The use of e-prescribing and electronic health records is accelerating

By Jessica Applegate • 10/24/05

On October 11, 2005, the Centers for Medicare and Medicaid Services ("CMS") and the Health and Human Services Office of Inspector General ("OIG") published separate, but parallel, proposed rules representing a unified effort to advance the goal of widespread adoption of electronic health records technologies by hospitals, physicians, and other health care providers. These proposed rules are in accordance with the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ("MMA"), which directed the Secretary of HHS, in consultation with the Attorney General, to create an exception to the Stark law and a safe harbor under the Anti-Kickback Statute to protect certain arrangements involving the provision of non-monetary remuneration (consisting of items and services in the form of hardware, software, or information technology and training services) that is necessary and used solely to receive and transmit electronic prescription drug information.

CMS is responsible for administration of the Stark law, while the OIG is responsible for administration of the Anti-Kickback Statute. The OIG and CMS tried to ensure as much consistency as possible between the proposed rules, given the differences in the respective underlying statutes.

CMS's Proposed Rules
The Stark law prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she has a financial relationship, unless an exception applies. The Stark law also prohibits an entity from submitting claims to Medicare for those referred services, unless an exception applies. However, the Stark law establishes a number of exceptions, and grants the Secretary the authority to create additional regulatory exceptions for financial relationships that do not pose a risk of abuse.

Exception Relating to Electronic Prescribing Information

CMS's regulatory proposal creates an exception to the physician self-referral prohibition in the Stark law for certain arrangements in which a physician receives necessary non-monetary remuneration that is used solely to receive and transmit electronic prescription drug information.

CMS's proposed rule protects the donation of qualifying electronic prescribing technology when the donation is made by hospitals to members of their medical staffs, by group practices to their physician members, and by prescription drug plan sponsors and Medicare advantage organizations to physicians. CMS is considering whether to limit the aggregate fair market value of all items and services provided to a physician from a single donor. CMS believes a monetary limit is appropriate and reasonable to minimize the potential for fraud and abuse, and is soliciting public comment on the amount of the cap.

The proposed exception would protect only items or services that are "necessary" to conduct electronic prescription drug transactions. This might include, for example, hardware, software, broadband or wireless Internet connectivity, training, information technology support services, and other items and services used in connection with the transmission or receipt of electronic prescribing information. CMS believes the exception would allow a hospital to provide a physician with a hand-held device capable of transmitting electronic prescribing information, even though the physician may already have a desktop
computer that could also be used to send the same information. However, the proposed rule would require the physician to certify that items and services provided are not technically or functionally equivalent to those that the physician already possesses or has already obtained.

In addition, to be eligible for the exception, the items and services must be "used solely" for the transmission or receipt of electronic prescribing information. However, CMS is proposing to create an additional exception to protect the provision of hardware and connectivity service that are used for more than one function, so long as a substantial use of the item or service is to receive or transmit electronic prescription information. CMS is soliciting comments on methodologies for quantifying or ensuring that a substantial use of hardware and connectivity services is for the receipt or transmission of electronic prescribing information.

Exception Relating to Electronic Health Records

In addition to the MMA-mandated exception relating to electronic prescribing information, CMS is proposing regulatory exceptions for certain electronic health record information technology and training. CMS intends to protect non-abusive arrangements involving the provision of software and directly related training services that are necessary and used to receive, transmit, and maintain the electronic health records of an entity's or physician's patients. Separate exceptions would apply to donations made before and after the HHS Secretary's adoption of product certification criteria, including criteria for the interoperability, functionality, and privacy and security of electronic health records technology. After certification criteria are approved, the proposed exception will expand for technology meeting the criteria, because the risk of abuse will be lessened and the benefits heightened after interoperability is achieved. CMS is soliciting comments on the proposed standards for these exceptions.


OIG's Proposed Rules
The MMA-mandated Anti-Kickback safe harbor is being implemented in separate rulemaking by OIG.

The Anti-Kickback Statute provides penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business reimbursable under Medicare or Medicaid. The types of remuneration covered specifically include, without limitation, kickbacks, bribes, and rebates, whether made directly or indirectly, overtly or covertly, in cash or in kind. Because of the broad reach of the Anti-Kickback Statute, concern has been expressed that it covers some relatively innocuous commercial arrangements. Accordingly, OIG safe harbor provisions have been developed to limit the reach of the statute somewhat by permitting certain non-abusive arrangements.

Exception Relating to Electronic Prescribing Information

Similarly to CMS's proposed rule, OIG's proposed safe harbor would protect arrangements involving hospitals, group practices, and prescription drug plan sponsors and Medicare Advantage organizations that provide to specified recipients non-monetary remuneration in the form of hardware, software, or information technology and training services necessary and used solely to receive and transmit electronic prescription drug information.

Exception Relating to Electronic Health Records

In addition, OIG is proposing separate safe harbor protection for electronic health records software not covered by the MMA-mandated safe harbor for prescribing. OIG is proposing safe harbors related to electronic health records software and directly related training services that are necessary and used to receive, transmit, and maintain electronic health records of the entity's or physician's patients. Similar to CMS's parallel proposed rule, separate exceptions would apply before and after the adoption of product certification criteria. OIG notes that, unlike electronic prescribing, Congress provided no direction with respect to any safe harbor for electronic health records. Given this, OIG believes they do not now have sufficient information to draft appropriate safe harbor language. OIG is soliciting comments on the proposed scope and conditions for electronic health records safe harbors.

To be assured consideration, written comments on the proposed rules must be received by CMS or OIG no later than 5 p.m. on December 12, 2005. If you wish to review the proposed rules in detail, you may find the full text of CMS's proposed rule here, while the full text of OIG's proposed rule is located here.


