Optimizing
Information Technology to
Enhance Billing Operations
Course Two – May 3
Presented by
Patrick Gauthier & Linda Hagen
Overview
Learning Objectives
1.
2.
3.
4.
5.
6.
Health IT Definitions
Health IT Vision and Reality
Importance of IT Planning
Essentials of Implementation
Process Re-Design – First, Get Better
Basic Self-Assessment & Stages of
Change – Get Real
7. Barriers to Change – Get with it!
What is the Role
of Health IT?
How can IT be “Optimized”?
Project
Any Silver Bullets?
We’re in Good Company
2008 Data
CPOE – computerized physician order entry
PACS –picture archiving and communication system
CDO – care delivery organization
First…some definitions
• HEALTH INFORMATION TECHNOLOGY (HIT) - Information processing
using both computer hardware and software for the entry, storage, retrieval,
sharing, and use of health care information. Two common components of
HIT are electronic medical records and computerized physician order entry.
• ELECTRONIC HEALTH RECORD (EHR) - In health informatics, an
electronic health record refers to the subset of a patient's electronic medical
record (EMR) that is integrated into a larger information network and owned
by the patient. In common usage, EHRs and EMRs are used
interchangeably to refer to a patient's medical record in digital format. Efforts
are underway to develop consensus definitions for these terms and others.
• ELECTRONIC MEDICAL RECORD (EMR) - An electronic medical record
refers to a patient's legal medical record, stored in digital format. It serves as
a repository for clinical data and may have additional capacities such as
computerized physician order entry (CPOE) and clinical decision support.
Efforts are underway to develop consensus definitions for this term and
others.
More Definitions
• HEALTH INFORMATION EXCHANGE (HIE) - Health information exchange
is defined as the mobilization of healthcare information digitally across
organizations within a region or community. HIE provides the capability to
move clinical information between separate health care information systems
while maintaining the meaning of the information being exchanged.
• INTEROPERABILITY - The ability of different information technology
systems and software applications to communicate, to exchange data
accurately, effectively, and consistently, and to use the information that has
been exchanged.
More Definitions
• PERSONAL HEALTH RECORD (PHR) - A PHR is a health record that is
"owned" and maintained by an individual patient, rather than by payers or
providers. Though the term has been around for several decades, it has
recently received renewed attention with the adoption of electronic health
records.
• REGIONAL HEALTH INFORMATION ORGANIZATION (RHIO) - A RHIO is
a multi-stakeholder organization, operating in a specific geographical area,
that enables the exchange and use of health information, in a secure
manner, for the purpose of promoting the improvement of health quality,
safety and efficiency. Officials from the U.S. Department of Health and
Human Services see RHIOs as the building blocks for the National Health
Information Network (NHIN). When complete the NHIN will provide universal
access to electronic health records.
More Definitions
• NATIONAL HEALTH INFORMATION NETWORK (NHIN) - The
technologies, standards, laws, policies, programs and practices that enable
health information to be shared among health decision makers, including
consumers and patients, to promote improvements in health and health care.
The vision for the NHIN is said to have begun in 1991 with the publication of
an Institute of Medicine report, "The Computer-Based Patient Record." The
path to a national network of health care information is through the
successful establishment of regional health information organizations.
• OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH
INFORMATION TECHNOLOGY (ONC) - Provides counsel to the secretary
of the U.S. Department of Health and Human Services and others within the
department for the development and nationwide implementation of an
interoperable health information technology infrastructure. The ONC also
provides management of and logistical support for the American Health
Information Community (AHIC).
IT Basics – what is EDI?
• EDI (Electronic Data Interchange) is a standard format for
exchanging business data. The standard is ANSI X12 and it was
developed by the Data Interchange Standards Association.
• ANSI X12 is either closely coordinated with or is being merged
with an international standard, EDIFACT. An EDI message
contains a string of data elements, each of which represents a
singular fact, such as a price, product model number, and so
forth, separated by delimiter. The entire string is called a data
segment. One or more data segments framed by a header and
trailer form a transaction set, which is the EDI unit of transmission
(equivalent to a message).
• A transaction set often consists of what would usually be
contained in a typical business document or form.
• The parties who exchange EDI transmissions are referred to as
trading partners.
IT Basics – what is EDI?
•
•
•
•
EDI transactions will significantly reduce administrative and operating
costs, gain efficiency in processing time and improve data quality.
Under HIPAA, as EDI transactions gradually replace paper-based
transactions, the risk of losing documents, encountering delays, and
paper chasing is minimized. Trading Partners benefit immensely using
EDI as it involves little if any human touch in highly routine process.
EDI supports
– 837 Health Care Claims
– 835 Payment Advice
– 270/271 Health Care Benefit Inquiry and Response
– 276/277 Claim Status Request and Response
– 278 Health Care Services Request for Review
Two basic methods are available to generate EDI claims transactions:
– Direct Submission by Provider
– Submission by Clearinghouse or Billing Service
IT Basics – Choosing a
Clearinghouse
What is a clearinghouse and what does it have to do
with medical billing?
• A clearinghouse is responsible for ensuring the
accuracy of your billing.
