From the Consultant’s Corner 1/31/14

Optimizing Clinical Documentation
Now Is the Time to Get Started

Many healthcare organizations capture clinical documentation via electronic health records (EHRs) and other technology-enabled channels. The ability to fully leverage clinical documentation to improve care, compliance and reimbursement depends on its quality. In my experience, engaging in clinical documentation optimization is a valuable exercise that can yield tangible benefits.

The October 1, 2014 ICD-10 deadline is probably the most compelling reason to focus on optimizing documentation right now. ICD-10 requires a high degree of specificity, and if your documentation doesn’t have it, you could see a drop in reimbursement and/or an increase in claims denials. On the other hand, if your documentation is detailed and reflects a true picture of the patient experience, coders can more accurately code claims, ensuring you receive full reimbursement for services rendered.

While a significant impetus for improvement, ICD-10 compliance isn’t the only driver for optimization. By striving for more detail and accuracy in clinical documentation, your organization can elevate care quality through better communication among providers. Strong documentation ensures everyone who interacts with the patient is on the same page about diagnosis, treatment and patient response. Embedding care alerts and reminders for patients in documentation can further enhance quality.

Comprehensive documentation also ensures you use technology—electronic health records, for example—to its full potential, which can drive physician productivity as well as adoption.

Thorough documentation can also enhance reporting, which in turn, supports better care delivery. Discreet levels of data are necessary to generate accurate quality reports.

Finally, better documentation fosters more timely claims submission, which results in improved cash flow and reimbursement and leads to fewer denials, ultimately preserving your revenue cycle integrity.

Acknowledging the importance of enriching clinical documentation is the first step toward optimization. To make meaningful progress, I suggest organizations consider and customize the following high-level next steps:

1. Establish goals. Be specific about objectives, timelines, training and who will do the work to drive and manage the improvement process and subsequent changes.

2. Determine early focus. High-volume, high-reimbursement clinical areas and processes make a logical place to start work. In my experience, strengthening documentation in these areas can prevent substantial hits to cash flow and revenue.

3. Examine specialties. Concentrate on those areas that have the most significant changes in documentation requirements, such as cardiology and orthopedics. The physicians in these areas will need to significantly “up their game” when it comes to documentation and can provide valuable input for system workflow retooling.

4. Identify areas of “quick wins.” Give special attention to areas of strong physician support because physician champions can serve as positive role models for adoption in other areas. Identify key players within specialties and promote their demonstrated success to break down change management challenges in other areas.

While ICD-10 makes optimizing clinical documentation a top priority now, improvement work in this area should be an ongoing process with the ultimate goal of elevating clinical care. Organizations that commit to a continuous effort to enhance detail, accuracy and consistency, can see real benefits in terms of both revenue and patient care. Although the idea of revamping clinical documentation may seem daunting, organizations can see big improvements with small changes. The key is acknowledging the importance of the work and getting started on the journey; in my mind, there is no time like the present.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions.

From the Consultant’s Corner 12/12/13

Looking Beyond EHR Go-Live: The Value of Continual Optimization

Many EHR vendors have developed implementation methodologies which leverage years of their collective clients’ experience to define “best practice” workflows and clinical content. These approaches are often valuable as they streamline the design/build processes. However, very few healthcare organizations I have worked with are exactly the same. Differences in culture, governance, size, ownership, hospital alignment, patient and payer populations, along with practice management and IT sophistication make a “one size fits all” approach less practical over the long term.

To complicate the EHR implementation decision making process further, medical groups are frequently required to make workflow and application design/build decisions concurrently with their vendor learning curve. Said otherwise, they are often not educated by their vendors about their full options and the downstream benefits/impacts of different options. As such, those downstream impacts are not recognized until after go-live.

Lastly, it is not practical or cost-effective to remediate every user’s concerns or preference during the implementation process. This would elongate the implementation timeline and explode the EHR budget. As such, medical groups need to make trade-offs between what are pre-requisites for go-live and what workflow or functionality can be fine-tuned after go-live.

These are a few examples of why healthcare organizations suffer from EHR project fatigue. While the implementation may end, on-going optimization is really what enables practices to leverage EHR functionality to improve quality and physician productivity.

The work never seems to end after go-live. Add to this list upgrades, clinical documentation enhancement, and training to support government regulations such as Meaningful Use Stage 2 and ICD-10. All of this requires resources and funding after go-live.

Governance will play an increasing role in how organizations prioritize all of the projects that compete for resources. Strong clinical leadership is essential for establishing standards related to quality and productivity. IT leadership will be tasked with organizing and managing projects based on budgets and timelines.

There is no abrupt end to EHR implementation. Optimization comes with continued refinements as physicians experience the system and see ways the EHR can address their unique needs. With strong clinical leadership, clear governance and a flexible vendor implementation approach, you can realize an ongoing, interactive process that paves the way for a successful future.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions.

