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Readers Write 9/2/09

September 2, 2009 Readers Write 8 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Implementing the Continuity of Care Record in PDF Healthcare Format
By Stasia Kahn, MD

 stasia

As an Internal Medicine physician working in a small digital office, I am frequently called upon to share data with other healthcare providers and patients. In 2005, a colleague introduced me to the Continuity of Care Record (CCR) standard. 

I was impressed with the interoperability of the CCR standard that would allow me to exchange healthcare data electronically with my peers, some of whom are working with an electronic medical record and others whose records remain paper-based.

Since the fall of 2006, I have been exchanging healthcare data primarily for referrals of complex patients. Data exchange based on the CCR is richer than the traditional paper medical record that most primary care physicians fax to their consulting providers.

For example, one of the beauties of the CCR is that complex medical terms are presented in a codified manner, such as ICD-9 codes for problems, NDC codes for medications, and LOINC codes for laboratory tests.  In addition, the CCR generator I use to pull the data from my database allows me to be selective and choose the relevant information that is needed to solve a particular medical problem; thereby improving the efficiency of the receiving providers.

The PDF Healthcare Best Practices Guide and Implementation Guide, which were released in 2007, supplied me with the tools to attach diagnostic images and text documents to the summary document. Most tests and procedures are in either image or text format, and by including these in the information exchange, I am able to help reduce healthcare costs.

In addition, the positive feedback I received from my peers who received PDF Healthcare files in place of traditional medical records gave me the confidence to recently begin exporting PDF Healthcare files to my patients for the purpose of populating an untethered personal health record (PHR). I believe that a patient-directed PHR that has been pre-populated with authoritative data from a primary care physicians’ electronic medical record is the quintessential, longitudinal health record that our national leaders believe to be the Holy Grail that can solve the ills of a broken healthcare delivery system.

In closing, my implementation of the CCR in the PDF Healthcare format has helped me to improve the quality of care I deliver to my patients and at the same time reduce the cost of caring for them. The CCR standard used with the PDF Healthcare Best Practices and Implementation Guides allows for the interoperable, electronic sharing of relevant, codified healthcare information at the point of care for specialty referral and into a robust longitudinal health record of interested patients.

Stasia Kahn, MD is an internist with Fox Prairie Medical group of St. Charles, IL.

Healthcare Clearinghouses
By Scott Bayou

Perhaps I am missing a piece of the puzzle, but I really don’t understand clearing-houses like Emdeon and others.

We have X12 transactions that are supposed to level the paying field, yet most hospitals that I speak with are still sending their payment data through a clearinghouse and receiving the remittances back from the clearinghouse.

On the way back is where the real confusion comes into play for me. I know from companies like HDX that there is a per-transaction fee associated with the creation of the transaction. This per-transaction fee is variable (based on your ability to negotiate?) and varies from 15-40 cents per transaction.

Why? What benefit is being purchased? Each hospital has the right to obtain their 835 remittance, and there are various products on the market that allow for conversion to fixed text formats. Buy once and create postings to your HIS while avoiding per-transaction fees.

What am I missing?

Reporting? Most people I speak with get a limited set of reports from their vendor, and have to pay more if they want to customize reports or add new.

Archival? These transactions are not that big and can be held in most hospital’s Imaging or Document Management applications.

Relationship with vendor? Perhaps, many Siemens customers are given options to purchase HDX – or are they a partner?  Not sure of the real relationship, but someone is making a ton of money out of something that should be transparent.

Management of variances? Perhaps, this is a problem that shouldn’t be, but always seems to exist in the X12 transaction processing world.

Managing the minute differences that are expected by various payers? This might be it! Lack of governance in the payer market begs the need for clearinghouses?

Maybe, but I would love to hear what others think about this.

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Currently there are "8 comments" on this Article:

  1. Hey Scott…
    Good point. Why do they???
    Here’s more whys –
    Why do people pay a premium for pre-cooked meals? Why do you buy lettuce in a plastic bag and not the head at half the price? Why do CIOs rely on vendors to do/maintain interfaces when the name of the game in HIT is interoperability and we all know, regardless of vendor promises, we can’t get there without the continuous and the direct involvement of internal IT staff?

    The answer – convenience… and the marketers have convinced us letting them do it is ‘less work for mother’. And less work for the CIO is a very sellable service.

  2. Healthcare Data Exchange (HDX) is now just a division of Siemens; it was once a subsidiary of SMS that operated fairly independently (so that other HIS vendors would work with HDX too), but it was folded back under the big tent when Siemens acquired SMS.

  3. Thanks to Dr Kahn for her great testimonial. Everyone interested in the future o HIT should listen very carefully to her words…. the reason for this is that the majority of healthcare is delivered in small offices like Dr Kahn’s…..very few of which are digitized. Dr Kahn has spend years and much much effort to blaze an HIT trail in an environment that must be conquered if HIT is ever to make advances. She is telling us very clearly the things that need to happen to have interoperability in the real world.
    The HIT world is dominated by silos of information, because this serves the needs of vendors…. and the people who buy and use HIT don’t know different for the most part PDF Healthcare and the CCR need to become pillars of interoperability for real world use of HIT. When I learned about these two utilities, I was surprised that they weren’t more well known or utilized. CCR being the result of much hard work by physicians (I believe largely from the camp of the AAFP) with standards bodies to actually package information useful for the clinical practice of medicine; PDF-H an off-the-shelf feature rich container for healthcare information that I can view or print from virtually any computer in the world. When will we wake up to this basic ‘blocking and tackling’ that is already available but underutilized?