Jessica Applegate is an attorney at the Milwaukee office of the law firm Michael Best & Friedrich in the Health Care Practice Group. The opinions expressed herein or statements made in the above column are solely those of the author, and do not necessarily reflect the views of Wisconsin Technology Network, LLC. (WTN). WTN, LLC accepts no legal liability or responsibility for any claims made or opinions expressed herein.

Petition Demands Privacy for Electronic Health Records

Petition Demands Privacy for Electronic Health Records
By M.L. Baker
Ziff-Davis Media
10/28/2005 3:52:00

PMHealth information technology legislation is swirling around Capitol Hill this week, and there's no shortage of recommendations of how it should be done.

Privacy advocacy groups began circulating a petition Thursday to bar employers from viewing patients' health information and giving patients control over who can see what medical information.

The heads of the two advocacy groups who wrote the petition say that, designed properly, electronic health records can protect privacy better than their paper counterparts.

That's because, unlike paper files, electronic systems can show varying levels of information to different people as well as track who tries to access what information.

But such controls must be mandated from the start, said Deborah Peel, head of the Patient Privacy Rights Foundation.

Click here to read about how providers have come up short on HIPAA privacy compliance.

"If health IT is built without protections, then every American is exposed to the same kind of damaging practices that Wal-Mart is seeking to implement," she said, referring to a recently leaked memo in which department store executives planned how to hire and retain employees likely to have the lowest health costs.

The petition being circulated by the Patient Privacy Rights Foundation and the Electronic Privacy Information Center states that patients should be able to choose who can view medical records, explicitly bars employers from viewing employees' medical records and states that sharing private information should not be a precondition of receiving care.

Also this week, the Commission for Systemic Operability released 14 recommendations to ease the creation of systems that could instantly supply a patient's health information when necessary.

The Commission, a bipartisan group created explicitly to advise Congress, recommended that anyone who knowingly attempts to obtain restricted information face criminal prosecution and that the Department of Health and Human Services figure out how to protect patients from the consequences of unauthorized access.

Though more explicit, these provisions are not so different from HIPAA, which states that employers will generally not be able to view information and lays out criminal sanctions and huge fees for harmful use of medical information.

Peel, however, said that the notion of who is authorized should be determined by patients. To avoid mountains of bureaucracy, the exchange of medical information for "routine use" need not be approved by or disclosed to patients. Peel said that this creates a loophole that thwarts HIPAA's intentions.

Health IT could restore protections without crippling paperwork, she said. "Consent is a data field. People that design the system could easily put consent in."

When he read the petition, Scott Wallace, head of the Commission, said that all the positions were reasonable and that none conflicted with the Commission's recommendations, Ending the Document Game.

The Commission recommended that the government, employers, and health care payors should all offer providers incentives to connect information.

It also urged that policy makers and IT vendors stop squabbling about details and adopt national, consistent standards on issues like assuring patient identity.

However, Marc Rotenberg, head of the Electronic Privacy Information Center, took issue with the Commission's recommendation that a national privacy policy should preempt state privacy laws.

"There's a real risk that Washington can get it completely wrong. A bad bill that preempts the states could become an anti-privacy law."

In that case, he said, individual states could provide a smorgasbord of possible solutions.

Wallace said that groups focusing on patient confidentiality can overlook the need to connect information, saying that actions required by some states are prohibited by others.

"Conflicting laws between those states stop my medical information from crossing the border. It is far more important that we have access to medical information than that we have states individually defining privacy needs."

Rotenberg said information technology could be readily designed to adapt to different state policies. For example, appropriate codes and tags could be attached to data so that both data, and privacy protections, could travel with the patient.

But John Halamka, CIO and associate dean for educational technology at Harvard Medical School, said consistent privacy and security policies are essential to connect information, and such policies often extend beyond certain classes of data.

State laws that were reasonable before electronic systems now impede patient care, Halamka wrote in an opinion piece.

The ultimate privacy argument against RFID. Click here to read more.

"In Massachusetts, doctors can't retrieve a complete electronic medical list from an insurance company, even with patient consent, if a medication related to mental health, substance abuse or HIV treatment is present.

"In Ohio, doctors must use a cryptographic electronic signature to prescribe medications electronically. In California, only paper forms are considered a valid patient consent."

Peel did not see separate state privacy laws as essential, providing that current national privacy policies were strengthened. She warned that patients worried that their health information could be used to harm them would find ways to keep that information out of the system, even if it meant forgoing care.

In that sense, she said, the ability to protect information is a prerequisite for the ability to connect it.

"Information technology can bring us the best of both worlds. It's not an either/or proposition, and it shouldn't even be framed that way."

--------------------------------------------------------------------------------
Copyright © 2005 Ziff Davis Media Inc. All Rights Reserved.

BusinessWeek Profiles Efforts To Establish National Electronic Health Records Network

The Oct. 31 issue of BusinessWeek profiles National Coordinator for Health Information Technology David Brailer, who seeks to "impose the kind of total quality management approach" used by General Electric and Toyota Motor on "one of the most chaotic and complex sectors of the economy." In May 2004, President Bush named Brailer to lead an effort to establish electronic health records for most U.S. residents by 2014. Since his appointment, Brailer has visited 40 states to place "his issue and himself on the map." In addition, Brailer has begun construction of the National Health Information Network. The health care IT effort has received bipartisan support but faces a number of problems. For example, "many cash-strapped hospitals and small-practice doctors have no interest in footing the bill for a medical Internet," which they believe will benefit health insurers most, BusinessWeek reports. Patients also have concerns that EHRs might compromise their privacy (Mullaney, BusinessWeek, 10/31).

http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=33417&dr_cat=3
Monday, October 31, 2005

Academy EHR Survey Shows Upward Trend in Implementation

By Sheri Porter
10/21/2005
Copyright © 2005 American Academy of Family Physicians http://aafp.org

Family physicians are "leading the pack" in implementing electronic health records into their practices. That's how Steven Waldren, M.D., assistant director of AAFP's Center for Health Information Technology, interpreted the numbers drawn from AAFP's recently released EHR Survey.

