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The Wisdom of Yogi Berra in Medical Benefit Appeals

Posted on October 31, 2018 I Written By

The following is a guest blog post by Keith J. Saunders, Esq., Founder & CEO of FHAS.

“This hearing will now come to order.  For the record, today’s date is…and the following parties are present…”

I have repeated this sentence thousands of times over the past twenty three years while serving as a hearing officer for the Federal Medicare program and as an Administrative Law Judge (ALJ) for the Commonwealth of Pennsylvania Medicaid program.  Serving as an adjudicating official for medical benefit appeals can provide one with a unique perspective on human nature and the shortcomings of the medical appeals process. 

In this post, I would like to share three takeaways from my experience in order to assist you in being a successful participant in the appeals process, whether you participate from the side of the payor or appellant.

Know the medical facts.

My first piece of advice is inspired by a quote from the great New York Yankees baseball player and manager Yogi Berra: “You can observe a lot just by watching”.  Most participants in medical benefit appeals fail to perform the requisite watching.

If you are going to successfully defend or pursue your appeal, you must know the medical facts of the case. This might seem obvious, however you would be shocked to learn how many times a claim denial is appealed and it is very apparent that the parties don’t know or understand the condition of the patient, underlying the facts of their case. For medical provider appellants who are part of large health systems, the need to survey all records within your system pertaining to the subject of the appeal is critical.

For third party payers it is likewise critical to ensure that you possess a complete understanding of the condition of the patient.  I once presided over a hearing where the health insurer was challenging the necessity for the patient to have a wheelchair.  They indicated that the medical information submitted with the claims failed to indicate that the patient could not walk.   If they had performed a survey of the medical records contained within the file they would have ascertained that the patient was a bilateral AKA. For those of you who do not frequently traverse through medical records, this acronym stands for bilateral above the knee amputee; this patient had no legs.

Understand why the claim was denied.

Turning again to Yogi Berra for my second piece of advice: “You’ve got to be very careful if you don’t know where you are going because you might not get there.” In order to be an effective advocate for your position, you must thoroughly understand why a claim for reimbursement has been denied by the third party payor.  One of the most frequent bases advanced for denials in both the Medicare and Medicaid programs is the blanket catchall basis of, “a lack of medical necessity”.  This basis is utilized to deny submitted claims which lack a valid physician’s signature on the order, claims which fail to meet specific medical necessity criteria, or even claims that were not submitted in a timely manner.

As an appellant, you must possess a thorough understanding regarding what has transpired from the reimbursement standpoint, end of story.  If you are an appellant, please read the basis for the claim denial being put forth by the third party payer. To take my Yogi quote further, it is impossible for you as an advocate to get where you want to go, that is, get paid, if you do not know why the claim has been denied. When you as an appellant receive a denial notice, whether it is an explanation of benefits or a remittance advice, review the basis for denial.  If it indicates that critical medical necessity evidence is missing, review your records to find it.

Arguments that the medical policy is foolish or that the payor doesn’t understand what the patient needs may make you feel better for having given the adjudicator a piece of your mind, but are ultimately ineffective. I once had an appellant argue to me that requiring a physician’s order was a foolish requirement for an orthotic device.  When I asked the gentleman making that arguments how a payor was to ascertain if an item was medically necessary, he indicated that they should just ask him, the vendor.  Needless to say that was not an effective argument.

If you have received a blanket denial, such as a lack of medical necessity, please reach out to the third party payor to ascertain what exactly is missing or unclear.  Once you have determined what the problem is, you are then in a position to solve it.

Know the coverage and payment guidelines.

My final recommendation is that you acquire an in-depth knowledge of the coverage and payment guidelines or medical policies which govern the items or services for which you are seeking payment.  As a hearing officer or ALJ, I would find myself frequently asking appellants or payor representatives to furnish the basis within the policies for the denial of items.  More often than not on both sides of a case, neither party could articulate why an item should or should not have been paid.

