Open Government Plan increases transparency for CMS and provides valuable data sets for Business Intelligence analysts

Recently I was invited to contribute to a great healthcare IT community web site. SearchHealthIT part of the TechTarget group contains several useful resources. I am looking forward to continuing to write about healthcare informatics and regulatory changes that are affecting each and everyone of us who are in the healthcare market.

My latest post: Click here http://searchhealthit.techtarget.com/healthitexchange/meaningfulhealthcareinformaticsblog/2010/04/08/open-government-plan-increase-transparency-for-cms-and-provides-valuable-data-sets-for-business-intelligence-analysts/

Summary of the H.R. 3590 and the impact on physicians

Today I reviewed a great summary of the H.R. 3590 bill that was signed into law on 3-23-2010. This was a pdf published by the North Carolina Medical Scociety. http://www.ncmedsoc.org/blog/wp-content/uploads/2010/03/HR3590-and-Reconciliation-Bill-Comparison-3-23-2010.pdf

It is clear that there will be many changes that practices will start seeing. Some are relating to the potiential increase in Medicare/Medicaid patients (estimated at 16 million new Medicaid receipients), also some of the new penalties associated with not participating in the PQRI initiative. It is estimated that a 1.5% to 2% penalty will be imposed begining in 2015 for non PQRI participants . So, if EHR is in your plans, and you the practice does see a high volume of Medicare/Medicaid then this maybe a good time to contact the vendor to seek assistance for PQRI.

I also saw how there will be some bonus payments (10% Medicare bonus) for primary care and general surgeons practicing in shortage areas 2011-2015.

New release on a powerful open source PACS/RIS clearcanvas 2.0

For all the open source fans, a new version if the clearcanvas RIS/PACS 2.0 has been released. clearcanvas is a great suite of imaging solution. This application has many of the functionality and features of some of the market’s top PACS/RIS application providers. The difference is this is “FREE” (more details on licensing available here:http://www.clearcanvas.ca/dnn/AboutUs/Licensing/tabid/105/Default.aspx )


I have installed this solution and I was very surprised how quickly it can be deployed. What were more impressive were the advanced capabilities it enables you to perform just by using their SDK. This solution was built on an extensible application framework.

This solution can be provide immense value for some of the healthcare organizations looking to implement a small PACS system to manage their imaging (Ultrasounds) without all the high costs associated with some of the packages offered in the market. An OB/GYN practice or Imaging center can eliminate all the costs associated with Photo-paper, expensive color ink, and the need to file by hand these images in the chart, just by simply rolling out this type of solution and offering the physicians access to high quality images through the clearcanvas client. For radiology, this open source package offers a great range of features:

• Image storage, retrieval and archival
• Image viewing and or streaming
• Modality work list
• HL7 capabilities
• Workflow engine
• IHE-modeled Scheduled Workflow
• Paperless protocoling
• Preliminary Diagnosis workflow
• Resident-Supervisor workflow
• Customizable technologist documentation
• Multi-facility, multi-HIS Master Patient Index

So if you are a big open source advocate, and want to reduce (eliminate) direct licensing costs, this may just be the PACS/RIS solution you need. But note that as with many open source solutions, having the appropriate skills to support and troubleshoot is critical. While you may purchase support through clearcanvas, it is important to fully evaluate your need, current hardware and how you plan on having the application supported.
Check out their web site http://www.clearcanvas.ca/dnn/Default.aspx

Real-Time Claim Adjudication a "new" way to look at collecting your money

In a time where we are reminded daily that much of the current technologies (EHR, HIE, EDI, and others) will reduce medical error, improve patient care, we tend to overlook the prolific results that other technologies have to offer to health organizations. The market offers that great solutions that billing departments across the nation would appreciate how it can reduce claim denials, put money in the bank much quicker and overall improve the practices bottom line.

Real-time claim adjudication (RTCA) is a solution that enable medical organizations to bill for services before the patient leaves the practice. This allows for the organization to submit a claim with the procedures performed and get a response displaying the allowable charges and patients remainder responsibility based on the contractual agreement.


This has been around for some payers in some states. Humana, some Blue Cross Blue Shied of some states (BCBS of NC has started the development but has not officially released any target dates). Some PMS vendors have been able to successfully enable practices to take advantage of this functionality. AthenaHealth was one of those vendors, with their RTA (Real time Adjudication) services, it makes for a very attractive model for any practice looking to lower the denial rate on their claims.


Using Real Time adjudication is a no brainer when one begins to realize how much time is spent on claim filing, refiling and working the denials. It is known that insurance eligibility verification does resolve some of the claim denial issues, however, much of the billing departments pains lies in dealing with payers who may deny some procedures and not others within the same claim, and then the battle to explain to the patient why they are now responsible for the balance.