"Our members are adopting technology in significantly higher numbers than they were in 2003 when we last conducted an EHR survey," said Waldren. "In two years, we've nearly tripled the adoption of EHRs in family medicine."

The survey, which garnered 2,569 responses, was conducted by e-mail and asked only about EHRs, said Waldren. "That means there was a selection bias that drove the numbers up; the Academy adjusted the numbers down to make up for the bias," he said. In 2005, the reported figure of 46 percent implementation was adjusted down to 30 percent. In 2003, the actual survey report of 24 percent implementation was adjusted down to between 10 percent and 15 percent.

As confirmation that the recent 30 percent figure is accurate, Waldren pointed to two paper-based AAFP surveys conducted in 2005 that posed a single EHR question and received a response percentage similar to that of the CHiT survey. In the physician profile survey, which netted 4,400 respondents, 29.3 percent of respondents said they used an EHR; an Academy immunization survey had 4,700 respondents, 30.3 percent of whom said they used an EHR.

Other 2005 CHiT survey highlights:

* 78 percent of respondents said their EHR improved patients' health; the same percentage said they would recommend their EHR system to a colleague.
* 20 percent of respondents said their estimated first-year implementation costs were less than $5,000; 25 percent said those costs were $10,000 to $19,000; a little more than 5 percent estimated costs at $50,000 or more.
* 9 percent of respondents said they thought they would implement an EHR within six months; 35 percent of respondents thought they would do so in one to two years; 8 percent said EHR implementation would take more than two years.
* Nearly 55 percent of respondents called cost the biggest barrier to EHR implementation, and nearly 33 percent cited decreased productivity as a barrier.
* Nearly 85 percent of respondents said that quick access to patient records was the EHR feature that proved most beneficial to their office.

Two other recent surveys, both published in the September/October issue of Health Affairs, reported significantly lower numbers of physician adoption of EHRs than did the CHiT survey.

The first of those two surveys, funded by the Agency for Healthcare Research and Quality and conducted by the Medical Group Management Association Center for Research and the University of Minnesota School of Public Health, captured data from more than 3,300 medical group practices. The study reported that just 14.1 percent of all medical group practices used an EHR, and only 12.5 percent of practices with five or fewer full-time physicians used an EHR.

Although the data from the MGMA survey are current, Waldren said the survey population differed from the AAFP survey in that the MGMA survey did not include solo physicians and two-physician partnerships.

The second survey, conducted by the National Center for Health Statistics, showed that 17.6 percent of physicians in office-based practices were using an EHR between 2001 and 2003.

Waldren said the data in this survey were old, especially in light of rapid changes in the health information technology field. He also pointed out that the survey looked at primary care providers as a whole and did not break out family physicians as a subgroup.

Electronic Health Records Promoted to Deal With Crises

Inside INdianaBusiness.com Report

10/19/2005 7:28:39 PM

RANAC President Keith Pitzele discusses the need for electronic health records.

A meeting (that took) place during the 3rd week of October in Carmel, CA focused on the benefits of using electronic health records during crises.

Doctors are learning about the need for national standards for electronic health records and what it takes to convert to a paperless office. Supporters of electronic health records say electronic records can be accessed immediately during disasters like hurricanes and flu epidemics.

Source: Inside Indiana Business

Press Release

Indianapolis … The avian flu threat and fallout from Hurricane Katrina underscore the need for electronic health records, which can be accessed immediately during crises. Yet few small doctors’ offices in Indiana, and less than half of large clinics, have paperless offices, estimates RANAC, an Indianapolis-based medical practice management company.

“Soaring health care expenses and recent disasters are now prompting doctors to seek the cost-saving and crisis management benefits of electronic health records,” according to Keith Pitzele, president of RANAC. Pitzele’s brother-in-law, who lives outside New Orleans, was among the thousands of residents unable to get prescriptions filled following Hurricane Katrina‘s destruction due to the lack of electronic health records.

Physicians learned about the need for national standards for electronic health records, and what it takes to convert to a paperless office. A national expert, Donald Schoen, MediNotes Corporation, Des Moines, Iowa, who is helping develop U.S. standards, discussed the urgency of using electronic health records. Dr. Donald McIntire, president of Indiana Pediatrics Inc., focused on office transition.

Source: RANAC

Web-Based Electronic Medical Records Offer Portability, Disaster Protection

The Software written about here is NOT Medinotes. However, it is an excellent source of information regarding the need for Electronic Health Records. Best, Stephen Complete Medical
___________________________________________________________________________

Author: Laurie Barclay, MD

Medscape Medical News 2005. © 2005 Medscape

Oct. 12, 2005 — In areas of Louisiana and Mississippi affected by Hurricane Katrina–related flooding, nearly 6,000 physicians directly involved in patient care were displaced, and numerous others suffered disruptions to their practice. As offices flooded and charts became waterlogged or computer discs were damaged, loss of medical records directly threatened patient care. Even worse, patient records containing identifying data and other sensitive information may have floated downstream into the wrong hands, leaving patients susceptible to loss of privacy and even identity theft.

