Healthcare

Observations from our Booth at HIMSS

2010-03-17T10:18:40Z

Many of you will find it surprising that I am not putting together a status report but rather blogging about my observations from the Infosys booth at HIMSS. Well for starters the blogs are easier to write and are just my own opinions. This time the HIMSS was all about complex ideas about making healthcare simpler, cheaper and better. But looking at the X-ray machines which some of our co exhibitors were presenting and the cost of the same for so little additional benefit was kind of counter intuitive – in the name of connectivity and at the cost of adding a chip to the machine we are probably going to end up making the diagnostic process so complex that it would be hard to counter argue about the cost reduction and at the end of the day can even end blaming the machine or the user for a wrong decision. This I believe the providers are learning well from the Payers and the politicians!

]]> Let me explain with a scenario:

“ Hi Welcome to the automated self service heart bypass surgery station. Your provider has the latest technology available to make this as painless and cheap as possible. Select your choice of options:
A – for Bypass surgery
B – for bypass surgery with assistance
….well you get picture and the capabilities that technology is going to bring to the table! Unfortunately most of us who would get into that machine will probably not walk out of that again.

About 40 years back my grandfather was told by his doctor walk 5 miles a day to help keep away from diabetes. He lived to be 80 by doing it. He just did that. Now my doctor gives me a medication with a page of side effects and sets up daily monitoring calls about compliance and also tells me to exercise, which I know I don’t need to if I take the pills! I know I won’t reach the 8th decade if I was on my own without the complex medical technology to support me. At the age of 40 , my grandfather acknowledged that he would become sicker and weaker as he grew older and took the steps necessary – so did his doctor; I don’t think I will even acknowledge that issue!

Essentially I am making a case for simplification, let’s just simplify the process and the cure. Preventive treatment is often cheaper than curative treatment and much more simpler to administer. We should start with one patient at a time!

Patient Centered Medical Homes: RHIO déjà vu

2010-02-25T10:48:00Z

Regional Health Information Organizations (RHIOs) gained limelight in 2004 when President Bush called for Electronic Health Records for every American by 2014. The primary objective of RHIOs was to create an interoperability and information sharing infrastructure so that 360 degree view or complete medical history of patient’s health records can be made available for healthcare decision making. The desired outcomes were improved quality of care, prevention of clinical errors, elimination of redundant tests or care, prevention of adverse reactions, better care coordination and reduction in healthcare costs. The concept of Patient Centered Medical Homes (PCMHs), also called Medical Homes, goes back to its introduction by the American Academy of Pediatrics in 1967. However this primary care model has gained popularity over last one year as President Obama rolled out healthcare reforms. Patient Centered Medical Home is a care model where primary care physician is responsible for complete care coordination of the patient. Primary care physician collaborates with other physicians and care organizations based on the care needs of the patient and also educate the patient on self-health management. PCMHs share the same goals as RHIOs in terms of improved quality of care, better care coordination, better clinical outcomes and reduced healthcare costs.

]]> Although there is shared objective, the key difference lies in how the RHIOs and PCMH s are organized and operate. RHIOs are collaborative organization of varied composition involving some or all of the organizations like federal agencies, state agencies, non-profit community organizations, hospitals, safety net providers, individual practitioners, pharmacies academia and insurers. PCMH are physician practice associations that follow “Medical Home” care model principles. While RHIOs focus on building an information sharing structure and all the participating providers/insurers have the onus of sharing health information for enhanced quality of care delivery, in PCMH the primary care physicians or a personal physician of the patient carries the responsibility for care coordination and sharing health information across the care team.
RHIOs have seen limited success. According to a survey of 109 RHIOs produced in 2005 by eHealth Initiative Foundation, top two obstacles to RHIOs were identified as sustainability/ funding and user adoption. Most RHIOs started with an initial grant for demonstration pilots but they lacked sustainable, financially viable business models. There was an unaddressed challenge of inequitable distribution of costs and benefits. While providers had to make large upfront investments in implementation of healthcare IT and development of interoperability infrastructure, financial benefits of improved outcomes and reduced inappropriate care goes to payers. Most of the providers did not have Electronic Medical Record systems and EMR adoption issues were a barrier to their participation in RHIOs. Workflows for unstructured, paper based health records sharing were not planned for in most cases.