• It is responsible for reformatting your data to a format
that is acceptable to the various insurance carriers.
Namely, programs such as Medicaid, Medicare, Blue
Cross, and a host of others require their medical billing
records to be in a certain format such as the EDI
standard format.
IT Basics – what is HIPAA?
• The Health Insurance Portability and Accountability Act
(HIPAA) of 1996 (P.L.104-191) [HIPAA] was enacted by the
U.S. Congress in 1996.
• According to the Centers for Medicare and Medicaid Services
(CMS) website, Title I of HIPAA protects health insurance
coverage for workers and their families when they change or lose
their jobs. Title II of HIPAA, known as the Administrative
Simplification (AS) provisions, requires the establishment of
national standards for electronic health care transactions and
national identifiers for providers, health insurance plans, and
employers.
IT Basics – what is HIPAA?
• While electronic records and mobile computing are enhancing
patient care, carrying unencrypted protected health information
(PHI) can place your organization at significant risk. State data
breach notification laws and federal HITECH rules require
notification in the event of loss or theft of data.
• Organizations can now be fined up to $1.5 million per incident.
• To meet data protection and safe harbor requirements,
healthcare data must be encrypted and its protection reported.
• Enforcing policies, auditing device usage, and the ability to
remotely wipe data are the differences between having to report
a breach or not.
Transformational Role of IT
Generally…
1.
Leads to safer health care by eliminating duplicate services and
identifying unsafe practices
2.
Supports higher quality care by virtue of access to records and
measure of outcomes
3.
Provides cost savings in the way of reduced consumption and
improved outcomes
Where providers are concerned…
•
Eliminate waste and variation in operations
•
Collect, analyze and report data
•
Standardize, normalize and develop data dictionary
•
Skill building potential
•
Differentiate and innovate
The Vision
 Paperless, accessible, accurate, and reliable
 Improved coordination of care, transitions and communication
 Administrative simplification
 Improved analytical and reporting capabilities
 Ability to make management decisions based on valid data
 Streamlined processes and automated workflow
 Improved revenue and productivity
 Alleviate access and capacity issues
 Enable integration, Shared Decision-Making, Predictive
Modeling, and Population Health Mgmt.
Reality
1.
It can take much longer and be more expensive than you expected
to truly implement a system
2.
CCHIT certification (EHR and Meaningful Use) is critical
3.
Security and privacy are more important now than ever
4.
Difficult to balance what makes you unique with what vendors have
to offer
5.
Tailoring and customizing software is expensive
6.
Hosting software and hardware is expensive
7.
Software contracts are difficult to negotiate
8.
Automating poor business process and inefficient workflow leads to
faster breakdowns
9.
Training is often totally under-estimated
10.
Some vendors will be acquired and some may go out of business.
Ongoing support is an issue.
Optimizing IT Investments
IT Planning
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Form an EHR Committee with Executive Sponsorship
Conduct strategic IT planning
Adopt a 12-18 month timeline
Conduct Needs Assessment: type and size of facilities,
specialties, core processes and documentation preferences
Develop budget (Total Cost of Ownership)
Expect professional Project Management
Gather all forms and “work-around” tools in use
Conduct business process analysis among core processes
(registration, assessment, treatment planning, billing, etc.)
Identify process quality and efficiency improvements
Document business rules and data definitions
Document technical, functional, reporting and financial
requirements
If you don’t know, ask for help
IT Planning
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Solicit proposals that address standards, CCHIT certification,
hardware, ASP (SaaS) options, networking, and
support/maintenance
Ask for “live” installation references
Conduct reference checks and conduct onsite observation
Develop use-case script for vendor demos to control scenario
Compare at least 3 vendors
Evaluate and score each objectively with a scoring tool
Negotiate contract terms including support and upgrades
Coordinate purchase and installation of all hardware
Coordinate purchase and installation of all software
IT Planning
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Consider the addition of an Independent Verification and Validation (IV&V)
consultant and/or a Project Management Professional (PMP) for the
duration of your implementation
Establish implementation plan and enforce accountability
Establish comprehensive training program
Develop Risk Management Plan to mitigate against risk of dissatisfaction,
vendor failure, product transition or “cut-over” problems, and changes to
regulatory matters pertaining to security, interoperability, etc.
Test, validate, verify, rinse and repeat before “going live”
Test data exchange with payers (EDI)
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–
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–
837 Health Care Claims
835 Payment Advice
270/271 Health Care Benefit Inquiry and Response
276/277 Claim Status Request and Response
278 Health Care Services Request for Review
Seven Essentials of
Implementation
1. Project Charter, Team, Planning and
Communication
2. Product/Process Alignment
3. System Configuration
4. Testing and Data Quality Assurance
5. Training
6. Go-Live
7. Review, Learn, and Improve
Importance of Workflow Analysis
• Provides:
– Unbiased view of the entire business process
– Congruence between Operations and Policy
– Model for Determining:
•
•
•
Process Improvements
Future Requirements
Missing Functions
– Enterprise Integration
•
•
•
People
Processes
Technology
Process Mapping or Flow Charting?






