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Opening the Door to Data Analytics in Medical Coding – HIM Scene

Posted on November 15, 2017 I Written By

The following is a HIM Scene guest blog post by Julia Hammerman, RHIA, CPHQ, is Director of Education and Compliance, himagine solutions.

Data analytics has moved from IT and finance to the majority of business functions—including clinical coding. However, most healthcare organizations admit they could do more with analytics. This month’s HIM Scene blog explores the importance of analyzing clinical coding data to improve quality, productivity, and compliance.

Coding Data in ICD-10: Where We Are Today

HIM leaders are implementing coding data analytics to continually monitor their coding teams and cost-justify ongoing educational investments. Coding data analytics isn’t a once-and-done endeavor. It is a long-term commitment to improving coding performance in two key areas: productivity and accuracy.

A Look at Productivity Data

Elements that impact coding productivity data include: the type of electronic health record (EHR) used, the number of systems accessed during the coding process, clinical documentation improvement (CDI) initiatives, turnaround time for physician queries, and the volume of non-coding tasks assigned to coding teams.

Once any coding delays caused by these issues are corrected, coding productivity is best managed with the help of data analytics. For optimal productivity monitoring, the following data must be tracked, entered, and analyzed:

  • Begin and end times for each record—by coder and chart type
  • Average number of charts coded per hour by coder
  • Percentage of charts that take more than the standard minutes to code—typically charts with long lengths of stay (LOS), high dollar or high case mix index (CMI)
  • Types of cases each coder is processing every day

A Look at Accuracy Data

Accuracy should never be compromised for productivity. Otherwise, the results include denied claims, payer scrutiny, reimbursement issues, and other negative financial impacts.

Instead, a careful balance between coding productivity and accuracy is considered best practice.

Both data sets must be assessed simultaneously. The most common way to collect coding accuracy data is through coding audits and a thorough analysis of coding denials.

  • Conduct routine coding accuracy audits
  • Analyze audit data to target training, education and other corrective action
  • Record data so that back-end analysis is supported
  • Assess results for individual coders and the collective team

Using Your Results

Results of data analysis are important to drive improvements at the individual level and across entire coding teams. For individuals, look for specific errors and provide coaching based on the results of every audit. Include tips, recommendations, and resources to improve. If the coding professional’s accuracy continues to trend downward, targeted instruction and refresher coursework are warranted with focused re-audits to assure improvement over time.

HIM and coding managers can analyze coding audit data across an entire team to identify patterns and trends in miscoding. Team data pinpoints where multiple coders may be struggling. Coding hotlines or question queues are particularly helpful for large coding teams working remotely and from different geographic areas. Common questions can be aggregated for knowledge sharing across the team.

Analytics Technology and Support: What’s Needed

While spreadsheets are still used as the primary tool for much data analysis in healthcare, this option will not suffice in the expanded world of ICD-10. Greater technology investments are necessary to equip HIM and coding leaders with the coding data analytics technology they need.

The following technology guidelines can help evaluate new coding systems and level-up data analytics staff:

  • Data analytics programs with drill-down capabilities are imperative. These systems are used to effectively manage and prevent denials.
  • Customized workflow management software allows HIM and coding leaders to assign coding queues based on skillset.
  • Discharged not final coded and discharged not final billed analytics tools are important to manage each piece of accounts receivables daily and provide continual reporting.
  • Systems should have the ability to build rules to automatically send cases to an audit queue based on specific factors, such as diagnosis, trend, problematic DRGs.
  • Capabilities to export and manipulate the data within other systems, such as Excel, while also trending data are critical.
  • Staff will need training on advanced manipulation of data, such as pivot charts.
  • Every HIM department should have a copy of the newly revised AHIMA Health Data Analysis Toolkit, free of charge for AHIMA members.

HIM directors already collect much of the coding data required for improved performance and better decision-making. By adding data analytics software, organizations ensure information is available for bottom-line survival and future growth.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Heard at #AHIMACon17: Lessons Learned for HIM – HIM Scene

Posted on October 18, 2017 I Written By

The following is a HIM Scene guest blog post by Rita Bowen, MA, RHIA, CHPS, CHPC, SSGB, Vice President, Privacy, Compliance and HIM Policy, at MRO.  

The American Health Information Management Association (AHIMA) held its annual convention and exhibit in Los Angeles last week. Beginning with preconvention meetings and symposia, this year’s event delivered a renewed focus on the profession’s stalwart responsibility to protect and govern patient information. Updates for privacy, security, interoperability and information governance were provided. Here is a quick overview of my lessons learned at AHIMACon17.

Privacy and Security Institute

The 11th anniversary of AHIMA’s Privacy and Security Institute didn’t disappoint. Speakers from the HHS Office for Civil Rights (OCR), Federal Bureau of Investigations (FBI) and HITRUST joined privacy and HIM consultants for an information-packed two-day symposium. The most important information for HIM professionals and privacy officers came from the nation’s capital.

Cutbacks underway—Recent defunding of the Chief Privacy Officer (CPO) position by ONC makes practical sense for the healthcare industry and the national budget. The position has been vacant for the past year, and during this time Deven McGraw successfully served as acting CPO and deputy director for health information privacy. Her imminent departure along with other cutbacks will have a trickle-down impact for privacy compliance in 2018.

Onsite audits cease—Yun-kyung (Peggy) Lee, Deputy Regional Manager, OCR, informed attendees that onsite HIPAA audits would no longer be conducted for covered entities or business associates due to staffing cutbacks in Washington, D.C. The concern here is that whatever doesn’t get regulatory attention, may not get done.

To ensure a continued focus on privacy monitoring, HIM and privacy professionals must remain diligent at the organizational, regional, state and national levels to:

  • Maintain internal privacy audit activities
  • Review any patterns in privacy issues and address through corrective action
  • Use environmental scanning to assess resolution agreement results
  • Review published privacy complaints to determine how to handle similar situations
  • Compare your state of readiness to known complaints

Interoperability advances HIPAA—The national push for greater interoperability is an absolute necessity to improve healthcare delivery. However, 30 years of new technology and communication capabilities must be incorporated into HIPAA rules. Old guidelines block us from addressing new goals. We expect more fine-tuning of HIPAA in 2018 to achieve the greater good of patient access and health information exchange.

