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A Halloween Tale Of Medical Travail

Posted by J. Paul Spencer, CPC, CPC-H in Electronic Health Records, Hot Topics, J. Paul Spencer, CPC CPC-H

“The barren trees of late Autumn, as if sketched against the sunset sky with a piece of charcoal, tapped in the wind against the windows of an operating room at Rhode Island Hospital. A patient was being wheeled away as a surgical technician wondered why there was one less drill bit in the OR than before…”

Rather than being the beginnings of an Agatha Christie mystery or yet another book by H. P. Lovecraft about reanimating the dead, what you have just read is the beginning of a story that led this week to the imposition of a $300,000 fine against Rhode Island Hospital. The missing drill bit was discovered to have been left in the patient’s head during brain tumor surgery. One wonders if this was discovered because the patient’s head kept pointing to Magnetic North, as the hospital didn’t follow an internal protocol of performing a postoperative x-ray in the OR when it is discovered that a surgical instrument is missing. Shortly after this incident, the same hospital had a similar incident involving a pair of forceps being left inside a patient’s abdomen.

While the above story is newsworthy, we have come to realize that medical mistakes have become problems that require increased attention. In an earlier posting in this space, I talked about steps taken in this year’s OIG Work Plan towards determining whether the quality of care provided is deserving of Medicare reimbursement. This goes hand in hand with fairly recent CMS efforts to eliminate payments to hospitals for “never events” and hospital acquired conditions. The two examples above topped a list of these occurrences first implemented in 2008 and which continues to expand.

As Rhode Island Hospital so unceremoniously discovered, having protocols in place is not the problem-solving panacea to adverse patient care events in a health care setting.  Incidents like the one above shed light on the inherent problems of this approach, not the least of which is that human beings are still the predominant providers of medical care. Given this fact, we tend to look for better, less spooky paths to improved outcomes.

With the current Halloween candy-like incentives being offered for implementing an electronic health record (EHR), the medical community seeks news of a positive return on this particular investment. Yesterday, CompTIA, an information technology trade group, released a study that gives a snapshot of EHR adoption. The study showed that roughly 50% of all physicians are using either a complete or partial EHR in their practices, which is a heartening figure given that the incentive payment period begins in 2011. Due to its source, the report included no news of how EHR adoption is affecting patient care. While some preliminary studies have yielded results showing that an EHR can be of great assistance toward favorable patient outcomes, the medical world awaits a larger volume of hard data to show this beyond a shadow of a doubt.

Another horrific element of the equation are the many different conceptions of “quality care” held by the patients themselves which become the great intangible in this debate. On one end of the scale is a person like me, who sees his doctor either once a year or in cases of abnormal bodily processes that I myself am unable to stop. The opposite end of the patient care spectrum is the malingering patient who looks forward to further testing for nothing in particular. In cases like this, can it be accurately determined whether a poor outcome is a patient’s frightening perception or the cold, skeletal deathly hand of harsh reality? 

Of all the ghastly and gruesome stops along the road to improved outcomes, medical providers are about to find that worst among these is declining reimbursement for care determined to be avoidable or unnecessary. As Rhode Island Hospital discovered this week, the path to providing consistent and quality care requires continuing effort and eternal vigilence against the dark forces who pay for care, but cheer up. In the end, the road is not half as scary as the effect of this on the world of acting. Now that’s terrifying!

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October 29th, 2010 | No Comments »

EHR Certification Organizations: A Closer Look

Posted by J. Paul Spencer, CPC, CPC-H in Electronic Health Records, Industry Updates, J. Paul Spencer, CPC CPC-H

Despite all appearances to the contrary, we are not in an age of skepticism. It was hoped that when we entered the age of the 24-hour news cycle, with constant access to information, as well as the accompanying advanced technological tools that go along with it, that the reporting of events would improve by providing a higher volume of information by which the viewer could make an informed decision on events, thereby allowing any one person to speak with an adequate knowledge base by which to debate the issues.

Instead, what we have now is not an age of advanced information, but rather one of hyper-choreography. News networks and wire services with an agenda shave the presented facts to fit a pre-determined narrative. As if that were not bad enough, stories that used to count as nothing more than the postscript to an evening newscast now becomes a “BREAKING STORY!!!”, such as the balloon boy hoax or the fact that a 90-year-old actress is in the hospital (gee, we couldn’t predict THAT eventuality now, could we?).

