For more about Dolbey’s Fusion CAC solution visit www.dolbey.com.

About Dolbey
Dolbey is a leader in providing dictation, transcription, speech recognition and coding solutions for healthcare in the United States and Canada. Together, Dolbey and Company, Inc. and Dolbey Systems, Inc. offer the award winning Fusion Suite™ of integrated products which is backed by one of the industry’s largest organization of certified professionals who assist in design, implementation and support.

About 3M Health Information Systems
Best known for market-leading coding solutions and ICD-10 expertise, 3M Health Information Systems delivers innovative software and consulting services that raise the bar for clinical documentation improvement, computer-assisted coding, case mix and quality outcomes reporting, and a robust healthcare data dictionary and terminology services to support your EHR. With 28 years of coding experience and more than 100 credentialed coding experts, 3M is the go-to choice for 5,000+ hospitals worldwide that want to improve quality and financial performance.

For further information, please contact:

Traci Miller, Marketing Executive
800-878-7828 x 119 / tmiller@dolbey.com
www.dolbey.com

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Action Items Based on Lessons Learned

By Howard Anderson for GovInfo Security

What can be learned from the more than 390 major breaches affecting more than 19 million individuals that have been reported as a result of the federal HIPAA breach notification rule? Plenty, breach prevention experts say.

Here are eight key breach-prevention insights from information security thought-leaders:

1. Don’t Forget Risk Assessments
The details of the biggest breaches last year “make it painfully clear that inadequate, if any, HIPAA security risk analysis took place prior to the breaches,” says Dan Berger, CEO at Redspin. “A comprehensive security risk assessment would have identified where PHI [protected health information] is stored, who has access to it and how it’s utilized in the normal workflow. The analysis would then investigate whether sufficient controls are in place.”

Because so many huge breaches have involved the loss or theft of mobile devices and media containing unencrypted PHI, Berger concludes that risk assessments were either not conducted or they failed to pinpoint that vulnerability. He urges organizations to conduct comprehensive assessments that take into account external and internal infrastructure, web applications and wireless security and lead to a mobile device policy and in-depth employee training.

2. Encrypt Mobile Devices, Media
“Even though encryption is what’s referred to as an addressable standard in the HIPAA security rule – which means it’s not actually mandated in all cases – I don’t see any reason why information shouldn’t be encrypted in all cases on portable media and devices,” says Robert Belfort, partner at the law firm Manatt, Phelps & Phillips LLP. “That’s one step that organizations can take that can address a very significant share of the types of breaches that are occurring.”

In addition to making better use of encryption, organizations should consider limiting or banning patient data storage on mobile devices, many experts advise. For example, David Szabo, partner at the law firm Edwards Wildman Palmer LLP, says organizations should “reassess their policies about how much information employees really need to take off the premises. … The whole issue of portable devices is one that organizations really need to look at hard.”

3. Beef Up Training
“People have to be trained to understand the policies of the organization, and they have to be trained about common-sense safeguards that they can follow to avoid breaches or the misuse of information,” Szabo stresses.

Timothy McCrystal, partner at the law firm Ropes & Gray, points out that the Department of Health and Human Services’ Office for Civil Rights has stressed the importance of ongoing training in its resolution agreements with organizations that have experienced a breach.

“I have participated in discussions with OCR on a resolution agreement, and that was a particular point of focus – that the organization not just have policies and procedures, but that employees and others had been trained on them, understood them and were actually implementing them in their day-to-day responsibilities.”

4. Conduct Internal Audits
In addition to training, an important step toward addressing internal breach threats is to conduct audits of records access, Belfort says.

“The belief that audit logs are being monitored and that there is a high risk that if you access a record improperly you will be caught through some sort of audit trail review can have a very important impact on behavior within an organization,” he notes.

5. Monitor Business Associates
About 22 percent of major breaches, including many of the largest incidents, have involved business associates. As a result, it’s essential to work with vendor partners to ensure they’re taking adequate breach prevention steps.

McCrystal says it’s important to ask business associates probing questions before signing a contract. Those questions should include inquiries about the companies’ privacy and security policies, use of encryption and reliance on subcontractors.
Healthcare organizations “should actually implement an audit from time to time” to ensure business associates are adequately addressing security, McCrystal adds. “Some of our clients, when contracting with business associates, have conducted audits of their privacy and security practices in advance of entering into a contract.”

6. Limit Data Storage
Fred Cate, a law professor at Indiana University, says the recent breach affecting 24 million customers of Internet retailer Zappos.com raises an important question for security professionals in all industries: “Are you collecting and storing more data than you need? Because if you are, you’re taking on more risks then you need to face.”

In the Zappos.com incident, a hacker gained access to an unencrypted central database containing a wealth of customer information. In the healthcare arena, numerous major breaches have stemmed from massive unencrypted databases stored on laptops or backup tapes.

Ozzie Fonseca, senior director at Experian Data Breach Resolution, notes that about half of 500 organizations across all U.S. industries that have experienced a breach said in a recent survey that they subsequently took steps to limit personal data collected and limit sharing of the data with third parties. About 42 percent limited the amount of personal data stored.

“Collecting and storing unnecessary information is never a good idea,” Fonseca says.