Luminary Healthcare Panel

Tuesday’s keynote session was the second most relevant discussion for my role as vice president of privacy, compliance and HIM policy at MRO. Panelists provided a glimpse into the future of healthcare while reiterating HIM’s destiny—data integrity and information governance.

HIM’s role extends beyond ensuring correctly coded data for revenue cycle performance. It also includes the provision of correct and complete data for the entire healthcare enterprise and patient care continuum under value-based reimbursement. The need for stronger data integrity and overall information governance was threaded through every conversation during this session.

Final Takeaway

Make no doubt about it! HIM’s role is expanding. We have the underlying knowledge of the importance of data and the information it yields. More technology leads to more data and an increased need for sophisticated health information management and governance. Our history of protecting patient information opens the door to our future in the healthcare industry.

About Rita Bowen
In her role as Vice President of Privacy, Compliance and HIM Policy for MRO, Bowen serves as the company’s Privacy and Compliance Officer (PCO), oversees the company’s compliance with HIPAA, and ensures new and existing client HIM policies and procedures are to code. She has more than 40 years of experience in Health Information Management (HIM), holding a variety of HIM director and consulting roles. Prior to joining MRO, she was Senior Vice President and Privacy Officer for HealthPort, Inc., now known as CIOX Health. Bowen is an active member of the American Health Information Management Association (AHIMA), having served as its President and Board Chair, as a member of the Board of Directors, and of the Council on Certification. Additionally, Bowen is the chair for the AHIMA Foundation. She has been honored with AHIMA’s Triumph Award in the mentor category; she is also the recipient of the Distinguished Member Award from the Tennessee Health Information Management Association (THIMA). Bowen is an established author and speaker on HIM topics and has taught HIM studies at Chattanooga State and the University of Tennessee Memphis. Bowen holds a Bachelor of Medical Science degree with a focus in medical record administration and a Master’s degree in Health Information/ Informatics Management Technology.

MRO is a proud sponsor of HIM Scene.  If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Waiting For The Perfect “Standard” Is Not The Answer To Healthcare’s Interoperability Problem

Posted on October 16, 2017 I Written By

The following is a guest blog post by Gary Palgon, VP Healthcare and Life Sciences Solutions at Liaison Technologies.

Have you bought into the “standards will solve healthcare’s interoperability woes” train of thought? Everyone understands that standards are necessary to enable disparate systems to communicate with each other, but as new applications and new uses for data continually appear, healthcare organizations that are waiting for universal standards, are not maximizing the value of their data. More importantly, they will be waiting a long time to realize the full potential of their data.

Healthcare interoperability is not just a matter of transferring data as an entire file from one user to another. Instead, effective exchange of information allows each user to select which elements of a patient’s chart are needed, and then access them in a format that enables analysis of different data sets to provide a holistic picture of the patient’s medical history or clinical trends in a population of patients. Healthcare’s interoperability challenge is further exacerbated by different contextual interpretations of the words within those fields. For instance, how many different ways are there to say heart attack?

The development of the Health Level Seven (HL7®) FHIR®, which stands for Fast Healthcare Interoperability Resources, represents a significant step forward to interoperability. While the data exchange draft that is being developed and published by HL7 eliminates many of the complexities of earlier HL7 versions and facilitates real-time data exchange via web technology, publication of release 4 – the first normative version of the standard – is not anticipated until October 2018.

As these standards are further developed, the key to universal adoption will be simplicity, according to John Lynn, founder of the HealthcareScene.com. However, he suggests that CIOs stop waiting for “perfect standards” and focus on how they can best achieve interoperability now.

Even with standards that can be implemented in all organizations, the complexity and diversity of the healthcare environment means that it will take time to move everyone to the same standards. This is complicated by the number of legacy systems and patchwork of applications that have been added to healthcare IT systems in an effort to meet quickly changing needs throughout the organization. Shrinking financial resources for capital investment and increasing competition for IT professionals limits a health system’s ability to make the overall changes necessary for interoperability – no matter which standards are adopted.

Some organizations are turning to cloud-based, managed service platforms to perform the integration, aggregation and harmonization that makes data available to all users – regardless of the system or application in which the information was originally collected. This approach solves the financial and human resource challenges by making it possible to budget integration and data management requirements as an operational rather than a capital investment. This strategy also relieves the burden on in-house IT staff by relying on the expertise of professionals who focus on emerging technologies, standards and regulations that enable safe, compliant data exchange.

How are you planning to scale your interoperability and integration efforts?  If you're waiting for standards, why are you waiting?

As a leading provider of healthcare interoperability solutions, Liaison is a proud sponsor of Healthcare Scene. While the conversation about interoperability has been ongoing for many years, ideas, new technology and new strategies discussed and shared by IT professionals will lead to successful healthcare data exchange that will transform healthcare and result in better patient care.

About Gary Palgon
Gary Palgon is vice president of healthcare and life sciences solutions at Liaison Technologies. In this role, Gary leverages more than two decades of product management, sales, and marketing experience to develop and expand Liaison’s data-inspired solutions for the healthcare and life sciences verticals. Gary’s unique blend of expertise bridges the gap between the technical and business aspects of healthcare, data security, and electronic commerce. As a respected thought leader in the healthcare IT industry, Gary has had numerous articles published, is a frequent speaker at conferences, and often serves as a knowledgeable resource for analysts and journalists. Gary holds a Bachelor of Science degree in Computer and Information Sciences from the University of Florida.

