Healthcare Round II, ARRA has passed now let’s see what AHCAA has to offer

There is a new kid in town and his name is AHCAA (Affordable Health Care of America Act)!!! This bill might send some software vendors back to redesign their booth and replace "Guaranteed stimulus money from ARRA" to something like "Our products are now more affordable than the free OpenSource as part of the AHCAA"

Travelling to conferences recently showed me an interesting trend, and that is of software vendors providing along with their package a "Guaranteed Certifiable Product" or "Guaranteed Stimulus Money". While some of the requirements have been described, it is alarming to see that this trend is spreading like wild fire and gaining momentum. Much of the concerns should be around how practices will gather the resources and the right stakeholders to apply meaningful use and implement policies and procedures as part exchange of electronic health records.

So, while we are coming to a better understanding of the ARRA HITECH, we are now facing a new round of recommendations and new potential incentives. On October 29th, 2009 House Speaker Nancy Pelosi announced a new Bill by the 111th Congress titled: Affordable Health Care for America Act".

After reviewing some of the sections that are relating to health care technology or HITECH, I discovered some very encouraging items in the bill. I will just list the very basic AHCAA HITECH summary of the areas I got through reading:

• The bill recommends that a study be conducted to see if providing higher rates of reimbursements or other incentives would increase the adoption of certified EHR.
  
• The secretary will have until January 1st, 2012 to develop a plan to integrate clinical reporting on quality measures which would include the following items:

o The development of measures that can demonstrate meaningful use of HER, and clinical quality of care furnished to an individual.

o The collection of health data to identify deficiencies in the quality and coordination of care for individuals eligible for benefits.

• Extension of Incentive payments from Act 42 USC 1395w -4(m) (1) where 2010 payments would be replaced by 2010, then instead of 2009 inserting 2010.

• Promoting low-cost electronic health records software packages that are available for use. Examples (can anyone say Medsphere is loving the AHCAA) which is based on the package of the Veterans Administration.

This was an abvious expectation from any bill that was upcoming. Making the push for electronic health records part of a public option, the motives are to encourage the adoption of EHR after many healthcare providers showed some resistance ARRA plans.

Between requiring electronic clinical data reporting, to adopting meaningful use, it to note that adopting some Electronic Health Record system will improve coordination of care, reduce medical error, and provide faster access to data when it is most needed. At this stage the only debatable factor of any EHR package is whether it offers a true Positive ROI.

This is the challenge that much of the current vendor must prove to the rest, otherwise everyone will look to OpenSource and vendors will lose a substantial market share.
　
　

How can the billing department increase efficiency

The billing or financial department:

Much of the practice’s income depends on this department. This is the team in the organization that ensures that your money is tracked down and retrieved from the Payers and challenging patients. So how can we assist through technology and how can different solutions enable them to be more efficient.

Easy to look up EOB:

First we will start by implementing an open source OCR product Click here. That’s right 0$ solution that will reduce the look up time of an EOB by at least 50%. A billing staff member can locate a document simply by searching the DOS (Date of service) or simply the patient insurance id and with the results displayed in a Google fashion.

Post patient payments electronically:

Next stop is to reduce or even eliminate the need to manually post payments. Now this solution depends on the organization’s billing system whether the PMS or HIS supports electronic remit (X12N 835 format) or not. This is the format that payers return their EOB. Fortunately that format can be utilized to post patient payments as well that have been made electronically through a web portal or from processed check payments. This dramatically reduces overhead by requiring staff to spend less time doing data entry.

Deposit payments from your office:

Let’s be honest here, checks will be around for few more years, just like when we were told that with Check Cards checks will cease to exist. Well, I am sure checks will continue to survive for a little longer. So, let’s see how we can still be more efficient around them. How about reducing or eliminating the couriers services for check deposits. If you can today deposit a check simply by taking a picture of it through your phone(ImageNet Mobile Deposit(TM)), then medical practices have got to be able to use the remote deposit feature that’s offered with many of today's banks.

Elegability Check:

Ok, if a practice is still not utilizing these services that are offered by most clearing houses, then this is the appropriate time to try them out. It is a very powerful tool, especially when it reduces your claim denials and patient balances that end up going to collections with 20% of your potential revenue.

While there are many additional ways to create efficiencies through out the practice, the billing department is a great place to realize cost savings immediately without major adjustments. Whether you employ claim adjudication, document management or simply outsource statement printing, it is very important to continuously talk to your vendors and stay connected with what is the latest and greatest.. This will ensure that you are constantly evaluating and implementing what matters to your practice.

P4P Quality measure with CPT is not in our future

History

“The system is broke”, is a far more common phrase we continue to hear. Whether it is a politician eager to promote more support for healthcare reform, or a patient who is too frustrated due to the sheer volume of bills they get from 10 different entities, just to have one procedure for appendix removal. Even physicians who are penalized for using too many CPT codes or procedure count to treat a complex condition and get penalized from the payers for it under their P4P programs are saying it.

So this begs the question, is P4P Quality measures with CPT the right thing? We are seeing that many of these programs have not shown a tremendous adoption from physicians. Take the PQRI initiative, statistics have shown an average of $700.00 return per physician which is relatively low comparing it to the costs the practice has incur. This begs the question, is it worth looking at P4P programs and worrying about implementing them? Is the technology available to measure the outcomes of patient treatment over time?

Is it possible that physicians will be paid based on treatment outcome?