7. Don’t Forget About Paper Records
Szabo points out that federal authorities fined Massachusetts General Hospital $1 million after an employee left paper medical records on a subway train. “We shouldn’t get too wrapped up in just thinking about computers and technical things – paper records can also be at risk simply because of the errors and omissions of employees,” he says.

8. Address Other Potential Vulnerabilities
Last May the HHS Office of the Inspector General issued a report based, in part, on audits of seven hospitals. Those audits, McCrystal notes, identified numerous technical vulnerabilities. “Five of the hospitals had wireless access vulnerabilities, including ineffective encryption, rogue wireless access points, no firewall separating wireless networks from internal wired networks … and no authentication requirements for entering wireless networks,” McCrystal says.

All of the hospitals had some access control vulnerabilities, including, for example, inadequate password settings and a lack of automatic log-off of inactive computers, he adds.

Some hospitals had certain audit log functions disabled. And others had uninstalled critical security patches, outdated anti-virus updates, operating systems that were no longer supported by the manufacturer and unrestricted Internet access for hospital users.

McCrystal advises hospitals to use the report to guide a self-audit to help identify vulnerabilities and reduce the risk of breaches – as well as help prepare for this year’s HIPAA compliance audits.

Most doctors still use desktops because iPads lack speech processing capabilities. One expert, however, says iPad EHRs are coming.

Eighty percent of physicians in a recent survey said they believe that the Apple iPad has an “exciting future in healthcare”–but they doubt it is ready for clinical use.

The survey of 100 “early adopter” physicians by Spyglass Consulting Group in Menlo Park, Calif., also found that 83% of the respondents used desktop computers to access clinical information, whether they were in the hospital, in the office, or at home. Some physicians said they used mobile devices to retrieve healthcare data when they were traveling.

Pretty much the same could have been said of physicians five years ago, when many of them used reference tools and calculators on personal digital assistants (PDAs) and smartphones, but few doctors looked up clinical information on those devices. Some physicians used tablet computers with their EHRs, and some used tablets or PDAs for e-prescribing, charge capture, or both.

One barrier to clinical use of iPads today is the attitude of hospitals. “Seventy-five percent of physicians interviewed reported that hospital IT [staff] was resistant to supporting personal mobile devices on the corporate network,” the Spyglass release said. “Hospital IT believes personal devices are insecure, less reliable, and more expensive to deploy, support and maintain than desktop computers.”

That finding jibes with other recent studies. But as the Spyglass report acknowledges, hospital security concerns are not the major obstacle to iPad use in clinical work.

“Significant software innovation will be required to realize the vision for anytime, anywhere clinical computing,” Gregg Malkary, managing director of Spyglass, said in the announcement. “Clinical applications must be rewritten and optimized to take advantage of the native capabilities of the Apple iPad and other mobile devices including gesture-based computing, natural language speech recognition, unified communications, and video conferencing.”

Malkary told InformationWeek Healthcare that, although Epic and Allscripts are both experimenting with iPad-native EHRs, he doesn’t expect the vendors to go into production on these innovations anytime soon. The big barrier, in his view, is not the technology, but the vendors’ reluctance to “redesign their applications from the ground up with a focus on patient-centric care.”

However, Allscripts’ Sunrise Mobile MD II product can be used on an iPhone or an iPad. Incorporating speech recognition software from M*Modal and Nuance, Sunrise Mobile MD II allows physicians rounding in the hospital to view clinical data in EHRs, capture charges, send secure messages, and, on the iPad, document notes.

DrChrono, which is more oriented to ambulatory care, offers an iPad-native EHR that lets doctors document notes and prescribe electronically using voice recognition. The Mountain View, Calif.-based startup firm announced this week that it had received $2.8 million in private equity funding.

Despite this spurt of activity, however, iPads still have a key drawback: their on-screen keyboards are unsuited for data entry, and voice-recognition software is still far from being able to sort medical terms into discrete fields in an EHR. That would require a breakthrough in the field of natural-language processing.

Some progress has been made on that front by vendors of computer-assisted coding programs, which help coders parse free text for terms referring to diagnoses and procedures. And Nuance Communications, which makes the popular Dragon Naturally Speaking voice-recognition program, is working with the University of Pittsburgh Medical Center to harness IBM Watson in natural language processing.

Malkary is encouraged by the fact that so many physicians have embraced mobile computing. Ninety-eight percent of the doctors his firm interviewed use mobile devices, and 70% own iPads, he said. “If this many docs bought the iPad, it’s a testament that we’re getting closer, from a form factor perspective, to something that integrates with their workflow. Now they’ve got to fill it out with applications.”

When are emerging technologies ready for clinical use? In the new issue of InformationWeek Healthcare, find out how three promising innovations–personalized medicine, clinical analytics, and natural language processing–show the trade-offs.

Speech recognition can help reduce costs, but healthcare organizations should take steps to ensure they’re not sacrificing quality in the process.

Everyone loves to save money but in today’s healthcare environment, cutting costs is more a matter of necessity than desire.

Rather than allow the quality of care to suffer, hospitals typically look for ways to work more efficiently and with fewer employees. For this reason, one process that has been of interest during the past five to 10 years is physician dictation. Because dictation typically requires four minutes of transcription for every minute of dictation, it’s often viewed as an area of potential cost savings—provided the process can be automated to a degree that allows for a significant reduction in worker hours.