How to Balance Privacy, Security and Quality with Offshore Coding: Three Critical Caveats for HIM – HIM Scene

Posted on October 4, 2017 I Written By

The following is a guest blog post by Sarah Humbert, RHIA, ICD-10 AHIMA Certified Trainer, Coding and Compliance Manager, KIWI-TEK. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Prior to ICD-10 there was a shortage of domestic coders, making offshore services a necessity for many organizations. But in a post ICD-10 environment, experienced U.S. coders are more readily available and accessible. Domestic coding services are still considered best practice by most HIM professionals. In fact, 72 percent of hospital respondents outsource more than half of their coding needs according Black Book’s October 2016 Outsourced HIM Report.

While acceptance of offshore coding services has grown there are important caveats for HIM professionals to know according to the Black Book report. Price isn’t everything when it comes to protecting your patient’s privacy and your organization’s financial performance. Additional offshore concerns continue to be reported by U.S. hospitals and health systems:

  • Increased audit costs
  • Higher denial rates
  • Missed procedure codes

As Black Book states, it is imperative for offshore coding companies to tighten processes in three key areas: privacy, security and quality. With ransomware on the rise, hospitals, health systems and medical groups have greater levels of responsibility to fully assess their business associates—especially those using protected health information (PHI) offshore.

Because of these concerns and those mentioned above, HIM professionals must carefully explore, vet and secure detailed service level agreements prior to even considering the offshore option. This month’s blog lays out three critical caveats to consider and weigh against the proven value of domestic coding services.

Verify and Test Privacy and Security for Offshore Coding

The first step for HIM professionals is to understand the annual attestation requirements. Originally required by CMS for Medicare Advantage (MA) plans, the following annual attestations have become best practice for healthcare provider organizations and other covered entities (CEs) working to protect PHI.

  1. Provide notice to CMS—30 days prior to beginning the contractual relationship—that offshore contractors will be used, providing CMS an opportunity to review and raise an objection if warranted.
  2. Sign an annual attestation to accurately report to CMS the use of any offshore contractors.

For example, if a hospital wants to use a coding or billing company with personnel located offshore, it must submit the initial notification, receive no objections from CMS, and then annually attest that protections are in place with the offshore vendor.

Beyond the two-step attestation process, HIM professionals must take the following five precautionary steps with all offshore HIM services vendors.

  • Discuss any offshore contacts with your legal counsel and the vendor prior to signing.
  • Include language to indicate that onshore vendors will not subcontract with offshore vendors or coders.
  • Make sure your vendors are aware of attestation rules and take precautions to safeguard PHI.
  • Obtain cybersecurity insurance that includes coverage for potential breaches of offshore data.
  • Identify any other clinical services that may be provided offshore, such as coding audits, and consult your legal counsel to determine if that service should be identified in the attestation.

Rigorous due diligence of offshore coding vendor privacy and security safeguards ensures HIM professionals are doing their part in reducing PHI breaches and ransomware attacks in healthcare. Six states went a step further by prohibiting Medicaid members from sending any PHI offshore: Arizona, Ohio, Missouri, Arkansas, Wisconsin and New Jersey. If your state provides healthcare services in any of these states, additional review by legal counsel is mandatory.

Watch Offshore Coding Quality

The second area for concern with offshore medical record coding services is accuracy.

Offshore coders are mostly former nurses or other well-educated candidates. Although global coding staff speak English and are highly competent, they may not be well trained in self-directed chart interpretation.

Our clients often report international coding accuracy concerns and the need for additional audits, higher denials and missed procedure codes—especially as global coders expand beyond relatively simple and repetitive ancillary testing and radiology cases. In fact, 22 percent of HIM executives continue to shy away from a non-U.S. workforce, according to Black Book.

When it comes to coding quality, here are five recommendations to measure, monitor and manage accuracy prior to engaging an offshore coder.

  • Confirm who is actually doing your coding initially, and after each month into the services engagement.
  • Know global coders’ credentials, testing results and accuracy scores.
  • Verify that less experienced coders aren’t engaged following the initial work assignment.
  • Conduct a minimum of monthly coding audits to quickly identify and correct any negative trend or patterns.
  • Refuse to accept lower quality standards for offshore coding.

Re-evaluate Your Options

The medical record coding industry has shifted. Now is the time to re-evaluate the risks and returns of offshore coding services—keeping privacy, security and quality top of mind.

About Sarah Humbert
Sarah serves as the manager of coding and compliance at KIWI-TEK, a 100% domestic coding and audit services company. She is responsible for coding quality control—accuracy, turnaround time and compliance.

Sarah oversees all coding processes, including coders’ performance, credentials and recurrent testing. She is a member of AHIMA, IHIMA, CHIMA, and she is also a Certified ICD-10 AHIMA trainer. Sarah has worked in a variety of health information management positions for Health Care Excel, MedFocus and St. Vincent Health System.

KIWI-TEK is a proud sponsor of Healthcare Scene. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

How to Train Business Office Staff to Perform Like ROI (Release of Information) Pros – HIM Scene

Posted on September 27, 2017 I Written By

The following is a HIM Scene guest blog post by Mariela Twiggs, MS, RHIA, CHIP, FAHIMA, National Director of Motivation & Development at MRO.  This is the third blog in a three-part sponsored blog post series focused on the relationship between HIM departments and third-party payers. Each month, a different MRO expert will share insights on how to reduce payer-provider abrasion, protect information privacy and streamline the medical record release process during health plan or third-party commercial payer audits and reviews.

Millions of payer requests for medical records are sent to hospital business offices every day. Business office staff are often tasked with pulling, compiling and sending Protected Health Information (PHI) to meet these requests.

Many payer requests are part of treatment, payment and operations (TPO) according to HIPAA. Payer requests are the “P” in TPO. However, others such as Medicaid assistance applications and disability requests are not covered under TPO. Knowing the difference and managing each request with the upmost regard for patient privacy is the focus of this month’s HIM Scene post.

Business Office Disclosures: Haste Makes Breach

Time is of the essence in the business office. Staff are focused on submitting claims, appealing denials or responding to audits and reviews as covered in last month’s HIM Scene. During the rush to get claims paid, key steps in the Release of Information (ROI) process may be skipped, compromised or mistakenly omitted. It’s during these situations that privacy concerns arise and PHI breaches may occur.

