HHS released a proposed rule Monday announcing a one-year delay of the implementation of ICD-10-CM/PCS. If finalized, ICD-10 would become effective October 1, 2014.
"Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets," according to an April 9 press release.
"This is what I expected," says Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass. "But I am happy to hear that they didn’t seem to consider bypassing ICD-10 and going right to ICD-11. This goes to show that they do see the value in the system."
She believes this delay will give providers the necessary time to implement and handle the costs associated with the change. "And now that we know the deadline, there is no excuse," she says. "At this point, we have a date in sight again and we shouldn’t waste away the time that we have. We were given the extra time; use it wisely."
The proposed rule, "Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets" also proposes the adoption of a unique health plan identifier under HIPAA. That proposal would implement several administrative simplification provisions of the Affordable Care Act and save an estimated $4.6 billion over 10 years for healthcare plans and providers. The proposed rule also includes the adoption of a data element that would serve as an "other entity" identifier (OEID), as well as add a National Provider Identifier (NPI) requirement.
The proposed rule explains that three main issues emerged in recent months regarding the previous October 1, 2013 compliance date, leading HHS to reconsider the deadline:
The transition to Version 5010 did not go as effectively as expected
Providers were concerned about a lack of resources due to competing statutory initiatives
Several surveys and polls showed a lack of readiness for the transition
"While we considered a number of alternatives for the delay…we believe a 1-year delay would provide sufficient time for small providers and small hospitals to become ICD-10 compliant and would be the least financially burdensome to those who had planned to be compliant on October 1, 2013," the proposed rule states, estimating that a one-year delay would add an estimated 10%-30% to the total cost of implementation for those entities that have already spent or budgeted for the transition.
Those in the healthcare industry offered mixed reactions to the proposed length of the delay.
“It is disheartening and encouraging in many respects. Disheartening for the facilities and practices who spent the money to prepare for the October 1, 2013 deadline but encouraging for those same people to be ahead of the game now as to breathe a little easier,” says James S. Kennedy, MD, CCS,managing director of FTI Consulting in Brentwood, Tenn.
“The best way to prepare for ICD-10 implementation continues [to be] to first practice ICD-9-CM correctly and then negotiate the differences in ICD-10” Kennedy says. This [proposal could] give us another year to get our infrastructure together and fill in the documentation and coding gaps so facilities can be ready to adapt to ICD-10.”
Meanwhile Cheryl Ericson, MS, RN, clinical documentation improvement education director for HCPro Inc, points out, "This gives everyone an opportunity to slow down, take a deep breath."
"Most organizations should maintain their current course of progress so that coders become fluent in ICD-10. This just gives everyone extra time for improvement and gives us greater opportunities to recognize weaknesses in documentation," she says.
She notes that the 2013 compliance deadline was going to be tight for most organizations, but the delay will give everyone time to consider dual coding prior to implementation. "Take this as a blessing in disguise. Train your staff members and get them comfortable so that when the transition does come, it won’t be as stressful," Ericson says.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer of First Class Solutions, Inc. in Maryland Heights, Mo., and former president, board member, and interim CEO of AHIMA, is disappointed that CMS is delaying a full year and would have preferred only a six-month postponement. "I’d continue to encourage providers to prepare for ICD-10 at a calmer pace and take advantage of spreading the cost of implementation over another year," she says.
To comment on the proposed rule, visit www.regulations.gov. Comments are due within 30 days of publication in the Federal Register. The rule is due to publish in the April 17 edition of the Federal Register.
Big news regarding the ICD-10-CM/PCS implementation timeline came Tuesday morning during the American Medical Association (AMA) National Advocacy Conference in Washington, DC.
Per CMS acting administrator Marilyn Tavenner, CMS plans to revisit the current implementation deadline of October 1, 2013. Tavenner said CMS wants to reexamine the pace of implementing ICD-10 and reduce physicians' administrative burden, according to an AMA tweet.
CMS told HCPro that it expects to release additional information shortly.
"Since the AMA announced its intention to try and delay the implementation of ICD-10, this news does not come as a total surprise," said Lynne Spryszak, RN, CCDS, CPC-A, clinical documentation improvement (CDI) education director for HCPro, Inc., in Danvers, MA. "Providers are expected to comply with meaningful use, transition their practices to the 5010, and implement EHRs in their office. When you consider that providers are also facing a decrease in their reimbursement rates it is no wonder that they feel that their backs are against the wall."
That said, providers have had plenty of advance notice, Spryszak noted. CMS announced the conversion to ICD-10 in January of 2009, giving them nearly five years to plan.
The American Hospital Association (AHA) supports the transition to ICD-10, but welcomes reevaluation of the deadline.