As a result, an increasing number of hospitals have adopted or are considering adopting speech recognition technology. The specific reasons for doing it may vary among institutions, but it’s a safe bet that cost savings will be atop nearly everyone’s list. Unfortunately, hospitals that expect speech recognition to produce a windfall may be disappointed.

“I think there’s no question that the expectation that speech recognition can help dramatically reduce the cost of document production is out there in the marketplace,” says Dale Kivi, MBA, director of business development for FutureNet Technologies Corporation. “The reality of it is, because it is not foolproof and there is an editing phase that’s needed to go along with the technology, the actual savings are considerably less than what people think it might be.”

That’s not to say there aren’t good reasons for installing the technology; it just means that hospitals need to look at the big picture when they’re figuring out their bottom line. Although there may be savings on up-front transcription costs, factors such as document quality and the way speech recognition is used within the facility play a significant role in the ultimate cost.

The Big Picture

Many speech recognition vendors tout the technology’s ability to increase productivity, and it’s generally agreed that speech recognition holds the promise of streamlining operations and reducing staffing needs. The challenge is to translate that promise into savings without sacrificing quality. Because the medical record has ramifications not only for patient care but for regulatory compliance and billing as well, the quality of physician reports is of the utmost importance.

“Keep your eye on what’s really important, which is the quality and usefulness of the documentation. There’s a big misconception with speech recognition that you should change the processes to only accommodate productivity. I think the purpose of any documentation process is to produce useful, quality documentation,” says Lynn Kosegi, director of health information services for M*Modal. “And as soon as you take away from that quality, just to [speed up] a process, you can pretty much guarantee that you’re going to make something else more expensive down the road.”

Speech recognition requires not only an up-front investment in the technology but also a comprehensive assessment of how it will fit into a hospital’s existing workflow. Considerations of back-end and/or front-end solutions typically begin here. Although many administrators allow transcription savings to strongly influence their choices, they may be overestimating value if they don’t account for their physicians’ level of interest or the cost of their physicians’ time. For example, some back-end solutions can be implemented with little or no disruption to a physician’s routine, but the process works best when physicians are willing and able to work with it.

“You can get a degree of accuracy from back-end speech recognition without any effort on the part of the doctors, but you’re certainly not going to optimize your efficiencies and your return on investment if you don’t get some cooperation on the part of the physicians to work within the restraints of whatever platform you happen to be using,” says Jay Vance, CMT, director of product development and deployment for Superior Global Solutions, Inc. “The reality is the technology is not perfect, and the more effort the user is willing to put into it, the better the return is going to be.”

Back-end speech recognition technology has the benefit of allowing physicians to dictate in a way that’s more like traditional dictation, but it still requires transcriptionists or medical editors to function effectively. Depending on the dictator’s speech patterns, the speech recognition engine may capture what was said quite well or rather poorly, and it is not uncommon for similar words such as “comma” and “coma” to be transposed. Convincing physicians to modify their dictation habits can help, but some simply do not “translate” well to speech recognition whether it’s because of an accent, a cadence, or some other factor. For this reason, human intelligence is required to determine whether what’s written in the report matches the doctor’s intent.

To avoid transcription on the back end, some facilities opt for front-end speech recognition. In this scenario, physicians edit their own reports before signing off on them. However, if poorly implemented, the technology can backfire. In many cases, physicians will end up either seeing fewer patients or working unsustainably long hours. Often, they will put less information in their reports and may not notice some of the subtle details that transcriptionists or medical editors would spot.

“In practice, what happens is that the number of errors that are pushed downstream, not necessarily from content but from picking the wrong patient visit or some of the other workflow issues, increases dramatically when left solely to the physician dictators,” says Kivi.

Unless physicians buy in to the new process and receive support from the institution in adapting speech recognition to their workflow, it won’t achieve the desired results. To balance clinical needs with administrative needs, it’s helpful to provide physicians with choices. What may work well for one department may not work for others, and many facilities use more than one speech recognition option. For example, many radiology departments have had success with front-end speech recognition because their reports are shorter, and they use a smaller range of clinical terms.

“One of the keys there, however, is to give the doctor the choice to be able to do their own editing or, if they decide to, just send it on to be edited by an MTSO [medical transcription service organization] or someone in-house,” says Linda Sullivan, CEO of New England Medical Transcription.

Other specialties, however, may do better with back-end speech recognition. A specialist’s consultation report or an operative report may be impractical for physician editing. The important thing to remember is that the people who use the technology—physicians, transcriptionists, and medical editors—determine how well it works.

You Can’t Just Plug It In

Nick van Terheyden, MD, chief medical informatics officer for Nuance Communications, believes it’s possible that some of the inflated expectations for speech recognition are a result of healthcare’s experience with other types of technology. In this plug-and-play generation, van Terheyden says simply installing a solution doesn’t provide the level of efficiency that most hospitals are seeking. There is training and workflow reengineering that needs to be done.

Good Samaritan Hospital in Vincennes, Indiana, followed that blueprint when it installed SpeechMotion’s documentation platform, which includes back-end speech recognition. Although the system was in place by October 2010, the transcription staff didn’t begin editing from it until February 2011. The idea was to give the staff time to learn the new software and give the system time to learn the doctors’ voices. Good Samaritan also wanted to make sure everyone on staff was transcribing in the same way and using the same formatting rules to take advantage of the system’s ability to remember what’s inputted. The training was spread out to minimize disruptions, but by the end of March 2011, the transcriptionists were becoming proficient at medical editing.