In the world of electronic health records, it was with great fanfare this past Monday that the Office of National Coordinator for Health Information Technology (ONC) named The Drummond Group of Austin, Texas and the Certification Commission for Health Information Technology (CCHIT) as the first testing and certification bodies for electronic health record systems. Thus far, most of the articles I have come across in the news universe have been the usual straight news pieces, complete with quotes from Mark Blumenthal (the national coordinator) about beginning the process of EHR certification and encouraging vendors to submit EHR’s for testing. A press release is sufficient. Nothing to see here. Move along now…..

Because the current initiatives for EHR adoption have the stated goal of achieving improved access to information as well as interoperability, the choosing of vendors to test EHR systems for meaningful use is an important first step. Finding out who the players are behind the initiative is equally important. I have a lot of questions that my unstoppable curiosity want answered:

  • What’s the background of these companies?
  • Who manages these companies?
  • Whose viewpoint is best represented and advanced by the selection of these companies to be the EHR certifiers?
  • (the true skeptic’s question:) Is there a hidden agenda to be found?

With a mouse and keyboard as my only tools, I set about the task of filling my head with information about the Drummond Group and CCHIT.  

According to their website, the Drummond Group has been in existence since 1999. They specialize in software compatibility testing across a range of operating systems and standards. They currently offer their own certification for tested products that sufficiently demonstrate interoperability. They make it very clear that they do not endorse or produce software in order to maintain “strict vendor neutrality”.

A few members of the management team of the company have ties to the oil industry, with founder Rik Drummond having served with the American Petroleum Institute for four years prior to founding his company. In the past, Mr. Drummond has also contributed to re-election campaigns for Rep. Joe Barton of Texas, the last donation coming in 2002. If that name sounds familiar to you, that is because Joe Barton is the man who humbly apologized to BP executives during Congressional hearings for the federal government forcing them to clean up the recent oil spill in the Gulf of Mexico. Based on the Drummond Group’s reputation for the quality of their testing, I’ll chalk these curious facts up to occupational and social associations. It would be hard to be optimistic about the future of EHR if Mr. Barton’s kind of thinking was represented in the certification of healthcare record systems. Mr. Drummond also has extensive experience in Electronic Data Interchange, which comes in handy when testing and certifying an EHR that presumably would double as a billing system.  

CCHIT is something of a known entity in the world of EHR certification. Founded in 2004 as a non-profit and run by volunteers, their focus is strictly trained on health information technology, as 60% of their name intimates. They have been offering certification and testing of EHR’s since 2006, which makes them something of a lead pipe cinch as a first selection, as they have experience testing  for functionality, interoperability and security.

This past April, Karen M. Bell, MD became the chair of CCHIT. Dr. Bell’s resume is peppered with past work done for payers and community medical groups in New England, such as her stint as the medical director for Blue Cross Blue Shield of Rhode Island.  She also worked as the Director of Health IT Adoption at ONC prior to taking her post at CCHIT. She has spent a good portion of her professional life in a variety of positions related to quality improvement. She also has experience as a practicing internist, albeit one that, given her medical training at Brown and Tufts Universities, was more than likely not one where the everyday headaches of  insurance reimbursement was ever a first-tier concern.

More certification agencies will be named in the near future. Thus far, despite my best efforts, I find no readily apparent hidden agenda, but I am beginning to wonder if the interests and input of small group practices are being adequately represented, or whether the journey towards mandatory EHR is most comparable to the creation of a series of bitter pills for physicians to choose to swallow. Only time will tell, one can only speculate, move along now, nothing to see here…….

As a physician advocate, I would add “yet”.

September 3rd, 2010 | No Comments »

The Hidden Costs of Mandatory EMR

Posted by J. Paul Spencer, CPC, CPC-H in Electronic Health Records, J. Paul Spencer, CPC CPC-H

From a purely spiritual perspective, one of my favorite musicians of all time was John Coltrane. There have been many musicians who have attempted to become one with their instrument in an attempt to achieve something beyond mere virtuosity who, while technically perfect, ended up being vacant in matters of the soul. Coltrane achieved the lofty goal of connecting the known and unknown world with the power of music to an extent not seen before or since.