"The AHA appreciates CMS' willingness to reconsider the timeline for ICD 10 implementation," Chantal Worzala, director of policy for AHA, told HCPro. "The AHA is supportive of the move to ICD-10 because it brings benefits for better clinical documentation, logical incorporation of codes for new technologies, and greater specificity to support accurate payment. However, changes in the environment that have occurred since ICD-10 was mandated for October 2013, including meaningful use, are putting significant pressures on hospitals. Implementing ICD-10 on schedule requires that the transition to 5010 go smoothly. It also requires that all parties be ready. We are closely tracking readiness of vendors and providers to implement ICD-10."
Tavenner indicated CMS plans to formally announce plans for new regulations in the coming days, according to an article by The Hill. Tavenner recognizes the concern that providers are balancing many different initiatives. "So we're trying to listen to that and be responsive," she said, per the article.
Until further information becomes available on the exact nature of the delay, providers should continue to push forward with their implementation efforts, according to industry experts.
"Even if they do delay ICD-10, especially for physician practices, this should not deter the infrastructure redevelopment to accommodate ICD-10's likely implementation in whatever time frame they do implement it, be it six, 12, 18, or 24 months from their previously announced date of October 1, 2013," said James S. Kennedy, MD, CCS, managing director of FTI Consulting in Brentwood, TN.
Mixed reactions
News of the potential delay is being met with diverse reactions.
"The provider population is just coming off the preparation efforts for 5010, so a slight delay may be appropriate," said Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer at First Class Solutions, Inc. in Maryland Heights, MO.
However, the delay should not be excessive, she said. Those proactive providers that have ICD-10 preparations well underway should be able to "get on" with their other activities, as they have a number of competing priorities right now.
The reaction by the physician community is to be expected: "There will be much rejoicing..." said Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. He believes that the physicians lack the tools they need for the transition. "If a tool were there that spoke clinical language and was available as an app on a smart phone or a tablet and would intercommunicate with the hospital and the physicians' offices, there would be no problem in meeting the existing deadline. Without this, it's dead in the water."
Meanwhile, as Kennedy explained, the rest of the world is already using ICD-10 and will likely transition to ICD-11 soon, while the United States is still using ICD-9. "Change is necessary if we are to develop a robust database of our patients' illnesses and treatments as to better measure outcomes and efficiency. While ICD-10 is not perfect—nothing is—we should not let the need for perfection be the enemy of the common good. Procrastination is not the solution," he said.
Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory specialist for HCPro, Inc, agreed. "I think it would be a tragedy to delay the process any further because we are so far behind the ball now that it is going to be even more difficult playing catch up." She too noted that until the move to ICD-10 is complete, there will be ongoing problems because the ICD-9 system is insufficient. "ICD-9 codes just don't work when it comes to reporting our diagnoses and procedures [for inpatients] and we need the added specificity," she says.
And of course, there are financial considerations. Many organizations have already invested huge dollars preparing.
"Providers and payers have done extensive work and spent millions to get ready for implementation, from training to systems issues, data conversions, budget considerations, staffing, etc. To put this major transition on hold will not only have a negative financial impact on what has already been done and create a major setback when we need to start up again, it will also add a mental blow when implementation comes around again—it feels a little like the boy who cried wolf!" explained Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro.
Mackaman said that those professionals and providers with whom she has spoken are looking ahead to the transition, recognizing that the benefits of moving forward—from data that will assist with improved patient care to improved statistical reporting and payment—far outweigh the advantages of stalling.
"At a certain point you begin to wonder why we don't just wait until ICD-11," said Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding, at HCPro. She too questioned the decision to delay so late in the game after providers have already invested in assessments and revised systems.
AHIMA and the AAPC were still formulating comments at the time of publication.
CMS included a major surprise when it released its final rule for the FY 2012 Inpatient Prospective Payment System integral to inpatient Medicare reimbursement at short-term and long-term acute care hospitals as announced in an August 1 press release.
CMS originally proposed a year-over-year reduction of 0.5% in payments to acute care hospitals under the FY 2012 IPPS, including a DCA of -3.15%. However, CMS finalized a cut of 2.0%, a decrease from 2.9% in FY 2011, which translates to $1.13 billion more in hospital payments in FY 2012 than they had received in the previous year.
“We’re very pleased to see that CMS has scaled back their proposed coding cuts,” says Joanna Kim, senior associate director for policy for the American Hospital Association (AHA) in Washington, DC. “We are quite disappointed that CMS did not change their methodology of analyzing documentation and coding, but are glad they recognized that the proposed 3.15% cut would be very difficult for hospitals to absorb all in one year.”
Kim suggests that hospitals look closely at the new payment rates and make sure they can budget appropriately.
James S. Kennedy, MD, CCS, managing director for FTI Healthcare in Atlanta, agrees that the temporary reprieve is a positive for hospitals. “The DCA is what it is. At least for next year, it’s good that we got a break,” he says. “But CMS will maintain its current methodology of calculating it and will continue to assess it to hospitals until they have recouped what they believe they have overpaid.”