Wendy Mangin, MS, RHIA, director of medical records at Good Samaritan, says the hospital was motivated to install speech recognition because more physicians were being hired, and many of them were requesting their office notes to be transcribed. The additional requests were creating a larger volume of work for the transcriptionists, prompting the hospital to replace aging equipment with more efficient technology to avoid having to add to its transcription pool.

“It is not perfect. It still takes the expertise of an experienced medical transcriptionist to edit that document to make it complete and correct,” says Mangin. “We knew going in that it wouldn’t handle every report that comes across, and that’s OK. If you can have 75% of the reports come across successfully for editing, you are definitely gaining productivity out of that.”

Mangin says it took a while for the transcriptionists to become comfortable with editing and learn all of the system’s keyboard shortcuts rather than using a mouse or a foot pedal. It was worth the wait, however, because those shortcuts have helped reduce turnaround time more than she expected. Prior to going live with editing, there were often 50 hours of work in the transcription queue. Now there are usually around five.

The increased productivity has afforded the transcription group extra time to help out in other areas, such as with progress notes for hospitalists, transcription notes for home care, and plan of care notes for the physical medicine department. Plans are also underway to begin editing for the radiology department, which currently uses front-end speech recognition.

Good Samaritan’s experience highlights an important aspect of speech recognition adoption: Hospitals can get more out of the technology by automating tasks that don’t require human intellect and concentrating manpower in areas that do. By relying on the system’s ability to apply headers and subheaders and its extensive medication dictionary—which significantly reduces the need to look up drug names—Good Samaritan’s transcriptionists are able to focus on more substantive tasks. This increased efficiency allows them to make medical information available sooner throughout the healthcare enterprise.

It’s Here to Stay

Quick access to medical information is becoming increasingly important. As speech recognition technology evolves, it will, by necessity, play a larger role in many hospitals. van Terheyden believes it will eventually help clinicians interact more efficiently with EMRs.

“As people implement EMRs, what they find in many cases is that they’re hard to navigate, they’re hard to learn, and speech can be more effective as a navigational tool,” he says. “So instead of having to go to the menus, select patients, do all these things through keyboarding, I can say, ‘Show me the current labs,’ and that carries out a whole activity behind the scenes and allows me to get the information to the screen without remembering a series of keystrokes or menu options.”

van Terheyden says advances in natural language processing combined with speech recognition will allow more clinical data to be mined from physicians’ dictated reports. That data may benefit patient care through functions such as extracting drug information and checking for patient allergies, or it may help hospitals collect meaningful use data.

Incorporating speech into mobile platforms will also improve efficiency, according to van Terheyden. However, while speech recognition technology offers greater efficiency, there are steps hospitals should take to ensure the system meets their needs if they’re considering adoption.

Perhaps the most useful information comes from facilities already using the technology. Find out their firsthand experiences and ask for a demonstration.

Cost and reliability are important, but it’s also vital to read the service contract. Kivi says some vendors require every piece of documentation to go through speech recognition, which may not be in a hospital’s best interest if it has numerous physicians who labor with the system. Other vendors will allow facilities to choose which jobs go through speech recognition, which can save time and money.

Kivi cautions there are vendors that include add-on costs, such as per-user licensing fees, service contracts, and up-front implementation costs. By comparing all costs and considering how the system fits into the existing workflow, a hospital can derive maximum benefit and save money.

“Absolutely we need to increase productivity and reduce costs, but we need a more holistic picture of what it means to reduce cost,” says Kosegi. “If you look only at transcriptionist productivity or the transcription piece as the means to reduce cost and you don’t look at using a technology like speech recognition to improve the usefulness of the documentation across the enterprise—for coding, for billing, for all of those other purposes—then, in the end, you’re actually creating a more expensive process and not a less expensive one.”

HealthGrades Quality Study Identifies Hospitals in Top 5% in Nation; Cities That Have Highest Concentration of Top Hospitals

Patients Treated at HealthGrades Distinguished Hospitals for Clinical Excellence Have 30% Lower Chance of Dying
How does the quality of care at hospitals in your area compare? Find out with HealthGrades second annual list of America’s Top Cities for Hospital Care. HealthGrades is the leading provider of information to help consumers make an informed decision about a physician or hospital. The independent rankings are based on a comprehensive study of patient death and complication rates at the nation’s nearly 5,000 hospitals.

As part of its tenth annual HealthGrades Hospital Quality and Clinical Excellence study, HealthGrades identified those hospitals performing in the top 5% nationwide across 26 different medical procedures and diagnoses, then ranked cities by highest percentage of these Distinguished Hospitals for Clinical Excellence™.

Selecting a Top Hospital Matters

In an environment where one in seven Medicare beneficiaries is harmed as a result of their hospitalization (Source: Department of Health and Human Services) and patients are fearful of the very institutions that are entrusted with saving their lives, it is important to identify and acknowledge those hospitals that are leading the way in reducing mortality and complication rates and to provide consumers access to this information.

For the communities themselves, these hospitals have significant impact. In some instances, the top cities named in this report can make the claim that almost half of their hospitals provide this level of care including: Baltimore (47%), Phoenix-Prescott (44%), Cedar Rapids (43%), and Richmond, Virginia (43%).