"There is concern about privacy issues, identity theft, and the ability of physicians to continue caring for their patients, particularly those who have complicated treatment plans that have been formulated over many years for chronic conditions," Jeffrey Glaser, MD, an anesthesiologist from Spinal Pain Associates of the Valley in Encino, California, told Medscape. "There's nowhere to go to be able to effectively retrieve their records. Another concern is that medical records contain information such as Social Security numbers, copies of drivers' licenses, and if those records get in the hands of the wrong people, that would pose a real problem."

One way to minimize practice disruption from catastrophes and to ensure patient privacy and continuity of care is with an electronic medical record (EMR) and an office management system that is Web-based. Examples of these products include Medical Office Online, a HIPAA-compliant application that integrates EMR and medical scheduling and billing software ($275 per provider per month); SmartEMR, a specialty-specific EMR application that organizes records and documents, facilitates billing and reimbursement, and integrates with prescription writing and imaging; and EZMedicalOffice, a private, custom-designed, HIPAA-compliant EMR application and database with automatically installed upgrades and data back-up, a search engine for office records, and strong encryption of all physician and patient information.

One Web-based EMR system, MD Synergy, is offering free training, activation, and use of their system for six months to any physician affected by Hurricane Katrina. Ordinarily, the initial start-up fee is about $5,000, with ongoing charges of about $200 per month, which includes automatic updates. This active server pages (ASP)-based system includes scheduling, demographic, and EMR information in a HIPAA- and privacy-protected format. The data are available on both the local server at the physician's office, as well as through the MD Synergy server, and it can be downloaded by the physician in a variety of file formats.

"The data can be backed up at many different locations at many different times, so even if one location is hit by a disaster, the data are consistently available," said Dr. Glaser, who has used MD Synergy in his practice for the past three years. "What sold me on MD Synergy, even before I thought about any possible disaster, was the ability to move my office to another location without having to move and reorganize thousands of medical charts. This way, everything's at your fingertips.... Imagine you're in vacation in Tahiti and you're contacted with a question about one of your patients — as long as you have Internet access, anywhere in the world, you can have access to all of your patients' records."

Thanks to the Windows-based, color-coded, drop-down system and online manual, Dr. Glaser was able to implement MD Synergy after 10 days of self-instruction and about two hours of training for his office staff. He has specific formats designed specifically for his practice, such as letters to referring physicians. Based on diagnosis and procedure, the system performs ICD-9 and TPT designation, and it can even do a CMS audit to ensure that documentation meets the requirements of level 2, 3, or 4 visits.

"It definitely made my practice more efficient and more cost-effective," Dr. Glaser said. "I sleep better at night — I'm a real detail-oriented guy, and I like using a HIPAA-compliant system that gives me comfort in knowing that my data is secure and protected. Even if there's a fire or flood, or if I move my office, that data is available at my fingertips."

During the American Academy of Family Physicians (AAFP) Scientific Assembly on Oct. 5, AAFP leaders and members affected by Hurricane Katrina endorsed the recently implemented Project Continuity of Care. The aim of this project is to develop a continuity of care record (CCR), an electronic file containing summarized health information for each patient. To minimize practice disruption and facilitate ongoing care, this file could be easily accessed, transported by patients on an inexpensive USB drive, printed as an Adobe Acrobat or Microsoft Word document, viewed by care providers using common Web browser software, and uploaded at hospitals or providers' offices.

Since early summer, the AAFP has collaborated with about 40 EMR vendors to incorporate the CCR standard into their products.

A similar approach is the System Providing Access to Records Online (SPPARO) software, consisting of a Web-based, patient-accessible EMR containing laboratory results and radiology results, an educational guide, and a messaging system enabling electronic communication between patients and staff. The system often includes safeguards to make sure that ordering physicians have a chance to contact patients before particularly sensitive information, such as pathology reports, is released. Patient access to clinical notes has been much less common, but it has been studied at sites including the University of Colorado Hospital (UCH) in Aurora.

In a randomized controlled trial of 107 patients with heart failure enrolled in a specialty practice at UCH, published in the May 2004 issue of the Journal of Medical Internet Research, the intervention group was not significantly superior in self-efficacy, but was superior in general adherence, and there was a trend toward better satisfaction with physician-patient communication. No adverse effects were reported from use of the system.

"Many patients find these systems to be of great value," lead author Steve E. Ross, MD, an assistant professor of general internal medicine at the University of Colorado Health Sciences Center, told Medscape. "Patients find it reassuring to be able to confirm their test results online, soon after they are completed, rather than waiting for a notification about the test results by mail (a notification that too often may be delayed or even neglected). They also report being able to assist in sharing clinical information from specialists with primary care physicians who may be part of a different medical system."

Although physicians anticipated that implementing SPPARO might increase their workload and hinder clinical interactions, post-trial interviews revealed that physicians and staff reported no change in their workload and no adverse effects (the results were reported in the September/October 2004 issue of the Journal of the American Medical Informatics Association). All physicians involved ultimately endorsed the concept of allowing patients online access to their clinical notes and test results.

"In general, physicians have been concerned that giving patients access to unfiltered medical information may confuse or worry them," Dr. Ross said. "Our own experience, however, is that patients who choose to review their records do so with very realistic expectations — they realize that they will not understand everything in the medical record, but they still get value from reading it, and appreciate the 'transparency' of clinical reasoning that patient-accessible medical records provide. Overall, our experience is that rather than feeling worried, these patients usually feel reassured and more confident about their care."

The UCH trial demonstrated that providing the medical record, including clinical notes, to patients with heart failure tended to improve compliance, but the authors concluded that additional research is needed to determine if patient access to these notes improves broader measures of health.

"How access to clinical notes might work in primary care is also an open question, since these clinical notes often contain assessments of sensitive social issues, such as marital discord, and psychological issues, such as substance abuse or depression, that could cause patients embarrassment or anxiety," Dr. Ross said. "In surveys, some patients have been concerned that online, patient-accessible medical records will pose security and privacy problems, but to date I am not aware of any reports of significant security breaches related to these systems."

