Readers Write: Tax Rebate? Insurance rebate!

Tax Rebate? Insurance rebate!
By Richard Gengler

Now that tax season is in full swing and the eventual rebate is around the corner, it is an ideal time to think about another kind of rebate. This one stems from the changes in healthcare policy with the Affordable Care Act (ACA) with the increasing push of the triple aim of improved patient experience, improving the health of populations, and reducing the per capita cost of healthcare.

With the individual markets becoming the fastest-growing part of the payer sector and increasingly competitive, payers are searching for any potential leverage to obtain, retain, and grow their membership base. There is more discussion on the importance of net promoter score (NPS), whereby payers can utilize their existing members to act as promoters.

By utilizing new innovations and alternative service modalities, insurance companies are able to hit all three parts of the triple aim. Almost on a daily basis we are hearing about innovations that have greater than 90 percent user satisfaction rates and significantly having positive impact on population health at potentially a fraction of the cost.

Health plans are required to have an 80 percent or 85 percent medical loss ratio (MLR), meaning that they spend this amount of the premiums they collect on medical expenses. The rest can be used for administrative, profit, and marketing. Any difference in this percentage must be refunded to the members, according to law. Great idea, but does this actually work?

Looking back to 2014, there are plentiful insurers offering rebates to their members in a wide variety of markets from individual, small group, and large group. Take, for instance, Celtic Insurance Company in Arkansas, which had $6,774,488 in rebates to its individual market. Or how about California Physicians Service ,with an astounding $21,819,095 for its small group market. In the large group market, Cigna Health and Life Insurance Company of DC sent back $5,608,359.

One would think this is an opportunity to fully engage and grow membership. Data from the Kaiser Family Foundation shows that many insurance companies are not meeting the medical loss ratio standards. This signals a missed opportunity.

To calculate the MLR is quite simple.

Let’s take, for instance, a population of 3 million Americans using a service that traditionally costs $1,751 per person per year. If there was an alternative service modality that is clinically equivalent for $30, this would create a savings of $1,721 and a percentage difference of 98 percent. If the premiums and other elements remain the same, this could be extrapolated out to provide bountiful rebates to the members.

Next time you are thinking about innovative strategies to increase the NPS of your members while increasing membership, think about your taxes. Your members will thank you, tell their friends, and increase your membership.

Richard Gengler is founder and CEO of Prevail Health of Chicago, IL.

Readers Write: All Claim Attachments are Not Created Equal

All Claim Attachments are Not Created Equal
By Kent McAllister

According to the 2014 CAQH Index, responding health plans representing 103 million enrollees returned data on claim attachments. There was approximately one claim attachment for every 24 claims during 2013 from those same responses.

Interestingly, the vast majority of claim attachments were submitted manually via paper delivery or fax. CAQH counted approximately 46 million claim attachments processed among the plans reporting, which can be extrapolated to roughly 110 million claim attachments industry-wide.

CAQH also estimates another 10 million prior authorization attachments. This statistic suggests a total of 120 million attachments annually across healthcare.

There’s a clarification, however, that must be made when dealing with attachments. Electronic attachments, in and of themselves, are not always the same despite industry rhetoric claiming that there is little difference between the healthcare sectors.

When dealing with the substance of attachments, there are two major distinct segments that providers must accommodate. These two segments are vaguely similar at the highest level, but distinctly different at the business process level for a few reasons. These two segments align with respective accountable payer organizations:

1. Health and dental plans: commercial health plans and federal and state fiscal agents and administrators,
2. Workers compensation (WorkComp): property and casualty insurance carriers and third-party-administrators.

The majority of the 120 million attachments are processed by health plans. Dental plans also manage an essentially equivalent business process for handling attachments, often through the same technical channels and human resources with similar skills.

Workers compensation claims, on the other hand, while voluminous, have a notably different set of business processes because of a number of distinctions in both the property and casualty insurance business and in the nature of “claims” in WorkComp parlance.

A WorkComp claim is generally related to an individual injured on the job. That claim may have a life of many months, or, in some cases, years. Resulting from that claim are typically many bills (or e-bills) that usually have an attachment. The e-bill submission process is more similar to property and casualty processes — such as auto physical damage — than to traditional health and dental plan processes.

An interesting contributor to this distinction is that property and casualty insurers are not considered “covered entities” under the 1996 HIPAA legislation. This is important, and any industry observers not recognizing this are failing to accommodate a major consideration.

Just as not all claim attachments are equal, neither are all vendors. For example, some companies that are heavily involved in the P&C space don’t work with the medical side, while others focus almost exclusively on medical. Vendors usually serve one of the two often-unrelated markets.

Providers must be aware of the differences. P&C electronic attachments, even though they may sound as if they’re in the healthcare setting, just don’t carry the same weight as electronic claims actually exchanged to support patient claims generated within a health system. Likewise, those vendors that work almost entirely in healthcare have little claim, if any, to the P&C market.

In a market filled with healthcare claims-related vendors, healthcare organizations must be able to place their trust in partners that understand the complete landscape of the healthcare space. They should also know that even though WorkComp may appear on the surface to be medical, it requires an entirely different scope of work than their counterparts working in the space. In this burgeoning sector of healthcare administration, messages are often painted too broadly with too wide a brush and healthcare leaders should be wary when entering into conversations that broach the subject of electronic attachments.

For the improvement of all parties involved, vendors should recognize and articulate the differences between health and dental attachment processes and WorkComp attachment processes in their public messages. The industry will be better served if vendors accept a mandate to clarify market confusion and to paint clearer lines as to their roles in electronic attachments.

Kent McAllister is chief development officer of MEA|NEA|TWSG of Dunwoody, GA.

Readers Write: Time for Providers to Lead the Price Transparency Revolution

Time for Providers to Lead the Price Transparency Revolution
By Jay Deady

With ICD-10 in the rear-view mirror, providers now face a new challenge – answering the public and media call for consumer price transparency. High-deductible plans now cover nearly a quarter of those Americans with commercial insurance, raising the ante on patient financial responsibility. Yet large numbers of patients remain confused about how much they will owe for hospital services—a full 36 percent, according to one survey.

This problem, unheard of in other consumer industries, not only endangers patient satisfaction scores, but threatens to increase the bad debt load of organizations already struggling with severely low margins.

While insurance companies and employers have deployed some pricing tools, they have done a poor job of accurately representing multiple providers’ fees within a geographic area. New technologies are available from a handful of companies that let providers take the price transparency bull by the horns and lead themselves.

These technologies transcend the usual approach of mere compliance with a state’s price transparency laws. Posting a list of charges on a provider’s website may satisfy the letter of the law, but it fails to give consumers an accurate picture of what they will owe for services. Knowing this, providers have struggled to come up with an alternative that does not reveal proprietary information to their competitors. Most have concluded there is no way for them to easily accomplish this and they refer questions to patients’ insurance companies.

But it turns out the path to truly efficient, accurate, and accessible price transparency is one that healthcare consumers can take themselves—directly from the provider’s website.

Healthcare consumers want – and deserve – an accurate understanding of what they will owe for services before they are rendered. The operative word here is “accurate”—as in an estimate based on the consumer’s current levels of insurance coverage. Or, in the case of a self-pay patient, an estimate based on the provider’s discounted fees for consumers that pay fully out of pocket.

Either way, with self-service pricing, healthcare consumers generate the estimates themselves, typically from an online calculator on the provider’s website. The process is quick and hassle-free. A consumer simply inputs their name, insurance plan number, and perhaps two or three more data elements. Within 10 to 45 seconds, a complete and accurate estimate appears, giving consumers immediate, line-item insight into what they will owe.

The process is powered by rules-based engines that automatically query, retrieve, and combine data from payer portals with the hospital’s charge master data and payer contracts. Analytics plays a critical role in assuring the estimate is accurate, including analysis of previously adjudicated claims to identify variances.

Such a tool neatly solves one of the most persistent challenges with implementing price transparency: the pitfalls of making proprietary financial information public. As a provider-facing solution, and because patient-unique information needs to be entered to generate an estimate, not just anyone can use the calculators. This is vastly preferable to putting a list of total charges or paid amounts out there for all competitors to see, which neither reflects negotiated rates with payers or the patient’s accurate out-of-pocket costs.