Electronic Medical Records system adoption by physician practices has received an impetus from ARRA healthcare IT incentives for Meaningful Use of EMR. However, PCMHs continue to face the very same challenge of inequitable distribution of costs and benefits as did the RHIOs. There is no one clear winner in reimbursement strategies that physicians and payers are willing to embrace. One of the principles in "Joint Principles of the Patient-Centered Medical Home” released in 2007 by leading primary care physician organizations is: “Payment must appropriately recognize the added value provided to patients who have a patient-centered medical home. For instance, payment should reflect the value of work that falls outside of the face-to-face visit, should support adoption and use of health information technology for quality improvement, and should recognize case mix differences in the patient population being treated within the practice.” The commonly used reimbursement models of Fee for Service and Capitation provide no incentives to primary care physicians to make additional IT investments and spend more time and effort in coordinating care. Pay for Performance strategy of payers account for added incentives for demonstrating improved outcomes in certain clinical metrics. But are these incentives adequate to cover the cost of additional responsibilities that Medical Home physician undertakes? It is to be seen if providers and payers can find the winning reimbursement strategy to make PCMHs a great success or will PCMHs go the RHIO way?

Healthcare Reform and its impact on individual market

2010-02-25T10:19:39Z

The debate on Healthcare reform is going on at full throttle in Washington DC as well as the rest of the country. No one knows where this is headed to or can confirm what the outcome will be. It looks more likely that we will see Healthcare exchanges will get setup. Most probably not at the national level, but instead at the state level.

]]> Whatever happens, one thing that seems to be certainly happening is the growth of the ndividual market.The individual searching for a viable affordable health plan is becoming more and more popular. Most of the large and medium Payers who have been focusing on groups in the past are changing their strategy to come up with innovative products and services to the individual buyer. With the changing market place, buying a health plan will look much more similar to buying auto insurance than the group business that we have seen in the past. This change presents a lot of challenges for the payers. Lot of potential new clients will be looking at comparison shopping, say on the internet or on the phone. New underwriting models will have to be developed as the group methods and models will probably not work for the new market. Also the speed at which a quote is generated will have to be increased multi fold. The new client would want to know what they need to pay with various Payers and various plans. Technologists would be scrambling to automate the current underwriting and quoting process so that they can get the quote to the prospective individual member in a matter of minutes if not seconds. The healthcare industry is faced with some unique and interesting challenges in the next few years to come.

Ever heard of getting caught between a rock and a hard place…

2010-02-24T07:42:23Z

Well, that’s where the provider community finds itself right now. I have been talking to quite a few providers (large and small, specialized and generic) and eventually I have formulated an opinion (You will never find me short of opinions). The hypothesis goes such…

]]> There are three types of providers currently in the market space,
1) Who believe that transition to ICD10 is not going to take place at all. Statements such as ‘Not in my lifetime’ and ‘I will see ICD11 before I see ICD10’, are commonplace among the practitioners of this faith.
2) Who believe in the fact that the transition is very simple and it is more of a media hype rather than actual issue. Statements such as ‘My vendor will take care of it all’ and ‘It is simply a matter of replacing one list of codes with another’ are the staple of this group.
3) Who believe that there is an issue but they are helpless to do anything about it because they are absolutely resource (read cash) starved and have many fires to fight. ‘Do I pick ICD10 over meaningful usage’ and ‘I don’t have any idea what is it going to cost me’ are often-heard platitudes from these industry bellwethers.

I have a different reaction to the three groups. I usually shudder involuntarily in the company of the representatives of the first group and am reminded of the age old adage ‘Ignorance is bliss’. In the company of the second group, I am not sure why, but I start seeing the images of Titanic hitting the iceberg (obviously the James Cameroon version). But it is the third group that I really empathize with.

These are a set of people who are not only well aware of the impending doom but are also the selected few who want to do something about it. These are the people who deserve every possible break and support that they can get to overcome this potential mess. And these are the people who sleep the lightest (if they can sleep at all).

Look at it this way, we have a provider system in this country which is working at less than 3% average margins (there are people who will contradict that statement and I have seen numbers as high as 15% but I go with the multitude here and discard the outliers). More than half of these systems are actually working at less than 1% or infact in negative margins. Their reimbursement rates are already way down, close to 60%, i.e., every dollar they bill, they get around 60 cents. On top of that, if they don’t fulfill their commitments to meaningful usage, they are in line for penalties ranging up to 10% in some cases. And, please don’t tell me that the government has earmarked significant dollars for getting meaningful usage compliant and hence that should be a wash for the providers. Has anybody ever implemented a decent (or for that matter any kind) of EMR for 44 thousand dollars? Throw up the transition to ICD10 on top of that and you have the classic case of good intentions gone haywire.