Pretzel Logic: Have Sympathy for Your Vendor 11/8/13

Well, the season is upon us again. I’m referring of course to Meaningful Use certification and attestation time, when ONC and CMS determine who’s naughty and who’s nice. Actually with the new HIPAA rules and proposed Accounting of Disclosure rules, it’s the Office of Civil Rights who will determine who’s naughty….and who’s naughtier. But that’s another story.

You may have heard from your EHR vendor or experienced firsthand or seen recent press coverage on the difficulties that vendors are experiencing with certifying their systems to support Meaningful Use Stage 2. Headlines such as “Stage 2 proves challenging for vendors” and “Fewer certified EHRs for Stage 2 may pose problems for hospitals, doc practices” may sound like normal vendor whining. But when the normally sunny and always encouraging Dr. John Halamka jumps on the criticism bandwagon, you know there might be some trouble underfoot.

I know, I know, it’s hard to have sympathy for vendors when you clinicians have a million MU hoops to jump through, but hear me out. First I need to point out the difference between attestation and certification. Attestation is governed by CMS and refers to what providers have to do, while certification is determined by ONC and refers to what EHR vendors have to do. In theory, certification is synced with attestation, meaning that ONC doesn’t require vendors to provide tools that do anything more than what CMS is asking providers to use them for. In practice, it’s too hard for the government to resist the temptation to use the MU regulatory lever to get vendors to do more, so there are some certification hoops that EHR vendors have to jump through that most clinicians are totally unaware of. Further, certification for Stage 2 is made even more complex by crudely constructed certification definitions which get amplified by messy testing requirements permeated with cumbersome “make-work”. Here are a couple of examples.

A significant evolution in the development of EHR systems is the idea of modularity. The MU program encourages development of certified “EHR modules” focused on a single EHR function (like e-prescribing or quality measurement), which in principle allows users to mix-and-match EHR components according to their own needs and preferences. Kind of like Google’s Android Market or Apple’s App Store. Great concept, but it makes sense only to the extent that the modules are well defined. As it turns out, they’re not. (sigh)

Take the certification requirement for exchanging transition of care summaries. It’s actually broken into two certification requirements, one for sending and the other for receiving. The original idea, forged in the Direct standard, was that this would basically be secure email. Yet, the ONC rules require much more than that. In order to get certified for sending and receiving clinical documents, ONC requires that the EHR component has to be able to create the standardized clinical document as well as deliver it to the intended recipient, and it has to open and parse the document after it has received it from the sender.

That’s like saying that Gmail should be required to generate spreadsheets, or Fed Ex should only be able to deliver parcels that they package, or that cable companies should only be able to deliver programming that they create. What would happen in such a world? Well, Gmail would be very clunky, Fed Ex probably wouldn’t exist, and we’d probably see even less competition in cable services than we do today as these artificial restraints force TV programmers (like HBO) to be married to distributors (like Comcast). In all cases we’d get less choice, higher cost, and lower quality.

Similarly, in the EHR market, the artificial restraints created by the transport certification rules are forcing bundling of secure email with basic EHR services. The result is that small focused vendors of secure email are getting blocked out of the market unless they enter alliances with larger traditional EHR vendors, because the secure email vendor applications don’t create clinical documents. And while some traditional vendors, like Epic and Meditech, are implementing their services in a way that allows their customers a wide variety of choices, most other traditional vendors either are locking their customers into proprietary approaches or haven’t yet figured out what to do because the certification rule is so darned complicated and unnatural.

Another example is the certification requirement for clinical quality measures. I have personal experience in this area because my company has a quality data analytics business and we recently got certified for MU Stage 2. There are 64 MU Stage 2 ambulatory clinical quality measures, and we decided to begin by getting certified for 26 of them based on our customers’ immediate needs. As part of the testing process, we were given ONC-provided dummy patient data on 22 fictitious patients, and we were required to generate each of the 26 measures on the panel of 22 dummy patients. OK, so far, so good. Unfortunately, it didn’t stop there.

The certification rules also require that we slice and dice the patient panel and associated clinical information and put each of the results of that slicing and dicing into separate standardized “QRDA” files. So for each measure we had to calculate the measure on the full panel of patients, and then stratify the results on four dimensions: race, ethnicity, gender, and payer. Then we had to generate a physician-level standardized file (a QRDA3) which contained all measure results for all 26 measures, and then show the breakdown of each measure by race, ethnicity, gender, and payer. Then we had to generate a separate standardized file (a QRDA1) for each patient in each measure, and each patient file could only include the clinical information relevant to a specific measure. So if the same patient had diabetes and hypertension, we had to parse the medical record and create a diabetes measure file with only the diabetes information, and a separate hypertension measure file with only the medical hypertension information. I’m not joking.

