I found this list of to-do issues from Rhonda Buckholtz on http://www.beckersasc.com:

Start anatomy and physiology training for coders: coders should be focusing on anatomy and physiology training to make sure they can code to the level of specificity required by ICD-10. Once the ICD-10 implementation date rolls around, coders will be in short supply and you want to build loyalty before then.

Start training physicians on documentation. “ICD-10 has a much higher level of specificity, and some of the concepts found in ICD-10 weren’t found in ICD-9.”…about 35 percent of the time, the coder is unable to assign an ICD-10 code based on physician documentation.” If physicians are hesitant to start documentation training, emphasize that if their claims do not get paid, they will be living on 65 percent of their previous revenue.

Talk to your vendors about their transition plans. Some vendors may even choose not to make the transition to ICD-10 — an issue you need to know about as soon as possible. “You don’t want to be left hostage at the last minute, finding out your vendor is not going to make the transition,” she says. You may also find the vendor offers the software upgrades for free, but you don’t have the hardware to accommodate it. Find out your areas of need now so you can budget for any necessary purchases over the next few years.

Talk to commercial payors about their transition plans. Check with your commercial payors immediately to find out how they’re making the transition to ICD-10. You need to know whether they are going to make changes to policies and payments so you can adjust your processes and reimbursement expectations to match.

Follow the “day in the life” of a diagnosis code. There are many ASC policies, procedures and software products that will be affected by the transition to ICD-10 — in fact, every piece of paper or program that contains diagnosis codes. To make sure you don’t miss any areas that will be affected, go through the “day in the life” of a diagnosis code at your facility, from the first time the surgery center calls the patient to the last check-in after discharge.

“Go through and do the physical inventory to find out where the diagnosis code is tied into your center,” Ms. Buckholtz says. Ask your staff members to help you in this process; chances are, your business office manager and receptionists will know where diagnosis codes live in your center and how they affect your operations.

Determine which policies and procedures will be affected by ICD-10. Some policies and procedures will be affected by the transition to ICD-10, especially those that require diagnosis codes on forms, Ms. Buckholtz says. For example, every time a surgery center provides a service for a Medicare beneficiary, the staff has to provide an advanced beneficiary notification. If your surgery center has made customized ABN forms for this process, you will need to adjust the code fields to fit with ICD-10.

“Only 22% said they were fully prepared to support ICD-10, with remediation plans in place and system upgrades underway. About 37% indicated that they were “somewhat prepared,” but not sure that they would be able to meet the deadline, while 36% were just starting to ready themselves for ICD-10. Just over 5% have not finished evaluating their IT capabilities or created a remediation plan for the new coding system.

“This is not terribly surprising,” HealthEdge executive VP Ray Desrochers, told InformationWeek Healthcare. “A lot of the largest payers got their act together early,” Desrochers said, but noted that the tier just below the biggest insurance companies did not really start on ICD-10 until this year, even though federal officials set the deadline in January 2009. “

Note to anyone hiring postdocs or profs: I identify as a cognitive scientist, not a psychologist. The University of Texas has notated my transcript to reflect my program of work (via the Interdisciplinary PhD path) as Medical Cognitive Science.

The title is “”Modeling the clinical predictivity of palpitation symptom reports: mapping body cognition onto cardiac and neurophysiological measurements.”

This dissertation models the relationship between symptoms of heart rhythm fluctuations and cardiac measurements in order to better identify the probabilities of either a primarily organic or psychosomatic cause, and to better understand cognition of the internal body. The medical system needs to distinguish patients with actual cardiac problems from those who are misperceiving benign heart rhythms due to psychosomatic conditions. Cognitive neuroscience needs models showing how the brain processes sensations of palpitations. Psychologists and philosophers want data and analyses that address longstanding controversies about the validity of introspective methods. I therefore undertake a series of measurements to model how well patient descriptions of heartbeat fluctuations correspond to cardiac arrhythmias.

