Healthcare Economy

Bad news first… HIPAA 5010 has nearly 1,000 unique changes. Some of these changes (like expansion of patient last name alone) could have thousands of impact points across your applications and databases. Overall, the number of impact points could easily run into a couple hundred thousand for an organization of average size. The direct and indirect impact of these 1,000 changes on the IT systems needs to be analyzed as the first step in the 5010 transition journey.

Now, imagine your engineers having to manually review each source file and record the impact. How would you ensure that the analysis is accurate – by engaging another developer to review the analysis reports, or by spending four times as much money on comprehensive testing? How would you ensure consistency between analysis reports from different developers so that you are able to see rolled up data for program level planning and tracking? What will be the basis of your status reports to senior management – just gut feel?

These and many more similar questions that are faced by the 5010 program manager converge into one important question – can this transition be automated, at least a significant portion of it? The answer is… yes and very much yes! That’s the good news.

Call it luck, or the generosity of CMS/X12, majority of the 5010 changes follow a pattern – and simple patterns are good candidates for automation. We are talking about patterns that are easy to recognize and automate (no fuzzy logic or artificial intelligence required here).  Take for example, the patient last name, or even better the ICD-9 code. If a tool can recognize the format of ICD-9 code (VVV.VV) in source programs and databases, it is easy to figure out the impact points. Of course the tool can confuse amount fields for ICD-9 codes, and building the ability to differentiate between the two is not that difficult. Not everything is going to be as straightforward, but as I said, majority of the impact is.

Based on my analysis, 80% of the changes or can be identified and remediated via automation. Testing is another area, where automation can allow you to generate 5010 test files (from existing 4010 files) that will cover majority of your business scenarios. I estimate that by leveraging automation in these areas, the overall savings could be anywhere between 40 – 70%. That is a staggering amount considering the cost of this transition could run into millions for an average sized organization.

Posted by Vijay Kumar B at 7:25 AM | Permalink | Comments (0) | TrackBacks (0)

Provider contracts (among other things) are written using ICD and DRG codes. As a result of the increase in number of codes in ICD-10, a new set of DRG’s will have to be created – to take advantage of the increased granularity of information for payments. Eventually every provider and payer will move to contracts based on ICD-10 and related DRG codes. But the switch will not take place overnight. There will be a transition period, during which contracts will be gradually migrated to ICD-10 world. It is this period that will require dual storage and processing of data.

Let’s first look at the issue from a provider standpoint. Providers will start capturing the ICD-10 codes for clinical purposes on Nov 1st 2014. But in most likelihood, contracts would be on ICD-9 and so the charges will need to be submitted on ICD-9 based DRGs. Later, at some point in time, few contracts will be on ICD-9 and remaining on ICD-10 – the charges will need to be submitted on both code-sets during this period. To be able to submit the charges on both code-sets the providers will need the ability to capture and store both code-sets based on the payer that the claim needs to go to. At the point of service, capturing both codes for the same service might not be a big challenge.   

The problem is more severe on the payer side. Payers have no easy way of knowing the ICD-9 as well as ICD-10 codes for the same service. Payers will need to pay claims and send remittances on the codes they receive. They’ll need to pay claims based on a code-set that’s in the contract. Maintaining one set of adjudication rules wouldn’t work. Crosswalks wouldn’t work either, partly because crosswalks can’t guarantee 100% conversion. The other reason is that practically speaking, crosswalks can’t be used in every rule of the adjudication process. So, dual adjudication platforms will need to be maintained for the transition period.

Given these complexities, the dual processing issue is at the top of my list of challenges with the ICD-10 transition. Backward compatibility and historical data support requirements make the issue more convoluted. And now I’m beginning to wonder if the so called “neutral strategy” for ICD-10 transition is practically feasible at all.

Posted by Vijay Kumar B at 7:15 AM | Permalink | Comments (1) | TrackBacks (0)

The question these days, on everybody’s mind is ‘How is the health reform going to pan out?’
With the passage of the bill in the house (though surprisingly narrowly) and with a clear democratic majority in the senate, the issue is not of ‘If’ but more of ‘When’ and ‘In what shape’ the bill will come into being. Now that we have pretty much moved beyond that point, the foremost question becomes what will be the ultimate impact of the reforms on three primary stakeholders, namely the patients, the providers and the payers.

Let’s speculate…

Today we will talk about the patients, that least cared for community despite all the promises about ‘patient centric focus’. Under the new bill, with the definitive advent of healthcare exchanges and possibility (however remote) of a public plan down the pike, the benefits seem tremendous for the uninsured and the underinsured. With a choice beyond the employer sponsored plans and possibility of designer plans (I guess a true Consumer Directed Health Plan scenario), even the currently insured seem to have a lot more freedom of choice. After-all, isn’t that what the free-market economy is all about?