That is where this hapless group finds itself. They understand the urgency of the situation. They even understand the potential impact of the transition on the quality of care. But… what do they do? Where do they get the 100-500k dollars to get an assessment done? And God-forbid, if they get an assessment consulting vendor, who charges them an arm and a leg and comes out with a 70 page PowerPoint presentation which not only states the obvious (i.e., all your processes and systems are going to be impacted) but also puts in the fear of God into them in regards to the fact that they better upgrade all their 3rd party systems at exorbitant fees and fully remediate all their custom systems, lest the wrath of God rains down on them, come 1st October 2013.

These are troubled times for this group. They want to do the right thing but face following challenges, in no specific order,
• The very top level executives are not in tune with the people who actually understand the problem. The execs still believe that the issue is either non-existent or simply vendor-driven switch.
• The struggle for limited resources between I10 transition and other ARRA mandates that actually have tangible monitory significance attached to them either through incentives or through punitive measures.
• The lack of education with respect to scope and cost of the effort, which makes them susceptible to the high level (read lacking substance), generic consulting efforts.
• Lack of understanding of where the payers are going, e.g., are they going to deny I9 based claims post 10/1/2013 or will they still entertain them? That lack of understanding directly leads to reduction in commitment.

So what is the solution?
Simple answer is nobody knows for sure. I can try to address the technical aspects of it by introducing the concept of a low-cost shrink-wrapped package to do baseline assessment (not just a high level PPT) and core scope and effort estimation, but still the process impact falls outside of it. What does one have to do to handle that sort of BPM consulting with its inherent ‘no-guarantee’ disclaimers? A crosswalk, that is much beyond what GEM proposes, is a must, not only for training purposes but also for post-transition production phase. Some kind of a tool to support contract renegotiation is a must too. In addition automated training and tools to support productivity are essential. But they all cost money, which is not there to begin with.

So whichever you look at it, it is not a situation I would fancy being in. ‘Rock and a Hard place’, anybody?

ICD 10 – Crosswalk Strategies

2010-02-16T04:14:57Z

ICD-10 codes are ten times as granular as their predecessors. This opens up whole new opportunities to improve patient safety, care delivery and streamline provider reimbursements – but all that is possible, if and only if I-10 codes are captured at the point of service (or the provider’s billing department). If the provider continues to capture I-9 codes and that’s what is going to be sent to the payer, then there’s a subtle chance that the benefits will be fully realized. But nonetheless that’s going to be the situation. Based on the market feedback, most providers will continue to capture, store and send I-9 codes for a long period post the compliance date. The transition period will be long, may be very long.]]> So, there’s going to be interoperability challenges for many years. Payers will expect I-10 codes, but providers will send I-9. Had it been the other way round, things would have been less complex, but still not simple. Converting an I-9 code to I-10 on the other hand is a very complex issue and a crosswalk will be required.

The major shortcoming of an I9 to I-10 crosswalk will be its effectiveness. As with any one-to-many mapping you’ll need additional data to be able to make an accurate judgment. Now this additional data might be there in the PWK (paperwork) segment – but it’s still unreliable to the extent that it’s optional in 5010 transactions.

Then, deciphering the PWK segment and make enough sense out of the physician’s notes to be able to zero in on the ICD-10 code is a complex issue. One could also look at the entire claim to determine the I-10 code that matches the scenario. But the rules will be complex and will need to be constantly reviewed for accuracy.

With any luck, effectiveness of the I9-I10 crosswalk will be in the 80% range. So that would mean 20% of the cases will need to be manually evaluated to determine the I-10 code. Assuming that 50% of the providers will continue to be on I-9 codes, that’s about 10% drop in automation. This will translate to significant backlogging and delay in claim payments.

Add to that, the doubts around accuracy. Firstly, there will need to be manual intervention to verify the accuracy of the crosswalk and secondly, manual intervention to process the old and current records that were inaccurately mapped. This will be significant cost overhead on the payer side.

All in all, payers will end up bearing the cost for providers not capturing the I-10 code. Providers will lose on cash-flow because of the delays in reimbursements. This is an ecosystem level problem. To reduce the transition period, payers and providers will need to move in the same direction, hand in hand and at almost the same pace. Otherwise, the industry will need to be prepared to deal with significant drop in automation, and delays and overhead costs.

