Portions of the presentation by:Copyright Claudia Tessier LLC, Boston MA 2009

EMR: electronic medical recordAn electronic medical record for a patient at a

particular site, providing such functionalities as e-prescribing, order/results management, work-flow tasking, communication and messaging

An EMR is NOT a paper record made electronic

EHR: electronic health recordThe sum of a patient’s EMRs and other health-

related information from multiple sites CCR: Continuity of Care Record

Electronic core data set about a patient’s health-care status and treatment, current and historical

Patient safety Quality improvement Rising healthcare costs Competitiveness Evolution not only toward electronic

medical record but also to computer-guided and -supported healthcare

Consumer-driven care (participatory health) Internet resources Personal health records

More timely, accurate, complete patient information No longer practicing

blindly Point of care access to,

capture of, transmission of patient information

Real-time, remote access Improved patient

care Improved patient

safety Improved

outcomes

Reduced costs of healthcare Reduced wasteful

duplication Improved efficiency Financial squeeze on

physicians Reduced hassles Improved quality

of life For yourselves For patients

Office workflow: Who does what, how, when, where, why?

Current practice management system? Information capture preferences? Staffing: Adequate? Ready? Colleagues: Supportive? Ready? Financial planning and expectations Realistic timeline What do you want/need from an EMR? What features do you want? What barriers do you face?

Increased revenues Improved reimbursement Increased patient volume Increased charge capture Decreased accounts

receivable days Increased net collection

rate Decreased denied claims Improved E&M compliance New business opportunities,

clinical trials, data Improved competitiveness

Improved quality of careImproved patient

satisfaction

Decreased costs Reduced chart filing

costs Reduced transcription

costs Decreased telephone

calls, faxes from pharmacy

Increased efficiencies, decreased hassles

Improved quality of life

Improved provider satisfaction

Improved staff satisfaction

Less time after hours

Clinical documentationOptionsManagementScanningCCR

Clinical and administrative workflow tasking

ePrescribingDrug interactionFormulary mgmtRefills

Referrals Order entry Results management

AbnormalsTrends/graphs

Summary listsProblemsAllergiesMedications

Health maintenance reminders

Charge capture & codingMedical necessityAutomated codingE&M coding &

compliance Decision support Clinical practice

guidelines

Practice messaging InternalExternal

Population/disease management

Patient portals Patient data entry mHealth Participatory

health

Expense Selection difficulties Staff resistance Time & effort

required Incompatibility of

hardware/software Ease of use Security Lack of technical

expertise

Obsolescence Ease of integration Concerns about ROI Solutions not right for

you Lack of

demonstration site Data/chart

conversion Increase

documentation Other?

Templates with guideline prompts Flow sheets, tables, summaries, etc. as

decision aids Internal messaging and flags for

coordination, self-reminders, goal prompts

Personalized results letters or handouts for patient education

Lab interface for results reporting Advance scheduling for follow-up

Develop effective team communication Measure for improvement and

accountability Incorporate performance and outcome data Coordinate care and services across

settings Queries to identify patients needing specific

care leading to flags or outreach

Educate yourself and others on EMRsConferences, web, colleagues, experts, etc.

Prioritize goals and problems to solveNarrow potential vendors: Determine

Cost Features and functions Usability

Set-up vendor demosInclude physicians, staffDevelop scenariosSite visits to similar practices

Practice size designed for, installed in? IHN/hospital linked? ASP-based? Is system designed for and installed in

endocrinology practices? Costs? Functionalities? Usability?

What does pricing include?Hardware

Data center only Peripherals

SoftwareTemplatesCPT codesE-prescribingCCR integrationPHR integration

What recurring costs?Software/hardware

maintenanceUpfront or annual

license fees

What else? Interfaces and conversion

costs including mapping data fields

License fees One-time or annual

ImplementationTraining

Travel costsSupport and upgradesBackup: where and whenOther?

What isn’t included?

What modes of information capture does it offer?TranscriptionSpeech recognition: front-end, back-endKeyboard entryDigital pen and paperHandwriting recognitionPoint and clickPull-down menusTemplates, custom or standardHome monitoring devicesData entry by patientDirect from mobile devices (mDevices)HYBRIDS

Integration with Practice management system ePrescribing Labs PayersOther?

Real-time eligibility determination?With which payers?

Real-time charge capture?With which payers?

Is system interoperable with Local hospital systems?Personal health records?Patient portals?Patient data entry systems? Other?

