Transcript Document

Portions of the presentation by:
Copyright Claudia Tessier LLC, Boston MA 2009
 EMR:
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An electronic medical record for a patient at a
particular site, providing such functionalities as
e-prescribing, order/results management, work-flow
tasking, communication and messaging
An EMR is NOT a paper record made electronic
 EHR:

electronic health record
The sum of a patient’s EMRs and other health- related
information from multiple sites
 CCR:

electronic medical record
Continuity of Care Record
Electronic core data set about a patient’s healthcare status and treatment, current and historical
 Patient
safety
 Quality improvement
 Rising healthcare costs
 Competitiveness
 Evolution not only toward electronic medical
record but also to computer-guided and supported healthcare
 Consumer-driven care (participatory health)
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Internet resources
Personal health records
 More
timely,
accurate, complete
patient information
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No longer practicing blindly
Point of care access to,
capture of, transmission of
patient information
Real-time, remote access
 Improved
patient
care
 Improved patient
safety
 Improved outcomes
 Reduced
costs of
healthcare
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Reduced wasteful
duplication
Improved efficiency
Financial squeeze on
physicians
 Reduced
hassles
 Improved quality of
life
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For yourselves
For patients
 Office
workflow: Who does what, how, when,
where, why?
 Current practice management system?
 Information capture preferences?
 Staffing: Adequate? Ready?
 Colleagues: Supportive? Ready?
 Financial planning and expectations
 Realistic timeline
 What do you want/need from an EMR?
 What features do you want?
 What barriers do you face?
Increased revenues
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Improved reimbursement
Increased patient volume
Increased charge capture
Decreased accounts
receivable days
Increased net collection rate
Decreased denied claims
Improved E&M compliance
New business opportunities,
clinical trials, data
Improved competitiveness
Improved quality of care
Improved patient
satisfaction
Decreased costs
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Reduced chart filing costs
Reduced transcription
costs
Decreased telephone calls,
faxes from pharmacy
Increased efficiencies,
decreased hassles
Improved quality of life

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Improved provider
satisfaction
Improved staff satisfaction
Less time after hours
 Clinical
documentation
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Options
Management
Scanning
CCR
 Clinical
and
administrative
workflow tasking
 ePrescribing
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Drug interaction
Formulary mgmt
Refills
 Referrals
 Order
entry
 Results management
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Abnormals
Trends/graphs
 Summary
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lists
Problems
Allergies
Medications
Health
maintenance
reminders
 Charge
capture &
coding
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Medical necessity
Automated coding
E&M coding &
compliance
 Decision
support
 Clinical practice
guidelines
 Practice
messaging
Internal
 External
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 Population/disease
management
 Patient portals
 Patient data entry
 mHealth
 Participatory health
 Expense
 Selection
difficulties
 Staff resistance
 Time & effort
required
 Incompatibility of
hardware/software
 Ease of use
 Security
 Lack of technical
expertise
 Obsolescence
 Ease
of integration
 Concerns about ROI
 Solutions not right for
you
 Lack of demonstration
site
 Data/chart conversion
 Increase documentation
 Other?
 Templates
with guideline prompts
 Flow sheets, tables, summaries, etc. as
decision aids
 Internal messaging and flags for
coordination, self-reminders, goal prompts
 Personalized results letters or handouts for
patient education
 Lab interface for results reporting
 Advance scheduling for follow-up
 Develop
effective team communication
 Measure for improvement and accountability
 Incorporate performance and outcome data
 Coordinate care and services across settings