Well, if you review the ARRA and what 2015 will bring you will a clear indication as part of the meaningful Use goals to be“clinical outcome measures, efficiency measures and safety measures”, you will realize that there is a tremendous emphasis on outcome measures this might not mean that you care providers would be required to follow the recommendations, but it will mean that if CMS does make the outcome measure as a mean to reimburse you on patient treatment, then as we know Payers will usually just follow.

What are the current facts?

The good news this possible change would not affect the way physicians provide care. Many care providers do see and treat the patient based on some mental measurements and grading if the patient is or is not improving. But it does get sticky when a group needs to report on it on paper. Take for example a patient being treated for a broken wrist. We can measure the outcome of the treatment based on the level of Pain, we can track the range of movement of the wrist after the cast is done and we can measure the improvement on the amount of time it took to have the cast off. While in many cases the person’s body will dictate some of those results, but we can still benchmark the treatment outcome.




However, when you consider the patients with chronic disease such as End-Stage-Kidney disease then the complexity increases tremendously. During a recent presentation by CTG, they had a very interesting approach to this challenge. They basically created a Master Patient Complexity index that they can use measure the patient condition through well defined scientific measures such as: Age, Hemoglobin, Creatinine, Bun, BMI, Calcium, Potassium and so forth. With a plot as radar spokes as shown here(Values are based on fictitious data and do not represent actual patient information).

Result and the impact of this direction

This can potentially result in a shift of paradigm. Physicians may not be paid on how many procedures done, but the improvement of their patient’s overtime using a proven Master Patient Complexity index. The current recommended model by CTG looks very promising and may as well be a starting point. There have been implementations of similar models by other groups such as Mayo Clinic. This would also mean that EMR/PMS products would need to have a different approach to how payors are billed and properly display the progress or patient treatment outcome of time. It is just another fun day for BI (Business Intelligence) and health analytics.

Conclusion:

While physicians continue to focus on providing care to their patients one must remember that doctors do have to be compensated appropriately. Using CPT for a way to measure care quality is definitely not an acceptable method of measuring the improvement on quality care, so considering other approaches is a must, and looking for technology as a tool to facilitate makes more sense than ever. It also means that physicians must become more involved in product and measure development. This will ensure that future EMR products will answer to the providers needs, improved measures to assist patients with complex conditions and create an efficient reimbursement system.

ARRA or stimulus Health IT calculator

The American Recovery and Reinvestment Act of 2009 (ARRA) has far-reaching effects in healthcare. Stakeholders affected range from patients, private physicians, and large hospital networks. The Act includes a planned expenditure of $34 billion for HIT, with $32 billion going to hospitals and physicians, as an incentive to adopt certified, interoperable Electronic Health Records (EHRs).

I have been getting a lot of requests to help calculate the potential incentives available for a practice. Many administrators and executives are asking if this pay for us to go paperless or pay for a full EMR implementation? Well, as easy as it may seem, you have to analyze your own numbers. As a lawyer told a colleague today about first home buyers. "You will get up to 8,000 dollars". The keyword there is "UP TO". So, for many practices the notion that each provider will get the max allowed amount will be depending on a lot of things. For many of the work I have been doing, I have developed a small cheat sheet or a calculator that can help shed some light on what dollars you may be getting based on Medicaid or Medicare provision. If you are interested feel free to email me the answer to the following questions and I will send you the results with some projections.

Email me or post a comment to this blog and I will respond.

A place to start:

For Medicare

____:Year when meaningful use
____:Number of MDs in your practice
____:#total allowable for Medicare Patients for 2008

For Medicaid

____:Year when meaningful use was
____:Number of MDs in your practice
____:%of patients with Medicaid
____:#Avg. Technology Costs
____:number of Midwives or PA or NP
____:Yearly maintenance and technology costs after implementation
　
　

Are your patients' health information protected enough to save you from the FTC or the new HIPAA under ARRA rules

With the new burden of newer fines and higher penalties from the modified HIPAA under the ARRA, and the new FTC “Red Flag” regulations, now healthcare organizations must re evaluate their current security protocols and infrastructure to keep the HIPAA auditors at bay.

In today’s fast moving technology, it is very hard for anyone to ensure that the next web site they visit will not install harmful Trojans, that can potentially logged every key stroked, or simply steal some files from their computer that could contain private health information.

Everyday Americans fall victim to identity theft because of information being stolen from computers in healthcare environments. And that includes having their health records used or insurance information to obtain health services and procedures. We are accustomed to hearing that most data breaches occur at large scale operations such as the heartland breach that hackers had potential access to the personal data of 600 million or more cardholders, even few years before that, the story of the chain TJX that had more than 45 million customers data compromised. But all these are extremely hard to accomplished, and require sophisticated and most advanced hackers. But what if you were told that your doctor’s office would be the next target right now, right out of their parking lot? Or what If a simple URL can land one of your nurses on the wrong web site that will automatically install a Trojan, which in turn will gain access to health data.

There are several threats you should be aware of as a consumer or a healthcare administrator. Again, the intent of this article is not to force you completely get rid of your computers and wireless networks, but it is to provide you with information that can assist in understanding your environment and the potential areas that may need to be reviewed.