First, I employ a formula for Bayesian inference and an initial probability for disease. The presence of particular phrases in symptom reports is shown to modify the probability that a patient has a clinically significant heart rhythm disorder. A second measure of body knowledge accuracy uses a corpus of one hundred symptom reports to estimate the positive predictive value for arrhythmias contained in language about palpitations. This produces a metric representing average predictivity for cardiac arrhythmias in a population. A third effort investigates the percentage of patients with palpitations report actually diagnosed with arrhythmias by examining data from a series of studies. The major finding suggests that phenomenological reports about heartbeats are as or are more predictive of clinically significant arrhythmias than non-introspection-based data sources. This calculation can help clinicians who must diagnose an organic or psychosomatic etiology. Secondly, examining a corpus of reports for how well they predict the presence of cardiac rhythm disorders yielded a mean positive predictive value of 0.491. Thirdly, I reviewed studies of palpitations reporters, half of which showed between 15% and 26% of patients had significant or serious arrhythmias. In addition, evidence is presented that psychosomatic-based palpitation reports are likely due to cognitive filtering and processing of cardiac afferents by brainstem, thalamic, and cortical neurons. A framework is proposed to model these results, integrating neurophysiological, cognitive, and clinical levels of explanation. Strategies for developing therapies for patients suffering from identifiably psychosomatic-based palpitations are outlined.

the mobilization of healthcare information electronically across organizations within a region, community or hospital system.
HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIE is also useful to Public Health authorities to assist in analyses of the health of the population.
HIE systems facilitate physicians and clinicians meeting high standards of patient care through electronic participation in a patient’s continuity of care with multiple providers. Secondary health care provider benefits include reduced expenses associated with: duplicate tests, time involved in recovering missing patient information, paper, ink and associated office machinery, manual printing, scanning and faxing of documents, the physical mailing of entire patient charts, and manual phone communication to verify delivery of traditional communications, referrals and test results.

A blurb from Modern Healthcare hit my inbox about proposed regulations for these HIE’s:

The exchanges are a central component of the Patient Protection and Affordable Care Act and aim to provide subsidized coverage to at least 16 million people who have lacked coverage at some point in the past year.

The proposed rule spells out requirements states must meet if they opt to launch an exchange, or online marketplace of qualifying insurance plans. The federal government will launch exchanges in states that do not do so by 2014. The regulations also outline the minimum coverage health plans must provide in order to participate in any exchange.

“I think what the regulation sets out is a framework that says every state may choose a little bit different option,” HHS Kathleen Sebelius said in a news conference at a Capitol Hill hardware store. “We sent out some minimum standards, but the fact that some states may choose the active purchaser, like Massachusetts, and other states may use an open market, like Utah, is perfectly allowable and flexible,” she added. “And again, I think it’s important—these are choices of private insurers in an active market. This is not government insurance. It really is the private plans and again that’s really going to be a state-based stratetgy and choice.”

Finally, the proposed regulations spell out which companies may purchase coverage for their employees through the exchange. The healthcare reform law allows both individuals and employees of firms with 100 or fewer workers to purchase coverage—usually subsidized by taxpayers—on the exchange.

Steve Larsen, deputy administrator and director for CMS’ Office for Consumer Information and Insurance Oversight, said at Monday’s news conference that states will still have the option of developing their own exchanges even if they are not prepared for a federal review in January 2013.

The march towards meaningful use (MU) has created a sense of urgency within the physician community to adopt EHRs for their offices — as it should. Hospitals and eligible professionals (EPs), which include physicians, began attestation for MU incentive payments on April 18, and the first payments were issued in May.

 

Central to physicians qualifying for stimulus payments is the use of certified EHR technology. Vendors began applying for certification in July of 2010, and physicians have begun the process of either choosing appropriate technology or making needed changes to existing systems in order to qualify.

 

With $27 billion in incentives up for grabs over the next five years and the potential for penalties hanging in the balance for providers who do not meet criteria, the stakes are high. But like any rush to a deadline, it’s important that providers and ambulatory surgery centers understand the full picture and take a careful, thoughtful approach to choosing systems that align with both workflow needs and future expectations to avoid the potential for costly mistakes.