I suppose in those situations they turned to another quote from Yogi: “If you ask me a question I don’t know, I’m not going to answer it.” Today there is no reason for any party to be unaware or unknowledgeable regarding medical policies or coverage and payment guidelines. All commercial health insurers and government programs, such as Medicare and Medicaid, publish their policies online.  Knowledge of the rules is one of the cornerstones to being a strong advocate for your position. From the provider standpoint, it is one of the critical components needed in order to have an item covered by a payor.

My advice may seem rather basic, but years of experience have shown me that it is a failure to address the fundamentals which causes most claims to be denied. In summary: 1. Know your patient and the medical records surrounding a claim; 2. Know the facts surrounding why reimbursement has been denied; 3. Know the rules which govern payment criteria for your claim.

If you pay attention to the foregoing you will be a much stronger advocate for your position and will likewise achieve and maintain a higher success rate in your appeals. In medical benefit appeals, as in baseball, “It ain’t over until it’s over.”

About Keith J. Saunders, Esq.
Keith J. Saunders, Esq. is the Founder & CEO of FHAS, a leading provider of medical review analytics and support services to government and commercial sectors. Weaving together over 30 years of experience working on behalf of health plans, providers, and government agencies, Mr. Saunders furnishes his clients with valued-based solutions that minimize administrative waste, maximize return on investment, and yield holistic results for all stakeholders. A former General Counsel to Blue Cross Blue Shield Plans, Mr. Saunders was an Air Force Judge Advocate proudly serving in Operation Desert Shield/Desert Storm. Mr. Saunders attained his Juris Doctorate from Duquesne University and is a long-time member of the American Health Lawyers Association (AHLA).

About FHAS
FHAS, a URAC accredited IRO and ISO 9001 certified company, is one of the largest independent providers of “healthcare as a service” (HAAS) for government and commercial clients with a particular focus on adjudication services and medical claims’ review services. In 1996, FHAS began furnishing Medicare Fair Hearing Services to Durable Medical Equipment (DME) Administrative contractors located throughout the United States. Since that time, FHAS has expanded its scope of appeals services to include complex medical reviews for the following: Medicare Parts A, B, PDRC Appeals, and DME Appeals, internal and external health plan appeals, and the entire Pennsylvania Medicaid fair hearing process. FHAS utilizes a network of board certified physicians, legal professionals, and other healthcare professionals with diverse specialties, who have the expertise to render decisions for external review requests. In addition to professional services, FHAS provides enterprise-grade software solutions to healthcare and insurance industries. Their newest product Cogno-Solve is a comprehensive, RPA software platform that automates claims and appeals decision-making functions.

What Precision Medicine Is Today and Where Is it Heading?

Posted on October 30, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In our latest series of Healthcare Scene interviews, we had the chance to learn about precision medicine with Nino da Silva, Executive Vice President at BC Platforms. For those not familiar with BC Platforms, they’re a company that has been working in precision medicine for a long time and one thing that makes them unique is their ability to marry genomics with other clinical information.

In this interview, Nino shares more information about BC Platforms and the work they’re doing and then we dive into where he really sees healthcare organizations having success with genomics and precision medicine today. We also ask Nino what a healthcare organization’s strategy should be for precision medicine and whether precision medicine is going to just be something done by large organizations or if it will be accessible to healthcare organizations of all sizes.

Finally, we dive into what BC Platforms is doing to push genomic medicine to the point of care and what it will take to make this a reality everywhere. And then we ask Nino to take a look into his crystal ball and predict where precision medicine is heading in the future.

If you’re interested in precision medicine, what’s happening with it today and where it’s headed, you’ll enjoy this interview with Nino da Silva, Executive Vice President at BC Platforms

Be sure to check out Healthcare Scene’s full list of healthcare IT interviews and subscribe to the Healthcare Scene YouTube channel.

My MEDITECH MD and CIO Forum Experience

Posted on October 29, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently had the pleasure of attending the annual MEDITECH MD and CIO Forum. Not only was the venue and MEDITECH hospitality great, but they also ordered up beautiful fall weather for the event in Boston. Although, I have to admit that it must be intimidating to speak at an event hosted in the round. Luckily all of the keynotes really delivered (See my post about Ted James, MD’s keynote).