Internal Threats:
The internal threads to your patient data can be identified in many areas. Just to give you an example, last week I visit with few technicians over a medium healthcare office, and as we were going through the DR planning (Disaster Recovery Planning), I asked about the offsite back up. To my surprise I received the following statements “We are covered on that, I take the tapes with me home”, I did not put too much though into it as I asked the next question assuming that the answer would have been yes. “Well, I am sure the backups are password protected and you are encrypting it right!”. Wrong, I received the following reply “Why? They are already in a tape, you think a thief will know how to restore from a tape”. Puzzled and disappointed I began to explain that it would be wiser to find a more secure method to store the sensitive patient information, and explaining how that can really jeopardize the practice and potentially open the door for possible law suits. After I went back to the office, I did a simple search in Google for “How to restore from a tape” and found the following: Results 1 - 10 of about 3,720,000 for How to restore from a tape. (0.16 seconds) . It was clear to me that there was a disconnect between the IT and Privacy and Security requirements. It is critical that sensitive data must be secured, and should not be transported offsite on laptops, tapes or hard drives without the appropriate encryption and protection.

Another internal threat would be the viruses or Trojans that find their ways into computers that are either unprotected or simply have expired Antivirus. Many of these infections originate from web sites that the users visited by mistyping a URL or simply clicking on the wrong link from a personal email. This has been a commonly used method by hackers to gain access to private information on computers through Trojans, key loggers and other remote control methods.

In a world where there are all too many horror stories of scammers, we begin to hear about cases of patients using factitious identity or posing as someone else, and using their insurance cards to gain access to cosmetic or medical procedures where the victim becomes responsible for picking up the tab. We are in an environment where a patient rushing their child to be seen for an illness and they say “their spouse has the insurance card” while the front desk feels obligated to let them be seen, and later come to the realization that the practice now has to write-off the costs of the procedures and treatment after realizing that their insurance was terminated or was not even for the right person. An insurance card does not present the practice with a picture ID, and in many cases where a valid license is and can be a requirement for the patient, many seem to not require that verification and increase the risk of false identity. This becomes a bigger issue as much of the current proposed health reform where the practice will not be able to bill the victim for the balance nor their insurance for a case stolen of identity.



External:
For the most part all health organizations have some sort of firewall already established. This is the device that protects them from outside intruders. But without the right hardware, you are left with a firewall that a hacker can easily discover the default password to, and remotely gain access to your network, or even

With that being said, I have found numerous times where health organizations use a common tool that allows them to logon remotely to their servers such Microsoft Remote desktop (RDP) without VPN (Virtual private network). That means that the server is exposed to the internet through a specific port that hackers can attempt to use to gain access. Some cases Brute force is used (where a dictionary of password is used to try several combinations of passwords for the administrative user), others just a matter of a previous employee still having an active account can gain access, take the data and sell it for profit.

While the above two require fairly advanced knowledge of hacking, there are always few simple ones that can truly be a very easy way to tap into your system or infrastructure. Wireless!!! In many cases if you approach a hospital the wireless infrastructure is so advanced and robust that you can actually detect if there is any attempt to connect to the network without being on the safe list of devices allowed, you can even detect if someone plugs in a new wireless network within the hospital wireless range. But the challenge here again, is that we are discussing the vulnerability of some of our small to mid practices. The ones that simply can not justify the cost of a $800 or more for a single access point. These are the cases where a simple low cost access point, that you plug and play allows you to get on a “secured” wireless can easily be cracked. WEP (some of the commonly used encryption methods by small practices) has poor architecture, and has been identified in the hacker community you can find posts that show you “How To Crack 128-bit Wireless Networks In 60 Seconds”.


The consequences:
In previous years, the above threats would have most likely been considered urgent but not important. Let’s face it, there was no real threat out there to begin with. As a matter fact, even the office that was meant to enforce the HIPAA rules had not levied a single penalty against any HIPAA-covered entity in nearly five years since they began its implementation. What has changed that would force everyone to really take a good look on their current security and privacy readiness. Well, as part of the new ARRA few modifications to the law have been made under (Sections 13409-13411):

• Congress gave state attorneys general authorization to enforce the HIPAA thought civil enforcement actions
• It makes the business associates directly responsible for complying with key HIPAA privacy and security provisions. This meant that the cleaning crew, the third party IT support provider, software vendor, accountant and anyone that comes in contact with your infrastructure or medical and insurance information is sharing the responsibility and potentially liable.
• Fines have dramatically increased under the ARRA fines. You maybe imposed to pay up to 50,000 dollars per violation per calendar year and up to 1.5 million dollars.
• HHS is required to impose civil monetary penalties in circumstances where it finds that a HIPAA violation was willful.
• The criminal provisions were expressly made applicable to individuals.
• The HHS Secretary is now required to conduct periodic audits for compliance with the HIPAA Privacy and Security Rules.

Things to do to help you:

• Implement Password expiration and complexity policies
• Implement strict internet use policies for employees
• Ensure that your IT team properly secures your patient data repository services
• Run periodically security auditing tools
• Ensure that you are using antivirus on every piece of equipment that is connected to your network including cell phone as well.
• Ensure that your backups are password protected, encrypted and properly stored
• Ensure that your business associates agreements reflect the new changes and explain to your vendors what they mean and that their liability insurance covers the extent of the fines and costs that can be a result of data breach
• Ensure that your wireless is using stronger encryption method
• Require patients to present photo ID during registration and ensure you have a B&W copy of it (Color copies are illegal in NC).
• Use biometric check-in devices that ensure the identity of the patient if you are looking for a secure and fast way to identify and check-in patients
• Use network appliances that add an additional layer of protection against SPAM, email viruses and block unwanted traffic from web sites.
• Train and educate staff on proper internet use

Conclusion

Whether you are still using paper charts or completely paperless, patient privacy and security must be a high priority in your list, whether the ARRA enforces the new rules or not. Your clients your patient’s data protection must be addressed. It is like having health insurance, without it, you are taking major risks. There are several organizations that provide you with assistance or HIPAA audits. Some of which are freely available online. Your help desk and engineers need to understand the consequence as well as the importance of implementing the right technologies that are proactive in detecting intrusion as well as protecting all assets in your infrastructure.
Reda Chouffani

ARRA summary

With a vision for change, and an advocacy for healthcare President Obama signed into law the American Recovery and Reinvestment Act of 2009 (ARRA). This authorizes more than 19$ billion dollars for Healthcare information technology. As this sets the stage much needed incentives for healthcare organization to shift gears to adopt Electronic Healthcare Records, but unfortunately has received significant skepticism from many physicians.

