the critical information necessary to comply to market demand and government mandates.

I would like to solicit debate to the readers of this posting regarding the above opinions and get new and fresh perspectives to consider as we move forward as an industry dedicated to creating better technologies for the improvement of Access to, Quality of, Safety and Cost efficiencies for healthcare that includes all stakeholders.

Posted by Gary O. Claytor at 03:05 AM | Permalink | Comments (15) | TrackBacks (0)