At the same time, self-service price calculators appeal to today’s information-driven patients and nicely align with how they already seek pricing on other purchases, from airfare to mortgages.

One of the most promising advantages of a self-service price calculator is its potential to engage consumers in multiple ways. After generating a price estimate, for example, the calculator could prompt high-deductible and self-pay consumers to view payment plan options. It could even engage those patients with concerns about their ability to pay and schedule time with a financial counselor. Realistically, we can only expect such concerns to grow along with the increasing number of high-deductible health plans. Since these plans were introduced in 2006, they have increased from 4 percent to a whopping 24 percent.

A deductible payment and co-insurance spread out over a year, or whatever the time span the provider and patient agree on, is clearly more manageable than a lump sum payment. Armed with clear, accurate information about how much they will pay—and how—healthcare consumers can better plan for paying their medical bills. This in turn will help reduce a hospital’s bad debt or charity write-offs.

Most important, patients who clearly understand their financial responsibility are more likely to schedule rather than delay urgently needed care. This reason, above all others, is why providers would be wise to take control of the price transparency issue now.

Jay Deady is CEO of Recondo of Greenwood Village, CO.

Readers Write: Trend Watch: Innovation Forges On in the Provider Sector

Trend Watch: Innovation Forges On in the Provider Sector
By John Kelly

Provider organizations face tremendous innovation challenges. The success or failure of new systems and technology will depend on their ability to adapt and anticipate the impact of major industry changes. Looking ahead to a successful 2016, hospitals and provider organizations should still expect barriers to using EMR data, should be wary of the hype surrounding cognitive systems, and should prepare for a value-based care partnerships world where providers and payers share information in ways not imaginable until recently.

EMR data will not be fully liberated in 2016

Barriers that exist to move data in and out of EMRs will not abate in 2016, despite pressure. The business model of EMR vendors and real technological barriers will continue to thwart the goals of interoperability sought under the concept of Meaningful Use.

The good news is that providers and payers are establishing pockets of innovation using edge technologies to support better care and risk sharing based upon shared data, and the public outcry over data blocking from EHRs will eventually force vendors to adopt standard APIs. We can expect the personal health data train to gain momentum with hundreds of new market entrants, but not in 2016.

Don’t trust the hype around cognitive systems

Technology-based cognitive systems in healthcare are not in our immediate future. There is lack of clarity around the FTC’s rules regarding software that makes a medical decision — when do they have to be certified as a medical device? Without medical device certification, can the output of cognitive systems be loaded into an EMR? What about malpractice liability?

Analytics vendors and their customers have been tentative in applying the technology to direct patient care, and counter to what other prognosticators believe, this liability and the fear of the unknown will slow down the cognitive market in the US.

ACOs will invest in payer technology

Successful ACOs will require the technology to support all-payer data ingestion. They will need to see the patients as a single population, but within the context of separate payer contracts. These organizations are beginning to invest in the technology that payers have used for years to successfully acquire and integrate claims data with their population health registries.

If providers are to succeed assuming risk, it will be by employing a highly-focused health management approach that addresses the specific risks associated with specific populations of patients. Population and risk analytics infrastructure requires capital investment beyond the reach of many small and mid-size provider organizations. To encourage providers to assume greater risk for performance, payers will offer shared information exchange platforms that augment provider capabilities with analytic services.

Accountable care continues to evolve

Healthcare market transformation will gain momentum in 2016 and provider organizations should also consider the following:

• Most first-generation ACOs will fail because they don’t know what it means to truly manage risk. They do not have the ability or will to modify how they treat patients. CMS, commercial payers, and the provider community have to figure out how to hold providers harmless on what they can’t control while also rewarding them for doing the things they can do well, then help them bet on their ability to delivery consistently on their promises.
• 2016 will see an assault on post-acute care providers, who until this point have long been profitable even as many provide little relative value. This will affect nursing homes, outpatient rehabs, and even vendors who sell to post-acute care providers. The release of Medicare data for public research, particularly in the area of Medicare fraud, combined with the high-profile budget line for post-acute care will accelerate the move to overhaul the post-acute care industry.
• Finally, don’t expect a change in administration to affect CMS innovation. Regardless of the 2016 Presidential election outcome, payment reform will continue, primarily both macro-economic reasons, but importantly as well, the political reality that both parties favor fundamental reform.

John Kelly is principal business advisor at Edifecs of Bellevue, WA.

Readers Write: The Many Flavors of Interoperability

The Many Flavors of Interoperability
By Niko Skievaski

As the shift towards value-based care persists, the demand for data is as hot as ever. That means the term “interoperability” will be thrown around a lot this year. Let’s describe the various flavors in which it will inevitably be discussed. I’ve seen many conversations become confused as the context for the buzzword is mixed. Here’s an attempt at outlining the various i14y use cases. (Can we start abbreviating it like we do i18n?)

Interoperability for Care Continuity

This is the iconic use case that first comes to mind. Chronically ill patients with binders full of paper records and Ziplocs bulging with pill bottles. As patients bounce around town seeing specialists, they often need to repeat demographic data, med lists, allergies, problems, diagnoses, prior treatment, etc. The solution to this use case calls for ad hoc access to a patient’s data at the point of care. A provider’s chart doesn’t necessarily need to be synced to all other providers in the disjointed care team. Rather, the data needs to be available upon request from the relevant provider.

New payment models have fueled demand for this solution. In a fee-for-service world, redundant tests actually brought more income to the health system,  whereas in value-based models, excessive costs are eaten by the organization. This aligns the provider and patient by incentivizing only the tests and treatments that have the highest likelihood of impacting the patient’s health. Understanding the value of any given treatment also requires looking across a wide set of patients. This brings us to the second use case.

Interoperability to Measure Value

In order to understand how to pay for healthcare based on value, we must make an attempt to measure the impacts to health: a patient’s health is a function of the healthcare they receive as well as a slew of other variables. Estimating this relationship requires a magnitude more data than we’ve traditionally measured. Beyond knowing the diagnosis and treatment, we’d need to control for behavior, family history, comorbidities, prior treatments, etc. Basically everything we can know about a patient’s health. And that’s for a single patient. To build a model, we’d need this information from a large sample of patients to determine the impact of each of these variables. But as treatments are provided to patients and we receive more results, we’ll need to be updating our models to refine their accuracy over time.

Much of this data is stored in an electronic health record over the time period a patient was cared for by that health system. But it’s likely missing data from care outside of that health system. And beyond that patient, how could we combine this record with a sizable population to make a predictive (or even representative) model? Even at very large health systems, limiting their records down to the few who have a rare diagnosis for a given sex and age, the sample set can become insignificantly small.

This i14y use case requires large sets of longitudinal data, rather than single patient records in an ad hoc query. Current attempts at producing such data sets have been extremely resource intensive and normally centered around research efforts focused on a single diagnosis in a de-identified manner. We’ve also seen rampant consolidation in the industry, partially driven by the notion that taking care of larger and larger populations of patients will enable more accurate estimations of value.

Interoperability to Streamline Workflows

This i14y use case has been around since before the term garnered widespread adoption in healthcare. HL7 was created back in 1987 to develop a standard by which health data could be exchanged between the various systems deployed at a health system: electronic health records, lab information systems, radiology information systems, various devices, and pretty much everything else deployed in data center. These systems are most often tied to a centralized interface engine that acts as a translation and filtering tool bouncing transactional messages between each.

So problem solved, right? Not quite. Over the past few decades, health systems have customized their HL7 deployments just as isolated communities evolve a language into a dialect. This proves problematic as each new software application adopted by the health system requires extensive interface configuration and the precious FTE that entails. Interface teams are increasingly the most backlogged tranche of the IT department. As health systems search for more efficient ways to deliver care, they’re more often turning to cloud-based software applications because of the dramatically reduced infrastructure costs and mobility.

This use case likely requires upgraded infrastructure that allows a health system to efficiently connect with and communicate with cloud applications. The customized HL7 dialects will need to be replaced or translated into something consistent and usable for cloud applications. HL7, the organization, is currently developing FHIR as a much needed facelift to a graying standard. In the coming years we look forward to seeing more FHIR adoption in the industry, and hope to avoid the level of customization we have seen with HL7v2 — although initial feedback and documentation from EHR vendors is not promising.