As part of this stimulus plan, there are four requirements: Certified EHR, Information Exchange, Meaningful Use, and Reporting on clinical quality measures.

“Certified EHR": It is believed that the CCHIT will be the certification method of choice. In a recent announcement made by CCHIT Chair Mark Leavitt, there will be three paths to certification for vendors and health organizations. Applications will adhere to one of the following: EHR Comprehensive EHR -C, Certified HER Module EHR-M, or Certified Site EHR -S. These certifications vary in requirements. For example, to become EHR-M or EHR-S certified, your system will be required to have patient-physician PHR communication capabilities as well as an ability to exchange data with a certified HIE (Health Information Exchange).

“Information Exchange: It is important to note that there has been a significant emphasis on data exchange in the certification process. The purpose is to reduce healthcare costs and medical errors by promoting care coordination. This means that for any services provided to a patient that would like there data to be shared across a community based HIE or National HIE, this information must be available to other participating health organizations with the appropriate access. This includes SSA, CMS and other federal or state entities.

The next requirement is “Meaningful Use”, while recently a document has been released with some outlines of the “Meaningful Use Matrix” from the HIT Policy Committee. Everyone is still awaiting a final definition of “Meaningful Use”. One thing to keep in mind regardless of the details of this requirement is that physicians may need to make few adjustments on how data is reported as well as recorded.

Finally, reporting on clinical quality measures is the last requirements in the ARRA. It is stated that the eligible professional must be able to submit clinical data in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary.

Physicians and other health organization must thoroughly examine the ARRA in great details, and all the changing environments surrounding them. Many have already successfully adopted electronic prescription, computerized physician order entry CPOE, patients using online PHR and all the possible potential adjustments surrounding the insurance reform. Taking the right steps forward will require careful planning and assessment.

Meaningful use released

It is finally here. We now can review the initial details behind meaningful use. With the release of the matrix and Preamble we can have a good grasp on what would be needed from everyone to follow the ARRA requirements.

The matrix is very well organized. From looking at it, not only technical individuals can see exactly which standard/MDX queries to create, but also clinical staff will be able to identify what changes are needed in the data collection and work flow adjustments.

These measures would be completed in three different stages 2011, 2013, and 2015.

The matrix has the following headings:

• Health Outcomes Policy Priorities
• Care Goals
• 2011 Objectives Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions
• 2011 Measures
• 2013 Objectives Goal is to guide and support care processes and care coordination
• 2013 Measures
• 2015 Objectives Goal is to achieve and improve performance and support care processes and on key health system outcomes

I truly hope that while everyone is reading these requirements, vendors out there are starting to make adjustments and will enable their clients to easily report on these objectives. Every vendor who is "certified EHR" (to be defined soon) should begin to publish some of the queries and report files needed to the healthcare organizations. If not I will be more than happy to assist anyone with the appropriate database access permissions to accomplish the measures. ;) you will just need to ask!


Now, I will start connecting to few databases and see what queries I can start playing with!

Here is the matrix Click here, and the Preamble

Healthcare RFID 360

Tonight, as I was playing with a new little gadget (RFID Reader) that allows you to logon to any windows workstation on network using RFID cards. This little device believe it or not was less than 50 dollars to purchase, it comes with an API Application Programming interface for in house programmers to create integrate with, and can be deployed in about an hour. While I would really prefer to use this with SSO (Single Sign On), but I did not mind settling for something small, simple and that can fit into a small budget. So, I experimented for a while with “TouchaTag" that a coworker recommended to me. At first, I did not see many uses of this RFID Reader on my desk, but as I dug deeper and started to see the simplicity and yet the power of using RFID, and the great potential it offers in the medical environment.



In most recent years, we are seeing a lot more use of RFID in the healthcare market place. Much of our common knowledge of the uses of RFID are usually limited to Asset Tracking, Real Time Patient/Asset location systems, and Patient identification systems.
But one challenge we face when planning to adopt the RFID technology has been the costly price tag. While in many cases the high ROI justifies the jump, it is still a huge project for any hospital to undertake. Traditionally you are required to have special RFID readers all over the place, and also the need to purchase Passive/Active tags for your assets. Interestingly there has been many new advancement in technology in the past years that not only lower the cost of acquiring these solutions, but also eliminate the need of expensive RFID readers spread all over the place and the cost of their installation.

Just imagine that you can start using Real-Time Location System (RTLS) tomorrow by only purchasing the TAGs, doing a site survey, get the software needed to running your assets/patients and voila! With the use of CCX (CISCO Certified Extensions), you can actually use the CISCO AP (Access Points) as your “RFID Antenas” to locate your Wi-Fi tags. This model allows you not only to maintain your existing CISCO Wireless infrastructure (which keeps the Executive team and budgeting team happy), but also allows for greater flexibility with the use of the many APIs that the vendors offer.