During 2002, about 100 million Americans used information obtained online, including health information, as a basis for making decisions, according to Simon de Lusignan, a senior lecturer in primary care informatics at St. George's–University of London in the U.K. Although physicians, as a group, tend to use the Web more than do many other subgroups of the general adult population, they are not yet sufficiently convinced that the Internet can help them provide higher quality care.

Before Web-based health applications fulfill their vast potential for improving healthcare, patient satisfaction, and utilization of healthcare dollars, further advances are needed, Dr. de Lusignan writes in a review published in the May 2003 issue of the Journal of Medical Internet Research. He recommends new e-technology formats including key clinical variables and incorporating a coding or classification system

"The pros of Web-based records are that they are simple and cheap, and are readily accessible wherever in the world you are," Dr. de Lusignan told Medscape. "My view is that having my medical record within an integrated health service computer system may be the best place for it. However, we should be encouraging internationally standardized unique identifiers to be developed that can be used regionally, if not worldwide."

To improve efficiency and patient safety, healthcare systems across the globe are either making computer systems interoperable, such as the Commission on Systemic Interoperability in the U.S.; or integrated, such as the National Health Service's Connecting for Health program in the U.K. However, few of these projects are applicable internationally. For example, the European Union has no unique identifier to date. Although there is free movement of labor within the EU, individuals will have to start a new medical record in nearly every country where they take up a new residence.

"The principal difficulty, in my view, is whether Web-based medical records can be made interoperable with the computerized or other medical record systems of any healthcare provider that a patient might visit," Dr. de Lusignan said. "At the lowest level, there might not be Internet access at the point of care. Where there is Internet access, how will the record be structured?"

Which coding or classification system is used in the Web-based EMR is particularly important. Currently, there is no international standard for how medical data are coded. For example, some parts of the U.K. use Read Codes whereas other parts use International Classification of Disease – Clinical Modification (ICD-CM) codes, and much of Europe uses the International Classification of Primary Care (ICPC) codes.

Other concerns raised by Dr. de Lusignan are accuracy of the Web-based record; who might have edited it; and potential privacy issues, which he suggests are probably overestimated but also vary among individual users.

"An international itinerant might feel that the benefits outweigh the risks, whereas a person in the public eye may take a different view," Dr. de Lusignan said. "Obviously the data security of a site containing medical records would be paramount. Many people from extortionists to health or general insurers would be very interested in these records! At what age parental responsibility passes to children may also be an issue, especially around issues like terminations of pregnancy and contraception."

Disclosure: Dr. Glaser holds shares in MD Synergy and was at one time on its medical advisory board. Dr. Ross and Dr. de Lusignan disclose no relevant financial relationships.

Reviewed by Gary D. Vogin, MD

Peace of Mind Guarantee

MediNotes Corporation Offers Unprecedented Guarantee to Cover Impending Government Requirements and Direction for Electronic Medical Records

MediNotes Corporation, a nationwide provider of Electronic Health Record (EHR) Solutions for Physicians announced, at its annual user conference, that it will provide a guarantee and assurance program. The program ensures that all MediNotes clients on its Software Assurance Program will be provided with the software to meet, and in some cases exceed, impending government requirements for Electronic Health Records.

"The MediNotes Electronic Health Record Solution is proven to help physicians improve their ability to provide quality healthcare. The tools are powerful and will only continue to improve as we incorporate government standards and initiatives. We want our physician users to have peace of mind that they can select MediNotes today and know that it will continue to work for them despite changing government regulations or requirements," says Don Schoen, President and CEO of MediNotes.

Dr. John Scibal, a user of MediNotes since 1999 says, "We are so pleased to hear this announcement. With so much news about pending legislation and new 'interoperability standards,' one can become concerned about making any investment in an EMR. Of course, having been a MediNotes customer during Y2K or HIPAA, I’m not surprised by their commitment. They’ve never charged more to keep the software compliant."

Connecting Americans to Their Health Care

Great Job by Marion Ball and her Blog found at: http://healthnex.typepad.com/. Here Ms. Ball explains what some American companies are considering. Her story is very good and worth your consideration.

((Marion Ball, Fellow in IBM's Center for Healthcare Management, IBM Business Consulting Services))

Last week IBM and eight other major IT industry companies announced their commitment to adopt electronic personal health records (PHRs) for their 800,000+ U.S. employees. And today IBM is rolling out its first-generation PHR system for IBMers in the United States.

As it happened, I was also working in Washington last week on PHR issues,at a conference called Connecting Americans to Their Health Care: Empowered Consumers, Personal Health Records and Emerging Technologies.

Here's a quick summary of this excellent event, sponsored by the Agency for Healthcare Research and Quality, the Markle Foundation, and the Robert Wood Johnson Foundation.

Keynote speaker Newt Gingrich sounded key themes that ran throughout the day:

* National security demands that we have electronic health records (EHRs) for every American by next year to respond to disasters like Katrina, pandemics like the Avian flu, and biological or other terrorists attacks. The cost of EHRs may be high, but it is dwarfed by the downside costs of such disasters. Consider the dual-purpose of past projects, such as the interstate highway system built during the Cold War to evacuate Americans from cities demonstrate.

* Fed Ex, eBay, Google and Travelocity are not the future. They are the present. In Korea, a diabetic patient can use a cell phone to test their blood sugar and transmit the results where they need to go.

* The term "personal health knowledge system" is more accurate than "personal health record" because it is not just about digitizing paper, but about much, much more.