ICD 10 – uncertainty around provider reimbursement

2010-01-29T04:51:40Z

CMS has used the opportunity brought in by the increased specificity of ICD-10 codes to increase the granularity of DRG codes. This will help CMS streamline Medicare payments. Since significant number of Medicare and commercial claims is paid based on DRG codes, the added granularity is bound to cause uncertainty around provider reimbursements. This uncertainty combined with the payment reductions under SGR (Sustainable Growth Rate) has the potential to significantly impact providers’ bottom-line. Payers are not immune to the impact either. It’s crucial that payers and providers simulate claim payments, compare the payouts between I9 and I10, and be better prepared for the change.

]]> Take for example the I9 code 304 (Radical Laryngectomy). 304 now maps to 36 I10 codes that specify whether the procedure is resection or excision, the approach used and the device(s) used. This increased laterality will allow the claim payments to be more aligned to the actual resources consumed during the procedure and the payments could vary significantly among these thirty six I10 codes.

Let’s hypothesize few numbers around negotiated rates, number and distribution of claims to project the potential impact on financials post transition.

As can be seen from the above tables, hospital-A will receive $10,000 less in claim payments for Radical Laryngectomy after transitioning to ICD-10. At the other end, plan-A will pay $400,000 less for Radical Laryngectomy after transitioning to ICD-10. This is a simple hypothetical example of how financials will be impacted. Modeling the organization wide or business line wise impact in a multi-specialty hospital or a large multi-state plan will be very complex.

However complex it might be, given the impact on bottom-line, both payers and providers will need to do some kind of modeling to project the impact of ICD-10 migration on their financials. Impact on financials due to increase in medical costs and inflation will need to be insulated from the impact due to ICD-10. That’s a pretty complex challenge in itself.

Finally, once the impact on financials has been projected, payers and providers will either need to re-negotiate their contracts, find some other way to negate the impact or accept the impact on profit/loss.

Patient enablement via technology

2010-01-25T08:09:05Z

Physicians, nurses and case managers spend time with patients to educate them on self-health management; however, technology is increasingly playing an important role in enabling patients lead a better quality of life. Two key dimensions of patient enablement are:
• Access to care at the right level and the right time
• Access to information that helps them manage their health
Technology is addressing both the dimensions of patient enablement. E-Consultation is enabled via internet, IP TV, kiosks and mobile devices which gives patients anytime, anywhere access to care for certain conditions that do not require physician office visit. E-Consultation can happen in synchronous mode over video/web chat or in an asynchronous mode over email. Some payors are reimbursing for eConsultation making this form of care a viable option for their members.

]]> With remote monitoring technology, patients now have access to high quality care in home setting. Wireless sensors and medical device integration enable patients to recuperate at home post discharge while their vitals are constantly monitored for any signs demanding intervention. Post-surgical care and long-term care have been made more comfortable for patients and care-givers by enabling access from home. Telehealth has made specialty care easily accessible to patients living in remote areas. They can now avoid inconvenience and expense of traveling to cities when they need medical care that can easily be supported by telehealth.
Advanced technologies are enabling patients lead a better quality of life and reducing their helpless dependency on others. Sensor networks supporting activity recognition coupled with sophisticated business intelligence capabilities of behavior modeling and predictive modeling can help in intelligent monitoring and interventions for geriatric care. For eg- Senior citizens need not be confined to old age home but can continue to live in their own homes where intelligent monitoring system learns their activity patterns over a period of time and alerts care-givers if any aberration is observed. If a person usually spends not more than 20 minutes in a bathroom, the system will alert caregivers if patient spends more than the threshold level of time there and check can be done for an accidental fall. Similarly, mildly cognitively-impaired patients can be enabled to lead a close to normal life leveraging sensor technology and advanced analytics. Such patients can venture out of their home on their own with a Personal Digital Assistant which can guide them if they are lost. It can provide them basic information of date, time, location along with guidance to reach back home from where they are. At a click of a button, they can also be connected to helpdesk that can arrange any necessary intervention. The technology-backed promise of access to care when it is needed is a strong patient enabler.
The other dimension of patient enablement is providing them information that helps them to take better care of their health. Simple interventions like sms reminders or automated phone call reminders to take medication on time can help improve medication compliance significantly. Lifestyle changes can be reinforced by constant guidance and encouragement for proper diet and exercises leveraging technology. Podcasts, videos and wellness applications can be downloaded by patients to empower themselves with information and tools for self-health management. A more interactive and personalized health education and health management experience can come from internet and IP TV. Telcos are experimenting with innovative health and wellness services to offer over IP TV. Whether you are looking for gluten-free recipes for a Celiac aunt’s birthday party or you want an effective exercise regime for post-pregnancy weight-loss, your TV may have the answer. The day may not be far when age-old adage can be rephrased to “A bit of TV a day keeps the doctor away”
Is there a risk of technology-driven enablement of patients resulting in hypochondria or some unintentional action which is detrimental to health? Well, the possibility cannot be entirely negated. This is why technology is not enough for true patient enablement. Patients always need physicians as trusted advisors to guide and support them on self-health management.

