“Take heed, hospital administrators – Uncle Sam is watching.”

Oh how true. Most everyone involved in healthcare knows that “Uncle Sam is watching.”

And we also know that good ole CMS is getting pickier and pickier about what they are going to pay for these days.

“While no healthcare sector is being spared from the reimbursement knife, the Value-Based Purchasing initiative is aimed squarely at hospitals.” {Value-based purchasing (VBP), which links payment more directly to the quality of care provided, is a strategy that can help to transform the current payment system by rewarding providers for delivering high quality, efficient clinical care. Click here for more details.} “It is part of a larger reimbursement reduction movement that also includes the Recovery Audit Contractor (RAC) program, Medicare-Severity DRGs (MS-DRGs) and pay-for-performance (P4P).”

“The intent is to use the combination of transparency and fiscal reward to drive clinical quality, patient-centric services and operational efficiency.”

“This program, which I call the ‘Hospital Acquired Payment Adjustment Provision,’ is an overall movement to control costs at the Medicare and Medicaid levels,” said Walt Zywiak, principal researcher for CSC. “CMS has decided it will not make payments for hospital-acquired conditions. Overall, how it works is that if a hospital submits a Medicare claim for any of 10 CMS-identified conditions that were not present upon the patient’s admission, payments for those claims will be reduced.”

The 10 categories of conditions that CMS selected for the Hospital Acquired Conditions (HAC) payment provision are:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma
   • Fractures
   • Dislocations
   • Intracranial Injuries
   • Crushing Injuries
   • Burns
   • Electric Shock
6. Manifestations of Poor Glycemic Control
   • Diabetic Ketoacidosis
   • Nonketotic Hyperosmolar Coma
   • Hypoglycemic Coma
   • Secondary Diabetes with Ketoacidosis
   • Secondary Diabetes with Hyperosmolarity
7. Catheter-Associated Urinary Tract Infection          (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:
   • Coronary Artery Bypass Graft (CABG) – Mediastinitis
   • Bariatric Surgery
     • Laparoscopic Gastric Bypass
     • Gastroenterostomy
     • Laparoscopic Gastric Restrictive Surgery
   • Orthopedic Procedures
     • Spine
     • Neck
     • Shoulder
     • Elbow
10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)

• Total Knee Replacement
• Hip Replacement

Source: http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp

So, we see that CMS is putting hospitals to the test when it comes to transparency in documentation and quality of care. As an administrator, how do you ensure that your physicians are accurately documenting care administered to patients, according to the rules of CMS? Are you relying on them to include this in their dictated reports? If so, how do you remind them {uh, change their behavior} to include documentation of POA conditions? Post-it notes? Posters on the wall? Notes in the Physician Lounge? {All of which make little-to-no impression on the physician.}

OR, have you invested in a compliance-driven documentation program, like ComplyMD, that will help your physicians deliver robust documentation to your facility? Chances are, you have not. Chances are, your EMR will not do this either.

Better documentation is becoming increasingly important. Remember, Uncle Sam is in fact watching. You better get equipped to handle all of his demands.

“Healthcare reform has now taken a prominent role in Washington, DC, with both the House and Senate working in concert with the Obama Administration to pass effective legislation.”

National Health IT Week 2009 will be in DC, taking place September 21st – 25^th. Details here.

“National Health IT Week is a collaborative forum now in its fourth year of assembling key healthcare constituents…..working together to elevate national attention to the necessity of advancing healthcare IT.”

With a new Administration that’s focused on “change”, healthcare reform has been one of the hot topics. We all know in healthcare that change is inevitable. We discussed that here a few weeks ago.  Healthcare IT hasn’t gotten this much attention from the government in quite some time. So, as an industry, we need to take advantage of such recognition. One reason that we, at ComplyMD, like all the healthcare IT buzz from DC is the attention it brings to ‘changing with the times.’ Many times hospital administration can be ‘iffy’ about investing in a new piece of equipment or a new software solution because of the financial side of things. Many physicians are ‘iffy’ because of the change that such solutions will bring about to their everyday workload – for better or worse. Healthcare IT solutions produce change in a facility.