 

ASCs are becoming increasingly aware of the MU provisions — specifically as they relate to the perceived need to deploy a certified EHR as opposed to a system that may be more appropriately aligned to their environment. Since ASCs are not eligible for stimulus payments, and MU certification criteria for ASCs were never developed, there has been no real incentive or benefit for them to invest in certified systems. However, some ASCs are now feeling pressure to purchase a certified EHR and make costly technology decisions in order to satisfy the needs of their physician base.

 

This pressure is the result of a little-known clause in the meaningful use regulations, referred to as the 50 percent rule. A clear understanding of the 50 percent rule and four other aspects of MU is imperative for ASCs and EPs as they weigh their responses to the mounting external pressures to deploy certified EHR technology.

 

1. 50 percent rule. According to CMS, ”any eligible professional demonstrating meaningful use must have at least 50 percent of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives.”

 

The latest guidance from CMS is that, when they refer to a “practice/location,” ASCs are included in that definition. Additionally, CMS has commented that “equipped” means that the technology needs to be available in such a way that the EP can use a certified EHR to accomplish all of their MU objectives.

 

This clause can potentially have the unintended consequence of leading ASCs to believe that they need to adopt certified technology that is not designed for their environment, and for which they receive no stimulus payments, unlike EPs and hospitals.

 

2. Potential solutions. ASCs under pressure to adopt a certified EHR product should first have their physicians determine where their encounters occur. If at least half occur at an office or offices equipped with certified EHR technology, then there is no need for that physician to be concerned about the 50 percent rule.

 

In cases where a physician does have more than 50 percent of patient encounters occurring at an ASC, there are two options that exist for the center: 1) significantly change the workflow within the ASC and the physician’s office to capture data associated with MU objectives, or 2) encourage physicians to carefully review the CMS definition of an encounter and potentially change the way in which they schedule their patient activity to avoid falling short of the 50 percent rule.

 

According to CMS, for the purpose of calculating this 50 percent threshold, any encounter where medical treatment and/or evaluation and management services are provided should be considered a “patient encounter.”

 

3. Workflow challenges. MU criteria were designed to address longitudinal patient care and a move towards the efficient electronic capture of patient data over time. To meet this need, EHR vendors have designed products to capture patient information over the course of many encounters.

 

It is a workflow that fits well in a physician office environment. But an ASC is much different. To efficiently address the workflow needs of an ASC, products need to be designed around procedures. That is, data capture needs to address the specific needs of a particular procedure being performed. This will not typically require the extensive evaluation that may occur in a physician office.

 

There are numerous examples of MU objectives that do not fit well within an ASC’s workflow. For example, a meaningful user must use a certified system for the following types of workflows, many of which do not translate well into the ASC environment:

• Computerized provider order entry
• Drug/drug interaction checking
• Drug formulary checking
• Prescribing electronically
• Reconciling medications
• Incorporating clinical lab results into the EHR
• Calculating and reporting clinical quality measures to CMS
• Providing clinical summaries to patients
• Submitting data to immunization registries and public health agencies
• Keeping problem lists, medication lists and medication allergy lists updated

 

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

• Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
• While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
• What accounts for the loss of productivity?
• When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

The patient safety study, conducted by David Classen of the University of Utah and coauthors at the Institute for Healthcare Improvement, compared three methods for detecting adverse events in hospitalized patients, including the Institute’s own Global Trigger Tool. The study drew on comparable samples of patients from three leading hospitals that had undertaken quality and safety improvement efforts.

Among the 795 patient records reviewed, voluntary reporting detected four events, the Agency for Healthcare Research and Quality (AHRQ) Indicators detected 35, and the Global Trigger Tool detected 354 events, ten times more than the AHRQ method.  In other words, the AHRQ indicators and voluntary reporting missed more than 90 percent of adverse events identified by the Global Trigger Tool.  If anything, the researchers say, their findings are conservative, because they rely on medical record review, which would not detect as many adverse events as direct, real-time observation would.