* We need to get past resistance to such a system by making it voluntary and allowing Americans to adopt it.

Gingrich called for setting up the rules of the game: The PHR belongs to the individual, though physicians and hospitals may have copies; the owner of the PHR always knows who accesses the PHR and who entered what data; it is illegal for insurers or employers to use the PHR; it is slander for anyone to make the PHR public.

Two of the main challenges now are: system interoperability so we can utilize our data in urgent situations, and a bill to protect citizen rights

Riding the Storm Out: Electronic Medical Records Proven Effective in Natural Disaster

Mobile Alabama doctor comforted by a backup of all his patient records during Katrina.

(PRWEB) September 25, 2005 -- The need for widespread usage of electronic health records is once again in the spotlight in the wake of the Katrina disaster. Dr. William Rogers, a podiatrist from Mobile, AL knows first hand just how important electronic health records can be. Dr. Rogers has utilized Charting Plus by MediNotes as his medical records system for over a year and the system proved its worth on August 29th when Hurricane Katrina ripped through the Gulf Coast.

“I decided to ride out the storm in Mobile. I backed my medical records up onto tapes and held them with me throughout the storm. I knew that as long as I was safe, so were my medical records. There is no way I would have been able to do the same things with thousands of charts and billing files,” states Dr. Rogers.

Don Schoen, President and CEO of MediNotes Corporation seconds Dr. Rogers’ statement. “I believe the aftermath of Katrina has forced physicians to take a good look at their medical records. With paper records scattered throughout the Gulf Coast, physicians are now dependent on what patients may recall about their medical situation and must begin piecing back together their history.”

Dr. Rogers was lucky, his clinic sustained minimal damage from the storm, however if things had been worse, he had all the information he needed to properly care for all his patients, right in his back pocket.

About MediNotes Corporation
MediNotes Corporation is a leader in electronic health record solutions for primary care and specialty medical practices and currently serves more than 3,200 installed sites and more than 9,000 users nationwide. The company’s dedicated employees are driven to create technology solutions that are proven, powerful and provide doctors and their patient’s peace of mind.

Tips On Maximizing Reimbursement--What Insurance Companies Don't Want You To Know

Please see the preceeding two article Headers below to see that we are fully attributing these three excellent articles which have all come from Medscape.com. This article will be the LAST of the lengthy articles published in detail. Complete Medical Billing believes that each article is so important that we have posted them in their entirety--for our readers benefit. Best, Stephen
__________________________________________________________
What Insurance Companies Don't Want You To Know: Tips on Maximizing Reimbursement

Debra C. Cascardo

Medscape Business of Medicine. 2005;6(2) ©2005 Medscape
Posted 08/04/2005
Introduction

Insurance carriers are not known for making prompt payment; any excuse to delay or deny payment to you means money for them. Some payers use software that looks for ways, such as bundling and downcoding, to avoid paying claims. Hundreds of denial codes show up on explanation-of-benefits forms, creating havoc while practices spend weeks -- even months -- attempting to get claims paid. Some insurers will pay a portion of a claim within 30 days and then use a variety of tactics to stall payment of the balance. Often, practices simply take what they can get in 30 days and let the payer keep the rest.

To assure you receive the maximum allowed in the shortest time, you must play by rules set by the insurance carriers. But what are the rules? In an effort to supplement revenue, practices often place the emphasis on seeing more patients, when they could achieve improved profitability by capturing claims appropriately, entering them promptly, and processing them correctly.

The following tips can help you streamline your reimbursement process to maximize payment and minimize wait time.
Track Your Lag Times

You cannot fix a problem if you are not aware of what the problem is.

Use your current billing software program to track your practice's lag time between service encounter and payment. Reports can generally be run from your existing billing software and should include your practice's top 4 payers. Run and analyze these reports at least once per quarter. Even if your practice's billing software cannot track the necessary information electronically, you should be able to perform the analysis manually.

What is the average time between the date the service was rendered and the date the claim was submitted? Is this an acceptable delay, or are your claim submissions being held up in your own billing department?

What is the average time between claim submission and posting of payment? Generate this report by carrier to determine which carriers take the longest time to reimburse you. Randomly select a few of those with long delays. Is the carrier unusually slow in processing claims or are claims being returned for corrections and/or additional information? Knowing where the problems lie can help you avoid delayed payment.
Set up Internal Controls

Now that you know where problems may lie, establish internal controls to ensure timely charge capture, posting and fee levels. Conduct regular operations audits to catch your errors and chronic problems. Self-audits allow you to spot and correct consistent under- and over-claiming that either leaves money on the table (under) or sends up red flags to third party payers (over).

* Be sure your staff is familiar with the insurance plans with which you have contracts
o Prepare a grid that shows
+ the carriers' names and plans
+ the copays
+ precertification requirements
+ the participating labs
+ noncovered services
+ any other pertinent contractual information

Post this grid near the phones or have it available on your computers for easy reference.

* Have the scheduler and/or receptionist always verify the patient's current demographic and insurance information
o Ask if there have been any changes when the appointment is made and again at the time of service
o Copy both sides of the insurance card
o Have the patient sign:
+ authorization to release information
+ assignment of benefits
+ payment of noncovered services
+ agreement to pay all collection costs if account not paid when due
o Collect the copayment
* Set guidelines as to the acceptable time between the date of service and charge entry
* Be sure that staff are appropriately trained on contractual adjustments and balances transferable to patients to avoid unnecessary write-offs
* Prepare "Patient Encounter" forms that contain the most frequently used ICD-9 and CPT codes preprinted to facilitate charge documentation
* Be aware of bundling rules and modifiers to correctly code
* Fully document all aspects of the encounter to avoid downcoding by the payer (For a carrier, if it isn't documented, it wasn't done and won't be paid.)
* Prepare a special "hospital charge ticket" for providers to indicate pertinent information for charge entry for hospital visits (patient name; date of service; charge and diagnosis codes)
* Determine the major reasons for claim denials and correct them
* Determine which area(s) of the practice generate the most denials and retrain them in charge capture and/or documentation
* Periodically review your fee structure

These regular audits can help you and your staff catch errors and avoid chronic problems.
Develop "Insurance Experts"

First, be sure your practice has current editions of the ICD-9 and CPT code books. If you don't use the current diagnosis and procedure codes, your claims may be delayed and/or denied.