“We recognize the concerns regarding possible financial disruption that may be caused by the proposed documentation and coding improvement payment adjustment,” CMS states in the rule. “We note, however, that these payment adjustments are necessary to correct past overpayments due solely to documentation and coding improvements. We have already delayed implementation of the required prospective adjustment amount, and we proposed only a portion of the remaining required adjustment to allow hospitals time to adjust to future payment differences and to moderate the effect of this adjustment in any given year.”
DRG adjustments
When it comes to the recalibration of relative weights for MS-DRGs, there are winners and losers every year, according to Kennedy.
Kennedy is pleased with the DRG for autologous bone marrow transplant was split according to their CC/MCC status. “They took the MS-DRG 15 and split it up into two parts, MS-DRG 16 (with CC/MCC) and MS-DRG 17 (without CC/MCC),” he explains. “Since CMS demonstrated that patients with CC/MCC require more resources that those without, this split better allocates CMS funding for this procedure.”
Additionally, the final rule divides excisional debridement and skin grafting in skin conditions not involving endocrine, nutritional, or metabolic principal diagnoses. “We agree with the commenters that data support the creation of three new debridement MS-DRGs 570, 571, and 572 for skin debridement and the revision of MS-DRGs 573 through 578 to include skin grafts only,” CMS says in the final rule.
This is a good change and there’s good data analysis behind it, Kennedy says. And it provides for greater reimbursement for hospitals that do grafts, which is correct because they do take more resources, he adds.
CC/MCC updates
CMS included a few notable updates to the list of CCs and MCCs for FY 2012.
For example, there is a new code for pancytopenia due to chemotherapy (code 284.11) as well as pancytopenia due to other drugs (code 284.12).
“To everybody’s surprise, these codes were designated as MCCs. There was an expectation that drug-induced pancytopenia would lose its MCC status because pancytopenia due to chemo used to code to aplastic anemia, a MCC,” Kennedy says. “This happened when the CDC implemented a code for chemotherapy-induced anemia, which used to be coded to aplastic anemia; it lost its CC status altogether! So I’m elated. Hospitals—especially cancer and pediatric hospitals—should be very grateful for this.”
“Similarly, code 294.21 (dementia unspecified with behavioral disturbance) wasn’t going to be a CC, but again because of commenters like ACDIS, CMS made it a CC.”
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA, the parent company of HealthLeaders Media, also noted the exclusion that was removed related to pressure ulcer coding.
When pressure ulcer site codes (codes 707.00–707.09) are assigned as the principal diagnosis with an additional code for the stage of the pressure ulcer there was a CC/MCC exclusion that would not allow the stage III and stage IV codes (codes 707.23–707.24) to serve as an MCC, she says. This exclusion will be removed for FY 2012 recognizing the stage III and stage IV pressure ulcer stage codes as an MCC when the reason for the admission was the pressure ulcer (i.e., principal diagnosis), McCall says.
2012 code changes
The new, revised, and deleted ICD-9-CM codes have been finalized for FY 2012. (A full listing of the changes is available on the CMS website.)
“They did add a fair number of codes after the proposed rule came out based on the March 2011 ICD-9 Coordination and Maintenance Committee meeting,” McCall says. “Some of the ones that were added were for added specificity, like for postoperative shock to identify whether it was cardiogenic or septic. All of these codes will be considered MCCs.”
CMS also added specificity to the complications associated with central catheter codes to identify whether an infection was considered a local infection due to a central venous catheter vs. a bloodstream infection due to a central venous catheter, McCall says.
There are additional codes for acute respiratory failure following surgery to identify whether it occurred in the presence of acute and chronic respiratory failures. “So they did have some added detail there, too,” McCall says.
CMS finalized more procedure codes than expected. “We thought we were only going to have one new procedure code this year, but they added almost 20 new procedure codes,” McCall says.
Additions include atherectomy codes (17.53–17.56), which were traditionally coded within the angioplasty series of codes, but those didn’t really reflect the true procedure being performed, she says, so CMS created specific codes to identify the atherectomies performed in the coronary and other vessels. This differentiation will be helpful in preparation for the transition to ICD-10-PCS because angioplasties and atherectomies will be considered different root operations in the new system so distinction will become increasingly important.
CMS also added endovascular and transapical heart valve codes as well as a code for the sleeve gastrectomy procedure, which can be performed either via open or laparoscopic approaches, McCall notes.