The researchers say that reliance on voluntary hospital reporting or the AHRQ indicators could lead to seriously flawed perceptions of patient safety in the United States.  They also note that the Global Trigger Tool detected a much higher rate of adverse events for hospitalized patients than previous studies have shown.  Although the Global Trigger Tool is a somewhat more resource-intensive method because it involves medical record review, the researchers suggest that it could be incorporated into commercial electronic health record systems, thus making it easier and less costly to use.

More disturbing perspectives that should keep you eating your apple a day:

An analysis by Jill Van Den Bos and colleagues at Milliman’s Denver Health practice in Colorado, based on insurance claims, estimated the annual cost of measurable preventable medical errors that harm patients to be $17.1 billion in 2008 dollars.  Ten types of errors accounted for more than two-thirds of the total cost, with the most common ones being pressure ulcers, postoperative infections, and persistent back pain following back surgery.  The researchers recommend that these three types of errors receive top priority for intervention and improvement.

John Goodman of the National Center for Policy Analysis, and coauthors, found that there is a social cost to adverse events, and it is based on what people would be willing to pay to avoid the risk of death or injury caused by medical management.  That dollar figure ranges from $393 billion to $958 billion.  Yet the United States has few policies to compensate patients harmed by medical errors, other than a “very imperfect tort system,” in which fewer than 2 percent of patients harmed ever file a malpractice suit and even fewer receive any compensation, the researchers note.

There’s a big problem with how the vast majority of healthcare providers—let’s say, practices with fewer than 10 docs—are dealing with federal requirements for meaningful use, which they must meet to get subsidies. Most of them aren’t dealing with the real requirements at all. And they’re so focused on meeting deadlines, they risk picking the wrong electronic medical record software.
While hospitals have IT departments and some level of resources to throw at the meaningful use program, most docs are heads down seeing patient after patient, with little interest in poring over pages of requirements, let alone figuring out how to meet and then report on them.

Nearly six in 10 healthcare organizations still need to buy an EHR system or upgrade an existing one to qualify for the federal funds, according the InformationWeek Analytics’ Healthcare IT Priorities Survey of 357 business technology professionals at healthcare providers. And 62% of respondents who have EHRs or are planning them say they’ll spend more than 20% of their annual IT budget on EHR projects this year. In other words, there’s still a lot of heavy lifting for U.S. hospitals and doctors’ practices to deploy systems that comply with federal guidelines.

Qualifying for the funds isn’t easy. Health-care providers must be using certified EHR systems that meet federal requirements, and they have to demonstrate that they’re making “meaningful use” of those systems, complying with a laundry list of 20 requirements for medical practices and 19 for hospitals. And they have to do all this for 90 consecutive days before the end of next year.

Despite the complicated process, a surprising

83% of respondents who are evaluating, deploying, or have deployed EHRs are confident they’ll meet the federal government’s deadlines and qualify for incentive funds. Specifically, 52% of them say they’re “very confident” and 31% are “somewhat confident”

A quarter of respondents anticipate no problems with EHR adoption in their organizations. That’s a high number considering the potential issues that can come up when deploying an EHR system, such as negative reactions from physicians and staff, disruption to patient care, security and privacy mistakes, and shortages of technical expertise. It could very well be that providers underestimate how challenging meaningful use compliance is.

Among respondents, an eyebrow-raising 31% of healthcare providers say their EHR systems already comply with the government’s meaningful use requirements. What they likely mean is that their systems have been certified as meaningful use compliant.

However, certification ensures only that products have the features and functionality needed to accomplish meaningful use. Additional programming and workflow adjustments often are needed to integrate with other systems and processes in a healthcare organization. Significant staff training is commonly required.
Healthcare providers also must ensure that their EHR systems are collecting the data needed to demonstrate that they’re using the systems in a meaningful way—to show that a certain percentage of patients have drugs ordered electronically and have lists of their allergies and medical problems in the system, for instance.
It’s not uncommon for healthcare providers to think they’re making great progress meeting meaningful use requirements, only to discover they’re missing the mark, says Dana Sellers, CEO of Encore Health Resources, a health IT consulting firm.