According to some recent MGMA statistics published in http://www.mgma.com/SwipeITWaste/ we can see some of the costs associated with claim denials:

57,168,299 Number of claims per year that must be resubmitted due to payer denial due to incorrect patient demographics from non-electronic registration


857,524,484 Minutes per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


14,292,075 Hours per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non‐electronic registration

289,762,993 Dollars saved per year by not having to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


While in the perfect world RTCA would work so well with an EHR, especially when the provider can submit the encounter electronically right after the visit, it is important to note that even if a physician write the data or circles the procedures and diagnosis on the paper charge sheet, the checkout individual may have the ability (depending on the Practice Management System) to perform the RTCA task and benefit from this wonderful technology.

High level review of new proposed certification process

With the recent publication of the Proposed Establishement of Certification Progreams for Health Information Technology, it has been the most anticipated item since the meaningful use proposed requirements. As many have anticipated, CCHIT is in fact on top of the list of the most likely to become the certification body or the (ONC-ACB) ONC Authorized Certification Body.

While most or possibly all the proposed rule focuses on what are the requirements on the certification body, testing and accreditation. The HIT recemendations very much in line with the CCHIT and that also includes the costs of the actual certification which still range from 30,000 to 50,000 dollars for complete EHR/EMR or 5,000 to 30,000 dollars for modules.

The document outlines some estimates on what products will be tested, including statistics on Commercial/Open Source EHR products, Commercial/Open Source EHR Modules and Self-Developed Complete EHRs modules. The total count of products tested is about 181.

The document also outlines that there will be addiotional certifications that the ONC will potentially use for other technologies. The reference was made to the Personal Health Records (PHR) as well as Health Information Exchange (HIE).

The much anticipated Proposal for certification or Certified EHR

While many are still talking to the EHR vendors at the exhibit halls at the HIMSS 2010, The Office of the National Coordinator for Health IT (ONC) released yesterday the notice of proposed rulemaking (NPRM) for the two certification programs. This proposed program has two proposals in it. One that will be temporary and the other would be permanent.

The proposed program outlines the following:

The first proposal would create a temporary certification program that would be issue temporary certifications through the authorized testing and certification bodies (ONC-ATCB) to test and certify complete EHRs/or EHR Modules. During this first proposal the ONC would assume most of the responsibilities during the temporary certification program. This means that no other organization (private ones) would serve as an accreditation body.

The second proposal would create a permanent certification program that would replace the first temporary proposal. This would also mean that the ONC is intended in allowing approved private sector accreditor to fulfill the responsibility of the accreditation body.

The National Institute of Standards and Technology has been working with the ONC to develop the test method and infrastructure that will be used by many of the testing laboratories in the testing stage for both proposed certification programs. This entity (NVLAP) would include specific calibration and or test standards related methods and protocols that would satisfy the needs and requirements of an “Certified EHR”.

The details of what would be the methodology used in the certification test is defined as “The same basic methodology used in third-party conformance assessment”.

More details to come once I can get through the 184 pages of the proposal.

News Media Party at the Georgia Aquarium HIMSS 2010

Another highlight of my day was the exciting news Media meet up. Organized by John Lynn creator of the EMRAndHIPAA.com (Great healthcare informatics resources). During this meeting, I was fortunate to meet up and discuss with several individuals the current challenges our healthcare faces as well as some of the exciting changes going on. John and I got do talk about healthcare technology, ARRA and some of the challenges we all face in this field. John who is very passionate about the healthcare field shared with me some of his thoughts on the current ARRA and impact it has on healthcare practices.
Jean DerCurahian who is a news writer for TechTarget was also attending, and had the opportunity to exchange some thoughts. We in the healthcare bloggerspere have a lot in common. Sharing our thoughts, opinions and experiences hopefully can bring value to others.

Visiting the exhibitors at the HIMSS 2010

The second half of my day I did have the opportunity to walk through the exhibit halls. And while it is overwhelming at first, I had my list already prepared of vendors I wanted to meet up and discuss their products. I categorized the vendors I wanted to visit into the following sections. This is just a tiny list of the ones I visited, but this was my initial list I created before hitting the exhibit hall:

EHR vendors
GE, AllScripts, Greenway, NextGen, e-MDs, eClinicalWorks,DDS Inc. (OpenVista)

Technology and Hardware vendors
DELL, IBM, CDW, Microsoft, Fujitsu, JAOTech

Solutions, Service providers
MEDNET, Claim processing with CPeople, Online Backups, MeDecision

Standards and HIE
Hl7, NHIN, NCHICA

Vendors with the coolest toys for my 3 year old.

