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for any provider to electronically exchange information about the medical
history of any patient may once have seemed like a worthwhile but distant goal.
Today, that capability is almost here.
electronic health records (EHRs) and health information exchange (HIE), is being
used to send data electronically and securely among healthcare organizations. But
availability doesn’t equal acceptance. Barriers persist in the form of
budgetary and time constraints, privacy concerns, and issues with data quality.
there is not even agreement on what interoperability entails. One view holds
that for the industry to truly benefit from interoperability, there needs to be
secure, automatic data exchange not just between providers but between
providers and health plans, providers and patients, and health plans and
patients—and none of that is happening enough.
Tripathi, president and CEO of the Massachusetts eHealth Collaborative, a
nonprofit professional services firm that provides consultation on EHRs and
HIE, says the industry’s interoperability capabilities are maturing.
literally 1 to 1 ½ years away from being able to say we have nationwide
interoperability capability for basic medical records,” Tripathi (pictured at right) says.
vendors are part of collaborations that support common data standards and other
components of a common interoperability framework, Tripathi says. By connecting
disparate networks, such a framework enables data exchange for users of the EHR
systems. Noting that these EHR vendors represent 85 percent of the national market
and are beginning to make the functionality part of their systems (rather than
a custom add-on), Tripathi says most of the market will be able to exchange
healthcare data electronically.
“In a very
real way, that is nationwide interoperability,” he says.
Medical Group (RMG), a multispecialty practice based in Worcester, Mass., has had
interoperability capability since 1993, when it began exchanging data with a
local hospital and area health plan, says Larry Garber, MD, medical director for
informatics and associate director of research. Today, RMG uses its EHR
functionality to exchange patient medical records with organizations in nearly
practice, which has 25 sites and 300,000 patients in central Massachusetts,
also exchanges data through the state HIE, called the Massachusetts Health
are such that when one of our patients shows up in the emergency rooms of any local
hospital, our electronic health record automatically sends a summary document
securely, using direct messaging, to that ER on that patient, telling the
doctors that these are the meds the patient is on, these are the allergies, the
medical problems, recent test results,” Garber (pictured at right) says. “And it all happens within 90
seconds of them registering in the ER.”
EHR vendor’s interoperability platform, the practice can also query other
organizations—with patient consent—for specific patient health data, Garber
also receives claims data from its contracted health plans through secure
interfaces. The data enable RMG physicians to see the treatment that patients
have received from provider facilities to which the practice is not linked
through its EHR or the HIE.
“I think we
really are among the best in the country in terms of interoperability,” Garber
Independence Blue Cross, a Philadelphia-based
health plan, was a founding member of HealthShare Exchange, the HIE
serving southeastern Pennsylvania and the greater Delaware Valley, including
southern New Jersey. HSX has 130 subscribers—including hospitals and
health systems, medical groups, independent physicians, health plans,
accountable care organizations, and behavioral health and post-acute-care
entities—with a clinical data repository that already includes more than 6
million patients (click on the exhibit below for more information).
Over the past year, providers have exchanged more than
300,000 direct secure messages via HSX, mostly between different health
systems, notes Greg Barnowsky, chief enterprise architect for
Independence. Every month, the HIE sends his health plan real-time notifications of thousands of admission, discharge, and transfer (ADT) events for its members that may trigger care management steps, Barnowsky says.
“We have the
ability to recognize that a member has been admitted to an individual hospital
with a tool called an automated care team finder,” he says. The tool also
notifies the patient’s primary care physician of the admission.
very lucky to be [part of] one of the very few plan/provider collaboratives for
sharing electronic health records” data, Barnowsky says.
technical means exist, not all providers are using interoperability
functionality. Several issues pose daunting barriers.
Resources. Certainly, healthcare organizations
are faced with competing priorities that squeeze already limited financial
resources and manpower. Interoperability requires some amount of funding and
internal expertise, depending on the provider’s desired level of functionality.
RMG, for instance, has four clinical FTEs dedicated to healthcare IT work,
to HealthShare Exchange is relatively uncomplicated. Small or solo practices
with limited resources can use standard, secure email messaging to receive
basic patient history data, Barnowsky (pictured at right) of Independence says. However, participants that
want additional functionality, such as the ability to query other EHRs, require
internal technical expertise.
For a health
system, the cost to join the HIE is not considerable, Barnowsky says. Payers
help to cover the cost of operating HealthShare Exchange, and provider funding
for joining HIEs is available from the Centers for Medicare & Medicaid
health systems are directing resources into their EHRs and trying to address
regulatory pressures, such as government mandates relating to meaningful use.
“That’s all competing with the ability to share information,” Barnowsky says.
Health information exchange functionality, such as
Carequality and CommonWell network capability, is increasingly being built into
the core EHR product, meaning there are no up-front costs for development or
implementation. Nor are most vendors charging a separate fee for this
capability, Tripathi says.
Liability. Providers are concerned over how to
manage the potential legal consequences if data is used inappropriately, Barnowsky
“One of the
biggest challenges we’ve had is the understanding of where you are from a
liability standpoint if your individual electronic health record is lost or
used in the wrong way,” Barnowsky says.