As long-time readers know, there’s almost nothing better to me than attending a user conference. At user conferences, you hear the “from the trenches” perspectives on what’s life really like on the front lines of healthcare and technology. In many cases, you listen to sessions and discussions at lunch that sounds like they’re speaking another language. For the most part, that’s basically what they’re doing. The language of an EMR user is really unique and different and it’s what makes an EHR user conference like this so special. Those attending speak the same language and are able to uniquely help each other.

Given users’ propensity to share the good, the bad, and the ugly, it was really great that MEDITECH invited me to attend their MD and CIO Forum. The good news for them is that I’ve been to enough EHR user forums that I’ve heard it all. Nothing really shocks me anymore and every EHR vendor has their challenges. In one session, someone commented on the 500 open tickets they had with support. I think it kind of scared MEDITECH that I was hearing this. However, I’d recently heard from someone using their competitor’s EHR who had 4000 open tickets. Only 500 tickets sounded quite good comparatively. Perspective and nuance really matter when you talk about problems. That’s something that’s often missed by many media these days.

While at the Forum, MEDITECH made a number of interesting announcements. Read on for details below and check out the 4 video interviews we live streamed from the conference on Facebook. The biggest announcement from my viewpoint was around voice enabling the MEDITECH EHR software. Together in partnership with Nuance, MEDITECH created a simple way for users to request information from the EHR using their voice and even to create orders. On the mobile side, they’re creating similar functionality in partnership with Google’s voice recognition. No doubt this is just the start of voice enabling the EHR.

It’s easy to see how voice will become really valuable if providers are able to get information and create orders while their hands are tied up examining the patient. MEDITECH was also smart about the voice created orders. It doesn’t just order things automatically but queues up those orders for the doctors to approve later. This is a common step we’ve seen smart vendors take when adding voice and other AI to the documentation process. We’ll see over time whether the accuracy and trust reach the point that this human verification process is no longer needed.

MEDITECH also announced a number of things around interoperability. First, outbound FHIR integrations are included in every MEDITECH EHR. Plus, they’re working on inbound FHIR integrations. They didn’t set a timeline on inbound integrations but they did say they’d be “coming soon.” MEDITECH also talked about their new API called MEDITECH Greenfield. If you want more information on Greenfield, be sure to read our interview with Niraj Chaudhry where we cover it in detail.

Another interesting announcement was MEDITECH’s new population health oriented integration with Arcadia.io. It’s great to see MEDITECH embracing outside third party data that can help their users provide better care to patients. Plus, the integration looked really seamless from a physician user perspective.

Another big takeaway for me came from a session on governance and end user buy-in. The takeaway was simple. Enduser buy-in and governance are a challenge regardless of what EHR system you choose. To get more specific insights into how to improve buy-in and governance in your organization, check out the live tweets I shared on the #MDCIO2018 hashtag on Twitter.

A few other observations from the event are that I don’t think most people appreciate what a huge step forward Expanse (their latest EHR platform) is for MEDITECH and their users. I’ve often written that there’s no one feature about EHR software that’s hard to implement. However, it’s the 1000 features you need to create a complete EHR that makes it such a challenge. It was a pretty brave thing for a 50-year-old company, MEDITECH, to go back and start nearly from scratch using the latest technology to create Expanse. That means that Expanse is still a work in progress where they’re adding features as fast as they can. However, it also is true that it might be the only EHR software that was built in the post-meaningful use era.

I was also surprised by a number of users I talked to who commented on how the price of MEDITECH really mattered to their organization. I’m not sure if these organizations had read the many stories of expensive EHR implementations damaging healthcare organizations financially or if they were just more fiscally conservative organizations. Either way, you could tell these users appreciated that MEDITECH charged a much lower price for their software than other EHR competitors out there.

All in all, I had a great experience at the MEDITECH MD and CIO Forum. Their users really reflect the culture of MEDITECH. They’re largely unassuming and just want to do what’s best for their patients. It was actually fascinating to see how the same cultures seemed to attract. No doubt, their users were still suffering from burnout like so many others. That’s common across all of healthcare. They also still had their long list of features and functions they wanted to be implemented. However, I have yet to attend an EHR user conference where that wasn’t the case.