In addition to selecting the best hospital, it is also important to become educated on potential complications and learn how to protect yourself during a hospital stay.

How Did Your City Rank? What Hospitals In Your City Made the Grade?

“Today’s healthcare consumer expects access to credible, independent information about the quality of care available to them,” said Kristin Reed, MPH, HealthGrades vice president of hospital ratings and study author. “HealthGrades is proud of its longstanding tradition of educating the American public about both the gaps in quality of care among hospitals, and with actionable information about the top-performing hospitals in their communities.”

Distinguished Hospital Facts

• Distinguished hospitals can be found in 38 states.
• The cities with the highest percentage of Distinguished Hospitals are found in 26 states. Distinguished hospitals had 30.07% lower mortality rates and 1.86% lower complication rates after adjusting for patient severity of illness.
• If all hospitals performed at the same level as Distinguished Hospitals for Clinical Excellence, 165,704 Medicare lives could have been saved in just three years and 6,800 inhospital complications avoided.

About HealthGrades Hospital Quality Distinctions

As part of this study, HealthGrades evaluates each of the nation’s 5,000 nonfederal hospitals in 26 procedures and diagnoses, allowing individuals to compare their local hospitals online at www.healthgrades.com. HealthGrades hospital quality distinctions are independently created; no hospital can opt-in or opt-out of being evaluated, and no hospital pays to be evaluated. Mortality and complication rates are risk adjusted, which takes into account differing levels of severity of patient illness at different hospitals and allows for hospitals to be compared equally.

Click here to view HealthGrades Top Cities for Hospital Care

Click here to view HealthGrades Methodology for selecting top hospitals

If used correctly, computer-assisted coding can help hospitals alleviate inefficiencies.

As computer-assisted coding (CAC) is deployed by an increasing number of hospitals, its effect on coders is coming into focus. The evolution of workflow changes, productivity increases ahead of ICD-10, and fear of diminishing job prospects are all buzz-worthy topics.

Workflow Changes
The existing workflow within many hospitals could be slowing down coders. Chris Casto, vice president of Dolbey Systems, says coders are currently using what he calls “buckets” of information. “They’re working out of the HIS [hospital information systems], a lot of times they have to log in to nurses’ notes, and they log into billing systems to look at chargemaster codes, so the workflow is really disjointed in a lot of ways.”

Casto believes CAC adoption helps pull those buckets together, giving the coder one place to go for information. “In that fact alone, they really do see, I think, a streamlined workflow because they’re not in multiple applications,” he says. “They’re not logged in all over the place. Everything they need to see is in one place, and it has to be that way for CAC to function effectively.”

Accessing information from multiple sources is indeed an efficiency issue for today’s coders, says June Bronnert, RHIA, CCS, CCS-P, director of professional practice resources at AHIMA. “CAC has the capability to pull all that into one place. Coders may go to one place vs. going to three or four or five,” she says. “That part has increased their efficiency because now the information they need is in a single location.”

Bronnert says the effects of CAC implementation on hospital workflow may depend on how activities are structured and recommends facilities examine their processes. “Start with documentation,” she says. “How is it generated? Is it handwritten? How much is electronic? And what systems is it in?” This will help determine where productivity gains and efficiency improvement are most needed, Bronnert adds.
“[CAC] is going to radically change the overall workflow,” says Gail I. Smith, MA, RHIA, CCS-P, “because coders are not going to be producing the code—they’re going to be verifying what the computer gives them.”

Smith, president of Gail I. Smith Consulting in Cincinnati and an ICD-10-CM/PCS faculty trainer for AHIMA, believes CAC adoption will remove the rote work from coders’ plates. “That easy stuff that we waste our time on, the computer can assign it if it needs no human interaction,” she notes.

And because coders will be freed from baseline coding tasks, they’ll be able to take on what Smith describes as more of an auditing role where strong decision-making skills will be essential. “It really forces the coder to work at a higher level,” she says.

John Ryan, MD, president of PLATOCODE, whose US operations are based in Los Angeles, says many of the clerical portions of a coder’s job are removed in a CAC environment. “Rather than having to scuffle through documentation and enter codes, you become an auditor,” he says. “The case comes up, and it’s as if the gremlins have been through and assigned a whole lot of codes, and the coder’s job is to make sure they’re correct.”

Coders will no longer start from scratch, Bronnert says. “Now they say, ‘Yes, this is the valid code for that, and it should be assigned,’ and they identify it within the tool that it’s the appropriate code,” she says, adding that coders’ roles are changing from conducting initial read and scans to “becoming an auditor, a validator.”

Bronnert believes it’s important that coders understand the technologies involved, and that “CAC is not an encoder,” although the two tools can work together and “a lot of them are doing that now.”

“You’re almost a detective in a way,” Smith says. “You have to be willing to challenge what the computer comes up with and, in some respects, investigate why it led down that path.” She believes having a user-level understanding of how the software works would be beneficial. “It’s another skill set for coders,” she notes.

With the fundamental shift from code entry to code review, Casto believes coders “still need to be on top of their game because the software isn’t going to be as good as your best coder. It will make mistakes. We expect that, and that’s why we need the coder to catch them.”

Casto isn’t sure the audit function coders assume in a CAC environment is necessarily a new skill, but says, “It’s a different way to spend your day.”