Interoperability Trends within the Healthcare Provider Sector

2010-01-21T08:45:36Z

To begin diving deeper into interoperability within healthcare, let’s talk about interoperability within the healthcare provider sector. The healthcare provider industry is suffering from, what a colleague has very eloquently described as, ‘extreme heterogeneity’ of IT systems even within a single provider.

]]> While I was working with a marquee healthcare provider – we had over 30 different applications, 10 different databases, 8 different server operating systems and more than 40 vendors supporting this ecosystem!! This is an extremely common scenario in this industry and is part of the great difficulty healthcare faces in managing it’s operations efficiently through technology.

The provider industry is approaching this problem through two different and competing paradigms

a) Rip out all these diverse applications and replace with a single monolithic end to end Hospital Information System / EMR / ERP.

This would work well for small organization with little investment in a few systems that have been recently (less than 5 years) implemented.
For those organizations which are large, complex, with long standing ingrained behavior patterns and processes – it becomes an absolute nightmare. Almost none has succeeded in successfully implementing such a strategy with a semblance of achieving the goal at reasonable cost, within reasonable timeframes and without impacting their businesses negatively.

b) Continue to work with disparate systems, optimize the number of applications through selective, prioritized consolidation, work with world class integration engine implementation and reach the most optimal mix of applications and systems necessary to provide the organization with an efficient and interoperable data flow.

This is the approach that most organization who wish to achieve true integration and seamless data flow with minimal costs and impact to the business, are moving towards.

It is thus becoming increasingly apparent that interoperability projects will very soon become the cornerstone of a provider’s IT strategy in supporting it’s business needs. With ARRA and the funding conditions that accompany it – meaningful use would be impossible without seamless data flow and therefore impossible without creating true interoperability.

The necessary products, solutions, platforms, skills and capabilities will very soon move from being a commoditized service currently delivered to low end IT players, to true value adds for the provider industry in it’s move towards automation and electronic data capture. This is very different from what will happen to HIS/EMR products and services – which will purely be associated with transaction data capture and delivered by a vast landscape of vendors and products.

“The Complete Electronic Medical Record” - What will “Complete Integration” require from a Service Provider?

2010-01-04T06:51:19Z

Observation

As we enter the next decade, it is interesting to reflect on where the leading healthcare provider and payer organizations were in 2000 and what has been accomplished to solve the evasive dilemma of creating a truly integrated Electronic Medical Record (EMR) that can provide a complete picture of an individual’s health available on demand.

]]> In the 1990s most of the world became familiar with and began using ATM machines to give us access to our financial data and also to provide cash resources. Now it is 2010 and the healthcare industry leaders are still embroiled in the definition of the EMR and implementing a complete one merely within a single Integrated Delivery Network (IDN), much less having global capabilities. The complicated nature of healthcare organizations and their focus on decisions by diverse committee creates politics that struggle to agree on definition and rules necessary for complete integration.

Solutions

Many organizations have completed the first and most costly step which is implementing the software that is capable of hosting the basic functionalities for entering and tracking data to perform clinical workflow, financial, billing and decision making functionalities. Now we are entering the next steps which include;

 Optimizing the implemented Product;
 Warehousing Data;
 Applying Business Intelligence Tools for researching operational efficiencies, improving quality, safety and development of new techniques and protocols;
 Medical Device Integration of data directly to the EMR;
 Interoperability that allows for accessing data wherever it exists and creating on demand views (EHR, PHR, P4P, EPM);
 Compliance for Regulatory and Safety standards’
 On going support and maintenance for Clinical and Financial applications.

Conclusion

The requirements for a true integrator will require the provision of service solutions that can leverage leading edge solution sets from internal and external sources. The understanding of the clients needs is paramount, shaping the solution that leverages horizontal services, Centers of Excellence (CoEs) and creatively teaming with leading edge organizations that provide domain specific products as a part of the overall solution set. This allows “World Class” healthcare organizations to depend upon a “World Class” Tier One integrator to supply all of its technology needs. These are necessary requirements for a “World Class” provider of services to compete in the next decade.