Interoperability to Engage Patients

This is likely the most interesting need for i14y because of its potential. Patients don’t currently walk into doctor’s office and demand that their health data be electronically sent to applications of their choosing. But then again, where are these applications? The inability for patients to authorize API access to their health data has undoubtedly stifled the development of innovative applications. Instead, new application creation has focused on the B2B space in search of enterprise revenue.

If a patient could download an app on their phone and authorize it to pull their medical history, an army of coders would mobilize in creating apps to engage patients as consumers. Application adoption would be holistically democratized and new apps would get to market instantaneously, as opposed to the usual 18-month B2B sales cycles. Applications would be developed to help patients decipher the complexities of care, track care plans and medication adherence, and benchmark against others with similar comorbidities. They could effortlessly download and store their records and be the source of truth. They could contribute their records to research banks that would be willing to pay for their use. Widespread adoption of patient authorized access to health data would almost make the other i14y use cases moot.

Luckily, we’re getting closer. There’s mention of its mandate in MU3. One of the challenges is solving for the chicken-or-egg problem. We need enough widespread adoption of a single authentication framework and data standard to simultaneously sway the development community and health systems to adopt. MU3 seeks to force the right hand side of that equation, however failing to mandate a prescriptive framework or standard in its current draft while wavering in its timeline. As written, it’s possible that health systems can comply with differing technology making the problem only slightly better.

I’m optimistic as accelerating demand has spurred i14y innovation across the sector. HL7 is rapidly organizing support around FHIR and SMART. Incumbent integration engines are stepping up their game and outside integrators are rapidly moving into healthcare. Startups are sprouting to tackle pieces. Some health systems are proactively standing up their own i14y strategies. EHR vendors are vowing to adopt standards and roll out tools to encourage application development. I don’t doubt that we’re beginning to see the fruits of the solutions that will be adopted in the years to come. But it’s on us — as providers, technologists, developers, and patients — to continue the rally cry by demanding i14y now.

Niko Skievaski is  co-founder of Redox.

Readers Write: HIMSS, Ice Cream, and the Law of Diminishing Returns (LoDR)

HIMSS, Ice Cream, and the Law of Diminishing Returns (LoDR)
By Mike Lucey

“Clearly the third scoop has fewer calories than the first and second. It is simply the law of diminishing returns.” This perverse application of the LoDR only returns a derisive, “You are pathetic” from my wife when used to justify the purchase of a large ice cream sundae. But I carry on and get the nuts on top — they are healthy.

It’s not that the LoDR doesn’t apply, just that I apply it to the wrong side of the counter. The medium at $2.75 (two scoops) and the large at $3.25 (three scoops) delivers less value to the ice cream lady. Extended (five or six scoops?), it would reach the breaking point where the ice cream would cost more to scoop then it would return in cash.

I wonder if some in our industry are confused as to which side of the counter they are on? More importantly, that the LoDR will flip the counter when we are not looking. Are we effectively and consistently asking the question, “Am I getting more than giving, or giving more than getting as I continue down this project path?”

Back in my days in financial services (maybe because our product was money), every project was systemically graded for current value. “Current” being the critical word. Not graded against the expected value we assigned at the start, but against the current costs, current value, and (here’s the kicker) current alternatives.

The Boston Globe recently published an article citing a Health Policy Commission study of the disparate cost of care in Boston-area hospitals. Using maternity services as an example, the study found large differences in what hospitals charge.

For us in the healthcare IT industry, it is notable that four of the five top hospitals are actively using or have recently installed Epic  with a big price tag (three Partners hospitals, one UMass). This correlation raises the question: how much IT cost flows through the system, and are there effective checks against these rising costs? Did LoDR flip the counter in these cases?

To Epic’s credit, there is a concerted effort on their part to control costs that are often embedded in questionable customization. In other words, the folks at Epic are applying the concern of LoDR against the impulse of the client to work toward the elusive “best” at an ever-growing expense.

As we head toward HIMSS, our annual festival of IT goodies, we get to see a whole new set of “current” alternatives. Can we review the new stuff through the filter of LoDR? Stuff that is truly new for me, does it get me more then I need to give? And the stuff that is newer than what I have, does it keep me on (or get me back on) the right side of the counter?

And for me the ultimate question: who’s giving away free ice cream? Because free ice cream has no calories. Everyone knows that.

Mike Lucey is president of Community Hospital Advisors of Reading, MA.

Readers Write: Removing Tunnel Vision from Enterprise Imaging

Removing Tunnel Vision from Enterprise Imaging
By Karen Holzberger

I find the evolution of technology to be fascinating. Just think about music. Fifteen years ago, CDs were the most popular way to access music. Now you can listen to music anywhere, instantaneously, from tiny devices. The population has universally embraced the change. Why has accepting change in healthcare been so slow and difficult?

I’m not saying we all need to be on the bleeding edge of innovation, but it’s important to remove the tunnel vision and recognize advances not just in diagnostic medicine or medical research, but also in health IT innovations that make things faster, easier, and less costly.

I was surprised when I read a recent report on enterprise imaging that their research and results was limited only to organizations with a vendor-neutral archive (VNA) or universal viewer (UV) technologies.

The need to access and store medical images has been the most common demand of radiology departments for decades, but to think that in 2016 enterprise imaging is only done with these two approaches – it’s like taking a Polaroid camera to the beach and waiting a week for the film to be developed.

Don’t get me wrong. This report got it half right, but VNA and UV solutions don’t fit the needs of every organization, and that can lead people down the wrong path. If healthcare facilities are going to succeed in advancing the quality of patient care, then it is time to accept new and nimble health IT solutions for enterprise imaging today that bring patient images to people’s fingertips as swiftly and securely as the cloud delivers your favorite song.

Over the last few years, cloud-based image exchanges have gained popularity as an option for enterprise imaging. A HIMSS Analytics Cloud Survey showed that 83 percent of healthcare organizations used cloud-based apps in 2014. While this simpler approach is not the same as a VNA, it allows facilities to achieve the same overall goals, often more efficiently. Facilities can be up and running on an image exchange in as little as two weeks and have central access to all necessary images via the cloud – anywhere, anytime.

VNAs are one of the oldest imaging technologies. When introduced, they finally allowed healthcare sites to collect data from all departments in one location and exchange that information with a broader audience. But what about patient care happening elsewhere and other types of patient data?

Today, it’s critical that facilities share information with other facilities, not just other departments within the same building. In addition, the shift to value-based care means facilities require quick, efficient technology that follows patients across a continuum, which takes more than just sending an image from point A to point B. Imagine only being able to listen to your favorite song on your iPod and not on any of your other connected devices.

VNAs can take up to two years to implement and can be horribly expensive. Further, since they don’t encapsulate all of a patient’s data, sites need to use them in connection with other solutions, like a picture archiving and communication system (PACS), to have a complete enterprise imaging strategy.

Cloud-based imaging, on the other hand, provides more than the seamless sharing of images. It delivers real value and efficiencies like capturing and sharing all relevant patient data, just like how the cloud allows you to access your music, videos, and playlists effortlessly between your phone, tablet and laptop. Which is why I’m perplexed that society openly welcomes this technology in our lives, but accepting technology that can make life-saving differences has proved to be so challenging.

The time to embrace is now. If not, I fear that we will only continue set back an industry that so desperately needs to move forward.

Karen Holzberger is VP/GM for diagnostics at Nuance of Burlington, MA.

Readers Write: Read This Before You Sponsor Another Hackathon

Read This Before You Sponsor Another Hackathon
By Niko Skievaski

Innovation is undoubtedly a hot topic right now in healthcare. For good reason: it’s said that one-third of spend is waste and payment models are shifting in an attempt to drive efficiency.

Technology is the obvious place to look for efficiency gains and health systems around the country are getting creative with ways to better utilize it. We see rampant partnerships with startup accelerator programs, direct early stage investments, innovation teams, and the advent of the “chief innovation officer” whose primary goals seems to be a gating mechanism for the army of entrepreneurs trying to make an impact.