Productivity Improvements and ICD-10
For hospitals whose documentation resides mostly in an electronic format, the adoption of CAC is likely to be less onerous, says Bronnert. “The CAC engines are designed to work with electronic documentation, so it’s a smoother initial process vs. if you have handwritten documentation that has to be scanned,” she says, adding that facilities able to avoid that extra step may gain greater efficiencies than those stuck with scanning handwritten material.

“There is certainly a direct correlation between the hospitals that have prepared to implement CAC and those that are well down the road with their EHR implementation,” Casto says, “because the technology they’ve needed to put in place and the processes they’ve needed to adopt to make their electronic health record work and to meet meaningful use are absolutely in line with what we need for CAC.”

Casto says hospitals that have either adopted EHRs already or are moving toward EHR implementation are “perfect candidates for computer-assisted coding.”

Mark Morsch, vice president of technology at OptumInsight, says CAC works best when at least some of the information is available electronically. “Most facilities today have a hybrid record, where some data is paperless, some may be scanned, and some may still be on paper. The more information that can be made available digitally, the more you can take advantage of automated coding,” he says.

By consolidating documentation into a single software platform, Morsch sees other benefits for coders. “Productivity gains from these new processes are helping hospitals now and will be imperative as we move to ICD-10 with an eightfold increase in codes,” he says.

Coders are presented with codes assigned by the system, and those codes include highlights that link each code to the supporting evidence in the clinical documentation. Coders then review the CAC-generated codes and accept or correct them based on their expertise. “CAC transforms the role of the coder from the task of full coding to a reviewer or auditor of coding,” Morsch says.

As an ICD-10 trainer who travels around the country, Smith says, “I’m seeing more and more hands go up when I ask, ‘Who’s implementing CAC?’”

Some of those decisions to adopt CAC are a result of the looming ICD-10 deadline. “[Hospitals] are trying to counteract the loss of productivity with removing those rote coding decisions,” she says, adding that there will likely be spin-off roles or entirely new areas of responsibility generated on the back end, including “looking at reports and looking at trending as another double-check” while the technology and its use mature and become more widespread. “There are lessons to learn, and we don’t know what those are yet,” Smith says.

Additional efficiencies generated by CAC adoption can be found elsewhere in the revenue cycle chain. Casto points to the technology’s ability to better “scrub” charts before they leave a facility as a way to reduce the number of disputed claims, citing one customer who experienced an 80% reduction in denials. “I think many of them have their eye on the future, which is ICD-10, and they know they’re going to have troubles there if they don’t get ready. But right now they can utilize the software to better prepare themselves and solve some immediate problems,” he says.

The Job Market
Let’s get to what, for some, is the elephant in the room: Does the adoption of CAC mean that a hospital needs fewer coders? “Every hospital has its own productivity standards on what they expect,” Bronnert says. “From what I’ve heard from those hospitals for years now is that it’s not that they need fewer [coders].” Instead, Bronnert sees coders being used more effectively and at a higher skill level. “They become even more valuable to a facility. I don’t see their roles or positions diminishing at all. I see them flourishing,” she says.

Smith says some early CAC adopters have reported demonstrable increases in productivity. “I think what’s going to happen is we’re going to need less entry-level coders, but we’ve been seeing that trend for years,” she says, adding that CAC will exacerbate the differences between new and experienced coders.

Although CAC and ICD-10 are “really two different subjects, they intersect with CAC,” Smith says. “Even if we didn’t implement ICD-10 in 2013, there’s definitely a need for increased productivity.”

Ryan doesn’t believe CAC reduces the number of coders a facility requires to stay on top of its workload. “CAC means they’re going to be able to cope with the changes in ICD-10, and clearly there are no fewer coders required if that’s the thinking you adopt,” he says.

Typically, when implementing CAC, hospitals don’t drop the number of coders on staff, Ryan says. Instead, coding departments are better equipped to handle vacations and other coder absences. “The second thing is that a lot of facilities are bringing on contract coders, who are expensive,” he says, adding that productivity gains brought about by CAC allow hospitals to “rationalize their use of expensive external resources.”

A third reason Ryan isn’t buying the idea that fewer coders will be needed with CAC is that existing coders may now finally have the time to make more use of their expertise and get involved in clinical documentation improvement.

“I think anybody who’s running a coding operation or has any oversight over a coding department knows that they certainly would not let any well-qualified coder out their door right now,” Casto says. Instead, he believes facilities that implement CAC “want to take the coders they have and get some extra bandwidth out of them.”

By implementing CAC, facilities may be able to work through backlogs, eliminate some outsourcing costs, and enable the existing workforce to be more productive. The software could also allow organizations to be better prepared for ICD-10 by affording them extra time for training. “A lot of them just don’t have that luxury right now,” Casto says.

New to Coding? Listen Up.
A handful of CAC providers are working with various educational institutions to introduce the technology into the curriculum, but the practice is far from universal. Ryan believes the number of available CAC products is too vast to make familiarity with any one platform a game-changer. “The CAC market, although I’ve been in it for 20 years, is still very young,” he says, “and people are still finding their way. I think it’s difficult for the training institutions because it’s the early days, and there are a number of competing models.”

“I think it’s a time of transition,” Bronnert says. “Right now, I don’t think [CAC training] is enough of a factor in the job market. Maybe in another three to five years it could be.”