To ensure business office disclosures are kept safe and secure, organizations should train their financial staff using the same information, curriculum and courses presented to Health Information Management (HIM) teams. The ROI steps are the same. And disclosure management processes must be consistent to reduce breach risk. Here are five key areas of disclosure management to cover with your business office employees.

1. ROI and HIPAA Basics

Ensure employees understand the definition of  HIPAA, the privacy rule, ARRA HITECH Omnibus, PHI and differences between federal versus state law. Each state is different and laws apply to where the care was given, not where the organization is headquartered. This is an important distinction for central business offices processing requests for care locations across several states.

Also emphasize which types of payer requests fall under HIPAA’s TPO exemption and which don’t. For those that aren’t considered disclosures for TPO, a patient authorization is required.

Another important topic to cover is the Health and Human Services (HHS) minimum necessary guidance under the HIPAA privacy rule. This guidance helps organizations determine what information can be used, disclosed or requested by payers for a particular purpose. Payers don’t need entire copies of records. They only need specific documents depending on the type of request. By helping business office staff thoroughly understand and apply the minimum necessary guidance, organizations tighten privacy compliance and mitigate breach risk.

2. The Medical Record

Define the various components of the medical record to business office staff. These include common documents, various types of encounters, and properly documented corrections and amendments.

3. Confidentiality and Legal Issues

Outline the legal health record concept and what it includes for your organization. All the various confidentiality and legal issues should also be fully explained. For example, with regard to state subpoena laws, one needs to know quash periods and whether special documentation must be provided. Louisiana requires affidavits while Virginia requires certifications from attorneys saying a notice of patient objection was not received.

4. Types of Requests

List all the various types of requests that might be received in the business office. For each category, differentiate which are part of TPO and which are not. Those that fall outside of TPO require a patient authorization and should be forwarded to HIM for processing. The types of requests to discuss with the business office include:

  • Treatment requests
  • Internal requests
  • Patient requests
  • Government agency requests
  • Disability requests
  • Insurance requests
  • Post-payment audit requests
  • Attorney requests
  • Law enforcement requests
  • Court orders
  • Subpoenas
  • Research requests

5. Sensitive Records and Other Special Situations

Identify and describe specific disclosure management practices related to sensitive records. These cases can include information on genetics, HIV/AIDS, STDs, mental/behavioral health, substance abuse and other sensitive issues. There are also special situations surrounding disclosures for deceased patients and minors. Sensitive records require special handling. Complex federal and state legal issues may be involved with these cases and business office personnel should be aware of them.

With so many details to know, many hospitals and health systems are opting to centralize all disclosures within the HIM department or with a single outsourced ROI vendor.

Make the Case for Centralized ROI

There is a national trend toward centralized disclosure management versus each department handling information requests internally. Beyond the business office, requests are also frequently received in the radiology department, clinical locations, human resources, physician practices, nursing units and HIM.

Maintaining oversight and privacy compliance for all these areas is an arduous task—and opens the door for breach risk. If you are in doubt about the ability of business office or other staff to properly and securely process requests, a centralized ROI model may be your organization’s safest approach.

About Mariela Twiggs
In her role as Director of Motivation and Development, Twiggs leads MRO’s internal motivational efforts and manages MRO Academy, a rigorous and required online educational and testing platform for all employees, which is comprehensive and current with external developments and regulations. Prior to joining MRO, she was CEO of MTT Enterprises, LLC, a Release of Information business. Previously, she worked as a Health Information Management (HIM) Director. Twiggs is the past president of the Association of Health Information Outsourcing Services (AHIOS), Louisiana Health Information Management Association (LHIMA) and Greater New Orleans Health Information Management (GNOHIMA); a fellow of the American Health Information Management Association (AHIMA); recipient of LHIMA’s Distinguished Member & Career Achievement Awards; past treasurer of LHIMA and GNOHIMA; and serves on the advisory board of the Delgado Community College Health Information Technology Program. Twiggs holds a B.S. in Medical Record Administration and a Master’s Degree in Health Care Administration. She is also certified in healthcare privacy (CHP) and is a Certified Document Imaging Architect (CDIA+) with expertise in electronic document management.

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Interoperability: Is Your Aging Healthcare Integration Engine the Problem?

Posted on September 18, 2017 I Written By

The following is a guest blog post by Gary Palgon, VP Healthcare and Life Sciences Solutions at Liaison Technologies.
There is no shortage of data collected by healthcare organizations that can be used to improve clinical as well as business decisions. Announcements of new technology that collects patient information, clinical outcome data and operational metrics that will make a physician or hospital provide better, more cost-effective care bombard us on a regular basis.

The problem today is not the amount of data available to help us make better decisions; the problem is the inaccessibility of the data. When different users – physicians, allied health professionals, administrators and financial managers – turn to data for decision support, they find themselves limited to their own silos of information. The inability to access and share data across different disciplines within the healthcare organization prevents the user from making a decision based on a holistic view of the patient or operational process.

In a recent article, Alan Portela points out that precision medicine, which requires “the ability to collect real-time data from medical devices at the moment of care,” cannot happen easily without interoperability – the ability to access data across disparate systems and applications. He also points out that interoperability does not exist yet in healthcare.

Why are healthcare IT departments struggling to achieve interoperability?

Although new and improved applications are adopted on a regular basis, healthcare organizations are just now realizing that their integration middleware is no longer able to handle new types of data such as social media, the volume of data and the increasing number of methods to connect on a real-time basis. Their integration platforms also cannot handle the exchange of information from disparate data systems and applications beyond the four walls of hospitals. In fact, hospitals of 500 beds or more average 25 unique data sources with six electronic medical records systems in use. Those numbers will only move up over time, not down.

Integration engines in place throughout healthcare today were designed well before the explosion of the data-collection tools and digital information that exist today. Although updates and additions to integration platforms have enabled some interoperability, the need for complete interoperability is creating a movement to replace integration middleware with cloud-based managed services.