The result was that we had to generate 122 persnickety, fussy report files, and that was only for a patient panel of 22 dummy patients. A typical ambulatory physician has an active patient panel of 2,000 patients, some of them very clinically complex. Generating measures on such a panel would require the EHR to generate thousands of stratified result files per physician each time the measures are calculated. I assume that someone somewhere intends to make excellent, society-enriching use of such finely minced information, but right now it’s not clear who that would be. Certainly not the physician.

It turns out that even CMS finds this output too hard to handle. Up until a few days ago, the Pioneer ACO program required that quality measures be submitted according to the QRDA approach beginning in January 2014. Many vendors have been hard at work developing these reporting functions. On November 5, CMS backtracked and announced that they could not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process. Doh!

These two examples are just the tip of the iceberg. They cover only five of the 49 required certification modules for Stage 2-compliant technology. I don’t have enough energy or patience to describe what lies beneath the other 44 requirments.

One of James Joyce’s readers is said to have commented that Ulysses was very difficult to read, to which he is said to have replied, you should have tried writing it! For Stage 2 MU, the same might be said for EHRs – they may be hard to use, but they are getting ever harder to program. My point in expressing sympathy for EHR vendors is not to cover up or apologize for their mercenary tendencies. Rather it’s to simply point out that there is stress on all sides right now. So if your vendor seems to be fraying at the edges consider showing them a little patience and maybe even give them a smile. And then, by all means, get right back to letting them know that their product is barely useable, their prices are too high, and their support stinks.

Micky Tripathi is president and CEO of the Massachusetts eHealth Collaborative. The views expressed are his own.

Practice Wise 11/5/13

What happened to my EMR vendor?

Where’s your product? With so many products on the market, is yours on track to MU 2014 certification?

As of this writing, there are 3,439 products listed in the Ambulatory Practice Type on the ONC-CHPL with 2011 certification and only 125 with MU 2014. Some of these listings are single products with multiple iterations, so the number is somewhat inflated. However, the disparity is not. If you have a product that met MU 2011, are you sure your vendor is going to be ready for MU2014? What are they telling you? Have they given you a timeline and a preview or a roadmap?

What’s going to happen to all the EPs who have attested for 2011 and won’t be able to attest with that same software for 2014? As a consultant I’ve been preaching this since day one (disclaimer, we also sell and support a 2011 and 2014 certified product). But many of my consulting engagements center on helping practices with workflow optimization on different products. I cannot tell you how many times I’ve had doctors tell me that their criteria deciding on which product to buy is “I’m buying product X because they are a big company.”

My response has always been:

• What’s their core business?
• How many EMR products do they sell? Is your product their prime application or one they acquired because they wanted the client base?
• What is their funding?
• What’s their track record in business? In this industry specifically?
• How many installs do they have?
• How many upgrades do you get annually? If not annually, what is the upgrade frequency?
• How have they handled earlier regulatory changes?

Current studies show that one out of three EPs that attested with a 2011 Stage 1 EHR are potentially not on track with their current vendors to attest for 2014 Stage 2.

Have you attested for Stage 1? Did your vendor assist you? This could be a good predictor of how likely you are to meet the next stages. We’ve assisted several EPs who’ve been audited by CMS for their Stage 1 90 day attestation. Those who had attentive vendors with solid products and good support were able to pass the audit easily by providing the proper documentation. However, we have a few that had vendors with little understanding of the audit requests and how to provide supporting documentation for their own products. Those providers failed their audits. They are in the market for a new product.

Nearly one third of ambulatory EMR vendors certified for Stage 1 have not had a single attestation to date. The year 2014 is predicted to be a banner year for EHR replacement purchases. Practices are looking for products that are easier to use, and can meet MU, PQRS, and other regulatory initiatives. If this describes your current position, choose wisely. Look at the vendor’s attestation rate, interview their customers (Google any vendor – you should be able to find both happy and unhappy customers). Don’t just rely on references they give you and industry surveys.

Ask questions specific to the mandated programs:

• How difficult/easy is it to attest using their product in Stage 1?
• Are they MU certified for 2014? If not, what’s their roadmap? Ask their current customers how true their release projections are.
• Will you be able to attest easily with their product along with your original product if you make the change mid-year?
• How much training and support do they provide for the various programs? Is that training live, web, video? What does it cost? Will they stand by you in an audit?
• Are they able to report via EHR for PQRS?  If not, will you report via claims or registry? What are the costs and extra time requirements for these?

Changing EMR products is just as costly as or more so than your first purchase. You’ll likely have additional costs for data conversion that you might not have had the first time around. Do your homework; you don’t want to keep changing products. Besides being costly, it’s disruptive to your practice and your patients only have so much patience with your ongoing practice disruptions.

Good luck!

Julie McGovern is CEO of Practice Wise, LLC.