We’ve directly participated in a dozen flavors of enterprise innovation programs over the past two years. With this experience, I’d like to ask health systems to try a different sort of program: just try our products.

That’s a lot easier said than done. Your organizations weren’t designed to adopt new technology. Over the past decades, data centers were constructed to house your intranet, EHR, ERP, LIS, MIS, and a slew of other acronyms. IT departments were invented to manage the onslaught of hardware and software subsequently installed on their machines. The systems are weaved together in a web of interfaces managed by graying whizzes from their cubicles.

Each new piece of technology requires budget, a new install project to be prioritized, FTE to be allocated, and expertise to be acquired. Why would any IT head want to shake up their delicate game of Jenga with new software? Especially software from an unproven startup. Especially software in the cloud.

This is poles apart from the modern, tech-savvy organization. Other industries felt market pressures and profit motives to become agile and modernize incrementally. Meanwhile, health systems felt little market pressure as costs inched up year over year.

Pressure later came from well-meaning government subsidies to adopt adequate electronic health record software, however exacerbating rather than toppling the Jenga tower. While health systems upgraded their hardware, the rest of the world moved to SaaS-based tools that eliminated the need for designated IT departments to show you where to click.

The mounting inefficiencies observed in everyday healthcare interactions could cause any millennial to quit her job and start a digital health startup attempting to bring a modern Web experience and level of service to an industry worth saving. This is the core of my request. We don’t need help starting more startups. We don’t need accelerators. We don’t need strategic investments. We need feedback.

I’m not referring to conference panels of CIOs or experienced entrepreneurs tearing startups apart. The feedback required to build an effective product comes at the front lines in the real world. It needs to get all the way into the hands of the doctors, nurses, support staff, and patients.

The technology crisis in healthcare is rooted in the lack of adoption of technology, not in the lack of technology. Similarly, your innovation won’t be in the tech you help to create — it will be in your ability to more rapidly adopt the tech that already exists.

Focus enterprise innovation efforts on decentralizing technology adoption. Figure out ways to let departments choose how to manage their work. Decentralize new technology budgets to get that decision-making process as close to the front line as possible.

The vendors will figure out ways to make it cheap enough by eliminating upfront capital and installation projects. IT should invest in infrastructure technology that allows modern technology to work within your facilities: fast Wi-Fi, modern browsers and devices, API layers, make SSO easy, etc.

Don’t partner with accelerators unless you plan allowing them to outsource your technology selection process. The primary reason those companies participate is to sell to you. And don’t invest in digital health companies unless you’ve used the product. Put your money where your mouth is. Otherwise, your investment is not strategic, it’s just money.

This will also force the business development teams to work closely with clinical teams for product validation. You’re all on the same team — align incentives. You don’t need to depend on accelerators and suits with MBAs to help you figure out if a startup’s product will improve care or increase efficiency at your hospital. The front line will tell you in 10 minutes if you let them use the product.

Niko Skievaski is  co-founder of Redox.

Readers Write: Dealing with the Aftermath of Hurricane ICD-10

Dealing with the Aftermath of Hurricane ICD-10
By Michael Nissenbaum

It seems only fitting to compare the October 1, 2015 transition from ICD-9 to ICD-10 to a hurricane. Like a hurricane, we tracked the pending event well in advance. The news media were filled with stories speculating whether ICD-10 would hit as expected and what the potential impact might be.

Even as we braced for the worst, ICD-10 made landfall with a great deal of noise and fury. But according to a Porter Research and Navicure survey, 99 percent of the 360 organizations who responded said they were ready for it and survived the event itself, meaning they were able to begin using ICD-10 when the deadline hit.

Yet Hurricane ICD-10 also shares another characteristic with its physical world counterparts: the aftermath may have a longer-term effect than the event itself. So while all the cork-popping and victory laps back in October may have been well deserved, providers are realizing the forecast is not all sunshine and light tropical breezes just yet.

As you address the ICD-10 aftermath, be wary of some of the issues that may still crop up  and prepare in advance to deal with them.

1. Be prepared to set up specialized “per payer” rules. While it would be great if every payer organization was now fully converted to ICD-10, it’s still not the case. For example, some smaller workers compensation carriers still aren’t accepting ICD-10 codes, so providers must process their claims differently. Ideally providers can set up special rules in their electronic health records (EHR) and/or practice management (PM) systems to automate this conversion and avoid the need to make manual changes, or even worse, submit paper claims.
2. Make sure your team is fully trained on the changes. While there is currently a grace period for unspecified ICD-10 codes, that leeway is scheduled to come to an end within the next year. Denials will then increase if you’re not prepared. The best approach is to act as if the grace period doesn’t exist. Ensure your team is trained to submit documentation that is specific enough to support the selected ICD-10 code in the event you’re ever audited. If your users are still struggling in this area, partnering with an expert third party for training may be a worthwhile investment.
3. Become experts on your most common codes first. We have gone from 13,000 codes in ICD-9 to 69,000 in ICD-10. That’s a lot to learn, but your team doesn’t have to master all 69,000 at once. Identify your practice’s most commonly used codes and make sure you can get them right every time. Once those are in good order you can expand the training on a prioritized basis.
4. Make the most commonly used codes available quickly through adaptive learning. Take advantage of technologies that “remember” the codes that are used most frequently and make them readily available without a lengthy search process. This will enhance user productivity and minimize user frustration.
5. Consider technologies that take advantage of natural language search. Another way to improve productivity under ICD-10 is help providers find specific codes faster. Natural language search allows a user to type in “chest pain,” for example, and be presented with answers that match chest pain specifically, as well as related terms such as angina and other heart-related diagnoses. This significantly reduces the time it takes for providers to search for the right level of specificity, especially when first learning new codes.
6. Take advantage of automated correlation between ICD-9 and ICD-10. Providers that are still learning ICD-10 may benefit from technologies that allow them to type in a familiar ICD-9 code and have the system narrow the choices to a closely related ICD-10 subset. While there will not be many one-to-one relationship between codes, trimming the options can be a huge time-saver.
7. Speed the selection process with filters. Technologies that use filters to navigate the ICD-10 coding process can also enhance productivity. These solutions deliver a step-by-step approach to drill down to the correct category (e.g., diabetes or chest pain,) followed by more precise options (e.g., left or right.)
8. Make sure your team understands the importance of these changes. It’s human nature to resist change and providers have had more than their share of changes thrust upon them in the last few years. But failure to comply with ICD-10 affects reimbursements for both the practice and the individual providers. Be as encouraging as possible and keep working to ease the transition.

While Hurricane ICD-10 may have passed through in October, there’s still work to be done. Many organizations are still suffering from productivity losses that could impact their financial success for a long time to come. If your organization is still not recovered from the ICD-10 aftermath, consider the implementation of time-saving technologies and partnerships with knowledgeable experts that can deliver the training and support you need.

Finally, it’s worthwhile to remember that the ICD-10 implementation date was pushed back twice, which is akin to giving providers 15 days warning for an impending storm versus a mere five days. Take note, all you rule-making bodies, and consider how a more sensible implementation pace contributed to the relative success of the ICD-10 transition. Something to keep in mind next time anyone considers cramming providers with a new round of arduous regulations in unreasonable timeframes.

Michael Nissenbaum is president and CEO of Aprima Medical Software of Carrollton, TX.

Readers Write: The Importance of HIT Succession Planning

The Importance of HIT Succession Planning
By Frank Myeroff

While getting ready for HIMSS 2016 Conference & Exhibition, I’ve had the opportunity to speak with many healthcare IT leaders about what’s on their priority list this year when it comes to acquiring, promoting, and retaining key HIT talent. One response that I heard over and over again was “Succession Planning.”