Too cool to miss:
Microsoft Surface, NHIN (participating vendors and the IHE)

My first day at the HIMSS 2010

So, the HIMSS 2010 is still going on, but I definitely needed to take this opportunity to collect all my thoughts and review my notes to see what I have learned so far.

My first day went as follows:

It started out with a great presentation done by the Governor of Vermont Jim Douglas. He discussed several of the advantages of having electronic health data and also how it will help the states improve healthcare and reduce the costs. He recognized that most governor are dealing with difficulties balancing their budgets while trying to avoid making any major cuts to critical services. He also covered that a big chunk of his state’s budgets is taken by Medicaid (26% to be excact) and that with the help of healthcare information exchange he is encouraged to see that there will be some potential cost reductions.

One very interesting subject that was brought up and cough my attention is what credentialing and jurisdiction will need to be applied when Telehealth becomes widely adopted. As we all know, TelHealth is when providers from out of state are providing care to local patients or providers instate are caring remotely for patients in other areas. This poses the questions on who gets taxed, what credentialling entities will be used and so forth.
While he did not discuss in details his thoughts on what is going on in capitol hill in regards to the “healthcare/insurance reform”, he did point out that it is a far more challenging task for each of the state governors ahead in reguards to dealing with balancing their books and continue to cope with the ever increasing healthcare costs.

Some of the additional sessions I attended included the review of "Meaningful Use" presented by Sanjay Shah and how the ARRA affected their hospital. He discussed how they have started planning on going paperless several years prior to the enactment of the ARRA. He was able to provide some very good insight to what hospitals need to plan for, and how the three stages of Meaningful Use will impact everyone.

In the presentation he did outline how there are still some areas where his hospital is facing some potential Meaningful Use Gaps. This included e-prescription needs, CPOE implementation outside of the ED, and potential upgrade requirements once the certification is announced.

Next came a presentation by Gregory T. Fairnak the Chief Architect of CONNECT Gateway project. And as he started talking about Opensource and some of the technical aspects of the solution, I was in cloud nine. This was one of the highlights of my day. As a junior software architect and a developper, getting to interact with Greg was a delight, and a great opportunity to pick his brain on some of the details of the CONNECT. I also had the opportunity to meet another icon “in the Opensource arena”. As many in the interfacing world already know, Mirth Project has been in the front lines of the EDI and Interfacing . I have personally assisted many of our clients overcome some of the high costs of interfacing by utilizing this powerful FREE solution. I had the chance to have a short conversation with Gary Teichrow one of the creators of Mirth. It was such a delight to hear how the product came about. I expressed by appriciation to his product creating and thanked him for such a great contribution to health informatics.
It is critical to also note that some of the Mirth components are being utilized by the NHIN (National Health Information Network) which as everyone already knows is the backbone of the federal healthcare information exchange for CMS, SSA, DoD and other federal entities.

This concludes one part of my day at the HIMSS!

North Carolina gets its share of the stimulus money and a boost to help with EHR adoption

Today the white house announced what has been awarded to the different states to support Health Information Exchange and assist care providers with training and technical support with Electronic health records.

This makes the state of North Carolina one of the 41 states to get $ 12.9 million dollars in funding to facilitate HIE for the state. While there are several other already established health record exchange initiatives, the NC HWTF (North Carolina Health and Wellness Trust Fund) has greater potential to get a strong NC HIE started.

In addition, with the establishment of the regional extension centers and their awarded 13.6 Million dollars available through North Carolina Area Health Education Centers Program (AHEC) North Carolina care providers will have better access to onsite technical assistance to help with the adoption of electronic health records.

For a full list of grants awarded visit: http://www.whitehouse.gov/the-press-office/sebelius-solis-announce-nearly-1-billion-recovery-act-investment-advancing-use-heal

Top 10 EHR failure contributing factors

With the Economic Stimulus bill recently enacted into law by president Obama, and recent relaxation of the Stark Rules allowing hospitals to subsidize up to 85% of implementation costs of HER many are renewing their interest in an EHR purchase. But while many are excited about the encouraging subsidize available, others are still fearful on undertaking such a complex project after many “horror stories” they hear.

One must wonder what is really the source and true factors that contribute to the de-installations and or lack of return on investment on EHR. By reviewing these items, we can separate fact from fiction and expose what can be done to avoid these pitfalls.

The following are the top 10 biggest contributors to an EHR failure for certain products available in the market place:

1. Lack of strong follow up from the EHR vendor:

After Go live date some of practices begin to sense that the honeymoon period is over. Faced with new workflow challenges and staff not always sure what to-do and resort to a best guess on how to perform certain tasks, frustration grows and lack of confidence of the product begins to show.