A study by the Aberdeen Group reveals that 76 percent of organizations will be replacing their integration middleware, and 70 percent of those organizations will adopt cloud-based integration solutions in the next three years.

The report also points out that as healthcare organizations move from an on-premises solution to a cloud-based platform, business leaders see migration to the cloud and managed services as a way to better manage operational expenses on a monthly basis versus large, up-front capital investments. An additional benefit is better use of in-house IT staff members who are tasked with mission critical, day-to-day responsibilities and may not be able to focus on continuous improvements to the platform to ensure its ability to handle future needs.

Healthcare has come a long way in the adoption of technology that can collect essential information and put it in the hands of clinical and operational decision makers. Taking that next step to effective, meaningful interoperability is critical.

As a leading provider of healthcare interoperability solutions, Liaison is a proud sponsor of Healthcare Scene. It is only through discussions and information-sharing among Health IT professionals that healthcare will achieve the organizational support for the steps required for interoperability.

Join John Lynn and Liaison for an insightful webinar on October 5, titled: The Future of Interoperability & Integration in Healthcare: How can your organization prepare?

About Gary Palgon
Gary Palgon is vice president of healthcare and life sciences solutions at Liaison Technologies. In this role, Gary leverages more than two decades of product management, sales, and marketing experience to develop and expand Liaison’s data-inspired solutions for the healthcare and life sciences verticals. Gary’s unique blend of expertise bridges the gap between the technical and business aspects of healthcare, data security, and electronic commerce. As a respected thought leader in the healthcare IT industry, Gary has had numerous articles published, is a frequent speaker at conferences, and often serves as a knowledgeable resource for analysts and journalists. Gary holds a Bachelor of Science degree in Computer and Information Sciences from the University of Florida.

ROI in the Business Office: Why HIM Should Keep a Watchful Eye – HIM Scene

Posted on August 16, 2017 I Written By

The following is a HIM Scene guest blog post by Lula Jensen, MBA, RHIA, CCS, Director of Product Management at MRO.  This is the second blog in a three-part sponsored blog post series focused on the relationship between HIM departments and third-party payers. Each month, a different MRO expert will share insights on how to reduce payer-provider abrasion, protect information privacy and streamline the medical record release process during health plan or third-party commercial payer audits and reviews.

According to most business office staff, pulling information and releasing medical record documentation to payers is a necessary evil to get claims paid and reduce accounts receivables. It is not their core competency.

Whether the request is unsolicited or solicited by the payer, time required to compile information and respond wreaks havoc on business office productivity. Also in efforts to meet payer deadlines and expedite claims, human mistakes can be made. Incorrect patient information might slip through the cracks.

Despite concerns, many business office directors prefer that payer disclosures be sent out by their own business staff—versus by the HIM department. If your organization follows that practice, this HIM Scene blog post is for you.

Two Types of Business Office Requests

There are two instances of business office Release of Information (ROI) to know: unsolicited and solicited requests. The unsolicited process takes place when medical documentation containing all the additional information pertinent to the service being billed is submitted proactively by the provider with the initial claim. The solicited process occurs when the original claim is sent without additional supporting medical record documentation and the payer subsequently (during the adjudication process) determines that additional information is needed. The payer then places a request for the additional documentation from the provider.

Unsolicited Releases During Claims Processing

The purpose of releasing information during claims processing is to expedite payment. In an effort to get the claim paid faster, medical records are sent proactively with the claim. This is especially true for high-dollar claims, payer policies, readmissions within 30 days and the published Office of Inspector General (OIG) Work Plan.

Sounds like a good intention with the organization’s best financial interests in mind. However, three concerns arise when business offices send medical record documentation to payers—versus having HIM professionals take charge.

  1. Business office staff may not know which parts of the medical record will be required to support the claim. Often, the entire chart is sent—a process that is not practical for high-dollar or long-length-of-stay cases.
  2. Sending the entire record is also not compliant with HIPAA’s Minimum Necessary Standard. By sending too much information, hospitals are at risk for HIPAA breach.
  3. Upon receipt of prepay documentation, the payer’s staff logs each record received, scans or otherwise digitizes the documents, and incorporates them into their own electronic systems. This creates a huge administrative burden on payers.

Similar challenges ensue with solicited payer medical record requests that occur during the adjudication process or retrospective reviews.

Business Office Disclosures for Payer Audits and Reviews

There has been significant uptick in payer audits and reviews, a topic that was covered by HIM Scene last month. This includes governmental and third-party commercial. According to one central business office director at an MRO client site, “The pull lists for payer audits and reviews keep getting longer and the piles of medical records to send keep getting higher.”

To reduce administrative burdens with payers, some organizations are allowing payers direct access to their EMRs and EHRs to obtain the required information during audits and reviews. While this process may lighten the load for billing personnel, it is laden with additional privacy risks.

Business office personnel complain about the travails of responding to all the various requests for records. However, a significant number of business office directors still insist on owning the ROI process for payer audits and reviews. When this is the case, there are several important steps for HIM directors to consider.

Three Steps for HIM: Educate, Track and Talk

For both types of business office disclosures, it is important to educate billing staff about the implications of a HIPAA breach and privacy risks listed above. Establish an organization-wide standard for ROI to keep PHI safe during all types of business office disclosures. Educating all personnel involved in business office ROI (whether for claims processing, audits or reviews) helps relieve frustration with the record release process.

Billers should also track which specific records, and what sections of each, were sent. By documenting and then reviewing this information, organizations gain valuable knowledge about payer trends—insights that can be used to prevent denials and negotiate more favorable terms for payer contracts.

