Healthcare Economy

Meaningful use should not be seen just as installing a certified EHR and generating the required reports. Ability to exchange Health Information securely over the internet is one of the foundations that need to be in place for realizing the key benefits of improved quality of care and patient safety at lower cost. While most of the stage 1 criteria may not have a direct dependency on Health Information Exchanges (HIE), you can expect to see increased relevance of HIEs in near future, in the context of implementing some of the Meaningful Use (MU) requirements.

Stage 2 of MU will focus on increased use of decision support. HIEs will facilitate integrated health records of patients across providers which is a key requirement for effective clinical decision support. HIEs will also play a key role in enabling better care coordination, which is a critical success factor for better clinical outcomes, a key focus area for stage 3 of MU.

The success of HIE would depend on the functionalities it offers and the extent of its adoption among the provider communities. A collaborative approach is required with participation from all stakeholders to build a successful HIE. A HIE is expected to facilitate exchange of Clinical information among the care providers, routing of referrals/authorizations and Lab orders/results and prescriptions, exchange of CCD between EHRs, secure communication between 2 providers and sharing problem lists/active medication and chart notes over the health information network. It can also host EHR systems within the network for use by providers on a pay-as-you-use model. Once the majority of the providers have been on boarded, it will act as an important source of information for disease registry and public health reporting.  Secured data exchange, identity management, non-repudiation, consent management, Record locator/Master patient index and provider directory are the key foundational components for delivering the above functions. Additionally, the exchange should be able to support interoperability and multiple vocabularies through effective vocabulary translation.

We are seeing increased activities in the HIE space, particularly in last one year, with the financial support from government providing the much needed impetus. We can expect even more buzz around HIEs as more community health information exchanges, RHIOs and states coming together to establish this useful foundation for meaningful use.

Posted by Jayanta Ghosh at 9:38 AM | Permalink | Comments (1) | TrackBacks (0)

With just three years to ICD-10, Industry players have no doubt set their game plan for the implementation of the upcoming disease code sets. But, even with all the plans in position, me truly feel that not much of effort has gone in looking at the aspect of clinical documentation & staff orientation relating the same.

I understand that CDI specialists mostly coming from a clinical background doesn't really require a full-fledged ICD-10 training. But, with diversified nature of the ICD-10 codes from its precursor and the enormous implication it has in the revenue stream certainly makes it necessary for any CDI staff of an organization to get started in absorbing the new and changed coding guidelines, understanding the renewed CDI metrics, and change in documentation associated with this new code set. 

It is important that organizations should foresee the existing challenges associated with the CDI programs and understand the implication of ICD-10 codes that can ever further worsen the situation. Let me just walk you through a recent ACDIS survey on CDI & ICD-10. It frankly reveals that most CDI staff (52% of 350 respondents) have only basic awareness of ICD-10 changes. (Basic awareness was defined as an understanding that the new system is coming and why CMS thinks the change is important.) Furthermore, 44% of respondents indicated their facility does not have an ICD-10 training timeline to their knowledge, and another 51% said that CDI staffs don't have a seat at the table when it comes to ICD-10 implementation planning.

We know that ICD-10 is granular, specific and precise. But the preciseness will never gets reflected through the codes unless the clinical documentation is accurate and to the context. ICD-10 is one single opportunity where capture of right information in clinical notes can be game changing. ICD-10 trained CDI specialist will facilitate improved clinical documentation that will further improve outcomes data and assist in preparing the healthcare entity for a variety of future payment methodologies. It will play a part in compliance with national core measures. ICD-10 oriented clinical documentation will be precise, thorough, and accurate to provide a defense for regulatory compliance reviews, including the Recovery Audit Contractor initiative, Zone Program Integrity Contractors, and Medicaid Integrity Contractors program.

Having a ICD-10 centric CDI program will always add great value to many aspects of the healthcare industry. By emphasizing the documentation requirements necessary for the capture of patient severity, acuity, and risk of mortality, healthcare entities can improve clinical data used for research, quality scorecards, and patient safety. Just as the HIM counterparts are gearing up, let the CDI team raise their awareness about the documentation changes on the way.

If still, one thinks there is still plenty of time for CDI specialists to get prepared or if organizations think CDI specialists already understand as much as they need to about the shift and nothing major have to be undertaken on this aspect... I would suggest organizations should better think again......