While Bronnert hasn’t heard from students that a lack of CAC training has hampered their job searches, she says, “I think that students should learn about the technology because it’s becoming more mainstream.” From the educational provider’s standpoint, she believes schools “are becoming aware of the technology as well and starting to incorporate it at some level into their programs.”

Smith doesn’t believe adding CAC principles to educational programs would be much of an adjustment. “We can very easily change our focus in education to giving students the codes and saying, ‘Is this wrong or is this right, and why?’ It’s not like you have to throw your curriculum away,” she says.

Smith suggests that instead of focusing on efficiency during the coding process, educators could work on cultivating students’ ability to dissect documentation and work backward from the code itself. “I would love to see education programs transition to more CAC-simulated activities so the students feel more comfortable and confident in their role,” she says. “That can be done in the safe learning environment of the college, so they can practice their skills and there’s not such a gap between education and industry.”

— Julie Knudson is a freelance business writer based in Seattle.

Most of the Medicare fee-for-service demonstration projects launched in the past two decades using disease management and value-based payments have failed to reduce costs, says a report issued yesterday by the Congressional Budget Office.

“In nearly every program involving disease management and care coordination, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the participating organizations were considered,” the report stated.

Further, while it noted that projects where care managers had substantial direct interactions with both physicians were more likely to reduce costs, the size of those reductions weren’t enough to offset the care managers’ fees.

Of the 10 demonstrations studied, six in disease management and care coordination, and four in value-based payments, the only one to show savings was a project that bundled payments for heart bypass treatment. In all, the heart bypass program reduced Medicare’s expenses for the procedure by about 10 percent with no significant changes in patient outcomes.

“The Heart Bypass demonstration yielded savings because Medicare was able to negotiate bundled-payment rates with the seven hospitals and the relevant physicians on their medical staffs that were lower than the separate payments that they otherwise would have received,” the report noted.

There were two other demonstration projects associated with different models of paying for heart bypass care, both of which didn’t show savings. According to the CBO, the key factor that affected the results was the nature of the incentives offered to providers. While the bundled payment demonstration showed savings at all seven participating hospitals, the demonstrations that paid bonuses to providers on the basis of their quality scores, estimated savings, or both, produced little or no savings.

The CBO also noted specific approaches taken in some of the demonstration projects that showed promise for savings if applied broadly to help achieve the program’s goals, including:

• Gathering timely data on the use of care, especially hospital admissions;
• Focusing on transitions in care settings;
• Using team-based care;
• Targeting interventions toward high-risk enrollees; and
• Limiting the costs of intervention.

In the end, it may be the very structure of how Medicare pays for services that was the biggest culprit, the CBO concluded.

“Demonstrations aimed at reducing spending and increasing quality of care face significant challenges in overcoming the incentives inherent in Medicare’s fee-for-service payment system, which rewards providers for delivering more care but does not pay them for coordinating with other providers, and the nation’s decentralized healthcare delivery system, which does not facilitate communication or coordination among providers,” wrote Lyle Nelson of CBO’s Health and Human Resources Division, on the CBO’s Director’s Blog.

“The results of those Medicare demonstrations suggest that substantial changes to payment and delivery systems will probably be necessary for programs involving disease management and care coordination or value-based payment to significantly reduce spending and either maintain or improve the quality of care provided to patients,” concluded Nelson.

The jobs picture last month improved overall — and the health-care sector, which has been a bright spot throughout the downturn, continued to grow.

As the WSJ reports, nonfarm payrolls rose by 200,000 people in December as the unemployment rate, calculated using a separate survey, fell to 8.5% from 8.7% in November.

Here’s the full report from the Bureau of Labor Statistics.

Job growth at private employers outstripped job losses in government. The health-care industry added 22,600 jobs in December, following a revised increase of 16,000 jobs the previous month. (Originally the government reported a slightly larger November gain of 17,200, as we reported.)

Data from the BLS show the type of facilities that are hiring, but not the specific types of jobs being added. For example, the report shows that hospitals added 9,800 jobs, but doesn’t reveal whether those are physicians, IT support staff or janitors.

Ambulatory health-care services added a net 11,300 jobs as doctors’ offices, outpatient care centers and home-health services all added positions.

Nursing-care facilities shed about 500 jobs. But the broader category of nursing and residential-care facilities overall gained a net 1,500 jobs in December.

Click here to read more information about OIG’s most wanted health care fugitives. In all, they are seeking more than 170 fugitives on charges related to health care fraud and abuse.

A Look Ahead Points to Increased Risks; Regulatory Expectations; Reputational Fallout

PORTLAND, Ore., Jan. 5, 2012 /PRNewswire via COMTEX/ — Hospitals and healthcare organizations will need more than a couple of aspirin to ready themselves for 2012. Industry experts representing healthcare law, privacy, security, regulatory and data breach were asked to forecast healthcare data trends for 2012. The overall forecast? Protecting patients’ protected health information (PHI) should be viewed as a patient safety issue. If the right actions are not taken, experts predict healthcare data breach will reach epidemic proportions this year.

2011 was the year when most physicians had mobile devices; when healthcare became one of the most-breached industries; and the Department of Health and Human Services Office for Civil Rights (OCR) cracked the whip with investigations and multi-million-dollar fines for organizations that didn’t meet their patient privacy obligations.