Facility administrators must be wise about their solution choices, ensuring their picks will produce good returns and [eventually] happy doctors, staff, and patients. With ComplyMD’s Surgeon Notes solution, we bring about a sort of change in documentation. Surgeons are able to document their procedures and the health of their patients at the point of service. Out with the old [redundant dictation] and in with the new [ComplyMD Surgeon Notes]. Whether we agree with the Obama Administration or not, we at ComplyMD like change.

“National Time Out Day reminds every member of the surgical team how critical it is to take time out for patient safety. Confirm correct patient, correct procedure, and correct surgical site before every invasive procedure.”

With ComplyMD, Every Day is Time Out Day. Our perioperative surgical documentation tool allows physicians and nurses to document in real-time the exact moment of the Surgical Time Out. So, there’s no question if it took place; there’s only evidence that the entire Surgical Team was in agreement at that time of the patient, procedure and site.

Time Outs are critically important in the Operating Suite. “Wrong-site surgery and other preventable mistakes still occur too frequently in US operating rooms.” These mistakes are often attributed to the Surgical Team not taking time to stop and assess the patient’s information and situation, but hurriedly rushing into each case and packing into a day as many surgeries as possible. Care is not always taken to assess the current situation with the current patient and make sure everyone is agreement on information regarding the patient, procedure and site before one incision is made.

This is why in 2004, “Joint Commission released the Universal Protocol urging that a ‘time out’ precede every surgical procedure to verify the correct patient information prior to incision. In support of the Universal Protocol, AORN began sponsoring National Time Out Day to raise awareness about the importance of requiring the entire surgical team—including physicians, nurses, and surgical technologists—to pause before all invasive procedures to communicate as a group and confirm key information about the patient and procedure to help prevent errors from occurring.”

Notice that phrase “key information about the patient” in the sentence above? Patient ID, procedure and site are important to ‘check’ before all procedures. But what about other “key information”? For example, “patient is allergic to penicillin”, “patient with an old MI”, “patient has COPD”, “patient is deaf”, etc. All of these (I would hope) qualify as “key information”. And most all of these would impact the way the Surgical Team cares for the patient, right? ComplyMD offers the luxury of having all of that information right in front of the Surgical Team at the Time Out on one single screen. So, nurses and docs don’t have to spend time flipping through the patient chart to find all the info, it is all captured on one easy-to-read screen (or printout). The ComplyMD Time Out is not only effective but efficient.

Consistent use of ComplyMD’s Surgical Time Out entry field satisfies Joint Commission’s requirement for the Time Out to be documented just before every invasive procedure.

“This year, AORN collaborated with American Nurses Association, the American Association for Accreditation of Ambulatory Surgical Facilities, the Council on Surgical & Perioperative Safety, and The Joint Commission to create a poster to remind professionals, health care providers, and administrators that ‘Every Day is Time Out Day.’”

They also had a National Time Out Day Video Content. To view some of the vidoes that demonstrate the Surgical Time Out procedure, click here and scroll down.

According to this article, “Health care is the only private-sector economic activity that has added jobs continuously since the recession began.” Does that mean that healthcare has not been negatively impacted by the recession? Of course not. We are all feeling the pain, in one form or fashion.

Written by Jeff Goldsmith, Hospitals and the Recession was featured in HHN Magazine online on July 6, 2009.

“The reality is that, despite the employment growth, the U.S. health system is in recession. Inpatient hospital admissions and elective surgery, as well as physician office visits and prescriptions filled, are all down by low- to mid-single-digit amounts. Colleagues in health insurance report that 2008-2009 health costs are trending in the 6 percent or 7 percent a year range. Only during the mid- 1990s post-Clinton-reform, managed-care panic have we seen this cost trend lower for a longer period of time.”

“Health care demand actually began softening before last fall’s thunderous financial market collapse. The downturn began in 2007 and may have been a leading indicator of a spreading family-cash-flow crisis….Most hospitals report rising bad debt and charity care, as people lose health insurance coverage along with their jobs. It should concern hospital leaders that the customer is less and less able to afford their product.”