“[CMS] created code 43.82 specifically for a laparoscopic sleeve gastrectomy,” McCall says. “Previously, this procedure did not have a specific code, and was reported as 43.89, which is for an ‘other total gastrectomy’.” But when paired with a principal diagnosis of 278.01, code 43.89 wasn’t included as an inclusive procedure for DRGs for obesity so it fell into the DRGs 981–983 for extensive OR procedures unrelated to the principal diagnosis, “which doesn’t make any sense at all because in this instance the procedure was related to the principal diagnosis (i.e., obesity),” she says. Therefore CMS not only created the new code for the sleeve gastrectomy, but also added it to MS-DRGs 619–621, which are the DRGs assigned for OR procedures for obesity.
Readmissions provisions
The Patient Protection and Affordable Care Act requires CMS to implement a program to reduce hospital readmissions for certain hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012.
The final rule finalizes readmissions measures for three conditions:
·Acute myocardial infarction (i.e., heart attack)
·Heart failure
·Pneumonia
CMS also finalized its definition of readmission as “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days.
In addition, the rule describes the methodology CMS will use to calculate excess readmission rates.
Hospital-acquired conditions
CMS proposed adding a new condition to the list of hospital-acquired conditions (HAC) subject to reduced payment provisions under the IPPS—contrast-induced acute kidney injury. Although CMS acknowledged in the proposed rule that there are no unique codes to identify the varying stages of acute kidney injury, the agency proposed to identify it as a subset of discharges with ICD-9-CM diagnosis code 584.9 (acute kidney failure, unspecified), a CC. CMS contended that it could accurately identify contrast-induced kidney injury when code 584.9 is listed in combination with specified procedure codes from the 88.xx code series.
After considering public comments on this proposed new HAC, CMS has decided to defer adding contrast-induced acute kidney injury as an HAC until “such at time when improved coding is available,” according to the final rule.
“I’m grateful that they chose not to use acute renal failure as an HAC. The ICD-9 and ICD-10 coding systems aren’t robust enough to track contrast-induced nephropathy,” Kennedy says. “While the logic for using contrast induced renal failure is sound, the ICD-9-CM Coordination and Maintenance Committee will have to create codes to implement this policy.”
If that happens, CMS might choose to add this as an HAC in the future, he says, as CMS has stated it is an area of interest and it believes there is room for quality improvement in this area.
According to the final rule, CMS did adopt five new ICD-9-CM codes to be added to their respective HAC categories:
Procedure codes 808.44 and 808.54 for multiple pelvic fractures are added to the falls and trauma category
Procedure codes 539.01 and 539.81 for infections related to gastric procedures are added to the surgical site infection following certain bariatric procedures category
Procedure code 415.13 describing a type of pulmonary embolus is added to the deep vein thrombosis and pulmonary embolism following certain orthopedic procedures category.
Three-day payment window changes
CMS continued to address comments about the three-day payment window in the final rule.
Specifically, commenters were looking for information on billing in relation to the three-day rule for free-standing physician offices, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro. However, CMS basically indicated further information would be available in the upcoming Medicare Physician Fee Schedule that will be released this fall.
“People need to read very carefully the physician fee schedule final rule for further billing instructions on how to divide up the overhead piece vs. the professional piece,” Hoy says. “We know [the three-day rule] applies, but how? We were hoping for some sort of formula.”
Other commenters asked for clarification on what “clinically associated” really means, Hoy says, but CMS provided no clarification on that matter.
Hoy offers another interesting note: CMS indicated in the rule that providers shouldn’t assume that all services provided during a continuous stay are related.
“CMS seems to be saying that continuous stays are not necessarily related and could result in some bundling of unrelated services if you made that assumption,” Hoy says. “Though this could be a positive change in terms of reimbursement if you get payment for a few services that didn’t need to be bundled, it makes it all that much more confusing and operationally difficult to individually review all of the services.”
Value-based purchasing program
CMS has finalized the addition of the Medicare Spending per Beneficiary measure in 2014 to the Hospital Inpatient Value-Based Purchasing program required by the PPACA.
While the proposed rule indicated the measure would assess Medicare parts A and B spending from three days prior to an inpatient admission until 90 days after discharge, the finalized measure tracks spending from three days prior to admission until 30 days post-discharge.
“One new measure that’s outside what we’ve seen to date is the Medicare spending per beneficiary measure . . . CMS had originally proposed that it measure spending from three days pre-hospitalization through 90 days post-discharge, but as we requested, they shortened the time period to 30 days post-discharge,” Kim says. “It’s a new type of measure, a spending measure, which we haven’t seen before in the inpatient quality reporting program.”
LTCH PPS changes
In addition to hospitals paid under the IPPS, the rule also updates payment policies and rates for those under the long-term care hospital prospective payment system (LTCH PPS).
LTCHs finalizes an expected increase of $126 million (a net increase of 2.5%), due to a 1.8% rise in payment rates and other policies, compared to the proposed rule, which estimated a 1.9% increase.