From the Consultant’s Corner 11/2/13

Change Management: The Path to EHR Clinician Adoption

Most of us are excited when we see provider order entry rates of 80-90 percent in our health systems. We should be proud of our users; it’s not an easy milestone to reach when transitioning from old systems or paper. Most of us also realize these target numbers are a poor indication of the overall performance and satisfaction of our clinicians. Let’s face it: we aren’t offering alternatives save for some scribes, emergent and transcribed orders, and perhaps we shouldn’t be.

Unhappy clinicians use the EHR because they have to. Happy adopters put the system to work for them, and demand results. They’re asking for the support to be efficient with the system, yet attentive with patients relevant and accessible data; timely, accurate and functional decision support;  the ability to personalize tools and content; feedback mechanisms driving content localization and formulary adaptation reflecting site needs. Where to begin?

We have strategy meetings seeking readmission rate reductions, clinical integration improvement, population health programs, business intelligence platform development and much more. Are we doing all we can to support EHR usability and functional flexibility with a true governance backbone?

Many of us are re-evaluating our approach to satisfaction or just starting down the path of improving adoption of the EHR. I’d suggest focusing on four themes to manage the change, identify resistance and provide the incentive for meaningful adoption.

1. Improve governance alignment. Many of us have too many committees. While that may not change, we can certainly align our leadership and communication. The Physician Advisory Council, P&T committee, Medical Group leaders, Medical Executive Chair, clinical CXOs, and clinician champions should have a shared adoption agenda and prioritization for improving the EHR. Disconnects between these groups lead to stagnant or slow optimization. Is your vision and elevator story for leveraging technology across the care continuum transparent and similar across your executive teams? Including representation on your EHR interdisciplinary leadership team from these groups brings speed and competency to decision making. We must align our agenda (and re-evaluate team membership) to reach our goals. For those large multi-hospital multi-practice sites, invest in and support a local governance structure that mirrors your corporate team. Build strong bridges with your sites. Develop a reputation of responsiveness and alignment.

2. Develop adaptation guidelines. What does standardization, localization, and adaptation mean in your organization? How much control do your practice sites and hospitals have to flex and evolve your clinical content tools? We have resource limitations, though we can be transparent about our aims. Perhaps you have four lab systems and have yet to standardize the ancillary approach. Perhaps evidence shows different patient population-based medication response so certain formulary variation is valid. Perhaps sub-specialty scope of practice demands different EHR design or content. Clinical evidence may drive order set template creation and the EHR note format may be in a standard design, but don’t wait to be asked for the rules of engagement. Educate your users on the rules of change, who to work with on feedback and why it’s for the benefit of all. Do your sites know your adaptation guidelines?

3. Define user segments and training needs. One-size-fits-all training? Yawn! Technology-savvy residents expect the high-powered EHR. Some long-time clinicians fear the computer mouse. Know your audience, customize your training approach and build a segmentation tool to help. Key segments include your usual hospitalists, PCPs, specialists, surgeons, floor nurses and LPNs, though getting granular is important. Work with your department heads to identify potential super-users, resisters, folks needing basic computer training, and more. Segment those who may act as mentors. Segment those needing 1-1 training support. Identify rare admitters. Flag who will need refresher training. Educate your EHR training team on your new powerful knowledge about your clinician population, and put it to work as you develop curriculum, training classes and agendas. Track proficiency and follow up with refresher courses and e-learning.

Enable practice and personalization. These steps are often forgotten. Get your users in an EHR playground before going live, and even before upgrades. Assist their familiarity with the new features, workflows and tools, but make it valuable time spent. Provide support to personalize their toolsets in the production environment before going live. Help them modify their note templates, add orders to preference lists and create personalized order set templates before working with patients. On day 1, they’ll hit the ground running and appreciate that the system can work for them.

4. Strengthen post go-live communication. Some parents compare an EHR go-live to child-birth; the hard work is just beginning. While you’re going to have frequent newsletters, emails and MEC presentations leading up to an EHR launch, don’t slow down. Gather feedback directly from users to determine key challenges and to prioritize change. Make it easy for clinicians to give feedback by connecting with them in the physician lounge or accompanying them on rounds. Do more than providing an issue or ticket tracking system – stay connected in their world, on the units, in the clinics. Your CMIO and CNIOs should be familiar faces at your sites bringing updates, feedback and asking for more. For those leaders who always wanted to be in a band and go on a road show, you’ve got your shot.

Many of us have a future vision of powerful data warehouses, predictive analytics, evidence-based practice driving improved financial and clinical performance with improved patient satisfaction and care. We’ve seen the bells and whistles of EHR systems, and we have IT teams eager and ready. Let’s show our users we’ve heard them – how can you improve your clinician adoption?

Jaffer Traish is director of Epic consulting at Culbert Healthcare Solutions.