Money is of great concern for consumers, providers, insurers, etc. Consumers are less and less able to afford healthcare. Hospitals’ case volume is down. Hospitals are also going to face challenges in Medicare funding reductions and might have to run their hospitals on “regular gas”. {Be not dismayed…}

“Demand for our services, while softened, has not collapsed. Unlike the real estate and financial services sectors, we have not squandered the confidence of our customers. People in crisis appreciate that we are a vital part of their safety net, and know that we are there for them when they need us. If we can accomplish the urgent task of health reform, we can affirm that promise for all of the people of our country. The hospital industry will enter the next decade chastened by this economic crisis, but stronger for it.” {But, be wise….}

So where does this leave us? We need to do the best with what we’ve got. Hospitals need to maximize their resources. Budgets are getting tight; capital spending budgets, especially. But spending can’t just automatically stop. With healthcare, you’ve got to keep moving forward, especially in the world of technology solutions. So providers must ensure they are spending wisely.

Spend some to get some. Spend money on solutions you know are going to provide cost reductions. When possible, spend on solutions that can provide revenue increase. ComplyMD is a great budget-friendly solution for these tight times. Decreasing your cost of transcription, while building better DRG’s with comprehensive documentation, ComplyMD can save you valuable dollars while helping ensure you’re not ‘leaving money on the table’.

Health Data Management reported this “First Look at ‘Meaningful Use’” article, which lists 15 of the 22 objectives for EHRs in 2011. Here’s the list:

* Use CPOE for all order types including medications
* Implement drug-drug, drug-allergy and drug-formulary checks
* Maintain an up-to-date problem list
* Generate and transmit permissible prescriptions electronically
* Maintain an active medication allergy list
* Send reminders to patients per their preference for preventive and follow-up care
* Document a progress note for each encounter
* Provide patients with an electronic copy or electronic access to clinical information such as lab results, problem list, medication lists and allergies
* Provide clinical summaries for patients for each encounter
* Exchange key clinical information among providers of care
* Perform medication reconciliation at relevant encounters
* Submit electronic data to immunization registries where required and accepted
* Provide electronic submissions of reportable lab results to public health agencies
* Provide electronic surveillance data to public health agencies according to applicable law and practice
* Comply with federal and state privacy/security laws and the fair data sharing practices in HHS’ Nationwide Privacy and Security Framework, released in December 2008.

Once this first round of definition and standards were released, we read in Modern Healthcare where

“the group invited feedback on whether the balance it sought to strike was ‘overly aggressive based on the current state of technology and the demands on new provider workflows, or not challenging enough to result in significant transformation.’”

Some believe the group did a nice job of establishing a decent framework for the standards. Some believe the objectives have set the bar a little too high, which could slow the adoption of EHR. The jury is still out.

“For better or worse, it is now the starting point for what surely will be months of debate on ‘meaningful use’ before the federal rulemaking is completed. That is expected to happen sometime early next year. Even then, the meaning of ‘meaningful use’ will remain fluid throughout the life of the EHR subsidy program, which is now slated to run through 2015.”

Here’s a helpful matrix that the group developed that outlines the Goals, Objectives and Measures of “Meaningful Use”.

There is one thing you need to be sure of: Make certain that your EHR not only meets the governmental standards and objectives, but also shows measurable results in your facility with positive feedback from active users. Make sure that your facility sees improved patient care, increased safety, reduced medical errors, and a healthier bottom line. To do this, you must be sure that your EHR covers all your bases.

In my time, I’ve seen a gap in the ability of EHRs to capture surgical documentation at the point of service. This is exactly where ComplyMD comes into play and fits seamlessly with most any EHR on the market. You’ve got to engage physicians. You’ve got to capture their attention at the point of service, when their knowledge of the patient encounter is most fresh. You’ve got to ensure they give accurate, comprehensive documentation. You’ve got to have ComplyMD’s Surgeon Notes solution.

“Industry officials said the federal money and standards setting provisions in the new law will be the twin charges that burst the financial dam that has kept electronic health-record system adoption at relatively low levels.”

“The Medicare and Medicaid incentive programs will more directly subsidize adoption of EHRs by providers. Hospitals will receive IT payments over a maximum period of four years…..For those hospitals using “meaningful” EHRs during fiscals years 2011 through 2013, the amounts will be a 100% payment the first year, and 75%, 50% and 25% the subsequent years.”