Mapping
Sequence of events
Decision points
Controls
Responsibilities
Information / systems
required
Results and records
obtained

Flow Charting
Sequence of events
Process Mapping
Records
Information
Process
Responsibility
Person
Doc.1
No
Record 1
Person
Yes
Person
Doc.2
Person
No
Doc.3
Yes
Person
Record 2
Person
End
Mapping Processes
1.
2.
3.
Map process as currently
occurs, including problems
Map
As-Is
Processes
Identify risks and barriers
associated with the process
Mitigate risks and barriers
associated with the process
4.
Identify opportunities for
improvement / efficiency
5.
Map optimized process
6.
Keep record / evaluation of
improvements made
Project Team
Identify
Opportunities for
Improvement
CHC Leadership
Risk
And
Barriers
Identify
Risks
And
Barriers
Project Team
Mitigate
Risks
And
Barriers
Project Team
Map the “Best
Practice”
Processes
Integrate
Best Practices with
EHR “Implied”
Workflows
Project Team
PDCA Cycle (Deming)
•Team Meetings
•Action Items Due Dates
•Minutes
•Agree Revised Process
•Evaluate Potential Results
•Retain project Records
•Pilot / Validate
•Management Support /
Reporting
Plan
Do
•Project Specification /
Contract
•Leadership
Responsibilities
•Team Members
•Team Responsibilities
•Project Milestones
•Project Timeline
•Project Goals, Measures
and Targets
Check
•Implement Project /
Process
•Documentation
•Records
•Train Staff
•Ongoing Monitoring
Act
•Evaluate Results
•Validate Data
•Confirm Specification Met
•Present Data to
Management
•Management Approval for
Implementation
Common Symbols
Symbol
Decision
Description
Indicates a decision and who is responsible for making the decision.
Usually formatted in an either/or decision mode.
Responsible Agent
Indicates a Predefined Process. An example is “patient check out process.”
Usually, this symbol is used in high level summary process maps.
Registration
This indicates a detailed process. This particular symbol includes the
person responsible for the process, also known as the process owner.
Registration Clerk
Process
Barrier
Electronic
Data
Storage
Data Storage in
a Paper Record
The Red Star indicates a fault in the process. Faults include gaps between
processes that should connect (e.g., a “hand-off” between the front desk and
the medical assistant).
Indicates electronic data storage.
Indicates data storage in a paper record.
Indicates flow of a process or workflow and connects elements of a process.
End
Indicates the termination of a workflow process.
Process Analysis