Can informed and enabled patients contribute to better outcomes?

2009-12-29T09:48:31Z

Yes, I believe so. Earlier patients were not well informed about their conditions, disease progression, medications, their side effects and the onus was entirely on the physicians to extract necessary information from patient and care-givers for treatment related decision-making. Extracting clinically significant information was a challenge in with language/cultural barriers coming into play or a patient who is inarticulate or unobservant about relevant signs and symptoms. With information explosion in the wake of internet wave, now a large number of patients visit physicians with prior research on their signs and symptoms as well as treatment options.

]]> Eighty-five percent of online adults from the United Kingdom, Germany, France, Italy and Spain report using the Internet to find health and prescription drug information, according to a new Manhattan Research survey and 67% of U.S. adults reported having searched for health information online according to a new Harris Interactive survey.

Physicians have genuine concern regarding the veracity of all the information that their patients are exposed to on internet. They also have to deal with unprecedented queries regarding diagnosis, treatment options, side-effect of medications etc. Discouraging patients to seek information online would be counter-productive to patient enablement. Physicians continue to be the most trusted source of health information for patients. They can support patients in their health education by guiding them towards reliable websites and addressing their queries.

An informed patient actively participates in health care and contributes to better outcomes by:
• Being more aware of signs and symptoms
• Clearer articulation of problem history and current complaints
• Better medication compliance
• Informing physicians about their unique response to a treatment protocol
• Observing side effects and improvements in condition
• Better ongoing health maintenance through diet compliance, exercises and recommended lifestyle changes

Additionally, patients perceive more empathy and have greater satisfaction from physician visit if the physician spends time to explain them about their disease and how to cope with it. Particularly in case of chronic diseases, it is critically important to enable patients and their care givers in disease management. Patients can be true partners of their physicians in managing chronic diseases if they are well informed about cause of disease, what aggravates it, what to expect from treatment, what are acceptable side effects and when to seek medical attention. Evidence suggests that enabling patients for chronic disease self-management results in improved health outcomes and reduced hospitalization. Informed and experienced patients or care-givers can in turn enable other patients leveraging Health 2.0 platform. About 35% of U.S. adults used social media for health and medical purposes in 2009 according to the Manhattan Research survey. 80 million U.S. adults in 2009 created or consumed health care content on blogs, chat rooms, message boards, online communities, online social networks and patient testimonials.

Interoperability requirements will underpin key health industry and health consumer trends

2009-12-29T09:19:52Z

As the global healthcare industry grapples with tremendous challenges on both cost and quality fronts; the healthcare consumer is simultaneously undergoing an equally dramatic change in behavior, attitude and awareness. This new-age healthcare consumer will soon demand a significantly more active role in managing his/her own health needs as well as filtering and monitoring the relevant services that would be provided by the health industry.

]]> At the foundation of these simultaneous yet converging trends of industry moving to patient centric care and the consumer moving towards demanding and receiving personalized and holistic attention; will be the demand for comprehensive, transparent yet secure flow of healthcare data, information and knowledge.

Currently the entire healthcare industry, globally across all sectors; is in the process of putting into place the basic transactional systems required to capture individual sector specific data needs for serving the healthcare customer through sector specific views. This process itself has been long, tortuous and has evolved over the last 20 years. Particularly in the US, this has resulted in an environment of extreme heterogeneity of systems that hold healthcare customer data – even within each individual sector such as payer, provider, pharmaceuticals, government, medical devices industry and retail health.

This rampant proliferation of niche systems has resulted in extraordinary obstacles to free flow of healthcare data; not least because of security and privacy concerns. HIPAA and related legislation was an important step towards enabling / mandating true interoperability of health systems.

Moving forward there will be a tremendously accelerating demand for the following types of interoperability requirements

a) Interoperability within individual sectors within the industry – as a basic requisite to view and analyze sector specific healthcare customer data
b) Cross sector interoperability will soon begin to demand extraordinary attention as the health industry moves towards true patient centric and personalized / holistic care.

Both these types of interoperability requirements need to be handled very differently even from a technology perspective

As I continue with these blog posts on interoperability, will delve deeply into various aspects of these, including key problems, trends, solutions and market demands in subsequent blog posts.

Suffice to say for now, that in the reality of the current technology landscape of the healthcare industry – interoperability needs and initiatives will form the basis of a significant portion of technology support in the move towards patient centric care.