The HIT profession is seeing shortages of talent, making succession planning more important than ever. Having a well-developed and current strategic plan in place will help your organization prepare for the future in these vital areas:

• Prevent vacancies when baby boomers retire. As senior HIT personnel begin to retire, including many CIOs, the industry will lose leadership, knowledge, and skills and that won’t be easy to replace. However, even after having this advanced notice, many organizations are still unprepared for their absence. Therefore, they will find themselves with many vacancies, and consequently may cause them to make quick and rash hiring decisions.
• Recognize and develop future leaders. As we face a leadership shortage in HIT and in just about every industry across the board, companies must identify and foster those individuals demonstrating leadership skills and abilities through mentoring, training, and stretch assignments so they are ready to take the helm when the time comes.
• Prevent turnover and costs associated. Employees at all levels are less likely to leave a company that is committed to providing meaningful work and opportunities to grow. A continuous flow of engaged people with defined career paths will stop the revolving door which can be detrimental to any firm. A high turnover is quite costly. According to the Wall Street Journal, experts estimate that it costs upwards of twice an employee’s salary to find and train a replacement.
• Maximize organizational value. Healthcare organizations with an HIT succession plan in place are more attractive. Management teams having a strategy for when a key player exits protects the value, integrity, and longevity of the company. As a result, your company’s reputation stays positive and in turn, attracts top performers to your company.
• Meet growing demands for high quality, cost-effective care patient care. Healthcare leaders face unprecedented pressure to meet the ambitious expectations of health reform, i.e. to reduce costs and simultaneously assure high quality patient care. Therefore, the industry needs to better prepare their HIT professionals to manage the complex organizations that provide and finance care.
• Guarantee the stability of business operations. HIT succession planning helps to mitigate risks and ensures business continuity. People are your greatest asset. They can also be its greatest downfall. If your company becomes overly dependent on the services of a few key individuals, it can lead to operational risks that can cause damage when one or more of those key people are no longer there.

With HIT succession planning on the minds of so many organizations right now, there are a number of ways to find the HIT talent who can ultimately step-in to fill those current and future roles:

• Hire more military technology veterans. Organizations are on a mission to find, hire, train, and accommodate US military veterans who possess the IT skills in high demand, such as cybersecurity. The military represents a large IT talent pool even though military technology experts may not have civilian HIT certifications or experience. Savvy organizations are able to look past that when onboarding and then later assist returning vets in obtaining those civilian credentials, including IT certifications. In addition, when hiring military veterans, they bring so much more to the job such as leadership skills, ability to perform under pressure, teamwork, respect for procedures, and integrity.
• Implement college-level internships. More and more organizations are moving towards creating HIT internship programs at the college level. They consider it a year-round recruiting tool which means having an ongoing pipeline of future HIT talent. In addition, interns are an inexpensive resource while at the same time are some of the most highly motivated members of the workforce. Internships.com allows a company to post a profile free of charge. This way, a company gets exposure to top colleges and candidates without breaking their budget.
• Re-hire retirees for expertise and training. One way organizations will succession plan is to pay retirees to come back. Many IT professionals are now returning as consultants operating under one- to two-year contracts for their help and expertise. In addition, they are being asked to train and mentor promising IT professionals. These seasoned workers have experience and a tremendous amount of knowledge to share.
• Hire and promote from within. In many cases, organizations lay out an HIT career path that they use to retain quality people. This approach fosters loyalty and also positions your company as a place that career-minded individuals want to work. If you hire or promote from within, it also helps you to retain other key people.
• Acquire talent from outside or competitors. If an organization does not have confidence that an internal candidate is ready for the position, they may have to recruit from outside and from the competition. Hiring from a rival firm can mean bringing aboard someone who already knows your industry, your HIT initiatives, and/or can bring valuable new project knowledge.

Healthcare IT succession planning should be a part of every company’s strategic plan. It’s vital for the vision of where your company will be going in the future and how it will get there.

Most importantly, succession planning in general will shape how your organization develops and nurtures its people, assures a continuing sequence and pipeline of qualified people to move up and take over when needed, and assures that key positions will be filled with the right people able to carry your company into the future.

Frank Myeroff is president of Direct Consulting Associates of Cleveland, OH.

Readers Write: What EHR Vendors Need to Know About Implementing Minnesota’s Electronic Prior Authorization Law

What EHR Vendors Need to Know About Implementing Minnesota’s Electronic Prior Authorization Law
By Tony Schueth

It’s January 2016 and electronic prior authorization (ePA) is now “required” by law in Minnesota. There has been surprisingly little fanfare about this deadline, and it’s my observation that most electronic health records (EHRs) and providers are not ready to comply. Here’s what EHR vendors need to know about implementing Minnesota’s law, also known as MS §62J.497.

It’s not necessarily a mandate. Minnesota really wants clinicians to do PAs electronically using standards from the National Council for Prescription Drug Programs (NCPDP), but there are no penalties for non-compliance. According to a state fact sheet:

• “Starting January 1, 2016, prescription drug authorizations – including prior authorizations (PA) and formulary exception requests – must be exchanged electronically, using the NCPDP SCRIPT Standard version 2013101.”
• “The law does not require prescription drug PA and/or formulary exceptions. However, for those entities subject to the law, if PA requests and responses and/or formulary exception requests and responses are exchanged, starting January 1, 2016, they must be exchanged electronically based on the NCPDP SCRIPT Standard version 2013101.”
• No later than January 1, 2016, drug prior authorization requests must be accessible and submitted by health care providers, and accepted by group purchasers, electronically through secure electronic transmissions. Facsimile shall not be considered electronic transmission.”

While the language is very strong, the statute doesn’t definitively say that every single PA must be done electronically.

State officials acknowledge they may be out in front of everyone else: “technological updates to enable this functionality can take time, and manual methods for prior authorization may need to be used until electronic functionality is available with all partners.” Kudos to Minnesota for showing leadership.

Should you wait?

Despite Minnesota’s lack of a true mandate, I wouldn’t recommend waiting for the regulatory axe to fall in Minnesota. The paper-, fax-, and phone-based prior authorization (PA) process is time-consuming and burdensome to physicians and expensive for payers. In contrast, ePA promises efficiencies.

It’s early in the adoption cycle, kinks need to be worked out, and implementation isn’t uniform. That said, pharmacies and prescribers ultimately will prefer ePA over current processes to help keep pace with the PA requirements associated with the increasing number of drugs used to treat the rising number of the chronically ill. Furthermore, large integrated delivery networks will select EHRs that are compliant with the statutes and regulations in their service area. These EHRs must be able to handle transactions, such as ePA, regardless of site of care.

What about e-prescribing of controlled substances?

Minnesota has had 62J.497 on the books to mandate e-prescribing for all prescriptions effective since 2011 and the state has some of the strongest e-prescribing adoption in the country. We have heard anecdotally that Minnesota has a goal of having all controlled substance prescriptions being electronically prescribed by the end of 2016. While that appears to be just a goal, there are two aspects of controlled substances prescribing that should be kept in mind.

The first is that e-prescribing of controlled substances (EPCS) is permitted both at the federal and state level. Even so, the facts about the legality of EPCS are often surrounded by confusion. Because of this misperception and the fact that there are no penalties for non-compliance, demand by prescribers is just beginning to appear. But that is changing.

The second is interfacing with the state’s prescription monitoring program (PMP), which is up and running under the auspices of the state’s board of pharmacy. All dispensers (pharmacies or providers that dispense from their offices) licensed by the State of Minnesota must report on a daily basis all controlled substance II-V and butalbital prescriptions that were dispensed. To satisfy the reporting requirements, all EHRs should be able to interface with the PMP to provide the necessary information.

New York takes a different approach

What is interesting is the contrast of Minnesota’s electronic prescribing and ePA “mandate” with New York’s I-STOP. The spirit (and language) of the rules are very similar for both states, except, of course, that I-STOP doesn’t mention ePA. The key difference is that I-STOP articulates the penalties for non-compliance. New York has the right to impose professional misconduct penalties (including fines and possible license revocation) for non-compliance with I-STOP.

As a result, it appears that most EHR vendors with clients in New York have enabled their products to handle e-prescribing – including EPCS – and have emphasized their readiness.

I applaud both states’ efforts to lead and urge EHR vendors not to wait until the last minute to roll out products in either state. Your customers will appreciate it. Furthermore, your competitors will have solutions available for those who aren’t either prescribing electronically or facilitating ePA yet.

Tony Schueth is CEO of Point-of-Care Partners of Coral Springs, FL.