Patient presents
New / existing
FDR
New
Registered?
No
Registration
process

FDR
Existing
Insurance
not updated
at front desk
MR process
Not always
printed
Print schedule for
next day and
update as
necessary
MR
Multiple
copies –
alternative
processes
required
Verify / update
demographics
Verify insurance
Hand necessary
forms
FDR
FDR
Copy insurance
card / Revs
printout
Given to check out
FDR
FDR
Demographics
Family history
Social history
Part medical history
Placement
into MR
Check out
process
Collect co-pay and
provide receipt
FDR
Mark as “Arrived”
on printed
schedule
No formal
No-show
process
No shows marked
on schedule

FDR
Print encounter
form
Arrives patient in
MM
FDR

MA process
A process map visibly displays complex
processes in a way that is easily
understood
Answers key questions:
1.
Who is the process owner?
2.
Which “actors” are involved?
3.
What transpires end-to-end?
4.
What decisions are made?
5.
What business rules govern the
process?
6.
What info / data is needed / produced?
7.
Where is the information stored?
From this map, mitigating steps can be
designed to eliminate risks, gaps and
barriers
From this map, time studies can be
conducted to find efficiencies
To Host or Not to Host
Does your organization have the capacity to
manage a sophisticated IT infrastructure
including:
•
•
•
•
•
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Staff?
Servers?
Network?
Software training?
Upgrades and “patches”?
Change Management?
If not, consider an ASP (application service
provider) or SaaS (software as a service)
option.
Meaningful Use

The use of a certified EHR in a meaningful manner
(e.g.: e-Prescribing);

The use of certified EHR technology for electronic
exchange of health information to improve quality of
health care; and

The use of certified EHR technology to submit clinical
quality and other measures.
HITECH Act Incentives
 EHR incentives are available only to certified eligible
providers and hospitals demonstrating meaningful use of
certified EHR systems
 On June 24, 2010, ONC published a final rule to establish a
temporary certification program for health information
technology.
 Several Authorized Testing and Certifying Bodies (ATCB)
will be approved by ONC to certify systems
Choosing a Vendor
• Most leading products are quite capable. Choice
should involve “environmental” factors:
– ONC Certification
– Track-Record
•
•
•
Reputation among your peers (local demands and variable
requirements)
Proven off the shelf interfaces (verify with RHIO partners)
Proven reporting capability (verify with State and payers)
– Competitors / Peers
•
•
Don’t be the first among your friends with a new vendor
Talk to other like organizations and learn from their experiences
– Available financial and implementation support
•
•
Hospitals / systems of care
Associations
6 Big Barriers
1. Organizational culture, beliefs, and values as
well as resistance to the concept of change
among clinicians (however ironic)
2. Management style, competing priorities and
capacity constraints
3. Various forms of tension
4. Failure to secure staff buy-in and/or executive
sponsorship
5. Lack of accountability
6. Budget / Total Cost of Ownership
Put Things Into Perspective…
In 10 years time, things will change
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EHR technology will have improved exponentially
Use of EHR technology will be universal and mandated
Data will be widely shared
You may have a different EHR vendor
You will certainly have replaced all your current hardware
Some things will remain the same
 Many of your staff
 Many of your patients
This is an investment in your organization, your
staff, and your patients
Change
“Given the costs and waste in our healthcare system, redesign may be
our only sustainable route to justice and financial solvency.”
“If everyone is thinking alike, nobody is thinking”
“Culture eats strategy for breakfast”
“We cannot solve our problems with the same kind of thinking we
used in creating our problems”
Thank You! Questions?
Patrick Gauthier
Director
pgauthier@ahpnet.com
888-898-3280 x.802
www.ahpnet.com