Note: MEDITECH is a sponsor of Healthcare Scene.

The EMR Twitter Roundup

Posted on October 26, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Lots of really interesting discussions happening on Twitter about the EMR. Some are around really exciting developments. Others provide great insights. Others are complaining about how far we still have to go. Enjoy these EMR insights and perspectives as we head into the weekend.


I saw KLAS present this information at the MEDITECH MD and CIO Forum last week. The data is pretty compelling when it comes to EMR Training and Education and it’s tie to satisfaction.


The answer to this question is that this caluclation is really hard and the rules around it are really complicated and distributed across a large number of organizations. If we could solve this problem, it would be a great thing for patients. However, in our current system, it is a really hard problem to solve.


It’s great to see well done policies facilitated by technology. This is a great example of where that’s possible. However, this next tweet explains why we have to be careful about it too.


I hope he’s wrong about it being immortalized. Hopefully it’s just a step forward and that we’ll continue to see workflows adapted and changed. My guess is that he thinks they need to be scrapped completely and start over. Well, when has that ever happened in healthcare? Not very often. So, we have to stick to incremental improvement.

Cryptoeconomics Perspectives from Vince Kuraitis

Posted on October 25, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Vince Kuraitis is someone who always seems to be ahead of the curve when it comes to technology in healthcare. So, it makes sense that Vince would be talking regularly about blockchain, bitcoin, and cryptoeconomics. He’s even been aggregating a list of Healthcare ICOs which is the best resource I’ve found on the subject.

Vince recently shared a tweetstorm on Cryptoeconomics which I thought was worth sharing with readers:

The last tweet is the most interesting. However, the body of tweets illustrates how much more there is to blockchain and creating an ecosystem of tokens. So many healthcare “blockchain” startups are just riding the hot term without a real understanding of what’s required to really build something of lasting value. Not to mention to build an ecosystem that creates value to everyone involved in the ecosystem. That means you have to connect people and that’s hard work.

Plus, as Vince points out, there are a lot of moving parts when it comes to decentralized systems. No doubt there are a lot of feaux blockchain companies who kind of are on the blockchain, but really don’t leverage any of the benefits. These are increasingly easier to spot. However, many of them put on a really good front.

The moral of this story is that blockchain is complicated. I believe that we’ll find some really amazing use cases for blockchain. In fact, they might even be really simple use cases that create a lot of value. However, what’s not simple is cyrptoeconomics and creating an ecosystem that functions well. It’s not a simple build it and they will come scenario.

Proactive Management of End-User Experience – Flipping the Paradigm

Posted on October 23, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

Managing the performance of HealthIT systems improves the end-user experience which leads to less burnout, better patient experiences and a healthier bottom line. Instead of monitoring individual systems, Goliath Technologies is flipping the paradigm.

Each day, hidden gremlins in HealthIT systems are eating into productivity and sapping team morale. These gremlins are relentless and just when you think you’ve caught one, two new ones rise to take its place. The net result is negative end-user experiences.

What is a negative end-user experience? It is any situation where an end-user of an IT system experience something unexpected that impacts their work in a negative way. This could mean:

  • Slow response times (click and wait)
  • Sluggish application performance (typing faster than words appear on the screen)
  • Inability to access the system at all
  • Frozen screens
  • Unexplained workstation reboots
  • Loss of network connection

…the list goes on and on.

In healthcare, when a negative end-user experience happens, patient care is impacted. Sometimes the impact is small – like having to wait a few extra seconds for the lab result to appear on the screen. Sometime the impact is significant – like having to reschedule or delay a procedure because clinicians cannot access the patient’s record to see contraindications.

Negative end-user experiences also increase the stress on the end-users themselves – adding to an already stressful environment.

