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Overview Optimizing Information Technology to Enhance Billing Operations Course Two – May 3 Presented by Patrick Gauthier & Linda Hagen.

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Presentation on theme: "Overview Optimizing Information Technology to Enhance Billing Operations Course Two – May 3 Presented by Patrick Gauthier & Linda Hagen."— Presentation transcript:

1 Overview Optimizing Information Technology to Enhance Billing Operations Course Two – May 3 Presented by Patrick Gauthier & Linda Hagen

2 Learning Objectives 1.Health IT Definitions 2.Health IT Vision and Reality 3.Importance of IT Planning 4.Essentials of Implementation 5.Process Re-Design – First, Get Better 6.Basic Self-Assessment & Stages of Change – Get Real 7.Barriers to Change – Get with it!

3 Access to Records What is the Role of Health IT? How can IT be “Optimized”? Tool Process Project Quality Data Analysis Audit Reporting Efficiency Productivity Any Silver Bullets?

4 We’re in Good Company 2008 Data CPOE – computerized physician order entry PACS –picture archiving and communication system CDO – care delivery organization

5 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.

6 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.

7 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.

8 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).

9 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.

10 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

11 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.

12 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.

13 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.

14 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

15 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.

16 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.

17 Optimizing IT Investments

18 IT Planning  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

19 IT Planning  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

20 IT Planning  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) –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

21 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

22 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

23 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

24 End No Yes No Process Person Responsibility Doc.1 Doc.2 Doc.3 Information Record 1 Record 2 Records Process Mapping

25 Mapping Processes 1. Map process as currently occurs, including problems 2. Identify risks and barriers associated with the process 3. 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

26 Common Symbols

27 Process Analysis 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

28 To Host or Not to Host Does your organization have the capacity to manage a sophisticated IT infrastructure including: 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.

29 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.

30 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

31 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

32 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

33 Put Things Into Perspective… In 10 years time, things will change  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

34 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”

35 Thank You! Questions? Patrick Gauthier Director 888-898-3280 x.802

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