Here’s a graph depicting the bonus structure for early EHR adopters:

Health I.T. Carrots

With these Health IT Carrots, comes Health IT Sticks. “The stimulus law calls for Medicare reimbursement penalties for physicians how delay adoption of health information technology until after 2014.” If you start in 2015, your Medicare penalty is -1%; 2016 penalty is -2%; 2017 penalty is -3%; 2018 penalty depends on overall adoption rate.

So what does all of this have to do with ComplyMD, a non-EHR healthcare solutions company? It has everything to do with ComplyMD. One of the gray areas of this whole carrot is “What is the definition for ‘meaningful use”? (We’ll get more into that next week.) But for now, I want us to focus on the plain fact that Electronic Healthcare is coming. Like it or not, every facility, every physician, every nurse, every hospital employee, every patient, everyone needs to accept the fact that technology is changing patient care. The government is pushing for adoption of EHRs; facilities are putting it off. The government is giving incentives for early adoption; some facilities are still putting it off. As we’ve discussed before, successful adoption hinges on a facility’s readiness for such a massive undertaking as EHR adoption.

Facilities: Why not begin getting your staff [especially your physicians!] prepared for the inevitable EHR, with other forms of technology that can later interface with your EHR. Many technologies out there involve the hospital staff; few involve the doctor himself. And this is where the strongest push back (in my opinion) will come from: Your Physicians. If you don’t prepare them, they’ll be your toughest barrier to adoption with EHR. That’s exactly where ComplyMD comes in to the rescue. ComplyMD is an easy to use documentation system for physicians to use at the point of service. We help eliminate the antiquated process of straight dictation to transcription, with our web-based documentation tool that most any physician can use. Plus we help reduce the risk of erroneous documentation before it happens. And our system interfaces with most any existing EHR (or other technology) on the market.

So, in my opinion, it would be in the best interest of many facilities to implement a sort of technology like ComplyMD that will engage your physicians in the documentation process, preparing them for the future of EHR.

This is part one of a two part series from Modern Healthcare Magazine’s May 26 article “Providers Turn to IT for Efficiency, but is it Working?” .  Though they start off discussing IT in laboratories, I believe we can take their words and apply it to any area/department of a healthcare facility.

“Indeed, technology plays a role in productivity across the board, and the healthcare industry is no exception. From faster laboratory results to real-time electronic information in emergency departments to online ‘dashboards’ that monitor performance metrics – providers have begun to embrace automated processes to improve their operations.”

Automated processes, along with point-of-care electronic systems can greatly increase operational efficiency. The keys to success (in my opinion) are: (1) a great implementation, which leads to great adoption and (2) an already well-run facility that’s ready for such an IT implementation.

Despite the boost in efficiency that IT can bring to a facility, there are usually some major hurdles to overcome.

“Still, there are significant challenges to adopting various technologies. Critics of electronic health records have said that the technology can be confusing and hard to implement, and it winds up disrupting work and limiting productivity.”

That is a very valid point. Technology can be confusing and often disrupting. And yes, if it’s not implemented right, it could perhaps limit productivity. That’s why you must have the right technology, implemented at the right facility, with the right people who are ready for such a change. Technology implementations will always bring about change. Naturally, we as humans are often resistant to change, especially when we what we’re doing now “works”. But bottom lines aren’t maximally impacted by what “works”. Patient care isn’t improved by simply what “works.” If you want to be competitive in this day and age, you better get ahead of the curve. Your facility better be ready for change, constant change.

The article goes on to discuss the tipping point for hospitals where cost savings and IT investments are realized. Some are of the opinion that this is often tricky to measure. And oftentimes, spending does not immediately translate to huge savings. (Obviously, that depends on the price you paid for that technology.) Further,

“Others believe technology adoption doesn’t refer to just the flashy, hot-topic products of the day, such as EHRs. Instead, it’s a matter of organizational design, and hospitals that are better prepared to adopt innovation will see better gains, according to researchers with Dartmouth College.”