“We are almost at the point in healthcare where reacting to negative end-user experiences is no longer acceptable,” says Thomas Charlton, CEO of Goliath Technologies. “When a system is slow, or not available, patient lives are impacted. Clinicians expect systems to be available when they need it and they want those systems to work as expected. It’s no longer about having an uptime of 99.999%, we have to monitor and manage the actual end-user experience itself.”

“Most of the time, people troubleshoot with free tools provided by the vendor,” says Donna Grare, EVP and Chief Technology Officer at Goliath Technologies. “When a user reports a problem like ‘I can’t connect to application A’, IT starts a troubleshooting tree from scratch because there are many things that could be the cause of the problem.  It could be limited to this user – an issue with their computer or their local network, for example.  It could be a broader issue based on changes made to profiles that impact many users – generally IT only finds this out when one call becomes 10, 50, or 500.  With that many calls coming in, it’s clearly not a simple, one person issue, but IT is stuck looking for the common thread between them.  This is very frustrating for both IT and the users.  One comment we hear often is IT saying ‘I’m very good at my job, and I can fix problems.  It would just be great if I could be proactive and get ahead of the problem instead of only hearing about it after it happens.’”

This is a very standard approach to system management. IT departments monitor the performance of discrete systems: server response times, network packet speeds, application error logs, etc to determine if something is wrong. Although better than nothing, this approach has several drawbacks.

“This traditional approach leads to a lot of finger pointing,” explains Charlton. “If I’m the manager responsible for the servers, I will point to my server logs and say that the issue isn’t with the hardware since all the servers are ‘green’. The application managers say the same thing and on and on. Everyone is reporting green yet end-users are still experiencing issues. That’s the second problem with the traditional approach, ‘green’ is often a state defined by the vendors of the systems. Just because something is green doesn’t mean that end-user experience isn’t deteriorating. Lastly, the traditional approach ignores how healthcare applications are inter-connected. Slow performance in one application can have a cascading effect on applications that rely on it for data.”

So what does proactive management of end-user experience look like? According to Charlton, proactive management means flipping the old approach to IT systems management on its head. Instead of looking at the individual elements of HealthIT systems, Charlton and the team at Goliath Technologies approach things the other way around. They start by monitoring the actual end-user experience and help IT teams work backwards from there.

“When healthcare organizations deploy our technology, they gain visibility to key end-user experience metrics right away,” continues Charlton. “We gather the performance from all internal systems into one place. There is embedded intelligence in our platform that is based on years and years of experience troubleshooting system issues. This intelligence monitors the gathered information and alters the IT team when system performance begins to deteriorate, often before the call from the end-users start coming in.”

This early warning is key to minimizing the impact on end-users.

For a real-life account of how the Goliath platform was used to address slowness with an EHR (spoiler alert: the problem wasn’t with the EHR application), check out this article.

I have to admit that before I sat down with Charlton and Grare, I had no idea that platforms like Goliath’s existed. Their platform is the result of years of work with other industries: banking, legal and managed services. Smartly, Goliath realized that they would have to pre-build connections to popular healthcare applications before organizations would adopt their platform. They currently have connections to: Allscripts, MEDITECH, Cerner and EPIC.

Given that the Goliath platform isn’t exactly new, I had to ask Charlton why more organizations haven’t already adopted the approach of pro-actively monitoring end-user experience. “I think there are three reasons why proactive monitoring hasn’t been as widely adopted as we would like to see,” says Charlton. “First, many have spent a ton of money on their core systems, but have not allocated enough to the tools they need to support those systems. So they end up just using what came with it. Those tools are good, but they look at systems in isolation. Second, I think many believe they have ‘proactive monitoring’ but are just doing the bare minimum – like pinging a system to see if it is up and running. That is very different than true proactive performance tracking. Third, I think IT people are just not aware there is a pro-active tool available like what Goliath offers.”

“We hear it all the time,” continues Charlton. “In fact we recently had a customer tell us: ‘I had no idea that this type of technology was available. I was trying to troubleshoot issues with the tools that came with the core system. Now that I look at Goliath’s system I realize I was trying to do brain surgery with a butter knife’. I couldn’t have said it better myself.”