A new pay-for-reporting program was also finalized in the rule for the following quality measures:
·Catheter-associated urinary tract infection
·Central line catheter-associated bloodstream infections
·New or worsening pressure ulcers
The first measure set for reporting will take effect in October 2012, with a 2% payment penalty for non-reporting beginning in October 2013.
Editor’s note: The final rule will appear in the August 18 issue of the Federal Register. Changes are effective October 1, 2012 unless otherwise specified. For additional information, including IPPS and LTCH PPS tables, visit the CMS website.
The HHS Office of the National Coordinator for Health Information Technology (ONC) released a final rule June 18 establishing a certification program for health information technology. The rule describes the temporary certification program for EHRs, and what organizations need to do to be authorized to test and certify EHR technology.
"[EHR technology certification] assures healthcare providers that the EHR technology they adopt has been tested and includes the required capabilities they need in order to use the technology in a meaningful way to improve the quality of care provided to their patients," according to the June 18 HHS press release.
The rule specifically establishes a temporary certification program that will help ensure the availability of certified technology prior to October, when some providers become eligible for EHR meaningful use incentive payments. It also states that a permanent program that will eventually replace the temporary one, according to the ONC website.
To qualify for incentive payments organizations must use certified technology per the Medicare and Medicaid EHR Incentive Programs provisions. The program was authorized in the 2009 Health Information Technology for Economic and Clinical Health Act enacted as part of the American Recovery and Reinvestment Act. The final rule takes effect June 24, when it will be published in the Federal Register. The ONC expects to release the permanent certification program final rule later this fall, according to the press release.
"By purchasing certified EHR technology, hospitals and eligible professionals and hospitals will be able to make EHR purchasing decisions knowing that the technology will allow them to become meaningful users of EHRs, qualify for the payment incentives, and begin to use EHRs in a way that will improve quality and efficiency in our health care system," David Blumenthal, MD, MPP, National Coordinator for Health Information Technology, stated in the press release. "We hope that all HIT stakeholders view this rule as the federal government's commitment to reduce uncertainty in the health IT marketplace and advance the successful implementation of EHR incentive programs."
As President Obama signed new legislation expanding EHR meaningful use incentive eligibility to outpatient-based hospital physicians, Congress recently introduced a new bill that extends eligibility to additional hospitals.
The need for additional clarifying legislation may speak to the lack of understanding on the part of Congress as to the implications of their initial language in ARRA, says Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, CPHIE, FHIMSS, president of Margret\A Consulting, LLC, in Schaumburg, IL.
Obama signed The Continuing Extension Act of 2010 (HR 4851) into law April 15. The Act changes the definition of "hospital-based physician" as it was original stated in the 2009 American Recovery and Reinvestment Act's HITECH legislation.
Amatayakul supports the broader definition. "This will open the door to many more providers who do need to be incentivized [to adopt EHRs]."
The Continuing Extension Act changes the word "outpatient" in the description of a hospital-based setting "whether inpatient or outpatient" to read "inpatient or emergency room setting." The change is in effect as if it was included in the original HITECH Act.
This was a necessary change, Amatayakul says. "It became obvious that [ARRA] was not going to cover providers that had to buy their own system, but did much of their work in hospital. For example, 90% of nephrologists work in dialysis center in a hospital, but many use their own system to document."
However, the new language explicitly stating the ineligibility of emergency room physicians may leave some wondering about their blatant exclusion from incentives. "[Physicians] contracted to work in the ED may have their own system and use it in the hospital," says Amatayakul, who believes it will be interesting to see what comes out in terms of public comment on this aspect of the act.
Bringing behavioral, mental health on-board
Meanwhile, Representatives Patrick Kennedy (D-RI) and Tim Murphy (R-PA) introduced the HITECH Extension for Behavioral Health Services Act of 2010 (HR 5025) to the House April 14. This proposed legislation would further expand meaningful use incentive eligibility to behavioral and mental healthcare providers.
The bill proposes the following change:
Public Health Service Act (42 U.S.C. 300jj[3]) is amended [to include] `behavioral and mental health professionals (as defined in section 331(a)(3)(E)(i)), a substance abuse professional, a psychiatric hospital (as defined in section 1861(f) of the SSA (42 U.S.C. 1395x(f))), a behavioral and mental health clinic, a substance abuse treatment facility'.
The new legislation would make inpatient psychiatric hospitals, as well as clinical social workers and clinical psychologist providing qualified psychologist services eligible for Medicare meaningful use incentives. It also makes public psychiatric hospitals, as well as private psychiatric hospitals and mental health and substance abuse treatment facilities with at least 10% of their patient volume being individuals receiving Medicaid assistance eligible for the Medicaid incentives.
EHR documentation can be dictated by billing rules and legal requirements, or by your need to describe your patients and provide quality care, according to the New England Journal of Medicine.