“Hospitals that are quicker to adopt technologies have better outcomes in treating patients”, according to Jonathan Skinner and Douglas Staiger, who wrote a working paper titled Technology Diffusion and Productivity Growth in Health Care.

Again, I’ll make the point: You must have the right technology, implemented at the right facility, with the right people who are ready for such a change.

With ComplyMD, it’s simple disruptive change. It’s not totally drastic (like an EHR/EMR). We replace after-the-fact dictation, with point-of-care documentation on our web-based application. This does involve a process shift, obviously. But we’ve seen that with the right people at the right facility, this does positively impact patient care, efficiency and productivity within the Operating Room, filtering down to other departments too (HIM, Coding, PACU, etc.).

We all understand that patient care is the most important aspect of practicing medicine. In Med School, physicians are trained to take care of patients. Many even specialize in a certain area of medicine and take care of certain kinds of sick people.But what about documentation and coding? Why aren’t physicians trained on how to best document what they did on patients? Isn’t good documentation important to continuity of patient care? Isn’t this how they are to defend themselves in a (heaven forbid) medical malpractice case? Isn’t this how they get paid? If physicians don’t know how to document, they’re losing….and its more than just dollars and cents. They’re honestly robbing themselves of being a “Best Pracitces” physician within the healthcare industry. So….WHY is this not taught to physicians in their formal education?

“The purpose of this study was to survey surgical residents and attending for their knowledge of documentation and coding and their opinions about its importance in their training and practice.”

The convenience sample: 60 surgical residents and 46 attendings from 5 surgical residency training programs

“Similar portions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS (documentation and coding for physician services). The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attending stated that they were somewhat knowledgeable.”

So 82-89% of residents and attending do not feel adequately trained in DCPS. So how will they learn? Think about it…CMS, Joint Commission and all the other players have so many rules and regulations that doctors must play by; but the docs are never taught the rules in the first place. It seems that docs have to (a) learn the hard way by making costly mistakes (b) take initiative towards independent training or (c) continue to be losers in the area of documentation and coding.

“As a group, residents answered 54% of 25 knowledge questions correctly, and attending answered 77% correctly.”

“Conclusions: Residents in this survey are aware of the importance of DCPS but feel inadequately prepared for this area of practice. The residents’ knowledge of basic concepts in DCPS is marginal. Attendings surveyed had similar opinions and somewhat better knowledge of the subject. A widely available, standardized educational offering on DCPS is needed and should be provided as part of the practice-based core competencies of surgical residency training.”

Obviously, a standardized educational offering on DCPS is not born overnight. So what can we do in the mean time until educational institutions have such an offering? We can give physicians the right tools for proper documentation and coding. ComplyMD is one of those tools. Our web-based application helps to train the physician on how to speak the proper language to coders and third-party payors, while accurately documenting the acuity of the patient and the procedures administered to the patient. With the right tools, physicians can learn how to play by the rules and stop being ignorant to the real facts about documentation and coding.

“If your documentation assurance program focuses on reimbursement alone, you’re not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it’s critical that the medical record accurately reflect the severity of illness and the services provided to your patients.”

If we really think about it, the quote above is totally true. Many facilities have implemented Documentation Assurance Programs, such as Clinical Documentation Improvement initiatives. And these programs oftentimes measure ‘success’ in terms of dollars and cents, rather than by quality documentation of severity of illness, continuity of care, level of acuity and risk of mortality.

“Many times, documentation specialists do a great job of picking up the complications/comorbidities (CCs) and major complications/cormorbidities (MCCs) but stop right there and miss the opportunity to add additional documentation, which will affect the drivers of acuity level and risk of mortality.”

Documentation Specialists are trained professionals who are taught to look for those CCs and MCCs. In an attempt to build the best DRG, they must capture these important conditions. But, they shouldn’t just stop when they’ve gotten to a certain DRG level. A good Documentation Specialist will not be focused on getting the patient into the highest paying DRG, but will be focused on painting the most comprehensive picture of the health of each patient.