2. Lack of training:

With a constant reminder of budgets and economic downturn some practices often resorting to less training and more self discovery tends to be another step into dangerous waters. With Computer Illiteracy many realize that they are still not comfortable with the product and don’t know enough to resolve some of the obstacles that accompany such products.

3. Unreliable infrastructure:

While many of the subsidies have reduce actual implementation/training and licensing costs of an EHR, weak and unreliable IT back bone infrastructure tends to offset the efficiencies that are meant to be gained. Far too many cases slow response, unreliable wireless and reoccurring system outages leave a terrible after taste of the EHR when it should be the one of the lack of infrastructure.

4. Not very user friendly:

While all care providers and clinical staff understand that when they are seeing patients all their attention is rightfully given to their patient, but too often they fall victim to the overwhelming screens, 2 dozen buttons to click or all flashing indicators reminding you that you have more work to follow up on.

5. Lack of interoperability:

It is clear that interoperability is “essential” for coordination of care and reduction of medical errors due to lack of information, and unfortunately many software makers lack to capital and expertise to arm their products with the ability to enable practice to participate in exchanging electronic health records within their community or just simply with a nearby hospital or IDN. In addition, it has been stated time after time that the ARRA’s ultimate goal is to promote exchange healthcare information to improve patient care.

6. Slow and painful ROI:

Statistic after statistic shows us that adoption rates for EHR have been slow, despite the growing enthusiasm. In some cases incentive payments can provide a boost, but often we find that citing a positive ROI is largely anecdotal. While upfront costs can range from 10,000 to 25,000.00 per provider in costs, it can take from 3 to 4 years before an actual positive ROI is seen in some cases.

7. Same engine under the hood for years:
As a developer I am guilty of trying to recycle applications I have created in the past and just performing a facelift on the interface. Unfortunately this trend has contributed to lack of new functionality and features for some of the products being used today. By simply changing a 10 year old product screen from black DOS screen to a “windows” based program with still the same engine under it. Many practices are still facing outdated functionalities and lack of new and much improved and newly discovered efficiencies.

8. Lack of sufficiency data visualizations:
Whether a healthcare organization is looking to identify the most common CPT codes used, performing internally RAC audits, or simply identifying trends in patient outcome measures, medical organizations are looking to EHR vendors to answer the calling. But with very few able to provide access and usable data, many are faced with the reality that data visualization is nothing but a dream. It is hard to truly understand the power information, but as stated in a recent article in the BusinessWeek written by Maria Popova: “Ultimately, data visualization is more than complex software or the prettying up of spreadsheets. It's not innovation for the sake of innovation. It's about the most ancient of social rituals: storytelling. It's about telling the story locked in the data differently, more engagingly, in a way that draws us in, makes our eyes open a little wider and our jaw drop ever so slightly. And as we process it, it can sometimes change our perspective altogether. “

9. Lack of or unreliable integration:

In the current healthcare environment, there are many connecting devices, entities and stakeholders. Whether you are ordering blood work or waiting for a pathology report to be downloaded integration is the glue that holds it all together. In certain cases missing labs, down interfaces and failure of communication can lead to dangerous and risky outcomes for the practice. Many of these situations lead to frustration and mistrust of the technology and products.

10. Loss of confidence:

At the center of it all, lack of staff buy-in poses the most common management mistake made that leads to complete EHR implementation failure. Many leaders discover after working hard on making sure the right product was selected for the right price that their staff is not confident in the adopted direction of the management. This leads the practice to face significant struggles. Ultimately, every staff member needs to buy-in to the change, and for this to occur successfully it is important to involve everyone in the process and ensuring they are part of the solution.

It is commonly cited that the practice should hold most of the blame for the failures of EHR projects and implementation. But who are we kidding here; it is like asking an IT engineer to manage a busy restaurant’s kitchen just because they watched few episodes of hell’s kitchen. The burden of a successful EHR should be shared amongst the product vendors who have far more experience in project management and technology as well as the team effort of an EHR committee from within the practice. Both parties must commit to proper education up front, continued education and follow ups to ensure that the product is being used the way it should be. The success of the project will benefit both vendor and customer.

In conclusion, while many of the indicated struggles above are contributing factors to failures of some of the EHR implementations out there. It is important to know that not all products have these challanges. In addition, many of the items listed can be resolved by taking the appropriate corrective measures. When in doubt always contact your vendor or a qualified healthcare IT export to assist you and your organization ensure that you are in the right path.

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!!!