"Clinicians need to take back ownership of the medical record as a tool for improving patient care; such a move could have many benefits, including reducing the frequency of diagnostic errors," according to authors David W. Bates, MD, and Gordon D. Schiff, MD.
Increasing physician efficiency and improving patient care may be possible through the use of EHRs—but a system lacking the right capabilities can hinder the process. For this reason, physicians may want to weigh in when it comes time to adopt new technologies or upgrade older systems at their organizations.
Consider diagnostic errors.
"Diagnosing illness is one of our most important professional responsibilities, and patients justifiably expect us to perform this difficult task well. Electronic documentation represents a pivotal tool that can help us to fulfill this responsibility," according to Bates and Schiff.
They believe physicians can use EHRs to access and display data from patients' prior clinical encounters and tests. Access to this information will improve their knowledge and facilitate rapid diagnostic judgments.
EHRs can also help physicians order and track tests, particularly when these functions are included with clinical documentation, according to the study. Physicians may want to press for systems that merge results management and documentation.
In addition, EHRs can (and should) use diagnostic checklists to facilitate documentation and decision-making and limit the chance of memory lapses.
And speaking of lists, Bates and Schiff believe EHRs can help physicians manage (e.g., update, create, and deactivate) problem lists. However, EHRs need to promote easier list management.
"Although such lists are vital for ensuring that important problems are not overlooked, clinicians will not maintain them unless they are made more useful and easier to incorporate into clinical conversations and documentation," they say.
Clinicians also need a place to document free-text narratives in their EHR to capture uncertainties, according to the NEJM article. They need to be able to "craft thoughtful differential diagnoses" and "note unanswered questions." And they need to be able to share the information with patients, consultants, and other healthcare providers. EHR systems also need to enable evolutionary documentation. Physicians should be able to update their patients' narratives, creating a well-documented history and ongoing assessment. This will be particularly beneficial for patients with chronic conditions.
"Systems developers and clinicians will need to reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers will need to lead by adopting a more rational approach than the current one, in which billing codes dictate evaluation and management and providers are forced to focus on ticking boxes rather than on thoughtfully documenting their clinical thinking," according to Bates and Schiff.
At the end of the day, while the systems have to meet the needs of HIM, compliance, and finance departments, they also need to work for the clinicians.
Upcoming EHR meaningful use subsidies may give many hospitals the additional incentive necessary to push toward a largely paperless existence.
Some facilities may be adopting their first electronic systems at this time. Others currently operating in a hybrid environment are likely looking to increase their EHR technologies to meet soon-to-be-finalized meaningful use measures.
Of course, cost is always a part of the conversation when vetting potential new technologies. Many providers may also want to insist on purchasing certified EHR technologies so they are eligible for incentives. But many other less obvious points warrant consideration when selecting potential EHR technologies, says Deborah S. Fernandez, RHIA, corporate services manager for New York-Presbyterian Hospital in New York City, who has been working with various EHR systems and technologies since the late 1990s.
First of all, as much as possible, HIM should be a part of the team that considers various EHR technologies. HIM staff can offer a unique perspective on what the new technology needs to be able to accomplish. For example, HIM staff members may be able to determine whether the potential technology will capture documentation in a way that meets legal requirements.
"It's terrible to make an investment like that and not have a full handle on everything [the system needs to do]," Fernandez says.
And don't forget about your record reproduction needs. Consider the various healthcare reform initiatives aimed at saving government dollars. It all translates into more audits for hospitals, says Fernandez. And that means reproducing your records for auditors.
"My facility is going to be receiving recovery audit contractor requests," she says. "That's a lot of printing."
For example, consider how systems print hard copies of your data. Some systems print information in the form of unwieldy spreadsheets instead of more consolidated narratives.
"Some systems are very nice and neat, but some of them are horrific," Fernandez says. "Some of these systems will print thousands of pages."
In addition to printing hard copies, don't forget to look at the ease with which potential systems can reproduce electronic copies of information, Fernandez says. Many auditors may soon begin to accept electronic versions of medical records, if they don't already.
But the electronic versions can be equally unwieldy; some systems produce huge files, she says. When considering various technologies, consider how easy it will be to save the data in the systems on a CD or DVD, for example.
And be sure to talk to vendors about how their technologies will interface with those you already have in place. Many providers will adopt different specialized systems for different areas of the hospital. This isn't necessarily bad, Fernandez says, because the technologies are designed to do different things. But at the same time, you don't want staff members to have to sign on to five separate systems to view information on a patient.
You'll probably need to push systems into working together for information to be available in this way, she says. Do yourself a favor and consider upfront whether technologies will be able to talk to each other.
"The idea that clinicians can view something in a single system might not sound like such a big deal, but it is," Fernandez says. "You want it to seem to the end user that you have only one system instead of a dozen."