But, and yes there is a ‘But’ with a capital ‘B’, with choice comes responsibility, a heck of a lot of it. Do we think that the common American ready to make complex decisions regarding their health coverage based on highly complex set of data points that are clinical in nature as well as mired in legal jargon of a contract? How many of us actually understand the exact definition of life-time benefit caps with their multitude of ingrained caveats? How does one determine the amount of copay we want to incur for medication for chronic asthma? Rating engines can definitely provide guidance towards selecting the right provider, but can they ensure that the ‘Right doctor’ is a part of the network belonging to the ‘Right plan’? And if not, what is the recourse.

Yes, I know, the freedom of choice activists are already sharpening their knives for me but I just want to produce one evidence in support of my case and that too not from healthcare industry. See what happened to millions of home-owners who were given the freedom of choice regarding their mortgages without a real tight control by a set of people who were well versed with the inherent shenanigans of the financial systems. We have unprecedented foreclosure rates in the country despite all the incentives that the government is providing and historical low finance rates. At least in this situation people just got hit financially. Imagine what could happen if similar catastrophe hits on the medical side. Now we are talking serious impacts, having to do with life and nascent quality of it.

Enough with the nay saying though. Let’s look at the positive aspects of it. There are many of those too. For example, open and transparent competition through a wide-spread and pervasive medium such as Internet could only help to increase the awareness among common Americans. After all, lendingtree.com and progressive.com have only helped in making Americans better prepared for mortgages and auto insurance respectively.

The ‘Exchange’ concept will also bring about better awareness of one’s health and its associated cost, hopefully leading to a society that is much more health conscious and proactive about managing its own health. The concept could (and I strongly believe, it would) lead to much faster adoption of electronic health record, especially in public domain (a la Healthvault and GoogleHealth) and that can’t be bad for an industry that is practically deprived of business intelligence and its associated benefits due to lack of electronic data.

This could definitely be a step in right direction towards building of a society that is more health conscious and is actually competent enough to make solid and rational decisions regarding its own health scenario (may be in 5-10 years) but let’s not forget there are always two sides to the coin and unless and until you are in Vegas, chances are the two sides do not have the same picture.

So what’s my final opinion… I guess I have not firmed up one yet (I am sure you could see that from my flip-flopping content in this blog till now). My head tells me that something drastically has to happen if we need to steer this rudderless ship called ‘Healthcare’ in the right direction and this new reform bill could definitely be that steering wheel. At the same time, I have this gut-wrenching feeling, deep in my stomach that ‘Are we chewing off way too much way too fast’. I don’t know. For a change, I am going to deviate from my ‘usually opinionated’ self and sit this one by. Let the test s of time make their own judgment on this one.

Posted by Rajiv Sabharwal at 7:05 AM | Permalink | Comments (0) | TrackBacks (0)

Here is a follow up to my earlier blog discussing the readiness of wireless infrastructure & applications to support a complete telehealth implementation. In the last blog we discussed around 2 facets of a telehealth implementation – Interaction and Interoperability. Here we will be discussing the remaining key facets  – Integration and Regulations.

Integration – The effectiveness of wireless applications and technologies depend significantly on how well they are integrated into the overall eco-system. Integration points extend across all functions – access, transmission & delivery of information. An effective telehealth implementation need to have in place a well defined end-to-end architecture that identifies all integration points and use the most appropriate solution for the same. Currently solutions to these integration challenges do exist – but more as individual silos (e.g. Mobile VPNs, Secure data transmission over mobile solve the access challenges, however, these are typically point infrastructural solutions not necessarily integrated to deliver a continuous support across the different information lifecycle  for all telehealth stakeholders. E.g. while doctors may have a secure access via Mobile VPNs, providing similar access to patients/relatives would require a different nature of integration). The other big integration challenge is one of aggregation of device data and exchanging the same to back-end health information systems – which at its best is still a work-in-progress.

Regulation – Regulatory requirements is one aspect in healthcare that cannot be ignored and can often pose a significant overhead related to technology investments required to achieve an effective telehealth implementations. There are 2 facets to this – one is the actual regulatory requirements around managing patient information, requirements on how remote interactions can/cannot be managed, requirements around privacy driving how securely information need to be transmitted as well as controlling who can access what information. The other is the varying nature of these requirements across locales (e.g. differences in such requirements across the US & Europe). With the increased rate of globalization (e.g. telehealth as a service can be delivered not just within US but across the Atlantic as well), it is important that solution providers and care providers look at both these facets of regulations to effectively deliver their telehealth implementation.

In summary, while wireless technologies and mobile applications do promise to be a key enabler of telehealth, it is important to take a broader perspective and evaluate the capabilities across the 4 critical facets of Interaction, Integration, Interoperability and Regulations. For an effective implementation we need to optimally bring together the advances in wireless technologies.