Readers Write: Industry Trends Impacting RCM in 2016

Industry Trends Impacting RCM in 2016
By Patrick Hall

Higher out-of-pocket costs, new reimbursements models, and rising operating costs are just a few of the trends that will impact provider revenue cycles in 2016. These industry developments will force providers to evaluate existing RCM strategies and possibly implement new technologies and workflows to simultaneously maintain financial health and address evolving consumer and regulatory demands.

Consider some of the more significant trends and their potential impact:

Higher out-of-pocket costs for patients

As the cost of insurance continues to rise, patients are shouldering higher out-of-pocket costs for deductibles and co-insurance. As a result:

• Consumers are paying more attention to the cost of care and requesting greater price transparency prior to receiving services.
• Providers need efficient tools to estimate a patient’s out-pocket-costs. This includes accurate eligibility and co-pay details, up-to-date information on a patient’s deductible status, and specifics on what services are included in a patient’s coverage.
• Consumers may need help managing the cost of their care. Providers may require automation tools to facilitate any special payment arrangements.
• Existing workflows may need to be altered. For example, in the past a practice may not have verified insurance information until the patient arrived in the office. Administrators may now elect to verify insurance details in advance of scheduled appointments and advise patients when a large out-of-pocket cost is anticipated.
• Providers face greater financial risk. When patients struggle to pay for services, providers risk losing revenue and must dedicate additional resources for collection efforts.

Overhead costs are rising, but not necessarily reimbursements

In order to preserve financial health, providers must:

• Remain diligent in controlling costs and managing the revenue cycle.
• Consider technologies that automate RCM processes and increase efficiencies.
• Make sure staff is well trained in order to maximize the benefits of technologies.

Provider reimbursement models are shifting from traditional fee-for-service to models that include incentives for the efficient delivery of quality outcomes

RCM is no longer as simple as sending out a claim after a patient office visit. Instead, providers must:

• Be proactive in managing the health of their patients.
• Implement workflows and technologies to help track patient outcomes.
• Improve care coordination to minimize test duplication, manage costs, and enhance outcomes.
• Prioritize efforts to collect patient payments at the point of care or in advance of procedures.

Meaningful Use and the transition to ICD-10 are less of a priority

Meaningful Use and ICD-10 have been top priorities for providers for the past several years. Today, however, most organizations have implemented certified EMRs and achieved some degree of Meaningful Use success, as well as made the transition to ICD-10. Providers now have more time and resources to address revenue cycle needs, possible platform upgrades, and the addition of apps to increase operational efficiencies.

In recent years, RCM has taken a back seat to competing priorities, but the changing healthcare landscape is forcing providers to evaluate existing strategies and technologies. This could be the year that RCM emerges from the shadows and perhaps into the spotlight.

Patrick Hall is EVP of business development for e-MDs.

Readers Write: Why Do Digital Health Startups Need So Much VC Investment?

Why Do Digital Health Startups Need So Much VC Investment?
By Tom Furr

It is projected that by the end of 2015, $4.3 billion in funds will have been raised to bolster digital health startups. The first half of 2015 saw $2.1 billion invested in this area.

To clarify, a digital health company is one that could not exist without broadly available digital technology (like the Internet) and serves the healthcare market exclusively — pure plays. A company that publishes software and happens to have a health application in its portfolio is not considered a digital health company. Providers and partners are also not in this area – they are service organizations.

It’s been reported that digital health represents eight percent of all venture funding. However, there are many companies that have been in business for nearly 10 years that have raised more than $50 million but are not experiencing anything approaching “Google-like growth.”

Even someone who reads business news occasionally understands that mega-startups like Uber are raising huge amounts of money to build a legal war chest to contend with suits and regulatory pressures around the world. There must be an obvious reason for the continued big raises for the Ubers out there as well as digital health companies.

So why are we seeing such a robust funding for digital health outfits? Is it that digital health companies require large capital requirements to contend with regulatory challenges akin to what Uber faces? Is it that digital health companies are started by people from healthcare who don’t really understand how to build scalable technology solutions that have great usability? Is healthcare continuing to be an industry that lags in the adoption of new technology? Are consumers, when they’re the ultimate end-user, unaware or unimpressed with the new offerings?

What’s going on? Companies may be bulking up with funds so they can last through a long, slow adoption cycle or the twisted path to regulatory acceptance. However, here’s my take on these important questions.

Is it that digital health companies require large capital requirements to contend with regulatory challenges in the healthcare?

I suggest that most established, large healthcare IT companies have been built on government subsidies and regulations that force providers to purchase their products. In some cases, this is the only way some companies will be successful, in stark contrast to software companies that build a product that adds value to the customer instead of it being a requirement.

The ability to transition from being forced to purchase to wanting to purchase (based on recognized value) has clearly built up lots of apathy in the industry against change or innovative products. That is why healthcare is the last major industry to send so many paper statements as compared to all other sectors, including banking and financial services.

Is it that digital health companies are started by people from healthcare who don’t really understand how to build scalable technology solutions that have great usability?

In my examination of currently available products, none strike me as being user-friendly or innovative. Even Athenahealth – arguably one of the top established healthcare IT innovators in digital health history — says it’s time for an upgrade to usability for all products, including their own.

I come from the payments space, which has similar characteristics to healthcare with regards to its established companies. However, it has seen massive amounts of innovation from companies like Square that is shaking up the status quo by building a solution that is easy to get up and running, even by my young son, validating the importance of usability.

3. Is healthcare continuing to be an industry that always lags in the adoption of new technology?

I think most will agree that healthcare is at the back of the line when it comes to applying innovative technology to operations versus clinical settings like the latest heart procedure. I challenge any of the established players to say they’ve kept back-end systems or user interfaces fresh. At least Athenahealth’s Jonathan Bush is willing to call a spade a spade, which I respect.

No established player wants to see their company become a Yahoo (they did not value contextual ads like those served by Google) or an IBM (which did not value a PC operating system as Microsoft did) when life gets comfortable and profits are healthy, so they crush innovation.

4. Are consumers, when they’re the ultimate end user, unaware or unimpressed with the new offerings?

If you look at any number of healthcare-related portals, it appears that usability was the last thing in mind when they were created. In fact, if it were not for Meaningful Use, would any of those vendors have even created portals? This gets back to my second point — that any new company is going to have to spend substantial amounts of money to educate patients on the value of their offering. In all likelihood, the same thing has to do be done with provider solutions.

So we’re clear, I am not advancing a radical change in the way the healthcare market behaves. It is an industry whose product is positive outcomes for people with, or prone to health issues. That must remain its focus. But it needs to realize that there are ways to do things better, faster, cheaper, and designed to be easy to use for providers and patients.

Let me restate my central question. Why is this happening? Let me ask you to join the conversation with your thoughts. Getting to the core reason will not only help healthcare investors, but more importantly, anyone providing or getting healthcare.

Tom Furr is founder and CEO of PatientPay of Durham, NC.

Readers Write: Inventing the Mid-Cycle with Patient Self-Service

Inventing the Mid-Cycle with Patient Self-Service
By Janie Tremlett

It’s no surprise that payment models in healthcare are transforming. What may come as a surprise, though, is how quickly these models are transforming. Healthcare is rapidly moving to incorporate measures of value into payment models, with more than two-thirds of payments expected to be based on value measurement in five years, up from just one-third today, according to a study conducted by ORC International.[1]

The study goes on to state that most of the key obstacles that need to be overcome during this shift are technology-related, with one of the biggest technology problem areas being data collection, access, and analytics. Hospitals and health systems’ financial health is now come to depend on getting and accessing accurate and current data, documenting data, and ultimately delivering good clinical outcomes.

Defining the Mid-Cycle

The mid-cycle is where revenue cycle meets clinical interactions and patient access. A value-based reimbursement system requires tighter integration of clinical records and other systems with providers’ financial systems. Today, however, a key bottleneck for many hospital revenue cycles occurs in the link with the clinical side. Identifying this bottleneck area and learning how to optimize it is critical for healthy financial performance, solid clinical performance, and for patient satisfaction and engagement. 

How can we optimize it? Start small.