Posted by Dr Suman De at 11:58 AM | Permalink | Comments (0) | TrackBacks (0)

Growth of consumerism, evolution of Insurance exchanges, electronic records with meaningful use etc are the most talked about terminologies in healthcare industry. A lot is being talked about how the industry will face this enormous challenge primarily driven by three mandates - the Patient protection and affordable care act (PPACA, March 2010), the upcoming ICD-10 mandate and American recovery and Reinvestment act (2009). I would like to shift the focus onto 'Healthcare fraud' subject and how it is going to shape up in the post reform world, specifically with respect to ICD-10 mandate.

Healthcare fraud, commonly referred to as fraud, waste and abuse (FWA) is a serious problem that affects every member and taxpayer. The other troubling concern is that there is no accurate estimate of the losses due to the fraud in the country. Different sources give varying ranges of losses. The generally agreed loss is somewhere between $70 billion to $234 billion .This equates to roughly around 3% - 10% of all the healthcare spending or in other words this number is roughly equivalent to the GDP of nation the size of Columbia or Finland. National Healthcare Anti-fraud association (NHCAA) estimates that only 10 to 30 percent of fraud and abuse is undetected, of which only 40-60% is ever recovered.  Every 2 million invested in fighting healthcare fraud is expected to return around 17.3 million  in recoveries and savings.

Some common examples of healthcare fraud include phantom billing, upcoding, unbundling and performing redundant medical services.

The healthcare reform landscape itself could offer potential opportunities to increase fraud and abuse. Given the enormity of the ICD-10 conversion problem and the absence of state mandates in most states  on having fraud and abuse prevention plans in place, it makes one to think that more and more likely we could see a further surge in the fraud and abuse claims over the first few years in the post reform world.

From an ICD-10 mandate standpoint, there are two key aspects for fraud detection.

a) The greater specificity and granularity offered by ICD-10 codes leading to greater data accuracy. This will significantly aid the development of sophisticated tools for detection of questionable patterns and suspected fraud.
b) With the transition in progress, and both ICD-9 and ICD-10 in effect, it will offer greater opportunity for fraud when people are less familiar with the new codes.

To see the benefits from the granularity of ICD-10 codes in the latter years and realize an overall improvement in fraud detection rates, I see that all payer organizations should focus on the following key things while implementing the ICD-10 mandates and prepare for the post reform world.

• Leverage fully all the internal BI/Data ware housing capabilities
• Invest in tools that are specifically targeted towards 'fraud and abuse' with special focus on all federal funded programs (Medicare, Medicaid)
• Leverage the federal funding set aside towards fighting fraud
• Study and leverage the highly successful fraud detection solutions prevalent in credit card industry (e.g., FICO's patented solution for credit card industry)

With the healthcare reform mandating several anti fraud initiatives for all government programs and more stringent penalties towards fraud, it is upto all large payers to take full advantage of new infrastructure which will be in place in the new post reform world. Also the key stakeholders - consumers, providers and payers should work collectively on cracking this growing problem with unknown estimate of losses.

  1- Source - National Health Care Anti-Fraud Association white paper
  2- Source - National Health Care Anti-Fraud association, 2008
  3- Source - National Health Care Anti-Fraud association, 2008

Posted by Hari Rebala at 6:11 AM | Permalink | Comments (0) | TrackBacks (0)

ARRA Meaningful Use (MU) mandates have put a transformation pressure on the entire US healthcare ecosystem and is pushing  the use of electronic health records (EHRs) across all provider settings.
The Health Information Technology for Economic and Clinical Health Act (HITECH) has authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery. Also HITECH  goal is not adoption alone but using  EHRs in a meaningful way by the providers  to achieve significant improvements in care.

The legislation encourages and gives an opportunity to entire provider community to use ARRA MU mandates as a catalyst to reorganize their processes, systems and take a holistic path to move in the direction of enterprise performance. The current MU guidelines  focus attention on the role of "meaningful use" in reducing healthcare costs and enhancing care outcomes. However realization of such value, is critically dependent on the ability of care delivery organizations to successfully overcome process, adoption and implementation challenges to be on a high performance growth path.

With the objective of improving clinical outcomes and reducing the healthcare costs, the MU mandates should be considered as an opportunity and trigger for catapulting the hospitals into taking  an integrated view of their clinical, operational and financial indicators and move towards Healthcare Enterprise Performance Management (HEPM). This approach shifts the focus beyond mere compliance and reporting to performance monitoring and continuous learning. HEPM provides comprehensive approach towards Meaningful Use that encompasses people, process and technology aspects of MU.