What’s the bottom line for HealthIT leaders? End-user experience (system performance) is a key contributor to workplace stress and clinician burnout. As competition in healthcare becomes more intense, patients as well as clinicians, will opt for healthcare organizations where negative end-user experiences are minimized. They will leave for green pastures where they don’t have to wait for a record to come up or explain to a patient how their surgery was delayed due to a systems issue.

If you would like to find out more information about pro-active end-user management, check out this upcoming live-webinar by Goliath Technologies on Tuesday October 30th at 12:30pm ET

Goliath Technologies is a proud sponsor of Healthcare Scene. 

 

Hospitals Taking Next-Gen EHR Development Seriously

Posted on October 22, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Physicians have never been terribly happy with EHRs, most of which have done little to meet the lofty clinical goals set forth by healthcare leaders. Despite the fact that EHRs have been a fact of life in medicine for nearly a decade, health IT leaders don’t seem to have figured out how to build a significantly better one — or even what “better” means.

While there has been the occasional project leveraging big data from EHRs to improve care processes, little has been done that makes it simple for physicians to benefit from these insights on a day-to-day basis. Not only that, while EHRs may have become more usable over time, they still don’t present patient data in an intuitive manner.

However, hospital leaders have may be developing a more-focused idea of how a next-gen EHR should work, at least if recent efforts by Stanford Medicine and Penn Medicine are any indication.

For example, Stanford has developed a next-gen EHR model which it argues could be rolled out within the next 10 years. The idea behind the model would be that clinicians and other healthcare professions would simply take care of patients, with information flowing automatically to all relevant parties, including payers, hospitals, physicians and patients. Its vision seems far less superficial than much of the EHR innovation happy talk we’ve seen in the past.

For example, in this model, an automated physician’s assistant would “listen” to interactions between doctors and patients and analyze what was said. The assistant would then record all relevant information in the physical exam section of the chart, sorting it based on what was said in the room and what verbal cues clinicians provided.

Another initiative comes from Penn Medicine, where leaders are working to transform EHRs into more streamlined, interactive tools which make clinical work easier and drive best outcomes. Again, while many hospitals and health centers have talked a good game on this front, Penn seems to be particularly serious about making EHRs valuable. “We are approaching this endeavor as if it were building a new clinical facility, laboratory or training program,” said University of Pennsylvania Health System CEO Ralph Muller in a prepared statement.

Penn hasn’t gone into many specifics as to what its next-gen EHR would look like, but in its recent statement, it provided a few hints. These included the suggestion that they should allow doctors to “subscribe” to patients’ clinical information to get real-time updates when action is required, something along the lines of what social media networks already do with feeds and notifications.

Of course, there’s a huge gap between visions and practical EHR limitations. And there’s obviously a lot of ways in which the same general goals can be met. For example, another way to talk about the same issues comes from HIT superstar Dr. John Halamka, chief information officer of the Beth Israel Deaconess Medical Center and CIO and dean for technology at Harvard Medical School.

In a blog post looking at the shift to EHR 2.0, Halamka argues for the development of a new Care Management Medical Record which enrolls patients in protocols based on conditions then ensures that they get recommended services. He also argues that EHRs should be seen as flexible platforms upon which entrepreneurs can create add-on functionality, something like apps that rest on top of mobile operating systems.

My gut feeling is that all told, we are seeing from real progress here, and that particularly given the emergence of more mature AI tools, a more-flexible EHR demanding far less physician involvement will come together. However, it’s worth noting that the Stanford researchers are looking at a 10-year timeline.  To me, it seems unlikely that things will move along any faster than that.

Hospitals Stumble When Asked To Share Medical Records With Patients

Posted on October 19, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

By this point, few would argue that patients are unlikely to be engaged with their medical care if they don’t have free, unfettered access to the medical records. However, unfortunately, research continues to suggest that providers are struggling to meet these goals — and from my point of view, shows signs that they don’t take the entire process that seriously.