Cloud Challenged
Healthcare has been slow to embrace cloud computing. Only 14% of respondents to InformationWeek Analytics 2011 Healthcare IT Priorities Survey are using public cloud services, while 47% have no plans to use either public or private clouds.

Thirty percent of companies across all industries use some public cloud services and just 33% have no plans to use cloud computing, according to InformationWeek Analytics’ State Of Cloud Computing Survey.

Electronic healthcare records are the most common application being hosted. More than 30% of survey respondents using public or private clouds are using it for this, followed by storage (28%) and financial apps (25%).

Clinical decision support, chronic disease management, business intelligence, and giving patients Web access to personal health records will get significant attention in the next 12 months, even though they aren’t connected directly to the first round of meaningful use requirements. Having technology in place for any
of these areas could help providers comply with later stages of meaningful use, however.
At Cleveland Clinic, the development of BI dashboards is a priority this year. The medical center has developed 20 dashboards over the past several years that are used by executives, nurse managers, and others to analyze financial, operations, clinical, quality-of-care, and other data, says Andrew Procter, administrative director of medical operations at Cleveland Clinic Innovations, the facility’s technology commercialization arm. The medical center has a “queue of requests” from clinicians throughout the organization, Procter says. “It’s a big part of what we do. It’s a big part of the culture” to use analysis that aligns clinical, financial, operations, and quality-of-care data to shape better decisions.

Mobile computing is another area getting attention. University General Surgeons, in Knoxville, Tenn., is evaluating whether to provide its six surgeons with tablet PCs with a hosted billing application. The tablet and app would make it easier for the physicians to document treatment information needed for billing while at a patient’s hospital bedside, rather than writing notes on paper and entering the charges later in the office, says practice administrator Michael Poulsen.

Microsoft’s Office and Windows empire can only grow incrementally at this point, and may yet decline with the emergence of cloud-based alternatives. Having reluctantly purchased a Mac, I can now understand the quality difference is huge, and I doubt Microsoft could ever catch up. But the sheer scale of the healthcare IT market has roused the Beast from Redmond to action. When Andre the Giant walks toward your street, you’d better pay attention!

Keep in mind that the governmental-regulation intensive world of healthcare IT is qualitatively different from what economics textbooks refer to as the “free market”.  As an apocryphal French bureaucrat supposedly said: “that may work in practice, but it will never work in theory.”

There is no level playing field here, and the historical principle of small, clever, innovative companies out-maneuvering the corpulent giants of yesterday is probably a fantasy for this domain. Mergers, acquisitions, and partnerships are the less risky path to market-share growth. Only the most powerful companies have the vast war-chest and legions of lawyers, analysts and lobbyists to compete for the insanely big bucks and shape the regulatory and competitive environment more to their liking. But what is the upshot of the Microsoft-Athena alliance for the rest of us? My contacts at www.softwareadvice.com have some timely analysis that bears examining:

What does this mean for ambulatory care EHR adopters? Not much for now, but it could pave the way to a much bigger collaboration between the two industry giants. Instead of acquiring EHR vendors as we discussed in April, Microsoft could be dipping its toe in the water by partnering instead. Partnering requires much less risk and is often the first step towards a larger move such as an acquisition.

From Athena’s standpoint, the partnership is a great opportunity to work its way into other organizations using Amalga. It’s a no-brainer and a win-win. For Microsoft though, the choice of Athena as a partner is surprising for a few reasons:

• We would still expect any Microsoft partner to possess the characteristics that we outlined in April of a lucrative acquisition target: large market share, scalable products, and .Net architecture.
• While Athena is a big brand and its system is scalable, it doesn’t have nearly the user base of bigger firms such as Allscripts or eClinicalWorks.
• The SaaS model provides zero synergy with SQL Server and Windows Server sales.

However, Athena’s commitment to cloud computing could prove to be attractive as Microsoft has been criticized for being late to the cloud party.