Top 2012 predictions in healthcare data:

Healthcare organizations will not be immune to data breach risks caused by the spread of mobile devices in the workforce, according to Dr. Larry Ponemon, chairman and founder, Ponemon Institute. In the recent benchmark study, 81 percent of healthcare providers say they use mobile devices to collect, store, and/or transmit some form of PHI. However 49 percent of those admit they are not taking steps to secure their mobile devices.

Class-action litigation firestorms are imminent, says Kirk Nahra, partner, Wiley Rein LLP. Class-action lawsuits will be on the rise in 2012, as patients are suing healthcare organizations for failing to protect their PHI. 2011 saw several class-action lawsuits for organizations, some of which involved business associates, due to breached patient data. Regardless of the outcomes, these lawsuits are a significant risk and tremendous expense for companies affected by them.

Social media risks in healthcare will grow, according to Chris Apgar, CEO and president, Apgar & Associates, LLC. As more physicians and healthcare organizations move to social media to communicate with patients and promote services, the misuse of social media will increase as will the risk of exposure of PHI. Often healthcare organizations do not develop a social media use plan and employees represent a significant risk, potentially exposing PHI through their own personal social network pages. These risks can lead to patient vulnerabilities, data breaches, civil penalties, loss of business and more.

Cloud computing is not a panacea; technology is outpacing security and creating unprecedented liability risks, suggests James C. Pyles, principal, Powers Pyles Sutter & Verville PC. With fewer resources, cloud computing is an attractive option for healthcare providers, especially as Health Information Exchanges (HIE) increase. However, privacy and legal issues abound, such as compliance with HIPAA privacy and security regulations and allocation of liability when a privacy breach occurs. A covered entity will need to enter into a carefully written business associate agreement with a cloud computing vendor before disclosing protected health information and should ensure that it has adequate cybersecurity insurance to cover the direct and indirect costs of a breach.

Growing reliance on business associates will create new risks, believes Larry Walker, president of The Walker Company. Economic realities will force healthcare providers to continue to outsource many of their functions, such as billing, to third parties or business associates (BA). However, BAs are considered the “weak link in the chain,” when it comes to data privacy and security. 69 percent of organizations that participated in the Ponemon study have little or no confidence in their business associates’ ability to secure patient data. Third-party mistakes account for 46 percent of data breaches reported in the study.

Organizations risk reputation fallout, according to Rick Kam, president and co-founder of ID Experts and chair of the American National Standard Institute’s (ANSI) “PHI Project,” a project to research the financial impact of a healthcare data breach. Identity theft and medical identity theft resulting from data breach exposure are causing patients financial and emotional harm, often resulting in patients seeking out different medical providers. According to the Ponemon study, the average lifetime value of one patient is more than $113,000.

Mobile will explode in healthcare, believes Christina Thielst, health administration consultant and blogger. The use of tablets, smartphones and tablet applications in healthcare is growing exponentially. Nearly one-third of healthcare providers use mobile devices to access Electronic Medical Records or Electronic Health Records (EMR/EHR) systems, according to a CompTIA study. Providers will need to balance usability, preferences, security and budgetary concerns, as well as adopt written terms of use with employees and contractors using personal devices at work.

Increased emphasis on willful neglect leads to increased enforcement of HIPAA, according to Adam Greene, partner, Davis, Wright, Tremaine LLP. The focus over the next year will be on the 150 HITECH Act audits and publication of the final rules implementing modifications to the HIPAA regulations. But the biggest changes may be at the OCR investigative level. Expect OCR to more aggressively pursue enforcement against noncompliance due to “willful neglect” starting in 2012, resulting in a sharp uptake in financial settlements and fines in the coming years. 2012 will be the year that OCR expects everyone’s training wheels to have come off their privacy and security programs.

Privacy and security training will be an annual requirement, says Peter Cizik, co-founder and CEO, BridgeFront. Healthcare organizations have gotten better at putting procedures in place, but staff are still not following them. Because the majority of breaches are caused by human error, not technology failures, targeted training and awareness programs are one of the most effective ways to prevent data breaches.

Rise in fraudsters will increase fraud risk education, according to Jonnie Massey, supervisor, Special Investigations Unit, Oregon Dental Service (ODS) Companies. Pressure, opportunity and rationalization: these three dangerous elements of the triangle can lead to committing a healthcare-related crime. During hard economic times, there are more fraudsters and more opportunities for them to gain or keep a healthcare benefit they are not entitled to. Educating those at risk for fraud and communicating consequences may deter someone from stepping over the line or help those at risk to prevent them from being a victim of healthcare fraud.

Healthcare organizations will turn to cyber liability insurance, according to Christine Marciano, president, Cyber Data Risk Managers LLC. As healthcare organizations continue to implement their EHR systems, they will consider options to protect themselves and their patients. When a healthcare organization or other HIPAA covered entity suffers a data breach the cost can be damaging not only to an entity’s bottom line, but also to the reputation of its brand. With the increased vulnerabilities and as part of a data breach response plan, healthcare organizations will increasingly turn to a cyber security/data breach insurance policy.

These top forecasts support the 2011 Benchmark Study on Patient Privacy and Data Security, by Ponemon Institute, that found the frequency of data breaches in healthcare organizations surveyed increased by 32 percent, costing the U.S. healthcare industry an average of $6.5 billion. For a free copy of the report, visit http://www2.idexpertscorp.com/ponemon-study-2011/

SOURCE ID Experts