Although most third-party payers base their rules on these Medicare guidelines, specifics can vary from payer to payer. Therefore, practices with more than 1 biller should assign 1 or more insurance companies to each. This allows a single biller to be an "expert" for specific third-party payers.

A biller can more easily keep up with the changes in a few insurance plans than in all of them. It also allows the billers to learn the nuances of submitting claims to "their" companies. Ideally, each biller will establish a rapport with an individual contact person at the insurance company who is able to rectify any issues that may arise with claim submission and reimbursement.

Billers should be prepared to handle multiple problems/questions for an insurer with each call. This will cut down tremendously on the wasted time spent waiting on hold for a representative to take the call.
External Controls

Practices can develop external controls to deal with payer issues by doing the following:

* Develop tracking mechanisms for denials.

o Review the explanation of benefits (EOBs) from each payer to track denials. Knowing why claims are denied can avert endless hours spent by staff appealing similar claim rejections.

o Use these rejections to revise future claims so they are acceptable.

* Determine which charges are paid at 100%. This might indicate the need for a fee analysis.

* Determine whether reimbursement is according to contracts.

o Know which payers do not pay claims according to the time frame outlined in their contracts.

o Know the allowed amounts listed in each contract.

o Take the proper adjustments as outlined in the respective contracts.

* Use data gleaned from the EOBs in future contract negotiations with the insurance company.

Hiring and Training

Having perfect systems in place is worthless if you do not have a staff able to implement them. Some tips:

* Take your time in hiring so you hire only those who best fit your needs and your corporate culture.

* Prepare and update a "Policies and Procedures" manual that fully explains the practice and each person's responsibilities.

* Offer adequate training so that new staff will fully understand these procedures.

* Encourage continuing education for staff.

* Make team work a part of everyday policy. For example, if the receptionist hasn't answered the phone by the third ring, the biller picks it up.

* To facilitate this, cross-train staff as much as possible.

* Make working conditions attractive and salaries competitive to avoid staff turnover.

It is up to your practice to assure you will be paid promptly and correctly. The more systems you have in place, training you provide, and knowledge you have of your practice and your third-party payers, the more likely you are to maximize your reimbursement and minimize the time between service and payment.

Debra C. Cascardo, President of Cascardo Consulting Group, a New York-based medical practice management firm; practiceprescriptions@webmd.net

Coding "Routine" Office Visits

Dr. Peter R. Jensen, MD, CPC authored a paper recently that appeared in the 2005--Volume 12, Number 8 edition of Family Practice Management. The article was then posted to the Medscape.com website on September 9th, 2005.

This article is a helpful reminder to Health Practices of choosing between the 99213 code for an office visit versus using code 99214 for the providers work with a particular patient. To see full article including sidebars and tables please go to http://www.medscape.com for complete document.
----------------------------------------------------------------------------------


Coding "Routine" Office Visits


Peter R. Jensen, MD, CPC

Fam Pract Manag. 2005;12(8):52-57. ©2005 American Academy of Family Physicians
Posted 09/28/2005

Before choosing 99213 for routine visits, consider whether your work qualifies for a 99214.

Data show that family physicians choose 99213 for about 61 percent of visits with established Medicare patients and choose 99214 only about 23 percent of the time for the same type of visit.[1] So 99213 must be the correct code to use for a "routine" visit, right?

Not necessarily. Many of us may be shortchanging ourselves by reflexively coding a routine office visit as 99213 when the clinical circumstances of the encounter justify the higher-level code. We have developed coding habits based on the misconception that repetitive, routine clinical thought patterns must automatically translate into low-complexity medical decision making. We simply do not appreciate the value of our cognitive labor. The best defense against this form of undercoding is a basic understanding of the medical decision making required for 99213 and 99214 visits.

Calculating Medical Decision Making
According to Medicare's Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.

The problems and data are evaluated using a system of weighted points depicted in the tables shown in the "Sidebar: How it Works". These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.

An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one "problem" point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.

The risk table (see "Sidebar: How it Works") is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.

After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The table "Medical Decision Making" (see "Sidebar: How it Works") shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.

Low Complexity vs. Moderate Complexity
Distinguishing between low- and moderate-complexity decision making using the point system described above may seem awkward, but it is not difficult if you use a systematic approach. First, consider low-complexity medical decision making. Suppose you see a patient with osteoarthritis that was previously controlled on acetaminophen. The patient now says that the pain has gotten worse, so you decide to switch to over-the-counter ibuprofen and schedule a return visit in two months with routine labs.

Using the point system, this visit would add up to two problem points (for an established problem, worsening), one data point (for ordering labs) and moderate risk (due to the presence of a "mild exacerbation of one or more chronic illness"). Because two out of three factors must meet or exceed the requirements for any given level of medical decision making, it is easy to see that this encounter reflects low-complexity medical decision making, which would correspond to a 99213. Simply put, patients who are correctly assigned this code are not very sick. It is difficult to believe that the overwhelming majority of visits to primary care physicians fall into this category.