It focuses on an integrated view of clinical, operational and financial metrics (which goes beyond the MU metrics) as well as their inter-relationships with different processes, roles, process owners and helps establish accountability with better control over performance.

It induces business process optimization and allows the enterprise to leverage synergies across various healthcare IT initiatives like EHR implementation, ICD 10 migration, ACO, BI etc. HEPM emphasizes strongly on end user training and sustained adoption advocating a high performance culture and facilitates measuring benefits realization from Meaningful Use and other initiatives in dollar terms. This in turn enables the provider executives in justifying the benefits from Healthcare IT and analytics investments.

In a nut shell HEPM approach  looks beyond the Meaningful Use reporting, motivates provider organizations to achieve high performance levels and builds synergies across various healthcare IT initiatives with MU as a catalyst.

Posted by Shishir Kumar at 5:56 AM | Permalink | Comments (0) | TrackBacks (0)

This month Nobel Foundation announced the Nobel prizes for 2010. Two of these Nobel prizes were of special interest to me and for the entire healthcare industry. First, the Nobel Prize in Physiology or Medicine 2010 was awarded to Dr. Robert G. Edwards "for the development of in vitro fertilization (IVF)".  Apart from the religious or ethical discussions, this Nobel Prize was an acknowledgment of Dr. Edwards' fifty year long struggle that gave healthcare industry a new dimension by successfully producing the first test tube baby in July of 1978. By some estimates, today more than 40 million children and adults are indebted to Dr. Edward for their precious life on this planet Earth.

Secondly, the Nobel Prize in Physics 2010 was awarded jointly to Andre Geim and Konstantin Novoselov "for groundbreaking experiments regarding the two-dimensional material Graphene". With my healthcare IT lens, I predict that Graphene will revolutionize and transform the entire healthcare industry. From Bio-devices to anti-bacterial solutions, from integrated circuits to new ways of monitoring and collecting patient's PHR data, Graphene will be the game changer. Graphene will bring an innovative revolution among our next generation of scientist and researchers.
 
Now let's come to the challenges of today's world where questions in many people's mind are on the subject of $1.1 billion "Comparative Effectiveness Research (CER)"!!! What can CER do to improve the nation's health? How are we going to institutionalize the sharing of health data across many different entities without exposing IIHI and PHI, not violating and jeopardizing security and privacy of individuals? How are we going to convert CER data into medical informatics that can help consumers, clinicians, purchasers and policy makers to make scientific informed decisions on the first 100 priority items suggested by Institute of Medicine (IOM) supported by facts that will improve healthcare at both the individual and population levels? What will be the role of Social Media Networking in the creation of CER? Since communities such as "Patients like me" and "Cure Together" are already sharing information with each other and discussing outcomes, risks, etc. Will there be any role for Health Vault, Google Health, or EHR on Facebook in the CER?

I think regardless of all these questions and concerns, CER will only be successful if all parties (consumers, patients, healthcare providers, caregivers, and insurers, public and private healthcare sectors) are jointly and actively involved in defining the goal of CER, which should be better healthcare outcomes for all of us by "providing the right treatment at the right time and at a aright cost" and not just better payment methods for our providers. However, so far the priority list seems to be very scientific and research driven and rightly so, but will it answer the basic questions, why our youths have growing number of obesity and type 2 Diabetes? Why 1/3 of our nations' teenagers have serious stress disorder? If we can make CER really relevant to our day to day health concerns and issues, then chances are that CER will emerge as part of our healthy life style management tool and yet not another data exchange initiative.

Posted by Aijaz Ahmed at 5:46 AM | Permalink | Comments (0) | TrackBacks (0)

Health Benefit Exchanges (HBE) or simply individual market - what to focus on? I believe this is the most talked about topic these days. I had very recently attended the AHIP Exchange Conference (NOv 8-10, 2010,Chicago), and somebody mentioned that the volume of the state-sponsored Health Benefit Exchanges is still unknown. But what everyone is sure of - is the fact that quite a significant portion of American population will be either purchasing healthcare insurance from HBEs or through some kind of a similar off-exchange model, by 2016. Please read my detailed post addressing this topic in the "Healthcare for One and All" column in Health Data Management.

Posted by Rajiv Sabharwal at 5:40 AM | Permalink | Comments (0) | TrackBacks (0)