Collaborate with privacy and the business office to determine which release information to track. Then establish a common database or software application to document each release to payers. Here are four ways to make the most of business office ROI tracking data:

  • Look for patterns in what payers are requesting. Any trends in payer request activity could offer opportunities for provider improvement.
  • Identify risk. Analytics can help business offices detect weaknesses in the revenue cycle, involving coding, documentation or other internal processes.
  • Educate coders, biller, collectors, physicians, etc. on payer trends and how collaboration can promote accurate, complete billing for services rendered and support a claim via medical record documentation.
  • Use data analysis. When payer contract negotiations arise, use payer trend statistics to your advantage in the next round of negotiations.

Talk with local payers and stay updated on policy changes related to claims processing, audits and retrospective reviews. Open communication with each payer is recommended to ensure records are sent in the most secure way possible. Communication with payers also reduces phone tag and minimizes payer-provider abrasion.

Finally, due to the importance of collecting medical record documentation, health plans are willing to pay for records. Business offices and HIM departments fulfilling these requests are encouraged to discuss and pursue reimbursement from payers.

About Lula Jensen

In her role as Director of Product Management for MRO, Jensen drives product enhancements and new product initiatives to ensure MRO’s suite of solutions enable the highest levels of client success and end-user satisfaction. She has more than 15 years of experience in healthcare, focusing on Health Information Management (HIM), Revenue Cycle Management, analytics, software development and consulting. In addition to holding product management roles at McKesson Health Solutions and CIOX Health, she also served as Revenue Cycle Manager at Fox Chase Cancer Center and taught a course on ICD-9 CM Coding and Reimbursement at Bucks County Community College. Jensen is an active member of the Healthcare Financial Management Association (HFMA), American Health Information Management Association (AHIMA) and Pennsylvania Health Information Management Association (PHIMA); she is a 2005 PHIMA Scholar Award recipient. Jensen holds a B.S. in HIM from Temple University and an M.B.A. in Health Care Administration from Holy Family University.

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Achieve MU3: Measure 3 with these 5 MEDITECH Clinical Decision Support Interventions (CDSi)

Posted on August 11, 2017 I Written By

The following is a guest blog post by Kelly Del Gaudio, Principal Consultant at Galen Healthcare Solutions.

Over the past several years, there has been significant investment and effort to attest to the various stages of meaningful use, with the goal of achieving better clinical outcomes. One area of MU3 that directly contributes to improved clinical outcomes is implementation of Clinical Decision Support Interventions (CDSi). Medicaid hospitals must implement 5 CDSi and enable drug-drug and/or drug-allergy checking.

From looking at this measure it seems like a walk in the park, but how does your organization fair when it comes to CDS?

Thanks to First Databank, users of EMR’s have been accomplishing drug to drug and drug to allergy checking for over a decade, but what about the edge cases you think will be covered but aren’t? Take a patient that is allergic to contrast for example. Since imaging studies requiring contrast are not drugs, what happens when they are ordered? Are they checking for allergies? In most cases, additional configuration is required to get that flag to pop. This is usually where we come in.

Let’s take a look at a simple CDSi definition provided by CMS.gov

“CDS intervention interaction. Interventions provided to a user must occur when a user is interacting with technology. These interventions should be based on the following data:  Problem list; Medication list; Medication allergy list; Laboratory tests; and Vital signs. “

Without a decent rule writer on staff, there are limitations within MEDITECH for accomplishing full CDSi. The primary reason we started recording these discrete data elements in the first place is the glimmer of hope that they would someday prove themselves useful. That day is here, friends. (If you don’t believe me, check out IBM’s Watson diagnosing cancer on YouTube. . .you might want to block off your schedule.)

In collaboration with 9 hospitals as part of a MEDITECH Rules focus group – Project Claire[IT] – we researched and designed intuitive tools to address Clinical Quality Measures (eCQM’s) and incorporated them into a content package. If your organization is struggling to meet these measures or you are interested in improving the patient and provider experience, but don’t have the resources to dedicate to months of research and development, Project Claire[IT]’s accelerated deployment schedule (less than 1 month) can help you meet that mark. Below are just some examples of the eCQM’s and CDS delivered by Project Claire[IT].

CMS131v5     Diabetes Eye Exam
CMS123v5     Diabetes: Foot Exam
CMS22v5       Screening for High Blood Pressure and Follow-Up Documented

Synopsis: The chronic disease management template will only display questions relevant to the Problem List (or other documented confirmed problems since we know not everyone uses the problem list). Popup suggestions trigger orders reminding the provider to complete these chronic condition follow-up items before letting the patient out of their sights. Our goal was to save providers time by ordering all orders in 1 click.

CMS71v7     Anticoagulation Therapy for Atrial Fibrillation/Flutter
CMS102v6   Assessed for Rehabilitation

“The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation.” – CMS71v7

The above quote is taken directly from this measure indicating the use of the Framingham Heart Study we used to identify and risk stratify stroke. Claire[IT] content comes complete with three Framingham Scoring tools:

                Framingham Risk for Stroke
                Framingham Risk for Cardiovascular Disease
                Framingham Risk for Heart Attack

These calculators use all the aforementioned data elements to drive the score, interpretation and recommendations and the best part is they only require one click.

*User adds BP. BP mean auto calculates. Diabetes and Smoking Status update from the Problem List. Total Cholesterol and HDL update from last lab values.
Ten year and comparative risk by age auto calculates.

*User adds BP. BP mean auto calculates. Diabetes, Smoking Status, CVD, Afib and LVH update from the Problem List. On Hypertension meds looks to Ambulatory Orders.
Ten year risk auto calculates.

*User adds BP. BP mean auto calculates. Diabetes and Smoking Status update from the Problem List. Hypertension meds looks to Ambulatory Orders. Total Cholesterol and HDL update from lab values.
Ten year risk auto calculates.

CMS149v5      Dementia: Cognitive Assessment

Synopsis: Not only is this tool built specifically as a conversational assessment, it screens for 4 tiers of mental status within one tool (Mental Status, Education, Cognitive Function and Dementia). The utilization of popup messages allows us to overcome the barrier of character limits and makes for a really smooth display on a tablet or hybrid. Our popups are driven by the primary language field in registration and our content currently consists of English and Spanish translations.