Now consider the cognitive labor required for a 99214 encounter, which calls for moderate-complexity medical decision making. Many physicians mistakenly believe that a patient needs to be in medical extremis to justify this level of medical decision making. If you break down the requirements, this misconception is easy to dispel.

Consider the patient above with osteoarthritis. If you add stable hypertension to the clinical scenario, the calculation of the medical decision making changes. In this case, you would garner three problem points (two points for the established, worsening problem of osteoarthritis and one point for the established, stable problem of hypertension). The data points would be unchanged (one point for ordering labs), and the risk would remain moderate (due to "mild exacerbation of one or more chronic illnesses"). Remembering that two out of three elements are required for any level of complexity, it now becomes apparent that the clinical circumstances justify moderate-complexity medical decision making.

This example shows that you can't always rely on clinical intuition to predict the complexity of medical decision making. The hypertension may not make the patient seem much sicker to the physician, but that small clinical wrinkle pushes the medical decision making to the next level.

Documenting a 99214
Of course there is more to selecting the correct code than just evaluating the level of medical decision making. The history and exam you document must meet certain criteria as well (see the code selection table - Table 1 ). Perhaps one reason physicians balk at the prospect of coding 99214 more often is the perception that the documentation is considerably more burdensome than for 99213. If you examine the E/M requirements for 99214, you will see that this is not the case. Remember that established patients require the documentation of only two out of three qualifying key components for any given level of care. Assuming that the medical decision making qualifies as being of moderate complexity and that medical necessity is clear, documenting either a detailed history or a detailed exam will support coding 99214.

Detailed History
According to the 1997 version of the documentation guidelines, a detailed history requires a chief complaint (CC), four elements of the history of the present illness (HPI) or the status of three chronic or inactive problems, a review of two to nine systems (ROS), plus at least one pertinent element from the past medical, family or social history (PFSH). Although this sounds like a lot of paperwork, the following example shows that it's not that bad. Consider our patient with osteoarthritis and well-controlled hypertension:


CC: Follow-up osteoarthritis.

Interval history: The patient states his arthritis is no longer controlled on Tylenol. He complains of bilateral knee pain described as a dull ache, which has been worsening for the past two months. The pain is worse after walking long distances and is sometimes associated with swelling in both knees.

Medications: HCTZ 12.5 mg po qd, atenolol 25 mg po qd, acetaminophen 650 mg po q4h prn.

ROS: Musculoskeletal - negative for myalgias, proximal muscle weakness, or joint redness or warmth; and cardiovascular - negative for chest pain, orthopnea or PND.

Pertinent PFSH: Positive for HTN, which is well-controlled on current medications.

That's all there is to a detailed history. The interval history contains five HPI elements (location, quality, duration, associated signs and symptoms, and modifying factors). The two systems of ROS (musculoskeletal and cardiovascular) and the PFSH (hypertension) are probative and informative. If you perform the documentation succinctly and precisely, the amount of information needed is not particularly onerous. The important thing is to document in an ethical manner by including only those elements that are reasonable and medically necessary for the clinical problems at hand.

Detailed Physical Exam
Instead of choosing to take a detailed history for the above 99214 encounter, some physicians may feel it would be more informative and within the bounds of medical necessity to perform a detailed physical exam. According to the 1997 E/M guidelines, this requires 12 bullets from any organ systems. Of course, each physician can perform whatever elements of physical exam he or she feels are clinically relevant, but a typical detailed exam for our patient with hypertension and osteoarthritis, for which nonsteroidal anti-inflammatory drug therapy is being considered, might look like this:


General appearance: No acute distress, looks about stated age, conversant.

Vitals: BP 130/80, HR 74, RR 20.

Eyes: Eye grounds clear with normal posterior segments.

Neck: No JVD or carotid bruits.

Lungs: Clear to auscultation and percussion.

CV: Regular rate and rhythm, no murmurs, rubs or gallops, and normal PMI.

Abdomen: Soft, non-tender, no HSM.

Extremities: Digits and hands show no active tenosynovitis or nodules; both knees have small effusions and demonstrate moderate crepitus and decreased range of motion; normal joint stability with no evident laxity; no peripheral edema, brisk pedal pulses bilaterally.

Skin: Normal turgor; no rash or levido reticularis.

This particular example contains at least 16 bullets, but the guidelines require only 12. Each exam element is clinically relevant and informative, satisfying the requirements for ethical documentation. As with the detailed history, the volume of data required for the detailed exam is not unreasonable.

Medical Decision Making
Whether you choose to fully document the history or the physical, it is important to remember to document the medical decision making as well. If a problem is uncontrolled, be sure to make that point clear in your assessment and plan. If the patient is starting new medications, don't forget to mention it. Continuing our clinical scenario, here's how one might reasonably document the medical decision making:

Assessment:

Worsening osteoarthritis.
Stable hypertension.


Plan:

Start ibuprofen 400 mg po tid.


Continue current blood pressure medications unchanged.


Patient was educated about GI risks of increasing doses of ibuprofen, especially when combined with alcohol.


NSAIDS can also lead to worsening hypertension, so I asked the patient to monitor his blood pressure more frequently.


Return visit scheduled in two months with CBC and renal profile.


Giving Yourself Credit
The key to understanding when it is appropriate to code 99214 for a routine visit is to train yourself to recognize moderate-complexity medical decision making in your daily practice.

The ability to distinguish between level-3 and level-4 services is not an academic issue. In the current climate of shrinking reimbursement and increasing overhead costs, most doctors can't afford to leave potential revenue on the table.

Pause for a moment before you code your next routine visit. Consider the medical decision making, including medical necessity, and let the intensity of the cognitive labor guide your code selection. Check to make sure your documentation is congruent with that code. You may be surprised how often 99214 is the appropriate choice.