After an eventful week on Capitol Hill, HIM directors are likely wondering how health reform will affect them. Understanding what is in the bill is an important first step to figuring out what is on the horizon. Only then can HIM directors begin to figure out how to manage those changes.
"It will be awhile until all of this is flushed out and there is a clearer picture for the impact on HIM or other healthcare professionals," says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIMentors, LLC, in Westchester, IL. After all, many of the provisions don't go into effect until several years in the future.
While a few details are still being worked out regarding EHR-related legislation, Congress took care of most of that in ARRA's HITECH Act. However, new healthcare reform legislation does address the topic briefly.
According to the reform, HHS is responsible for studying and reporting back on ways to increase EHR use among smaller healthcare providers, including recommendations for further legislation to increase funding. The resulting report will also discuss possible higher reimbursement rates or incentives for small providers who use EHRs, as well as assist with training and education, and implementation assistance to the providers.
But while EHRs are not a big part of the new reform bill, the administrative simplification provision is, according to Dan Rode, MBA, CHPS, FHFMA, vice president of policy and government relations for the American Health Information Management Association in Washington, DC.
The provision should allow for easier and more timely updating of the HIPAA transaction code sets. The language would allow the HHS secretary to set up a process to update on a more regular basis, as well as issue a uniform guide for the use of the transactions, both of which should be positives, Rode says.
"The industry has already finalized 5060, and we're still trying to get to 5010," Rode says. "And the secretary's guide could presumably eliminate many of the variances in how we report data on claims."
However, these changes are unlikely to come sooner than the switch to HIPAA 5010, set to occur on January 1, 2012, as part of the preparation for the changeover to ICD-10, which goes into effect one year later.
But once the changes do occur, the industry will be able to keep up with HIPAA transaction code set changes much more easily, Rode says. "They could come annually after that, with minor changes each year, as opposed to huge switch as we are seeing when we move to 5010."
A few new provisions for Medicaid may look familiar. For example, a new provision mandates the use of National Correct Coding Initiative edits for Medicaid claims filed on or after October 1, 2010. In addition, the Act contains new provisions for the nonpayment of healthcare-acquired conditions for Medicaid claims for discharges as of January 1, 2010.
The legislation will also have indirect effects on HIM departments—for example, the sheer volume of their work. That's a lot more coding, a lot more requests for information, a lot more insurance companies to deal with, a lot more transcription. In fact, it means a lot more of almost everything HIM staff members manage on a daily basis.
"Where there is more volume, there is more work," Grzybowski says. "So there will be an impact on resources needed, which is unfortunate given the labor shortage already in existence for HIM."
"Unfortunately, that problem will probably continue for a while," Rode says. "But hopefully as we move toward increased EHR capabilities, that may help. ICD-10 may also help to make coding easier and more accurate as well by eliminating vague codes."
And that could be very important as the bill contains provisions for additional fraud and abuse. Providers have seen in the past that when the government looks into reducing waste and abuse, HIM departments tend to see additional auditing activity. Grzybowski believes this will be no exception.
"An increased emphasis on conducting audits, both internal and external, will occur as greater volumes mandate greater need for quality checks and controls," she says. "In addition, many of these audits will provide for recapture of reimbursement from providers to help fund the enormous expenses, which accompany this reform bill."
But whether the additional funding set aside in the Act will translate into new auditors or just increased volume by those already in existence remains to be seen. However, the government may simply expand the programs it already has (e.g., Recovery Audit Contractors), Rode says. He also believes the government may focus on auditing for deliberate fraud, as opposed to, for example, abuse in the form of coding errors.
Regardless, HIM departments will need to update their processes and increase their efficiency to keep up with patient volume increases, according to Grzybowski. This includes using technology to improve workflow, and electronic document management systems.
"Use of consultative and interim staffing resources should also increase due to both the labor shortage and the increasing use of technology," she says. "Overall, change management skills will also be essential."
HIM directors may come to appreciate the Act's emphasis on quality and having good data, both of which highlight the HIM department's role in managing information.
And finally, the reform could bolster hospital bottom lines, formerly hindered by receivable problems when patients couldn't pay for their care. "It could well stabilize healthcare organizations, which will be a positive in the long run for everyone," Rode says.
Adding its voice to the EHR standards debate, the American Hospital Association asked for changes to proposed EHR standards, implementation, and certification.
The AHA sent its recommendations and comments regarding the interim final rule specifying the initial set of standards, implementation specifications, and certification criteria for EHR technology to the National Coordinator for Health IT in a March 15 letter.
The AHA made recommendations in five areas:
On EHR certification for meaningful use
The AHA believes:
There needs to be "a clear distinction between the responsibilities of healthcare providers and the responsibilities of vendors of health IT products," as certification is intended to support providers, not impose an additional burden.