Coltrane was known for taxing the patience and constitution of his many band mates. One incident involved a drummer who became so tired of trying to keep up with one of Coltrane’s saxophone marathons that in order to end the solo and earn a break, he felt he had no other option but to throw a cymbal at Coltrane. There is a legendary story about John Coltrane and Miles Davis having a conversation about the physical limits of music. John Coltrane was asking Miles Davis how he could control his innate need to continue to play until the musical resolution was discovered, if at all. Davis, in his legendary, gravelly whisper of a voice, looked at Coltrane and said “Take the horn outcha mouth!”.

I love this story for two reasons, one being that it continues to make me laugh after repeated telling, but more so because here we have a perfect illustration of finding a simple solution to a complex problem.

If only the solution to physician documentation and medical records were so easy. Sadly, as we get closer to the beginning of the incentive period for meaningful use of an electronic health record, it appears that the “solution” offered in the form of mandatory EMR is looking a lot like the beginnings of a Rube Goldberg device.

The Office of National Coordinator for Health Information Technology (ONC) projected this week that 50,000 additional IT workers will be needed by providers across the country in order to meet the meaningful use criteria. Without the gift of a calculator on my desk, I quickly compute in my head that with a maximum incentive of $44,000 over a five-year period (remembering that not every provider will qualify for this dollar amount), you would have to find one IT person at a salary of $8,800 a year to break even. If you’d like to place a wager on your odds of finding this unicorn of the IT world in today’s economy, give me a call.

Let’s look at a timeline for a moment to put this in perspective. In order to qualify for maximum incentives, registration of meaningful use of an EHR begins this coming January. At the time of this writing, that’s 126 days away! The Certification Commission for Health Information Technology (CCHIT) is still reviewing applications for companies that will test and certify EHR systems to determine whether they have the ability to meet the meaningful use criteria. Also in the equation is the plan for regional extension centers to assist providers during the transition. Currently, 5 states lack an extension center and 28 states, including California,  have only one center currently open to offer assistance.

Seventy community colleges across the nation are also part of the plan, offering non-degree training courses for IT professionals to bring them up to speed. While the ONC’s website gives a time frame of “six months or less” for this training, the issue of whether 4 months of instruction prior to registration is sufficient will go unanswered up until the moment when the training is most needed.

We all crave simple solutions. The Great Migration currently underway towards the goal of electronic health records, given the rampant shortcomings of paper records, is a noble goal. Yet I may not be alone in rethinking whether the established timeline to qualify for maximum incentive payments is too short to be of value in the long run. Unfortunately, unlike the removal of a saxophone from one’s mouth, an easy fix does not appear to be readily available.

August 27th, 2010 | No Comments »

The Many Ways of Being Newsworthy

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Electronic Health Records, In the Press, J. Paul Spencer, CPC CPC-H

As I begin this post, it’s been a typical Friday. My 4-year-old son took an interminably long time getting dressed this morning, I showered, shaved, ate breakfast and my picture ended up on the front page of the Milwaukee Journal Sentinel….

OK, so one of those things is atypical. I’ll give you a hint: I usually eat breakfast.

For more information on my 14th minute and 58th second of fame in my lifetime, click here (I’m the guy with the orange guitar). The story accompanying my grainy image is self-explanatory. So as not to worry readers who may not click through about the reasons for appearing in the newspaper, it doesn’t involve an indictment, a drunken man running onto a baseball field or (surprisingly, to those who know me) a vicious automobile accident. In these troubled and trying times, it’s nice to be part of a good story for a change, and I’m looking forward to tomorrow’s events as described in the article.

So now that we all know what a happy story looks like, let’s explore the flip side as it applies to health care compliance. I came across a story out of Florida that is a good case in point. A couple from a town called Land O’ Lakes (like you, I immediately thought of butter) were making their Sunday run to their local recycling center. When they got there, they found that there was no room for their paper items in the designated dumpster at the center. This was because someone had filled the paper bin to capacity with discarded medical records. In some cases, the records included Social Security, credit card and driver’s license numbers in addition to medical information.  