But what I am really interested in discussing today is another subject that I found very interesting. We all know that the US is few years behind Europe and some Asian countries when it comes to cell phone technology. When you are walking in downtown Paris, you can put your cell phone close to a movie poster and get all the show times for that movie, or when you are in the subway you can pay for your ticket using your cell phone. So, how is that possible, and what technology is that using, but most importantly, can that technology be useful in the healthcare environment and worth adopting.

Well, most of the new cell phones that are manufactured and shipped to Europe and Asia have a chip that provides them with NFC (Near Field Communication) capability. Believe it or not, it is using RFID technology as well. There is a number of these phones that allow you to use Near Field Communication technology that has a short-range high frequency wireless communication technology which allows you to read an RFID tag directly from your phone. Why this is important you may ask??? Well, first starters, if the technology is available, then it is only fair for us to have access to it so we can apply it to resolve different business challenges.


What I found out was that in the Nederland’s they are using this technology very effectively. Basically the home health nurse can take her cell phone and she touches the (patient's) card with it, then identification information about the patient is submitted (over the network) to the phone; contact persons, medical data, care arrangement, are exchanged between the phone and medical application on the Home health servers. Now, some may argue that it would be easier to use a laptop, access all that information on it, and use Wi-fi or Wireless Broadband to communicate, but unfortunately with the economy and high costs of this type of infrastructure makes it a less attractive option and not an impressive ROI.



So this Mobile phone technology can be applied in a hospital environment. It will be less expensive that the typical RFID installation and you will no longer be required to use the smart phones that come equipped with the bulky RFID reader anymore. Plus this technology is a simple extension of the ISO/IEC 14443 proximity-card standard. This means that care providers can identify patients and even medication details (if we tag medications with tags).

Examples of other healthcare technology companies in Europe such as Dutch electronic-monitoring company Elmo ICT Solutions introduced a similar NFC product recently and it was called MobiCare-EasyID. It has sold about 1,500 NFC phones made by Samsung.


NFC technology in mobile phone handsets can also be used to open locked doors, or to download a URL or other information from a separate NFC device, such as an NFC tag embedded in a smart movie poster.


I would like to think of a scenario that I can be walking down the street and come in contact with a lost done, use my cell phone to check a dog's embedded RFID tag to see who he belongs to and contact his/her owner.

Cool toy of the month!!!! Watch your internet shows on your TV

Ok, it has been a while since i was able to watch anything that talks about technology on TV. I used to watch in the past TechTV, but that's long gone and been replaced. I settle now for reading/watching tech podcast during lunch at work, or before I start my day in the morning. The challange I kept finding was that I can never efficiently organize and view that information as entertainment. Ok, let me explain. In the evening instead of learning about Desktop virtulization or the latest micrtosoft developpement tools 2010, I am stuck surfing tv reality shows between commercial breaks from MSNBC and CNN. So, I finally made a decision to bring those useful shows to my TV. And that's when I discovered the D-Link 520/510. These are neat little devices that act as a Top Set where they connect to your wireless network and your tv, and allow you to bring your media library to your TV and control it using a remote control. Just imaging the following:
at 10:00 AM you receive an update from an RSS feed you signed up for, and it talks about the latest microsoft Surface SDK, and different showcases or uses in the medical field.
Now imagine that you are too busy to click on it and view it, because like all of us you have deadlines a boss breathing your neck. So, you are disapointed that you missed that opportunity to learn something new and cool.
Then you go home and realize that you have this little cool toy that actually keeps track of your favorite RSS feeds, and presents them to you directly on your TV. Well that toy or one of them is the D-Link 510/520.
You kick back on your couch or start on your tradmill, then press play and voila. You are now watch and learning about the exciting new Microsoft Surface and trying to think of ways you can get your boss to spend 15k on it to prove how cool it would be to use as part of your next EMR presentation.

PS: i am convinced that this technology one day very soon will be in the radiology departments as well as other specialties!!!

Can you exchange patient healthcare records

While many of us are exposed to the ARRA or stimulus, many healthcare groups are still wondering how this is all going to play out once all the requirements are defined. In a series of blogs I will be posting, I am going to discuss three different subjects with several scenarios of different practice types with different infrastructure and package.

The three subjects I am going to cover will be:

Interoperability
Meaningful use of a "certified EHR"
Certified Package

I will start by discussing the first one, and it is my favorite one. In the last few months, I have been very fortunate to participate with some very smart people. We worked together as part of the Technical & development Committee for NCHICA to create a draft that identifies our recommendations for a state wide/Community base Health Information Exchange Network.

Basically our goal was to identify the architecture of a NC HIE that would be able to participate a the national level and facilitate the exchange of health records amongst stakeholders such as (ER, Hospital providers, Physicians, State entities, SSA, and others..).

During that process I have learned tremendously from the team, and I could not help but try to envision how many of the providers I know would use and benefit from such a system.
So to help explain how a State HIE and its uses would look in the future, I have three practice scenarios to explain the implementation:

Practice 1:Dr. Smith with Practice SoloProv is a small provider practice with a single physician who is using a Basic EMR. This EMR called SoloEMR is a small vendor that is not planning on getting certified, and will not be enabling any interoperability in their software.

Practice 2:Dr. Jones with BusySpecPractice is a mid size busy specialist practice that feels that an EMR might slow them down, and elected to stick to paper charts but would like to participate at a state level HIE.

Practice 3: Dr. Ashton with Busy multiSpec which is a mid size busy multi specialty practice that has implemented recently a well known EMR that does support interoperability and also is planning on using the state HIE.