Capturing Data Pre-Service

There is an opportunity to engage patients in a pre-registration workflow pre-service — before they have even stepped foot on premise — on a personal device, such as a laptop, smartphone, or tablet. Several items go into a pre-registration workflow, some of which can include a confirmation or update of a patient’s demographics and insurance information, completion of forms and questionnaires, and bill payment. Capturing that information beforehand has a great impact when it comes to anything that needs to be sent to the patient, such as appointment reminders, billing, mail order prescriptions, and lab results.

In addition to asking for demographic information confirmation, you have the opportunity to ask clinical screening and clinical intake questionnaires relevant to a patient’s appointment as part of the pre-registration process. These questionnaires can help determine any number of issues, like maybe the patient is scheduled for the wrong appointment, before they ever show up on site.

For example, a patient may be scheduled to receive a procedure at a certain location, but, based on his or her answers to a questionnaire, it turns out the patient is in a wheelchair and the original appointment location wouldn’t be appropriate because the spacing and equipment don’t allow for the size of a wheelchair. It could have been a disaster for the patient to actually go to the appointment, not only because it would have been a waste of time for the patient, but also because the hospital would have wasted an appointment time slot with expensive equipment and would have to spend time finding a new appointment time and location for the patient. Through a questionnaire given pre-service, this can be found out and flagged in advance.

Facilitating Data Capture On-site

Just like the airline industry, where travelers can check in for a flight on a kiosk at the airport, patients can do the same at a hospital or health system. The big advantage to having an on-site registration and check-in solution is healthcare facilities can capture patient data on patients who they’re not expecting to arrive, like a walk-in, and thus can’t ask to complete a pre-registration workflow.

Instead of registering and checking in face to face with a member of the hospital staff, kiosks — whether they’re free-standing, wall-mounted, table-top, or tablet kiosks –  can be designed for a quick two-minute interaction. They’re an effective way to identify patients on-site, give them questionnaires, take them through relevant workflows, and triage them. Even the most basic question, “Are you here for a scheduled appointment or are you here as a walk-in?,” can allow healthcare facilities to optimize their patient flow.

If you take it a step further and ask questions like, “What are your symptoms? What is your pain level?” healthcare facilities have the opportunity to prioritize patients and get them to the right place in a timely fashion. Kiosks also can be used to educate or inform patients. For example, if healthcare facilities want to encourage their patient population to get flu shots or to think about getting tested for a certain disease, they could display notifications or reminders on these kiosks.

Automating Clinical Intake Documentation on the Front-End

There is a lot of clinical intake documentation that we can pull out of the clinician workflow that really gets down to them simply interviewing patients. We can take these parts to the patient to do electronically, and then feed it directly into the EMR. We call this concept of patient-directed digital questionnaires a “virtual clipboard,” a tablet or kiosk with the same questionnaires patients would have been given in paper form, but now just automated.

The virtual clipboard is a practical, low-cost way to save time and start providing relief to clinicians during their clinical workflow. Specific areas that can be automated using a virtual clipboard include:

• History of present illness
• Medication reconciliation
• Chief complaint
• HIV, drug, alcohol screening
• Behavioral and mental health screening
• Antibiotic over-prescription screening

Identifying and Optimizing the Mid-Cycle

These results are certainly within reach. By taking a small step in extending patients the ability to enter their own data, healthcare systems can strengthen their documentation initiatives, which will ultimately optimize their revenue cycle and bolster their bottom line.

[1] The 2014 State of Value-Based Reimbursement, ORC International, 2014.

Janie Tremlett is GM pf patient solutions at Vecna Technologies of Cambridge, MA.

Readers Write: Inefficiencies Lost, Productivity Gained: Healthcare Communication Systems the Key

Inefficiencies Lost, Productivity Gained: Healthcare Communication Systems the Key
By Lindy Benton

Healthcare providers continue to seek a unified electronic view of patient’s health data, one that is comprehensive and fully accessible across the enterprise. Considered the health IT holy grail for many hospitals, the benefits of such are far reaching. A unified platform for communication and data collection facilitates better collaboration among care teams, increased productivity, and improved performance across the healthcare continuum.

Progress toward this objective has been a challenge for providers because of the lack of effective methods to capture and manage unstructured data that typically resides outside the EHR. Hospitals struggle to integrate information needed from ancillary systems as well as from disparate sources, such as paper files and even verbal exchanges. Only when data from these sources are aggregated and accessible through a single repository can a truly comprehensive view of the patient’s path across the spectrum be achieved.

Recent advancements in health information exchange and integration, however, have positioned the industry closer than ever to meeting this goal. With new options for solutions that facilitate the secure exchange of health information and management of healthcare communication, providers are within reach of a single integrated platform to view all patient data.

Providers can now document all interactions – phone calls, faxes, web visits, medical records, and even face-to-face conversations – tie them to the patient record, and centrally store them for viewing, processing and retrieval. By combining the capture and management of all communication types, hospitals are able to close gaps in documentation processes and create for themselves a complete view of patient information available and exchangeable across the organization.

Taking such steps has implications not only at the point of care, but also in the revenue cycle. As hospitals continue to invest countless resources to ensure full and accurate reimbursement for services, there are ever-present nuances and variables affecting this process. Documentation of the hospital’s communication surrounding payment, therefore, can protect the investment being made to secure these hard-earned dollars.

Of course, this is just one example of many improvements realized from a unified view of patient data. The following are additional opportunities for health systems to better leverage health information and communication management systems for improved performance, workflow and quality outcomes.

Financial Performance

Performance in denials remains an area of concern for many hospitals. Nearly two-thirds of errors leading to initial denials originate in patient access departments and issues associated with eligibility, authorization, or demographic information. Systems that document hospital efforts to secure authorization – verbal, fax and electronic – can be leveraged to prevent and overturn denials, shorten appeals, and reduce cost to collect. Documentation of the agreed-upon level of care also helps hospitals avoid retro denials for lack of medical necessity, translating into countless thousands in savings for the hospital.

Physician and Staff Alignment

Lost physician orders cause frustration among physicians, increased wait times for patients, and bottlenecks throughout the hospital. Routing fax and electronic exchanges through a central platform allows providers to receive and manage all orders in one location. In so doing, the hospital improves workflow, process times, and service to both physicians and patients. For example, with fax and electronic orders in a single location – searchable by patient and available enterprise-wide – physicians and staff can confirm in advance that orders are complete and accurate for all patients prior to service. Whenever and wherever the patient arrives, staff are able to immediately locate and process the order, reducing delays and cancellations that can result from missing orders.

Centralizing fax and electronic communication also gives providers the opportunity to reduce costs and risks associated with standalone fax machines. By converting to an electronic process, providers gain the benefit of a digital audit trail of individuals who have accessed each record, reducing the risk of a HIPAA violation caused by unauthorized access to paper files. Converting to an electronic fax process can also reduce document delivery costs such as maintenance and paper by up to 90 percent.

Patient Experience

Studies have shown that more than 50 percent of patients say that good communication is the primary reason they chose a hospital or clinic. Similarly, a patient’s rating of provider communication skills has been shown to be the strongest predictor of overall HCAHPS scores. Creating a positive patient experience means managing the hospital’s message from the first point of contact to the last. With systems available to capture and centralize all patient encounters – phone, electronic and in-person – providers can review interactions to improve quality, conduct service recovery, and reinforce communication best practices across departments for a better overall patient experience.

Workflow

Hospitals need convenient access to patient records while ensuring that protected health information remains secure. Secure sharing of records between systems and team members can eliminate time-wasting and error-prone processes. A central point of access to patient data reduces duplication, rework, and back-and-forth between departments.

Patient Safety and Quality

Movement toward a value-based delivery model has placed even greater emphasis on care coordination. Systems that streamline the process of getting the right information to the right people mean faster response times, better care transitions, and possibly improved continuity of care. With quality assurance programs to ensure compliance with hospital policies and procedures, providers can better protect patient safety and promote better outcomes.

Hospitals can now close several gaps in documentation through an enterprise-accessible patient record. Real-time, seamless access to critical patient information fosters an environment for better care outcomes and improved revenue cycle performance. There are clear benefits to aggregating communication and capture systems and pairing them with the electronic health record to tell the full tale of the patient’s story from the moment of entry to the time of exit.

Lindy Benton is president and CEO of MEA|NEA|TWSG of Norcross, GA.

Readers Write: 501(r) — Are You Ready for This?