Queries to identify patients needing specific care
leading to flags or outreach
 Educate
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yourself and others on EMRs
Conferences, web, colleagues, experts, etc.
 Prioritize
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goals and problems to solve
Narrow potential vendors: Determine
Cost
 Features and functions
 Usability
 Set-up vendor demos
 Include physicians, staff
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 Develop
scenarios
 Site visits to similar practices
 Practice
size designed for, installed in?
 IHN/hospital linked?
 ASP-based?
 Is system designed for and installed in
endocrinology practices?
 Costs?
 Functionalities?
 Usability?
 What
does pricing
include?
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Hardware
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Data center only
Peripherals
Software
Templates
CPT codes
E-prescribing
CCR integration
PHR integration
 What
recurring
costs?
 What
else?
Interfaces and conversion
costs including mapping data
fields
 License fees
 One-time or annual
 Implementation
 Training
 Travel
costs
 Support and upgrades
 Backup: where and when
 Other?
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Software/hardware
maintenance
 What isn’t included?
 Upfront or annual
license fees
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 What
modes of information capture does
it offer?
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Transcription
Speech recognition: front-end, back-end
Keyboard entry
Digital pen and paper
Handwriting recognition
Point and click
Pull-down menus
Templates, custom or standard
Home monitoring devices
Data entry by patient
Direct from mobile devices (mDevices)
HYBRIDS
 Integration
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with
Practice management system
ePrescribing
Labs
Payers
Other?
 Real-time
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With which payers?
 Real-time
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eligibility determination?
charge capture?
With which payers?
 Is
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system interoperable with
Local hospital systems?
Personal health records?
Patient portals?
Patient data entry systems?
Other?
 Different
implementation paths for different
practice sizes and specialties
 Realistic timeframes
 Staff involvement
 Workflow changes
 Data conversion: scanning, CCR
 Support and maintenance
 Backups and recovery
 Plan
and test, plan and test
 Policies & procedures
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Privacy, confidentiality, security
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Medicolegal requirements
Backups and disaster recovery
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 Support
and maintenance
 Modular or “Big Bang”
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Have flexible timetables
 Appoint
a project manager
 Assign responsibilities
 Modify schedules
 Start immediately following training
 Implementation never ends
Incorporates much greater specificity and clinical
information, which results in:
•Improved ability to measure health care
services
•Increased sensitivity when refining grouping and
reimbursement methodologies
•Enhanced ability to conduct public health
surveillance
•Decreased need to include supporting
documentation with claims
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Key issues include training courses, but equally ramping up to
productivity standards and confidence
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Training courses abound (albeit they are getting full faster today
than in the past)
Future needs to meet:
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Training programs will yield competence but not speed
Need approach to building coding skills in live environment, not just training
courses
Coders will need to train in real environments with real notes/encounters and
see where skill gaps exist
Multiple passes –at first getting comfortable with coding, then testing
productivity. See where the gaps exist and retrain specifically.
Computer-assisted coding will greatly assist the transition
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Dual coding environment –specific notes, engine suggested codes, coders code,
after-the-fact analyses of generic versus specific codes
Organization will want to be sure they understand revenue risk from non-specific
coding prior to 10-13.
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The Problem
Needed approach

Physicians have learned how to
 Note-by-note and ICD-by-ICD analysis
document at the detailed level over of the specific changes each physician
the last 20 years
needs to make
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More detailed information required Data-driven training with physicians –
their documentation, their
to get to the most specific codes
deficiencies, needed changes
(e.g. laterality, body part, etc.)
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“Small footprint” discussions over
Organizations have meaningful
time—topic-by-topic rather than allrevenue risk with ICD-10 if
at-once. Aggregated plan between
documentation is not up to the new now and 2014
standard
No physicians want to worry about
this now, but every physician will
need to adapt

Follow-up data analysis to determine
effect of training and to structure
additional interactions
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Value of training: Average doctor
revenue X 20% risk = $120,000 –
200,000 per doctor.. How much
spending to avoid the risk?
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 Diagnosis
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Codes (ICD-9 to ICD-10-CM)
Goes from 5 positions (first one alphanumeric,
others numeric) to 7 positions, all alphanumeric
From 13,000 existing codes to 68,000 existing
codes
Much greater specificity
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Laterality (left, right)
 Body part (e.g. bone
in the hand)
 Stage of disease (e.g.
severity of pressure
ulcer)
 Injury (e.g. hit by
baseball)
 Episode of care (e.g.
initial visit or
followup)
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Present evidence of what
physicians do or do not
document today
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Documentation of diagnoses and procedures
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Codes must be supported by medical documentation
ICD-10-CM codes are more specific
Requires more documentation to support codes
Expect a 15% increase in documentation time (per
AAPC)
Revenue Impacts of specificity
▫ Denials
▫ Additional Documentation
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Coverage and payment
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New coding system will mean new coverage
policies, new medical review edits, new
reimbursement schedules
Changes will be made to accommodate increase
specificity
May need to discuss changes with patients
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Contracts with plans
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Coding more specific and includes severity
Renegotiations will be based on new coding, coverage,
and reimbursement
Difficult to measure what the changes will mean to
overall reimbursement
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Billing and eligibility transactions
 Updated
transactions include support for
ICD-10
 New codes mean more specificity
 How smooth the transition?
 Expect increased reject, denials, and pends
as both plans and providers get used to new
codes
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Laboratory orders
 Will
need specific ICD-10-CM codes for
laboratory orders
 Expect coverage changes
 Need to support the tests ordered
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