As for many of the patients of Practice 1 are becoming more aware of the advantages of having access to their PHR (Personal Health Records) they started requesting from Dr. Smith that they would really like to see their records on state HIE as well as receive updates under their (Google Health or Health Vault). This puts a lot of pressure on Dr. Smith as he realizes that he will need to do something before patients start looking at other providers that may have that edge or those capabilities. So, he approach the software vendor but with no luck. Then he decided to take a another approach. He came up with a plan to basically charge a patient a small fee to cover the cost of a staff member entering that data directly into the State HIE web portal. Not only the basic medication list, allergy and vitals, but also scanning sections of the paper chart to be uploaded. While the cost per patient becomes break even with what he is charging, he realizes that this is his only option unless he goes for an EMR package that has that functionality of Interoperability. This model allowed him to still maintain business as usual, but also allowed him to print/receive updates on his patients anytime their records are updated by another health provider. Unfortunately, the down side to this model is that the provider will be missing out on the stimulus money, but also on the advantages that an EHR offers. Anything from Drug interactions, to E&M coding, Rx History, Paperless office and much more.

Practice B, is a busy specialist practice. No time to waste typing on a tablet PC or laptop. They do everything on paper, and very comfortable with that method, and not looking into any change anytime soon. However, they realize that they would like to move the practice toward a EMR model and the next years, and would like to minimize the upfront costs as well as lowering the risk and change. With this group, it was a very simple yet powerful approach. They decided on using an EMR lite package that not only allowed them to access/request patient records from the Community/State HIE, but also perform electronic prescriptions as well as enter the basic clinical information electronically (Vitals, allergy, diagnosis, procedures, basic notes..) which was available for the Community/State HIE, and the rest of the medical record was still transcribed. This group was able to maintain the efficiency, be more informed before making decisions, and still provide the same amount of attention the patient deserves during the visit.
Now in my opinion this model above is a lot better than the first one. You have access to more information of the patient conditions (problem list, medication, allergies, vital and such), also the provide has visibility of the patient "CCD" or summary record provided by the HIE, but still does not provide a way for the practice to "measure quality or improvements". This is the part where the NQF will select our of their existing criteria which one will be utilized and implemented as part of "meaningful use".

With the last practice 3, recently implemented an EHR system across multiple departments. Each has all their patient records stored electronically. From the radiology department to the pediatrics. If you are a patient there, there one comprehensive electronic health record that contains all your data gathered from across the departments. So, you will have all your imaging stored as a standard DICOM, then you have all your lab data in HL7, and your overall summary of record as a CCD. Anytime any outside entity needs your record, the Community/State HIE sends a request and then receives a response with all your medical data from this group. The nice thing about this model, is that the providers did not have to do anything different to enable the interoperability here. Except of course paying for it (some vendors are planning on charging you for that functionality separate!!!!). In addition, this group will have as part of their participation in the Community / State HIE, any new patient or existing patient's PHR or LHR can be downloaded to a special tab in the EHR (Outside Records) to allow care providers to view patient's medical records from previous or other entities. Unfortunately this model is most likely the most costly for a practice, although it has tremendous advantages and will truly be the best case that the ONC and our administration would like to see, it is still the most challanging.

I am a firm believer that technology is going to help improve our healthcare system. The cost of it would be the variant here, but nevertheless, it is something that is needed. My mission while working with providers is to show the value technology can bring. Whether it is using EHR, or efaxing, virtualization or just simply securing their network to better protect patient information, it is important to show the many positive things that technology can bring to the table, it is just a matter of putting the RIGHT one to resolve the RIGHT problem. It does not always have to cost an arm and a leg either. I have seen enough successful open source products out there, that we don't have to continue to use cost as an excuse.

My favorite open source products:
Open Vista (VA EMR)
CONNECT (NHIN that allows for Health Information Exchange)
Mirth (Interface Engine for Labs, Demograhpics, DICOM CCD and many more.)
ClearCanves (My favorite .net PACS solution, and it is open source and as good as the 100k solution).

I will cover more of those open source solutions in another blog.

The health Provisions in the stimulus package and what it means to your practice

While I am trying to juggle between getting all my work done, and packing to prepare for our new office move, I had to find time during my non excising lunch and do a quick blog message.

Earlier this week president Obama signed the stimulus bill, so that meant that everything that is proposed for our healthcare is now law. But after spending two nights trying to read the healthcare section of the 1071-page American Recovery and Reinvestment Act, I still had a lot of questions to ask about what are we really getting, and how do the healthcare groups go about getting it. I even had more questions than the ones I started out with.

So, as I googled all my concerns and questions, I found articles that really put a negative spin on the new stimulus bill. I have read things about how the seniors in the US will face rationing, and how doctors will be influenced by the government. These articles could not be more wrong. It was important to really stay positive and make the best out of the assistance that healthcare has long needed to help the adoption of the technology that it most definitely needs. I found many of my answers in the following site Click Here.

The incentives proposed for the health professionals are payments of 15,000 to 18,000 dollars for the first year, 12,000 dollars for the second payment and on until the fifth and last payment of 2,000 dollars.