The first thing I thought of with this story was regarding EHR, and how stories like this may become obsolete within five years. Then I begin to think the opposite, with the personal theory that as practices transition from a paper record to an electronic record, we may see instances like this more often thanks to record destruction companies attempting to cut corners.

Then I begin to daydream, first about dancing in rain made of Newcastle Brown Ale to the music of the Who, then shaking my head and quickly transitioning to the government’s recent re-dedication to recovering money lost from Medicare and Medicaid due to fraud.

Having been involved with coding and compliance for several years, I’ve learned that there really is no end to to the devious machinations of the ethically-challenged in our business. From podiatrists who bill foot care on patients who have had previous foot amputations to DME suppliers forcing unneeded power mobility devices on the local population of elderly residents, extending to the virus of identity theft currently infecting  some medical practices, you need a chain saw to cut through the levels of immoral behavior in this industry.

The damage that these assorted criminals inflict is not restricted to the CMS trust funds. Medical providers who spend their waking hours operating by the rules inadvertently find themselves in the outer remnants of the spotlight that shines on the crooks. The doctors acting above board and rendering legitimate services ultimately pay a high price for the actions of the bad seeds in increased regulation, investigation and bad public relations for the health care industry as a whole.

The current administration has doubled down on recovery of overpayments through fraud and abuse investigations. For the future of Medicare and Medicaid, I see this as overdue. There are many ways to make the news, but perhaps the best approach for the honest medical provider is to implement and follow policies that insure that you end up in the non-”perp walk” portions of the local news.

July 30th, 2010 | 1 Comment »

CMS Releases Final Rule for Meaningful Use of EHR

Posted by J. Paul Spencer, CPC, CPC-H in Electronic Health Records, Industry Updates, J. Paul Spencer, CPC CPC-H

Two things made this a beneficial week for people in America.

The first positive thing is just knowing that the World Cup of soccer won’t be occurring for another 4 years. My mind marvels at the fact that the rest of the world loves this sport with a passion. On television, a great majority of this sport looks like ping pong expanded to fit onto a field. In addition, apparently if you breathe on someone the wrong way in soccer, it’s common practice that the offended party throws themselves on the field as if they have just been assassinated. I haven’t seen acting this bad since the explosion scenes in the second and final season of The Rat Patrol. Thankfully, ice hockey training camps open in 7 weeks to assist me in getting memories of this “sport” out of my head.  

The second positive thing that occurred holds the promise of transforming a great deal of the health care system in the United States. The final rule was released by CMS this week involving the meaningful use of electronic health records (EHR).

The rule clarifying meaningful use differed slightly from the proposed rule. Originally, there were 25 standards that had to be satisfied in order to meet the definition of meaningful use. In the final rule, only 20 markers will need to be met in the beginnings of the program, with the 25 standards having been divided into two groups.

The first group consists of 15 “core” standards which must be met. These include such things as electronic prescribing, implementing and maintaining lists of drug interactions and drug allergies, the recording of patient smoking status and the reporting of quality measures to CMS. The remaining 10 standards are now placed in what is called a “menu set”. In order for a provider to demonstrate meaningful use, one can meet any five of the remaining ten criteria from the menu in addition to the core standards. This would be in effect for the first part of the incentive program, with the expectation that the remaining 5 standards on the menu will eventually be satisfied. 

Based on the number of comments received on the proposed rule about the burdensome nature of meeting some of the core standards, CMS has sharply reduced the percentage of patients that must fall under 8 of the standards.

With the release of this final rule, providers can now begin a one-year journey toward demonstrating meaningful use and maximizing incentive payments from CMS. The process of selection of a certified EHR system can now begin in earnest, if it has not already. As stated in a previous post here, the Office of the National Coordinator for Health Information Technology (ONC) is currently in the process of certifying health systems with the ability to meet the meaningful use standards. After selection of a certified EMR system, a registration link through the CMS website will become available sometime in January of 2011 that will allow providers to register to participate in the incentive program.

It is a time of paradigm shift in American health care. The release of this final rule brings all of us one step closer to fundamentally altering the doctor/patient end of the delivery system. A period of high drama, either from dread anticipation of this final rule or from attempting to guess which soccer player pretends he’s just been killed, has come to an end, with many new beginnings to follow.

July 16th, 2010 | No Comments »