Realistic timelines are necessary. AHA recommends one year between certification criteria finalization and vendor system certification, and an additional two years after certified products become available before providers must implement and/or use them to meet meaningful use criteria.
The ONC should support CMS in creating a grandfathering provision for already-installed EHRs that permits providers to meet meaningful use criteria.
On implementation issues
The AHA offered the following commentary:
While the interim final rule's definitions of EHR technologies in the interim final rule provide a solid framework for discussing certification, they don't take into account the complexity of EHR systems deployed in hospitals. Clarification is needed regarding which elements of an EHR system need certification and verifying that certain common practices will not necessitate additional or separate certifications.
The AHA recommends that ONC specifically state the following: A hospital only needs to attest that its EHR system includes elements certified against the meaningful use objectives it must meet; a hospital's EHR system may also include auxiliary components and feeder systems that the hospital will use to meet meaningful use objectives, but do require separate certification; hospitals may install interfaces and programs to connect or complete EHR modules and related systems, but they do not require certification; hospitals may modify or customize certified EHR technology without needing additional certifications; and hospitals "will not be held responsible for having certified EHR modules for functionalities that no vendors support."
The AHA believes there should be no requirement to conduct separate, on-site certifications for all best-of-breed systems or those composed of a base system with add-on components.
The AHA encourages ONC and CMS to provide clear guidance establishing minimum requirements for hospitals to demonstrate an EHR is certified, and that those requirements be subject to notice and comment. AHA believes requiring hospitals to attest to their certification status is a legal compliance burden that could "result in significant penalties if hospitals and enforcement agencies have differing understandings of the specific requirements."
On EHR certification criteria modifications
The AHA recommends the ONC do the following:
Take all necessary regulatory steps (e.g., publishing a final rule or even a second interim final rule) as soon as possible because EHR vendors and stakeholders require lead time to bring certifiable products to the market.
For measures included in the meaningful use final rule requiring a number or percentage as a response, include certification criteria for the generation of the health IT functionality measures. In addition, certification of EHR products should require only generation of the associated measure.
Include certification criteria for any new objectives in CMS' EHR incentive program final rule.
Remove the electronic claims submission and electronic verification of insurance eligibility certification criteria
On certification criteria and standards
The AHA recommends:
Changing the medication reconciliation certification criteria to avoid potential safety concerns. AHA suggests that the criteria should state, "Display simultaneously two or more medication lists and provide tools for the clinician to perform medication reconciliation that will result in a single list."
Adopting Health Level Seven Clinical Document Architecture Release 2 Level 2 Continuity of Care Document (HL7 CDA CCD) as the sole standard for patient summary records.
Certifying vendors based on their systems' ability "to accurately and reliably collect and report" on quality measures once they are ready for automated reporting.
Delaying quality reporting until at least 2012 because of the lack of "appropriate e-specifications for hospital quality measures"
Deferring adoption of the public agency reporting standard until there is one viable national standard
On privacy and security
The AHA recommended that:
The rule specify that for EHRs seeking certification, privacy and security certification criteria are "addressable" the same way that certain HIPAA security rule specifications are "addressable."
There be a delay in the accounting of disclosures criteria and standards until the HHS Secretary issues an updated rule. This will help ensure that the technical specifications match the obligations that the forthcoming rule puts in place.
Revisions should be made to ensure that EHR technology is capable of providing electronic access and copies of health information for patients.
The ONC should clarify that the interim final rule's standards for encryption and hashing do not involve any additional requirements for HIPAA covered entities beyond those that the security rule already requires.
The audit alerting criterion be eliminated because it "goes beyond" HIPAA and HITECH requirements and exceeds the current capabilities of products on the market.
Many hospital-based physicians puzzled by their apparent exclusion from EHR meaningful use incentives may find some relief in a provision included the latest Senate jobs bill, "The American Workers, State, and Business Relief Act of 2010 (H.R. 4213)," which passed on Wednesday.
Section 219 in the draft bill amends The American Recovery and Reinvestment Act of 2009 language. The current law states that hospital-based physicians are excluded from receiving EHR subsidies. However, the Senate bill would change this language so that only hospital-based physicians, who provide services in a hospital inpatient or emergency room setting, are excluded from receiving EHR subsidies.
In other words, the Senate bill as written would make hospital-based physicians, who provide their services primarily at hospital outpatient centers and clinics, eligible for EHR incentives.
The inclusion of the clarifying provision suggests that the Senate may believe CMS is interpreting ARRA's language too stringently. CMS' interpretation, as seen in the proposed EHR meaningful use incentive program, is that all hospital-based physicians are ineligible for incentives. CMS' final rules on the EHR meaningful use incentive program are due out late this spring, according to CMS.
The legislation now moves to House for reconciliation with the House-passed version.