CMS108v6     VTE Prophylaxis
CMS190v6     VTE Prophylaxis is the ICU

Synopsis: Patients that have an acute or suspected VTE problem with no orders placed for coumadin (acute/ambulatory or both) receive clinical decision support flags. Clicking the acknowledge tracks the user mnemonic and date/time stamp in an audit trail. Hard stops are also in place if NONE is chosen as a contraindication. The discharge order cannot be filed unless coumadin is ordered or a contraindication is defined. These rules evaluate the problem list and compare it to the medication list to present the provider with the right message.

Learn more about the work of our focus group and Project Claire[IT] by viewing our MEDITECH Clinical Optimization Toolkit.

VIEW THE TOOLKIT TO ACCESS:

  • Deliverable Package of Complex Rules, Assessments, CDS’s and Workflows
    • Problem List Evaluation
    • Total Parenteral Nutrition
    • Manage Transfer Guidance
  • Surveillance Dashboard Setup Guide
    • Dictionary Setup & Validation
  • 6.x Rules Setup Guide
    • Basic Rules for Assessments, Documents & Orders
  • IV Charge Capture Setup Guide

About Kelly Del Gaudio
Kelly is Principal Consultant at Galen Healthcare Solutions, and has been optimizing MEDITECH systems for over 10 years. She worked for MEDITECH on an elite 4-person team (the MEDITECH SWAT Team), whose sole concentration was clinical optimization, ROI analysis, MU certification, and achievement of HIMSS EMRAM Stage 6/7. Kelly currently leads Galen’s MEDITECH practice, and championed a focus group, which led to the delivery of Project Claire[IT], a MEDITECH content package of complex rules, assessments, CDS’s, and workflows that evaluate, suggest, and support documentation of chronic and acute problems. Learn more about Kelly in the #IAmGalen series.

About Galen Healthcare Solutions

Galen Healthcare Solutions is an award-winning, #1 in KLAS healthcare IT technical & professional services and solutions company providing high-skilled, cross-platform expertise and proud sponsor of the EMR Clinical Optimization Series. For over a decade, Galen has partnered with more than 300 specialty practices, hospitals, health information exchanges, health systems and integrated delivery networks to provide high-quality, expert level IT consulting services including strategy, optimization, data migration, project management, and interoperability. Galen also delivers a suite of fully integrated products that enhance, automate, and simplify the access and use of clinical patient data within those systems to improve cost-efficiency and quality outcomes. For more information, visit www.galenhealthcare.com. Connect with us on Twitter, Facebook and LinkedIn.

EMR Clinical Optimization CIO Perspectives – EMR Clinical Optimization Series

Posted on July 26, 2017 I Written By

The following is a guest blog post by Julie Champagne, Strategist at Galen Healthcare Solutions.

Most HDOs today face a decision: start over with a new EMR or optimize what you have. A poorly executed implementation, coupled with substandard vendor support, makes EMR replacement an attractive and necessary measure. Further, the increase in mergers and acquisitions is driving system consolidation and consequently increasing the number of HDOs seeking EMR replacement to address usability and productivity concerns.

Galen Healthcare Solutions spoke with two prominent health information technology leaders, who have quite a bit of experience in the optimization field to hear their views on the topic. Sue Schade, MBA, LCHIME, FCHIME, FHIMSS, is a nationally recognized health IT leader and Principal at StarBridge Advisors, providing consulting, coaching and interim management services. Jim Boyle, MPH, CGEIT is Vice President of Information Services of St. Joseph Heritage Healthcare (Anaheim, Calif.). In his current role, Jim oversees the delivery of applications and technology and is a member of the executive leadership team. Below are their perspectives

Opportunities for EMR optimization generally fall into three categories:

  • Usability & efficiency: Improve end-user satisfaction and make providers more efficient and productive
  • Cost Avoidance: Improve workflows to increase utilization and decrease variability
  • Increase Revenue: Implement analytics to transition from volume to value


Recently, three prominent Boston-area physicians contributed an opinion piece to WBUR, “Death By A Thousand Clicks”. They postured that when doctors and nurses turn their backs on patients in order to pay attention to a computer screen, it pulls their focus from the “time and undivided attention” required to provide the right care. Multiple prompts and clicks in an EMR system impact patients and contribute to physician burnout.

HDOs should then limit their intake to what can be accomplished within one quarter, referred to as a sprint. Accountability should be assigned, and visual controls or Kanban should be leveraged.


 
For HDOs that experienced failed EMR implementations, making corrections and reengineering is a necessary first measure. Typically, a deficiency in the additional support for the system implementation is to blame, and employing qualified application support staff will help to address and resolve end user dissatisfaction.
 
 
 
To realize lasting impact from the EMR, extensive post go-live enhancement and optimization is needed. Leveraging the operational data in the EMR system can support many initiatives to improve workflows, as well as clinical and financial performance. Prioritization of the levers that can be adjusted depends on the HDO’s implementation baseline and strategic goals.

 
The most important deciding success factor for an optimization project is focusing effort and ensuring the scope is not too large. Further, it is of critical importance to set measurable and attainable metrics and KPIs to gauge the success and ROI of the initiative. Quantification of staff effort and IT investment is also important.

Gain perspectives from HDO leaders who have successfully navigated EMR clinical optimization and refine your EMR strategy to transform it from a short-term clinical documentation data repository to a long-term asset by downloading our EMR Optimization Whitepaper.