501(r) — Are You Ready for This?
By Jonathan Wiik

Last time I checked, hospitals have a lot on their plates. Remember October? ICD-10 ring any bells?

In case you haven’t heard, another new set of regulations — under section 501(r) of the Affordable Care Act — is set to take effect in 2016 for all 501(c)(3) non-profit hospitals. The implications: comply or lose your tax-exempt status.

It’s a hard truth, but the healthcare industry is facing more regulations than nuclear power—look it up. These new regulations are far from straightforward. Compliance with 501(r) can be incredibly complex. The entire process can take anywhere from several months to a year, depending on how smart your people are.

Not to mention expensive. Staff, signage, documentation, training, etc. are all crucial elements of effective 501(r) compliance. What’s more, you may need to hire a new employee or two just to manage the task.

In a nutshell, 501(r) requires that you satisfy new regulations around CHNA, FAP, ECTP, AGB, and EAC. (Go ahead and look up those up after you read up on nuclear power—or just read on.)

Here’s what you need to know about 501(r):

• Congress passed the Patient Protection and Affordable Care Act (PPACA) in 2010.
• Prior to this, some non-profit hospitals had been engaging in aggressive billing and collections efforts that brought their “charitable” status into question.
• This led to the enactment of section 501(r), which requires non-profit hospitals to demonstrate the benefits they provide to their patients and community from a financial standpoint.

As part of 501(r), non-profit hospitals must now meet four specific requirements in order to maintain their tax-exempt status:

1. Conduct a periodic community health needs assessment (CHNA).
2. Provide written financial assistance and emergency care policies (FAP, ECTP).
3. Establish limitations on charges for emergency or medically necessary care (amounts generally billed or AGB).
4. Set policies and procedures related to billing and collection activities (extra ordinary collection or EAC).

There are three basic approaches you can take when it comes to compliance:

• Ignore it, do nothing, and assume that you’ll handle it when something happens.
• Check with the experts in your organization to see where you stand.
• Take a proactive approach, put a team together, perform an assessment, and establish an action plan. (Hint: choose option 3 if you want to bolster your charity status, prevent poor patient experiences, ensure your tax-exempt status, and maybe even reduce future expenditure.)

Here’s how to get 501(r) right:

• Measure the pros and cons, risks and rewards of tax-exempt status against the costs of 501(r) compliance. I the juice worth the squeeze? Personally, I think it is for a variety of reasons, but it’s still helpful to understand what you’re in for.
• Document, document, document. Proper documentation is a crucial requirement of 501(r), but it can also be used to show that you’re making a good-faith effort to comply with the rest of the requirements.
• CHNA. This may actually help support your strategic plan. Are the programs offered by your hospital meeting most of the needs of your community? Are all your resources in sync with the community? Have community wellness and health in general become better, worse, or stayed the same?
• Reputation insulation. Compliance can actually help you avoid negative patient experiences and minimize bad press. Along with the “worth” of your non-profit status in the community, in hard and soft costs, the fines can pile up quickly.
• Use third-party data to presumptively determine eligibility for FAP. 501(r) clearly permits the use of presumptive eligibility, which enables you to assess a patient’s financial health early in the revenue cycle. By streamlining this process with third-party data, you can realize increased or accelerated cash flow as well as save time and money by converting manual workflows into automated processes.
• Documented standard work. The use of third-party data can help facilitate a consistent (unbiased) and efficient method for identifying which patients are eligible for financial assistance, effectively taking the guesswork out of the equation. Additionally, 501(r) requires that you thoroughly screen patients for eligibility before sending them to collections or initiating extraordinary collections actions. Again, by using third-party data, you can identify which self-pay accounts can be pursued for collections and which accounts can be presumptively qualified for charity care. This allows for an accelerated segmentation of aged self-pay accounts into payment, charity, and bad debt buckets.

At the end of the day, it’s important to evaluate your patient mix and adjust policies to fit any changes, as well as track and measure your results. Be sure to establish measureable goals to ensure that your FAP-reporting processes are meeting 501(r) standards as well as your patient population mix. Setting a specific number of goals will help keep the focus on the high-priority tasks, ensuring that your processes can be measured more effectively. Are you ready for this?

Jonathan Wiik is principal, revenue cycle management, with TransUnion of Chicago, IL.

Readers Write: Clinical Decision Support: Are We Ready to Invest?

Clinical Decision Support: Are We Ready to Invest?
By Jaffer Traish

Sometimes great ideas are just ahead of their time. Microsoft launched a smart watch in 2004. Digital currency received 100M in venture funding, but collapsed in the dotcom era. Google Glass has come and gone – or has it?

Evidence-based medicine and the marriage with technology is another open playground. Opportunities abound to create interactive, engaging clinician workflows to support real-time decision-making and enhance not just clinical outcomes, but the patient experience and revenue integrity.

The Hearst Corporation’s portfolio includes efforts to improve real-time medication decision support, maintain the currency of order sets and care plans, as well as drive care team and care transition communication. Wolters Kluwer is similarly working on the above, as is Elsevier in their respective product portfolios. The CMS value-based purchasing and other HITECH act incentives provide some soft carrots to push forward.

EHR vendors also provide significant clinical content (sometimes including specialties as well) that provide a very practical head start, though with no assessment of evidentiary integrity. Some startups like Stanson Health are also tackling niche areas of decision support.

The meta-analysis, categorization, and dissemination of evidentiary information is not a hard science. Teams of clinicians and coders together can review hundreds of articles and publish findings relatively quickly. Most healthcare systems have enterprise subscriptions to evidentiary libraries to consume these findings. Even as there is disagreement among communities over studies and trials, that very disagreement is the impetus for further study.

Some EHR vendors support communities of clinicians coming together to bridge the gaps in knowledge and best practice findings, especially in pediatric care.

Healthcare systems aren’t software development shops. Most don’t develop teams to tackle this opportunity. Instead, they hire analysts to manually manage the change (painful and expensive). The evidence subscription vendors have been trying, though they aren’t the EHR experts – the integration approach has been flawed. Groups like OpenCDS are refreshing and bring attention to standards development and process, though still ahead of its time. Last but not least, implementation, rollouts, ICD-10, and other priorities have taken the spotlight.

Clinicians are adjusting to their systems. Are they be ready to do focused collaboration on their (ex.) 200 order sets with evidence depth?

EHRs are maturing their decision support tools. Are they ready to participate more fully in sharing public specifications for standard decision support ingestion?

Evidence vendors have grown revenue streams on non-integrated IT tools. Are they willing to wipe the slate and start fresh with new API models?

Revenue cycle teams have been focused on SBO models, centralization, and patient satisfaction, but there is a strong link to revenue integrity with the reduction of unnecessary tests and improved standards of care. Is the CFO ready to demand this value?

In talking with many CXOs, some truly want to insource this activity while others would prefer to pay –  to have content and evidence managed externally and reap the lessons and value from others. Both models could prove effective. Today, the costs are high dollar subscriptions. Perhaps these costs need to be part of a risk strategy and not paid without successful implementation.

Today, if an African American would have better outcomes with a different antibiotic, the clinician should have this information at his/her fingertips in the workflow.

Today, if a drug is removed from the market, it should be removed from the clinician’s selection in swift manner without much manual intervention.

Today, if the several major children’s hospitals wanted to jump online and compare their pediatric specialty order sets, they should be able to do so with ease and share the best.

Today, if there are 500 opportunities to improve clinical content with evidence supported changes within an organization, the CFO should know what the patient outcomes and related costs/savings may be.

The list goes on, and we can do all of this today – manually.

The challenge is not dissimilar from the interoperability debate. Just as we need a national patient identifier, adopted patient security measures, and implementation cost-sharing that includes practices, hospitals, patients and providers, the same theme can be found here. We need public specifications through collaboration, a change in the way evidentiary information is so proprietary today and closer partnerships with innovation teams.

Organizations each pay $50k-1.2M for decision support systems today in existing budgets. Various market analysis projects decision support to be a market of $550M by 2018, and upwards of $2B in the future. Let us demand more for our healthcare dollars.

 Jaffer Traish is VP of the Epic practice at Culbert Healthcare Solutions of Woburn, MA.