Things that will be potentially requested from health professionals in order to be eligible for the incentives:

• Submission of claims with appropriate coding (such as a code indicating that a patient encounter was documented using certified EHR technology) ---This reminds us on how we reported on PQRI.
• The use of Electronic Prescribing (e-Prescription, and this can be achieved with third party vendors, so you don’t have to change your EMR if it does not support it).
• The ability to exchange / forward your patient medical data to “data repository” defined by the Secretary ( RHIOs and hospitals have implemented these types of data warehouse and can store any of the following (which one they will request is the million dollar question):

Electronic Referrals and Consultation

Electronic Lab Orders/Results

Electronic Prescription

Electronic Imaging of patients

Electronic medical history

Radiology reports

Discharge reports

• Treatment plans
• An attestation
• A survey response

Since I am still reading the Healthcare section of the stimulus, I will continue on this blog in the next few weeks and describe some of the ways that small to mid practices can utilize to benefit from this.

Obama’s push for digital health records and what I think its flavors should be

While our new administration is doing the right thing by pushing for the modernization of our healthcare system, it is important to have a plan that will work and motivate everyone in the healthcare industry.
In my view the 5 year timeframe that our government is looking at will be very short to accomplish EHR implementation and standardization, especially in the small to mid size medical groups. In working with some of these types of offices in the last 10 years, I realized that many of them have complex workflows, and many encompass diverse delivery systems while many still suffer from the lack of proper infrastructure (Backups, server hardware requirements, scanners, efaxing,…etc.).
It is important to note that, in order to overcome the daily challenges that these groups are faced with (small IT Budgets, lack of HIT knowledge, and few uncooperative providers, high software costs), the new administration will have to create a road map that will impose some standards and also still be flexible by having different flavors of the modernization plan.
The package that should be offered will offer different options for different models as shown below:

Small Size Practices

• The offering of a complete web based solution (PMS/EMR) that will eliminate having to make large IT hardware/software investment, and still allow the practice to have EHR. Which package is needed would be a another blog subject).
• An option for the practice to use an EMR package that has been certified and approved by a Healthcare body.
• Educate the practices of the advantages of medical data sharing.
• Strong financial incentives in form of tax breaks or grants to offset the costs of time spent in training, and other requirements to get the new system going.
• Appoint at the state level a body that does nothing but consult with the practices and make sure they are seeing the benefits of such a system.

Mid Size Practices

• Work with these groups and allow them to keep using their current systems to maintain their patient medical records. Since these are the groups that have long implemented successfully many of the EMR packages that are offered.
• Provide financial incentives if they choose to migrate to a new EMR package.
• Provide financial / technical assistance to interface these systems to a central data repository. Similar efforts have been seen working with RHIOs where there is a substantial amount of resources needed to accomplish this.

Community health systems and hospitals

• I think we can all agree here that based on many of the recent statistics that still a larger number of hospitals are using electronic health records. So, the need here would be to centralize or allow for data sharing with the central data repository.

The only thing that I would add is that the effort should be shared amongst government and non government entities. Many health groups have successfully implemented some sort of central data repository where information is being exchanged and shared. The government role should be to enforce the standards, and offer reward to those who take the initiative to get on board.

Navigating in the rough waters Part 1: (small practices)

Navigating in the rough waters Part 1: (small practices)

During these difficult times, I find it that the media is more focused on the negative news and the problems that businesses are facing, rather than making recommendations and special reports on how we can become part of the solution. In our group, when we have our weekly brainstorming sessions, we discuss our economy and go around the room asking all individuala to provide feedback in the following format: what can we do to help practices navigate through these rough Waters and be part of the solution not the problem.

This was the mindset that we have been in, even during consulting with clients. As healthcare technologists, when we meet with clients and discuss how we can assist them with their technology needs, we focus on listening to what they are looking to resolve. And more than ever, where are hearing that it is about how we can use technology to “SAVE THEM MONEY, and INCREASE THEIR REVENUE” as well as how is the new administration is going to assist them.

So, in my mind it is two subjects that we need to tackle.

PART 1: Plug the leaks in your practice

When I got married, my wife and I were young and eager to see what it feels like to live on our own house. We chose to rent an older home close to my work for about a year. During that period, we were paying off school loans and such, and trying to save as much money as we could. Things went well during the summer up until the winter time. Living in the Carolinas with 30 degree temperatures had raised our gas bill to over 300 dollars a month. Keeping in mind that we both worked full time and had a relatively small house (1200 sqft), we did not know what to do, and the landlord did not care much. We knew that it was too expensive for us, so we had to do something about it. The only option we had while bound to a lease contract was to find ways to save on our gas bill. So we came up with a good short and effective list of solutions:

Wear thicker clothes and lower the thermostat by an additional 3 degrees.

Request the landlord to put weather stripping in all the cracks and the doors to the outside.

Close the rooms that we don’t go in and close the vents in them.

Perform maintenance on the Heating unit to get it to function efficiently.

While we knew that this was the last time we would live in a home without doing an initial inspection, we were extremely pleased with the results that we saw the next billing cycle. We were able to save over 40% on our gas bill. This was a great solution that had measurable results.

With the similar model, I found that we can apply different solutions to a medical practice that can help cut costs, and especially during this difficult economy. The following are some examples of things that can benefit a practice through the use of technology:

Review the clearinghouse services you are getting and add more functionality

Things to consider:

Patient eligibility: Get your money upfront when a patient does not have valid insurance, and eliminate the need to waste resources in filling an already denied claim, in that this will be saving precious staff time and money.

Automatic Electronic Remits Posting: if you thought about it in the past , and were too afraid to try it, well this is the best time to make the jump. Eliminate the time spent on data entry for the payments by allowing the system to do it automatically for you. This will give your billing staff enough time to allow them to focus on getting the AR where it needs to be.