Some EHR systems are coming out with functionality that
enables providers to self-enroll in data-sharing networks by clicking on a link
to a contract and agreeing to terms. These are standard contracts that define
the “rules of the road” of the network and essentially state that providers are
responsible for what they do on the network, including getting appropriate
permissions from patients, Tripathi says.
challenge is the incongruency of state privacy laws that govern patient data.
Again, Tripathi says this is a manageable issue. The potential solution is
similar to the approach used by Amazon in dealing with varying state tax laws that
relate to online sales. “Computers are very good at managing [variation],”
Tripathi says, and the greater penetration of networks such as Carequality and
CommonWell will pressure states to align policies with nationwide standards.
On the other
hand, a federal law preventing federally funded substance abuse clinics from
releasing data on patients without separate consent is a more challenging
barrier, Tripathi says.
Data quality. Continuity-of-care documents—the
electronic vehicle for exchanging bulk data—are standardized to an extent but
still allow for local customization that clinicians find frustrating
of those is just really bad. They’re really bloated. They have way too much
information in them. They’re inconsistent,” Tripathi says.
determining whether a patient is allergic to penicillin may require sifting through
a large electronic document, making it easier to telephone for the answer,
lies in increasing the number of users and the amount of data being exchanged.
If users, rather than software engineers, specify what does and does not work in
interoperability functionality, vendors will respond over time and make
have to be motivated to exchange data, and that may present the greatest
obstacle to date.
Incentives. RMG has such strong interoperability
capability, Garber says, in part because it engages in risk-based contracting,
which offers incentives for lower-cost, high-quality care. But many physicians
still practice under the fee-for-service model, which incents volume.
claims data for clinical analytics to better predict and manage patient health,
and for business analytics to assess the acuity level of their patients when
determining financial risk.
if other physicians were similarly incentivized, they, too, would improve their
the technology that holds you back,” Garber says. “It’s the individual
organizations and whether they’re motivated to turn on the [interoperability]
functionality to make it happen.”
barriers are overcome and EHR vendors make interoperability for basic medical
information more readily available, provider-to-provider data exchange by
itself may be insufficient.
argue that without plans and patients and providers all working cohesively—all
engaged—you will not have a successful system,” Barnowsky says.
can incent physicians to provide better care by linking payment to care and can
motivate members to engage in wellness programs in return for lower premiums.
All of this is what drives down overall costs and improves quality, Barnowsky
says. This approach requires not simply data but the ability for data exchange
among all three groups of stakeholders.
from personal health-tracking devices to individual patient care plans can help
with population health management initiatives. In a program at RMG, for
example, several hundred patients with both diabetes and hypertension have home
blood pressure monitors that can download readings to the practice’s EHR, which
analyzes the data and issues alerts when problems arise, Garber says. “The
computer lets us know when there’s something significant to see,” he says.
discount the patient or plan out of that model, providers may still have ways
to exchange information, but you may not be able to get the results or sustainability
needed to improve population health,” Barnowsky says.
EHRs, which are used by providers only, nor HIEs, which some experts say lack scalability
for national reach, appear to be a true solution for such three-way data
solution is Fast Healthcare Interoperability Resources (FHIR), a new standard
for health data exchange that is said to be more flexible and simple to use
across disparate organizations.
Blue Cross adopted the FHIR standard as part of its member health and wellness
portal, allowing member information to be more easily exchanged with vendors of
health and wellness programs.
has real-time data exchange capabilities, Barnowsky says, unlike the typical
file transfer method, which requires several hours. “That will drive a whole
new ecosystem of health and wellness in the future,” he says.
agrees that three-way data exchange is necessary and that FHIR may provide a
viable answer. Despite existing barriers, he believes that the quality of clinical
care documents will improve, and he is optimistic about where healthcare interoperability
“I would say
that we are on the cusp of having the version 1.0 of real nationwide
interoperability, which is a significant milestone for the industry,” he says.
“And it’s just going to get better and better over time.”
Karen Wagner is a freelance healthcare writer based in Forest Lake,
Ill., and a frequent contributor to HFMA publications.
Interviewed for this article: Greg
chief enterprise architect, Independence Blue Cross, Philadelphia; Lawrence Garber, MD, medical director for informatics and
associate director of research, Reliant Medical Group, Worcester, Mass.; Micky
president and CEO, Massachusetts eHealth Collaborative, Waltham, Mass.
TRIMEDX: Moving Healthcare Providers Toward Mature Clinical Asset Management
This article includes a discussion by TRIMEDX leaders about the best ways to mature a clinical asset management program.
HealthTrust: Optimizing Purchased Services
Andrew Motz, assistant vice president, supply chain consulting at HealthTrust, discusses the value of a data-driven approach when procuring purchased services.
Change Healthcare: Accelerating Revenue Cycle Transformation
Jason Williams, vice president for strategy and business analytics, Change Healthcare, discusses the importance of technology and technology-enabled services in reinventing the revenue cycle.
Ensemble Health Partners: Driving Revenue Cycle Innovation
Judson Ivy, president of Ensemble Health Partners, discusses the value of revenue cycle outsourcing and the importance of selecting the right partner.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.