ICD 10 – processing adjusted claims

2009-12-28T12:08:42Z

The necessity for dual processing with ICD-10 is not just a result of interoperability between entities on disparate code-sets. Even if we assume that all the payers and providers are migrating to ICD-10 (desirable, but hardly a pragmatic situation) on Oct 1st, 2013 (compliance date), dual processing is going to be required for some adjusted claims and inpatient claims.

]]> Assume that a claim with service date prior to the compliance date was rejected by the payer post compliance date, due to incorrect coding. The provider must code the claim correctly and resubmit it to the payer. If the provider’s coding and billing systems can’t support ICD-9 codes anymore, the claim can only be submitted manually. Of course the product vendors are aware of this problem, so their billing systems will continue to support ICD-9 codes beyond the compliance date.

Ideally, product vendors will allow users to capture ICD-10 codes (regardless of the date of service) and internally (within the coding and billing systems) translate to ICD-9 based on the date of service. But the vendors might also provide limited support with two sets of UI’s, one to capture ICD-9 and another for ICD-10 codes, leaving it for the coders to decide which code-set and UI to use. The first option will naturally be desirable - the providers would use some kind of a crosswalk or VOSER software to convert codes in this option.

On the payer side, adjudication programs will need to base their logic on contract term effective dates and the dates of service (DOS). If the DOS or the discharge date (for inpatient claims) is prior to the compliance date, the adjudication programs will pick up the contracted rates that are based on ICD-9 codes (and matching DRG and CPT codes). Otherwise the ICD-10 rules will apply. The codes that are used by the adjudication programs will flow in to the claim output process, so the remittance process will not require major revisions. The remittances will automatically reflect the correct coding.

Finally, when the remittance is received back by the provider, payment posting will take place using the code-set that was originally used to submit the claim.

The following diagram illustrates an arrangement that will work while processing adjusted claims.

5010 – Are you really ready? – Part 2

2009-12-22T07:52:05Z

Few weeks ago, in one of my blogs, I had attempted to set some basic tenets for the tactical option (downgrade-store-and-forward) for complying with the 5010 mandate. They primarily covered,
• A dynamic rules based bidirectional converter
• A comprehensive store-and-forward mechanism for storing and retrieving reduced data
• A clear performance management strategy to manage data reduction (for down conversion) and data addition (for up conversion)
• A robust API to provide access to reduced data for the downstream applications, and
• A comprehensive test bed and associated test strategy
I promised in that blog that I would not ignore the strategic approach (remediating downstream applications to make full use of the mandate) and would tackle that in a future blog. So here we are. Lets see what are the basic tenets for the strategic approach.

]]> Strategic Approach

The strategic approach is the course of action that incorporates remediating all the downstream applications (core, transactional, or peripheral) fully to support all changes associated with shifting from 4010 to 5010. As the focus shifts from the front-end (EDI gateway, mapper software etc) to the back-end (claims adjudication engine, eligibility system etc), it is imperative that the scope of the assessment and remediation grows manifolds. In some cases, I have seen code volume to the extent of 100 Million lines of code (yes, you did not read it wrong, that is 1 followed by 8 zeros). Now that is a heft piece of code base to go through and pin-point, say the 500k lines of code that are actually going to use the attributes that have changed between 4010 and 5010. Needle in a haystack anyone? So few of the basic tenets for a strategic remediation are driven by this singular fact and lead to core necessity of automation. Lets try to put them on paper

• A three step approach covering high level business process impact in step one, application portfolio assessment as step two and low-level code assessment as step 3, is of paramount necessity. Try to do the code assessment directly and you will hit a wall before you can blink or say go through one or two disjointed source systems. On the other hand, ignore deep-dive into the code at your own peril because attempting to remediate without having gone through a comprehensive business process mapping is sure-shot recipe for failure.

• A semi-automated tool to map all the business processes of the organization, to capture all the business requirements at one place in a hierarchical process order, and to generate a rough order of magnitude effort and cost estimation so that you can define your roadmap much more intelligently rather than taking a stab in the dark. The step/activity seems innocuous and invariably I hear that we already have it. After all we run our business every day. Well, I don’t mean this to be demeaning to anybody but precedence tells that 90% of the software/remediation/upgrade/transformation disasters can be directly attributed to lack of clarity upfront with respect to business process definition and its alignment with the application portfolio and system infrastructure. So, it would not hurt to do a quick double-check. There is not much to lose and upside is significant

• An automated tool set to support code crawling at the least and coverage of process map also in the best case scenario. It does not take a rocket scientist to figure out that having to focus on 5% of the code set to identify and remediate the changes is going to be a lot less effort and cost intensive than to have to do that against the complete code base. So why not have an automated tool provide you with that 5% code base that actually uses one or more of the tokens (attributes that have changed between 4010 and 5010). Afterall if a line of code does not use one of these tokens, how likely is it that that line of code will be impacted by a change in one of these tokens? Not very likely.