Claim Submission: There are still practices out there that send claims via paper. This is the time for the switch. You are wasting your dollars if you are paying someone to print, folder and mail a claim. You can save on stamps and staff pays to do it electronically.

Practice trends: Getting the right reports to help you realign your practices goals is critical. Since you are still a business, it is important to see how you are doing and not wait for a phone call from the accountant at the end of the year. Some clearinghouses offer dashboard that give you a snapshot of where you stand, and what are certain services that are more financially beneficial to you than others

Working your collections and statements

Things to consider:

Outsource Statements: It is nice to see how we can have an assembly line when working on statements. One person prints, the other folds and stamps, however having a company that will reduce your costs and errors is far more beneficial in the long ran. You can start to see saving right away with this method, by uploading your electronic statements and letting them print them and mail them for you.

Outsource Collections: While it is nice to get a third party collection agency to call and try to get your money back, it is critical to choose the right company. One that will not make you loses your patients by scaring them off. These services will help you get more of your money, and allow your staff to be more efficient.

Revisit your IT support and maintenance contracts

Things to consider:

SLA contract and flat fee support package: This is the one thing that motivates an IT company to do the best job they can, by preventing problems. Having an SLA (Service Level Agreement) forces the IT Company to try to minimize the time spent on a problem as they want to ensure that they would need to spend less time on fixing things they can prevent to keep the margins up.

Get a good lite Preventative maintenance package “lite managed Services”: While it is a common practice for an IT shop to recommend monitoring the workstations, the servers, and even the temperature in the room, you only need to have monitoring done on critical equipment in your building. The front desk computers, or the ones in the break room are not important devices, you can save yourself money by buying some spare ones and keeping them in the back ready. Your main goal here is to prevent major downtime and loss of revenue by focusing on monitoring Backups, servers, server room temperature, and logs of critical applications such as RIS/HIS/EMR/PMS/Exchange... The provider’s tablets can be skipped as long as there is a good policy and training around saving important files or personal documents to the local computer disck drive, which would jeopardize data.

Get that EMR you have always wanted today

Things to consider:

Gethe best package for the best price: Because of the tough times and some good old competition, we finally have affordable EMR/PMS packages, and plenty of room for negotiations. We are seeing 20 to 30% off some of the top EHR packages out there. This would be a huge savings that might not last for long.

How About Free EMR: If you haven’t heard this yet, well it is true. You can get a free EMR and the only cost is the maintenance and support. OpenVista is the OpenSource (developed by a comunity of developers) EMR product developed and currently used by the V.A. in many hospitals. There is a commercial version of the product that medical offices can use and its Free!

Get Free Money from the government

Things to consider:

Grant money: whether you are a Community Health center or a private practice, the new administration is working on some great packages to offer as part of the healthcare modernization push and Stimulus package. Our president Obama is looking to get Healthcare IT some much needed financial assistance to get us where we should be. So, you have to start looking at the details of the stimulus package and how you can get approved for that assistance.

Free or low cost e-RX: Take advantage of the bonus that Medicare is currently offering. If you are seeing a large volume of patients from Medicare, then you should highly consider implement e-prescribing (e-Rx). This 2% bonus based on your anual reimbursments will last up until 2011 and then it will be reduced to 1% bonus, and by 2013 you will start losing about 0.5% of your total reimbursements from Medicare.

Remove the paper based tasks

Things to consider:

Low end scanning solution: Get with your IT Company or Copier machine guy and see what you can do about those paper EOBs that you have to keep in the back. While most of us think that we can shred them, it is critical to keep them around if you ever get I.R.S. knocking on your door, or one of the payers decides to take back some money and you need to have some supporting documentation for a claim or two. Turing your EOB into electronic documents will save your staff a lot of time as they will not have to spend a lot of time looking in boxes and such for 10 minutes or more for a single EOB.

Hybrid document management system: This is by far the most cost effective EMR and paperless solution. It offers the best of both worlds. Having all the benefits of an EMR while still keeping it simple to use for the clinical staff, and still maintain the same amount of patients and workflow.

eFax: Implement an eFax solution. You only have to spend just few hundred dollars and get a complete eFax solution. Believe it or not, you can get a complete eFax application for free as part of your windows Server 2003. All you need is a modem. This will save your nurses from having to chase paper lab results, and other faxed patient documents. One other advantage is to eliminate the need to spend time scanning, filing them, or the toner when printing them.

Consider refurbished workstations

Things to consider:

Refurbished workstations: As the computer prices have dropped, there is potential saving in buying refurbished workstations. They still hold the same warrantees, and would still run just as good as the new ones.

Free software

Things to consider:

Free office tools: Many practices thing of Microsoft Office suite when you mention word processor. In reality, you spend over 299 on to get those applications. I highly recommend looking at the free OpenOffice.Org OpenSource product. It does everything that word, excel and PowerPoint do. Except it will cost you 0 dollar.

Lower your electric bill

Things to consider:

Turn off the switch: Turn off PC, speakers, calculators and monitors automatically. Many of us underestimate the power consumed by PCs even when we don’t use it. During the night time when a PC is in standby, it is still running up your bill. So, if you want to save 30% or more on your energy consumption then buy a smart power surge for your workstations. A power surge like “Power-Saving Essential Surge Arrest 7 Outlet with TEL 120V” for as little as 20 dollars. This surge protector is smart enough to sense when the computer goes to stand by, and then it shuts off power to the PC, Speakers, calculators, digital picture frame, and last but not least monitor. This is truly a great out of the box idea that will save you tremendously on your electric bill.