About Sue Schade
Sue Schade, MBA, LCHIME, FCHIME, FHIMSS, is a nationally recognized health IT leader and Principal at StarBridge Advisors providing consulting, coaching and interim management services. Sue is currently serving as the interim Chief Information Offi cer (CIO) at Stony Brook Medicine in New York. She was a founding advisor at Next Wave Health Advisors and in 2016 served as the interim CIO at University Hospitals in Cleveland, Ohio. Sue previously served as the CIO for the University of Michigan Hospitals and Health Centers and prior to that as CIO for Brigham and Women’s Hospital in Boston. Previous experience includes leadership roles at Advocate Health Care in Chicago, Ernst and Young, and a software/outsourcing vendor. Sue can be found on Twitter at @sgschade and writes a weekly blog called “Health IT Connect” – http://sueschade.com/

About Jim Boyle
Jim Boyle, MPH, CGEIT is a Vice President of Information Services of St. Joseph Heritage Healthcare (Anaheim, Calif.). Jim Boyle is nationally recognized as part of a new generation of health care informatics professionals who understand IT’s full potential to greatly improve peoples’ lives. In his current role Jim oversees the delivery of applications and technology and is a member of the executive leadership team for St. Joseph Heritage Healthcare, which comprises over 860 medical group providers and 1300 affiliated physicians across California. Since joining St. Joseph Health 12 years ago, he has held eight different positions, including project manager, application analyst and IT director at Fullerton, Calif.-based St. Jude Medical Center. Jim can be found on Twitter at @JBHealthIT and LinkedIn.

About Galen Healthcare Solutions
Galen Healthcare Solutions is an award-winning, #1 in KLAS healthcare IT technical & professional services and solutions company providing high-skilled, cross-platform expertise and proud sponsor of the EMR Clinical Optimization Series. For over a decade, Galen has partnered with more than 300 specialty practices, hospitals, health information exchanges, health systems and integrated delivery networks to provide high-quality, expert level IT consulting services including strategy, optimization, data migration, project management, and interoperability. Galen also delivers a suite of fully integrated products that enhance, automate, and simplify the access and use of clinical patient data within those systems to improve cost-efficiency and quality outcomes. For more information, visit www.galenhealthcare.com. Connect with us on Twitter, Facebook and LinkedIn.

 

Finding Civility in Payer Relationships: Audits, Reviews and HIM – HIM Scene

Posted on July 19, 2017 I Written By

The following is a HIM Scene guest blog post by Greg Ford, Director, Requester Relations and Receivables Administration at MRO.  This is the first blog in a three-part sponsored blog post series focused on the relationship between HIM departments and third-party payers. Each month, a different MRO expert will share insights on how to reduce payer-provider abrasion, protect information privacy and streamline the medical record release process during health plan or third-party commercial payer audits and reviews.

Civility is defined by Webster’s as courtesy and politeness. It is a mannerly act or expression between two parties. While civility in politics has waned, it appears to be on the rise in healthcare.

New opportunities for civility between payers and providers have emerged with the shift from fee-for-service to value-based reimbursement. Population health, quality payment programs and other alternative payment models (APMs) are opening the door to better collaboration and communications with payers. Optimal patient care is a mutual goal between payers and providers.

HIM professionals can also contribute to stronger payer-provider relationships. Our best opportunity to build civility with health plans and payers is during audits and reviews. HIM professionals who take the time to understand the differences will make notable strides toward a more polite and respectful healthcare experience.

Payer Audits vs. Payer Reviews: What’s the Difference?

It’s no secret to most HIM professionals that the volume of health plan medical record requests continues to increase significantly. In fact, between 2013 and 2016 the number of requests for HEDIS and Risk Adjustment reviews increased from one percent to 11 percent of the total Release of Information requests received by MRO.

The main difference between audits and reviews is the potential negative financial impact to providers. Payer audits include risk for revenue recoupment while payer reviews do not.

For example, audits conducted by third-party payers are intended to recoup funds on overpaid claims. The most common reason for a post-payment payer audit is to confirm correct coding and sequencing as billed on the claim to determine if payment was made to the provider correctly. In audits, the health plan’s intention is to recoup funds on overpaid claims.

Payer reviews do not carry financial risk to the provider. Instead, payer reviews deliver valuable insights providers can use to improve their relationships with health plans and patient populations.

The Upside of Payer Reviews

HEDIS and Risk Adjustment reviews are the most common types of payer reviews. Payer data submissions for HEDIS are due to the National Committee for Quality Assurance (NCQA) by June of every year. Medicare Risk Adjustment results are due in January and Commercial in May.

Since these payer reviews both overlap and occur simultaneously, HIM departments are deluged with medical record requests. Understanding the importance of these reviews improves communication between HIM, Release of Information staff and health plan requesters.

HEDIS Reviews

HEDIS reviews can benefit providers during contract negotiations because the HEDIS performance rankings can be used to gauge the quality and effectiveness of different health plans for potential participation with the facility.

Risk Adjustment Reviews

With these reviews, health plans are required to prove the needs of the population to CMS so they can continue to provide services for higher risk patients and pay providers for the care of this population.

In both cases, medical records are needed to provide the analysis, so HIM is involved.

HIM’s Role: Reimbursable Release of Information

In 2015, 85 percent of MRO’s audit and review requests came from third-party vendors representing health plans. Both post-payment audit and review requests are typically chargeable to the requesting party. Due to the importance of collecting medical record documentation, health plans and payers are willing to pay for records.

HIM professionals are encouraged to pursue reimbursement for payer requests. This is especially true if your HIM department is working diligently to accommodate the payer deadline for record receipt.

A provider’s Release of Information staff should be able to work directly with these requesters to ensure payment for the timely delivery of records. HIM professionals can reduce payer-provider abrasion and ultimately strengthen relationships to improve compliance. It’s the first step to increasing civility in healthcare.

Watch for our August HIM Scene post to learn more about how to secure patient privacy when sending records to payers and health plans.

About Greg Ford
In his role as Director of Requester Relations and Receivables Administration for MRO, Ford serves as a liaison between MRO’s healthcare provider clients and payers requesting large volumes of medical records for purposes of post-payment audits, as well as HEDIS and risk adjustment reviews. He oversees payer audit and review projects end-to-end, from educating and supporting clients on proper billing practices and procedural obligations, to streamlining processes that ensure timely delivery of medical documentation to the requesting payers. Prior to joining MRO, Ford worked as Director of Operations and Sales at ARC Document Solutions for 15 years. He received his B.A. from Delaware Valley University.

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