This is exactly where ComplyMD comes in. In attempt to paint the most vivid picture of (1) the health of the patient and (2) the procedure(s) performed on the patient, we aid physicians and staff in capturing the most documentation about each patient encounter. ComplyMD does not focus on CCs and MCCs, nor do we get involved at all with DRGs. We are focused on capturing complete and accurate documentation about each patient, to enable better patient care through knowledgeable patient information. With this comes data capture on severity of illness, continuity of care, level of acuity and the risk of mortality, with the bonus of MCCs, CCs and ultimately building an accurate DRG. We’re not focused on DRGs; we’re focused on enhancing patient care through comprehensive documentation.

Bert Amison of KPMG LLP said it well…

“So often, hospitals concentrate so much on reimbursement that they put other issues on the back burner. Many times, when we conduct an analysis of hospital documentation, we find little or no opportunity on the hospital reimbursement side, but there is a lot of opportunity on the risk-adjusted mortality side.”

His punchline bears repeating.  “There is a lot of opportunity on the risk-adjusted mortality side.” ComplyMD is just the right solution for capitalizing on this kind of opportunity within healthcare facilities.

Many hospitals have not implemented fully functioning IT systems into their surgical theaters, largely due to the complexity of this market segment. And the big question for hospitals considering a peri-operative system is “enterprise solution vs. niche solution”. Patricia Aysse, program manager of surgical services at MUSC Medical Center in Charleston, S.C., says her “hospital officials made the tough call of using a best-of-breed IT system in the OR instead of the components of the enterprise system that runs most of the rest of the hospital, forgoing the advantages of built-in interoperability because the enterprise system ‘was not going to meet the full peri-operative need’.”

I agree that niche systems are the way to go, if they out-perform the enterprise. While interoperability is important, risking lower performance for the sake of convenience is not a wise decision. If the niche system is better, find a one that interfaces with your existing system and move forward.

“I haven’t seen a noteworthy change in any type of documentation solution since the dinosaur system I saw in 1970”, said Lemak. “We’ve chosen to implement ComplyMD at Lemak Sports Medicine because it’s a type of documentation process we’ve never before seen – and we like it. ComplyMD will revolutionize the way we document our procedures.”

Lemak Sports Medicine, located at Brookwood Hospital, consists of three practicing physicians and three fellows. ComplyMD Surgeon Notes is a great fit for Lemak because of their high volume of orthopaedic cases. Scheduled for an early summer implementation, ComplyMD will shift the cumbersome, antiquated process of documentation from redundant dictation/transcription to a smart, physician-friendly tool. ComplyMD enables the vivid documentation of patient health and accompanying procedures, immediately generating complete and accurate data that is instantly available to both his office staff and the hospital/facility staff. The value of ComplyMD’s artificial intelligence intrigued Dr. Lemak. The system adapts to his team’s documentation behavior, allowing them to focus more on patient care and still generate a compliant and complete operative report.

“Dr. Lemak is known for excellence in healthcare. We’re delighted he selected ComplyMD Surgeon Notes to be a part of his successful practice,” said Curtis Palmer, CEO of ComplyMD. “His extensive experience will allow us to further develop ComplyMD’s radical process shift in healthcare documentation.”

* * * * *

ComplyMD allows physicians to vividly document the health of their patients and the procedures administered during their encounters, immeidately generating complete and accurate data for physicians. ComplyMD shifts the documentation process to enhance rich data creation, improve efficiency and maximize productivity in healthcare facilities.

Lemak Sports Medicine: World renowned orthopaedic surgeon, Dr. Lawrence J. Lemak, has played an integral role in sports medicine and arthroscopy research. He specializes in sports medicine, arthroscopy and reconstruction of the knee, shoulder, hip and elbow. As a leader in the field of arthroscopy, Dr. Lemak has published articles in numerous medical journals and has given presentations in the United States, England, Europe, Japan and South America. Many professional sports organizations call upon Dr. Lemak’s expertise as he serves as Medical Director for Major League Soccer, NFL Europe, Professional Golf Association and the Ladies Professional Golf Association. He is also Team Physician for many colleges and universities throughout Central Alabama and the Southeast. He is the National Medical Director for PhysioTherapy Associates, a leader in outpatient physical therapy with over 600 locations throughout the country. Dr. Lemak serves as the Associate Dean of Entrepreneurial Medicine at the University of South Florida, and is a Trustee of Alabama State University.