Different implementation paths for different practice sizes and specialties

Realistic timeframes Staff involvement Workflow changes Data conversion: scanning, CCR Support and maintenance Backups and recovery

Plan and test, plan and test Policies & procedures

Privacy, confidentiality, securityMedicolegal requirementsBackups and disaster recovery

Support and maintenance Modular or “Big Bang”

Have flexible timetables Appoint a project manager Assign responsibilities Modify schedules Start immediately following training Implementation never ends

Incorporates much greater specificity and clinical information, which results in:•Improved ability to measure health care services•Increased sensitivity when refining grouping and reimbursement methodologies•Enhanced ability to conduct public health surveillance•Decreased need to include supporting documentation with claims

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Key issues include training courses, but equally ramping up to productivity standards and confidence Training programs will yield competence but not speed Need approach to building coding skills in live environment, not just

training courses Training courses abound (albeit they are getting full faster

today than in the past) Future needs to meet:

Coders will need to train in real environments with real notes/encounters and see where skill gaps exist

Multiple passes –at first getting comfortable with coding, then testing productivity. See where the gaps exist and retrain specifically.

Computer-assisted coding will greatly assist the transition Dual coding environment –specific notes, engine suggested codes,

coders code, after-the-fact analyses of generic versus specific codes Organization will want to be sure they understand revenue risk from

non-specific coding prior to 10-13.

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The Problem Physicians have learned how to

document at the detailed level over the last 20 years

More detailed information required to get to the most specific codes (e.g. laterality, body part, etc.)

Organizations have meaningful revenue risk with ICD-10 if documentation is not up to the new standard

No physicians want to worry about this now, but every physician will need to adapt

The Problem Physicians have learned how to

document at the detailed level over the last 20 years

More detailed information required to get to the most specific codes (e.g. laterality, body part, etc.)

Organizations have meaningful revenue risk with ICD-10 if documentation is not up to the new standard

No physicians want to worry about this now, but every physician will need to adapt

Needed approach Note-by-note and ICD-by-ICD

analysis of the specific changes each physician needs to make

Data-driven training with physicians – their documentation, their deficiencies, needed changes

“Small footprint” discussions over time—topic-by-topic rather than all-at-once. Aggregated plan between now and 2014

Follow-up data analysis to determine effect of training and to structure additional interactions

Value of training: Average doctor revenue X 20% risk = $120,000 – 200,000 per doctor.. How much spending to avoid the risk?

Needed approach Note-by-note and ICD-by-ICD

analysis of the specific changes each physician needs to make

Data-driven training with physicians – their documentation, their deficiencies, needed changes

“Small footprint” discussions over time—topic-by-topic rather than all-at-once. Aggregated plan between now and 2014

Follow-up data analysis to determine effect of training and to structure additional interactions

Value of training: Average doctor revenue X 20% risk = $120,000 – 200,000 per doctor.. How much spending to avoid the risk?

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Diagnosis Codes (ICD-9 to ICD-10-CM)Goes from 5 positions (first one

alphanumeric, others numeric) to 7 positions, all alphanumeric

From 13,000 existing codes to 68,000 existing codes

Much greater specificity

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Laterality (left, right)

Body part (e.g. bone in the hand)

Stage of disease (e.g. severity of pressure ulcer)

Injury (e.g. hit by baseball)

Episode of care (e.g. initial visit or followup)

Present evidence of what physicians do or do not document today

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Documentation of diagnoses and procedures

▫ Codes must be supported by medical documentation

▫ ICD-10-CM codes are more specific▫ Requires more documentation to support codes▫ Expect a 15% increase in documentation time

(per AAPC)▫ Revenue Impacts of specificity

▫ Denials▫ Additional Documentation

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Coverage and payment

New coding system will mean new coverage policies, new medical review edits, new reimbursement schedules

Changes will be made to accommodate increase specificity

May need to discuss changes with patients

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Contracts with plans

Coding more specific and includes severity Renegotiations will be based on new coding,

coverage, and reimbursement Difficult to measure what the changes will mean

to overall reimbursement

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Billing and eligibility transactions Updated transactions include support

for ICD-10 New codes mean more specificity How smooth the transition? Expect increased reject, denials, and

pends as both plans and providers get used to new codes

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Laboratory orders Will need specific ICD-10-CM codes for

laboratory orders Expect coverage changes Need to support the tests ordered

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