Most recently a new study found that not only may hospitals be failing to meet state and federal rules on patient medical record sharing, they may not even be communicating about their own policies consistently.  As a patient with complex medical needs, I found this troubling, though sadly, not so surprising given my past experiences.

The study, which appeared in JAMA Network Open, looked at the way in which 83 US hospitals handled medical record requests by patients. The research team conducted the requests between August 1 and December 7, 2017, tracking what medical information was made requestable, what formats of release were available, costs to receive the information and request processing times. Researchers reviewed hospital processes using medical record release authorization forms and telephone calls with medical records departments.

After analyzing their data, the researchers concluded at least some hospitals weren’t complying with regulations regarding medical information request processing times. Of the 81 hospitals that responded to the researchers with mean times of release for records, seven had ranges extending beyond state requirements before applying the single 30-day extension granted by HIPAA.

In addition, they found that patients obtained different information regarding medical records request processes when they filled out form versus when they communicated directly with medical records departments. For example, just 53% of hospitals gave patients the option to request the entire medical record on their record request forms, while when the medical record department was contacted, all the hospitals said they were able to and release an entire medical record to patients.

Perhaps offering some insight into why patient portals aren’t as muscular as they could be, just 25% of hospital medical record departments said via phone that they were able to release records to online patient portals, and less than half (40%) shared this detail this on their forms.

Another issue highlighted by the study was that the hospitals studied seem to be vague about the costs patients faced in receiving records. Apparently, 22% of hospitals disclosed they would charge patients for such records but did not specify cost, and 43% didn’t specify that there would be a fee.

Having inadvertently walked into a cost backsaw once or twice in my pre-HIT days, I can’t stress enough how disheartening unexpected records fees can be for patients. After all, in some cases patients don’t get the care they need if they don’t have up-to-date-records, and until we have a completely universal interoperability scheme in place patients are on the hook to make this happen.

Getting the records seems to have been pricey. All but one of the hospitals were able to quote the cost for receiving records on paper, at prices which began at zero but went as high as $541.50 for a 200-page record. On the digital side, 59% of the hospital stated a cost of release above the federally-recommended $6.50 flat fee per page for electronically-maintained records.

As the study authors note, it would be helpful if federal regulators keep their eye on issues related to patient medical record access, which is more costly, confusing and time-consuming than it might appear at first glance. In the meantime, hospitals might consider doing a self-audit to see if they are offering patients consistent information on the process when we ask for badly-needed medical data.

 

Taming the Healthcare Compliance and Data Security Monster: How Well Are We Doing?

Posted on October 18, 2018 I Written By

The following is a guest blog post by Lance Pilkington, Vice President of Global Compliance at Liaison Technologies.

Do data breach nightmares keep you up at night?

For 229 healthcare organizations, the nightmare became a reality in 2018. As of late August, more than 6.1 million individuals were affected by 229 healthcare-related breaches, according to the Department of Health and Human Services’ HIPAA Breach Reporting Tool website – commonly call the HIPAA “wall of shame.”

Although security and privacy requirements for healthcare data have been in place for many years, the reality is that many healthcare organizations are still at risk for non-compliance with regulations and for breaches.

In fact, only 65 percent of 112 hospitals and hospital groups recently surveyed by Aberdeen, an industry analyst firm, reported compliance with 11 common regulations and frameworks for data security. According to the healthcare-specific brief – Enterprise Data in 2018: The State of Privacy and Security Compliance in Healthcare – protected health information has the highest percentage of compliance, with 85 percent of participants reporting full compliance, and the lowest compliance rates were reported for ISO 27001 and the General Data Protection Regulation at 63 percent and 48 percent respectively.

An index developed by Aberdeen to measure the maturity of an organization’s compliance efforts shows that although the healthcare organizations surveyed were mature in their data management efforts, they were far less developed in their compliance efforts when they stored and protected data, syndicated data between two applications, ingested data into a central repository or integrated data from multiple, disparate sources.

The immaturity of compliance efforts has real-world consequences for healthcare entities. Four out of five (81 percent) study participants reported at least one data privacy and non-compliance issue in the past year, and two out of three (66 percent) reported at least one data breach in the past year.