• A large set of 5010s to test and a comprehensive test strategy along with associated test cases and test scenarios. There are 968 unique and more than 6500 combinational changes between 4010 and 5010 TR3s, not to mention the changes that are specific to companion guides. If you want to be at peace that you have tested every possible scenario, you better have a comprehensive list of the changes between 4010 and 5010, especially the ones that are specific (and hence configured) to your environment. The vendors may certify your 3rd party applications as 5010 compliant, but one can take them on their word only at one’s own peril. One must have a large number of 5010s to test those compliant applications and what better way to generate those 5010s but to create them from existing 4010s using, yes you guessed it, the same converter that was described in step 1.

• Steer clear of over-dependence on your vendors. Granted that for core pieces of transactional software that you do not have code for, you have to depend upon them but have you thought about what percentage of your total application portfolio falls under that category. I have heard from people that they don’t need to do anything as all their systems belong to one vendor who has promised a miraculous upgrade to take care of their entire problem at a low-low cost of few Million dollars. I am not sure when I face such optimistic sentiments. Inherently I am the ‘glass half full’ kind of a guy but that does not mean I bury my head in the sand in face of the oncoming train either. If one carefully looks at a COTS implementation in their environment, one would realize that 30-40% of the code base is actually custom built for their implementation. We don’t call them COTS (Customizable off the Shelf) products for nothing. Do you remember all those services cost that went into creation of the interfaces specific to your environment etc. So do you seriously think that the vendor’s next upgrade will cover those custom interfaces also by default? And what about those pesky little Access databases that hide better than the ‘Oracle in Matrix’? By a rough estimate, an average payer organization has only around 20% of their total code base that is truly vendor driven. For providers, the number go up a bit but not by much (around 35%). If you can live with supposed coverage of 20 to 35% of your portfolio then yes, may be you can rely completely on your vendors and sleep peacefully but if I were a betting man, I would say I would not take those odds.

So these are a few of my favorite things, when it comes to 4010 to 5010 transition using strategic approach. Maybe I am a bit too close to these things for me to maintain an impartial objectivity but every bone in my body screams that you miss out on one of these, you get ready to get your fingers burned. Maybe a heck of lot more than just the fingers.

The Law of Supply and Demand - "Healthcare Rationing for our Future”

2009-12-14T12:37:30Z

Supply and demand is perhaps one of the most fundamental concepts of economics and it is the backbone of a market economy. Demand refers to how much (quantity) of a product or service is desired by buyers. The quantity demanded is the amount of a product people are willing to buy at a certain price; the relationship between price and quantity demanded is known as the demand relationship. Supply represents how much the market can offer. The quantity supplied refers to the amount of a certain good producers are willing to supply when receiving a certain price. The correlation between price and how much of a good or service is supplied to the market is known as the supply relationship. Price, therefore, is a reflection of supply and demand, according to Investopedia.com, a Forbes company.

]]> Let us consider then the latest proposal in the United States Senate to pay for “Healthcare Reform” in part by taking $500B out of Medicare and also, perhaps, change the eligibility age for Medicare, at the same time, to 55 years of age rather than the current 65 years. So, we are going to add a decade of Americans to the Medicare roles while taking $500B out of Medicare?
If you believe the Supply and demand concept and also understand how care givers are reimbursed by the government then it is easy to see the calamity this can cause in the healthcare market space. You see, the $500B is not being taken away from the patients directly but rather the caregiver’s reimbursement rates. Hospitals, Physicians, and other associated care giving entities in the continuum of care will be squeezed by this lack of funding. Consequently, more of them will literally stop accepting Medicare patients but rather opt for direct pay or other private insurance funded patients out of a need to stay in business. The more “Public Option” centric healthcare becomes the more physicians and clinicians will opt out of the business, leaving a severe shortage of caregivers leading to a severe lack of supply of healthcare.

If that last paragraph is mind boggling so is the reasoning behind the thinking of Government Controlled healthcare. One thing is certain however, the more severe the shortage, the better it will need to be managed minutely giving technology providers even more challenging technologies to develop.

HIPAA 5010 transition – building a case for automation

2009-11-20T07:25:06Z

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.