  4. Re: Healthcare Clearinghouses

    IMO, beyond continued comfort and lack of change, what providers get with clearing houses is business process outsourcing. The business office can simply (and often) say, “Magically the data is extracted from our HIS/EMR and money appears in return.” If the provider is more deeply engaged, then they describe how claims are scrubbed, rejections reduced, and whatnot — the “clearing house helps improve payments.”

    If the hospital actually works with and understands X12 messaging and understands the full scrubbing/pre-submittal validation process, then the value of a clearing house is (again, IMO) reduced. However, most hospitals do not directly grok X12.

    If we ignore the outsourcing aspect and the direct pain of X12 grokage, the final value of a clearing house communications infrastructure. While the transactions are most standard per HIPAA) the communications protocols are not at all standard. Said another way, each payor has the ability/option of creating custom protocols for communication and providing such details in their companion document. e.g., UHC can use real time web services with multi-part HTTP Post while BCBS of AL can use sftp while Medicare of CA can use ftps. Sigh.

  5. Thanks for sharing the information about CAQH CORE. If we really want clearinghouses to go away, this is the kind of endeavor that is needed. Any effort to move the health care system toward uniformity and transparency – and to thus lesson its existing complex and proprietary nature – is a step in the right direction. There are an estimated 6 billion medical claims filed each year. If every single one of those claims could be filed according to the exact same data protocols, with no payer specific differences for required fields; imagine the time and money that could be saved!

  6. Scott perspective is very accurate, but is really only identifying clearinghouse issues from a provider’s perspective. While the industry’s largest clearinghouse (formerly NEIC) was started by some of the nation’s largest insurance companies, today’s payers have a different perspective on clearinghouses since the advent of HIPAA Transactions and Code Sets. Most payers (and providers) were forced to invest in claims processing systems as a result of HIPAA and the need for HIPAA compliance. As a result, many payers developed the ability to accept and send transactions without being dependant on clearinghouses for transaction exchange with providers. One must also consider that a clearinghouse will charge both the provider and the payer for the same transaction (Medicare and Medicaid are exceptions, due to government policies preventing the payment of transaction fees to receive electronic claims, these payer entities have offered direct transaction exchange with providers well before HIPAA came into effect). According to HIPAA, when a provider and a payer exchange transactitions via a ‘direct’ transaction exchange (no middleman), then neither of these ‘covered entities’ can charge the other a transaction fee. While several large payers (Blue Cross, Medicare FIs & Carriers, Medicaid FIs) could accept transactions from providers prior to HIPAA (~2002), this industry trend has accelorated each year since HIPAA. The push to reduce ‘the cost of healthcare’ has further promoted direct transaction exchange between providers and payers. There are at least two indicators that verify this; the numerous ownership changes of most major clearinghouses and the financial statements published by publically traded clearinghouses. There are even instances where payers will offer ‘other incentives’ to providers to exchange transactions with the payer without use of a clearinghouse (cost justified by the elimination of clearinghouse transaction fees paid by the payer). Hospitals are employing direct transaction exchange with payers to a greater degree than physicians or physicain groups. This is also evident in clearinghouse financial statements that separate revenue from hosptials from revenue from physicains. Clearinghouse revenues from physicains has not dropped nearly as much as clearinghouse revenues from hospitals since HIPAA. Physicians also tend to pay higher transaction fees than hospitals. The convenience of using a clearinghouse is often ofset by the lack of control a provider has over the content of claims (editing for payer acceptance compared to editing for payer adjudiction) and electronic delivery of claims (one size fits all when a clearinghosue is used, isn’t that convenient). Most sophisitcated hospitals recognize the benefit of investing in a ‘claim editing and edi system’ that does not rely on a clearinghouse and does not employ transaction fees. Often, both financial performance (cash collections) and the billing productivty improve when replacing a clearinghouse-based vendor with a claim editing and edi system. It comes down to a ‘control vs convenience’ decision, and convenience has costs built in for both providers and payers. The recent HIStalk posting on Cigna and Emdeon shows a growing trend among payers, and one that Blue Cross pursued many years ago. Clearinghouses also face other threats to their way of doing business, and the healthcare industry’s 5010 conversion will further test clearinghouses due to the lengthy conversion period in the CMS timeline. Entities like the Utah Health Information Network (UHIN, http://www.uhin.org) are examples of state sponsored ‘switches’ that providers and payers use to exchange transactions without incuring transaction fees, clearinghouse delays, claim aggregation prior to re-transmission, inability to process payer acknowledgement reports and a host of other issues associated with clearinghouses. It’s not just a cost-based or convenience decision. UHIN has been in existance for almost a decade and is often ‘the model’ that RHIOs or the like try to emulate because it is a financially viable entity for information exchange between providers and payers. If you currently opt for a ‘convenient’ method of transaction exchange, with today’s emphasis on reducing costs in healthcare, you may want to consider other options available.







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