It isn’t surprising to find that healthcare organizations struggle with data security. The complexity and number of types of data and data-related processes in healthcare is daunting. In addition to PHI, hospitals and their affiliates handle financial transactions, personally identifiable information, employee records, and confidential or intellectual property records. Adding to the challenge of protecting this information is the ever-increasing use of mobile devices in clinical and business areas of the healthcare organization.

In addition to the complexities of data management and integration, there are budgetary considerations. As healthcare organizations face increasing financial challenges, investment in new technology and the IT personnel to manage it can be formidable. However, healthcare participants in the Aberdeen study reported a median of 37 percent of the overall IT budget dedicated to investment in compliance activities. Study participants from life sciences and other industries included in Aberdeen’s total study reported lower budget commitments to compliance.

This raises the question: If healthcare organizations are investing in compliance activities, why do we still see significant data breaches, fines for non-compliance and difficulty reaching full compliance?

While there are practical steps that every privacy and security officer should take to ensure the organization is compliant with HIPAA, there are also technology options that enhance a healthcare entity’s ability to better manage data integration from multiple sources and address compliance requirements.

An upcoming webinar, The State of Privacy and Security Compliance for Enterprise Data: “Why Are We Doing This Ourselves?” discusses the Aberdeen survey results and presents advice on how healthcare IT leaders can evaluate their compliance-readiness and identify potential solutions can provide some thought-provoking guidance.

One of the solutions is the use of third-party providers who can provide the data integration and management needs of the healthcare organization to ensure compliance with data security requirements. This strategy can also address a myriad of challenges faced by hospitals. Not only can the expertise and specialty knowledge of the third-party take a burden off in-house IT staff but choosing a managed services strategy that eliminates the need for a significant upfront investment enables moving the expense from the IT capital budget to the operating budget with predictable recurring costs.

Freeing capital dollars to invest in other digital transformation strategies and enabling IT staff to focus on mission-critical activities in the healthcare organization are benefits of exploring outsource opportunities with the right partner.

More importantly, moving toward a higher level of compliance with data security requirements will improve the likelihood of a good night’s sleep!

About Lance Pilkington
Lance Pilkington is the Vice President of Global Compliance at Liaison Technologies, a position he has held since joining the company in September 2012. Lance is responsible for establishing and leading strategic initiatives under Liaison’s Trust program to ensure the company is consistently delivering on its compliance commitments. Liaison Technologies is a proud sponsor of Healthcare Scene.

Insights from Ted James, MD at the MEDITECH MD & CIO Forum

Posted on October 17, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Over the next couple days, I’m attending the MEDITECH MD and CIO Forum. This is essentially the user conference for the MD and CIO users of MEDITECH software. This morning, they kicked off the event with Ted James, MD, Medical Director at BIDMC/Harvard Medical School. He provided a number of great insights into what’s happening in healthcare and what leaders can do to be more successful.

Below you’ll find a Twitter summary of Ted James, MD’s keynote. You can also watch the live video interviews I’m doing from the event on the Healthcare Scene Facebook page and follow along on Twitter using the hashtag #MDCIO2018.


Healthcare change seems to be an ever ongoing theme. The question really is around the pace of change.


Anyone that’s been through meaningful use understands this experience.


Routine is a powerful idea. So powerful that it prevents change.


Leadership is the key to any change and was a definite theme from Ted James, MD’s keynote.


I love the concept of nudges, but it only works for a subset of use cases in healthcare. Why? Because so many things in healthcare are really complex.


These 3 ideas were really interesting, but I definitely need more time to fully process what they mean. What do you think of these 3 ideas?


This was a really fascinating idea. It illustrates the need to constantly communicate changes so that people get use to the change before the change even occurs. Familiarity with something changes the experience.


Moving an iceberg feels like an apt descrition of healthcare.


This reminds me of when I recently heard that more yoga won’t fix the physician burnout problem.


This is an important lesson for leaders.


This was a refreshing experience to see so many women at a MD and CIO event.

Check back later for more coverage from the MEDITECH MD and CIO Forum.