Posted by Karthik Srinivasan at 6:59 AM | Permalink | Comments (0) | TrackBacks (0)

Across globe, Healthcare sector is witnessing major attention due to emphasize on improving healthcare coverage, controlling costs of healthcare and increasing patient satisfaction. And this has resulted in a major transformation of the healthcare sector.

• Promoting Healthcare Quality and Safety, by avoiding medical errors, rewarding physician based on performance parameters and consistently delivering evidence based care. Pay for Performance (P4P) program links the financial remuneration of healthcare providers to the quality of care that they deliver instead of reimbursing the cost of resources utilized to provide the treatment. Wireless technology due its pervasive nature will play a critical role in achieving the quality and performance objective by mobilizing workflow, real-time access to information and sending timely alerts. Applications enabling medication safety are on the mobilization priority list for Healthcare providers. It is extremely important that the right medication is administered to patients in the right dosage at the right time. The sheer volume and complexity of health management in hospitals can make the task of administering patient medication quite challenging.

• Health record digitization and real time patient information access- Providers are getting convinced on Electronic Medical Records (EMR) adoption in order to improve quality of care. According to HIMSS Analytics Ambulatory Healthcare IT Survey 2008, nearly one-third of providers in an ambulatory setting reported having an electronic medical record system in 2008. But still usage of EMR technology is most prevalent among larger provider organizations. In near future mobile based EMR application will help to support higher quality care, while protecting patient privacy and cutting costs.
Cell phones and wireless technology will become the key driver for physician and patients for real-time pervasive information access. The benefits of doing so is best illustrated with this example. The readily available patient records on an attendant’s mobile phone can lead to faster and better decision making, which is extremely critical during a crisis. Consider for instance a patient who is allergic to some standard medication. If this vital piece of information is available over a handheld device to the attending nurse, it could potentially save the patient’s life during an emergency. The benefits accruing from mobilization of EHR can be easily measured by documenting the number of emergencies addressed using a mobile interface during a certain period. Speedy communication can be a life-saver during emergencies, for example, when an accident victim needs to be taken in for immediate surgery. If the medical team accompanying the patient in the ambulance can transmit the important details over a wireless device directly to the hospital’s records, they can begin the preparations for the emergency operation even before the patient arrives on the premises.

• Huge thrust on keeping healthcare cost affordable - Higher cost driving change in care delivery models viz Retail clinics, Patient centric medical homes (PCMH), Medical tourism to lower cost countries, Chronic Disease management program and increase e-prescription. All these changing delivery models will get huge benefit from leveraging wireless technology. Mobile prescription, appointment scheduling/alerts, Mobile Home monitoring, Mobile disease management etc will improve the quality of care and convenience and at the same time reduce healthcare cost.

Posted by Anant Kulkarni at 11:09 AM | Permalink | Comments (0) | TrackBacks (0)

That wireless applications & infrastructure can have tremendous impact on the telehealth landscape is now well accepted. However, it is important to realize that wireless technologies alone cannot deliver the promised benefits and many challenges still exist before these promises turn to reality. In a telehealth scenario there are 4 facets that need to work together effectively to create maximum value. In this series of blogs, we will look at each of these facets, the role of wireless technologies in each and the gaps that need to be filled before it can be put to use successfully.

Interaction – By interaction we refer to the way the technology will be used by the different human stakeholders in telehealth – Patient, Relatives & Care providers. Wireless/mobile applications can be a great enabler for relatives and care providers – providing access to real-time information & alerts thereby ensuring immediate care and support during emergencies. However when it comes to patients, particularly the aged, information via mobile devices does not necessarily provide the best interaction model. Rather it will be the more traditional channels of telephony and television that can be most effective. It is imperative for providers to choose the best interaction method based on the stakeholder profile for effective care via telehealth.

Interoperability- Interoperability is required at different levels. At the patient’s home, it is about the different devices and systems being able to exchange information and interwork to ensure that critical real-time patient data is transmitted securely and effectively to the back-end. At the back-end interoperability is about the ability to aggregate this information arriving from multiple devices with different contexts and deliver the same to the provider information systems for effective execution of care workflows. There have been significant innovations in the form of wearable devices, digital versions of commonly used home health devices with the ability to transmit data wirelessly to the back-end etc. Unfortunately, interoperability was not a feature that has been a given in these devices – with most vendors delivering end-to-end systems for managing the information. Recent alliances (e.g. Continua Health Alliance – www.continuaalliance.org) have been pushing towards standardization in this matter and this has resulted in device level recommendations (e.g. Zigbee Healthcare Profile – www.zigbee.org) that can go a long way in solving the interoperability issue. However, this is currently a work-in-progress area rather than one that has completely evolved. The matters are further complicated when we consider the interoperability issues at the back-end with HL7 and non-HL7 systems having to interoperate and process the information from home.

More to follow…

Posted by Karthik Srinivasan at 10:51 AM | Permalink | Comments (0) | TrackBacks (0)