Benefiting Financially from an Electronic Health Information Exchange

While there is a growing demand for “interoperability” between hospitals, clinics, pharmacies, and physician practice information systems, the cost often exceeds the potential benefits. In this session, participants learned how to make participation in a health information exchange (HIE) financially viable.

Daniel Marino, president and CEO, Health Directions, LLC, Chicago, IL

Marino started his presentation by outlining his goals for attendees: to be better able to analyze a cost/benefit analysis for local HIE participation, prepare a business case for HIE interoperability, and produce financial benefits from health information networking no matter the level.

He next reviewed EMR trends in healthcare explaining that:

•The US spent more than $2.2 billion in healthcare in 2007, yet most of the information exchange is rudimentary. •According to the CDC’s National Center for Healthcare Statistics 2008 survey, only 25.9% of medical practices had some form of EMR.

•The US is adopting EMR technology at a much slower rate than other industrialized nations.

•According to a 2008 study conducted by the Institute of Public Health, physicians who use EHRs believe the “systems improve the quality of care and are generally satisfied with the systems.”

Marino then discussed government’s role in promoting EMR technology through promoting incentives for quick implementation of EMRs in medical practices, CMS payment of incentives to physicians for reporting quality data using an EMR, the adoption of EMRs by the Department of Veteran Affairs Hospitals since early 2005, proposed bills that have been introduced to incorporate EMR technology within all physician offices over the next 3 years, and the promotion of EMR technology by the Obama administration as a means of changing reimbursement and slowing the rise in healthcare spending.

“Government’s position on reducing cost is to tie provider reimbursement to quality data and outcomes,” continued the speaker. “Medicare (CMS) already began quality-based reimbursement with the PQRI program.” Additionally, some plans are beginning to follow the government’s lead, and government has created two legislative initiatives that focus on improving healthcare and incorporating more technology.

One, of course, is the $790 billion ARRA, approximately $60 billion of which is allocated toward health IT, training for more primary care physicians, research on chronic diseases, community health centers, and “comparative effectiveness” research. For HIT, the Health Information Technology for Economic and Clinical Health Act (HITECH) provides $19.2 billion, $17 billion of which is for physicians incentives, leaving $2 billion for use by the National Coordinator of Health IT. This is information Marino admits many already know, but he feels its worth reviewing anyway.

In order to tap into this $17 billion, explained Marino, providers must prove “meaningful” use, which he simply defines as use of a certified product as determined appropriate by the secretary of HHS, an EHR system that is connected to others, and a product that complies with submission of reports on clinical quality measures. Those who adopt systems early and meet these requirements will benefit the most, with those who utilize and EHR system in 2011 seeing a potential of $44,000 to $64,000 over five years from Medicare and Medicaid, respectively, says Marino. He added that late adopters will receive significantly less, providers may receive incentives under only one of the programs, and reductions in fees will start in 2015.

The HITECH act, said Marino, aims to accomplish health information technology infrastructure for interoperability, save the government $18 billion, and strengthen federal privacy and security law through standards maturation, with the Congressional Budget Office estimating that 90% of physicians and 70% of hospitals will be using comprehensive EHRs by 2020.

“So, what exactly is interoperability?” asked Marino rhetorically, adding that most physicians are confused by its definition. He explains it as the “ability for EMRs to electronically share data and communicate with one another; the systemic exchange of patient health information; the exchange of patient health information between entities, providers, patients, health plans, pharmacies, and laboratories; and the use of regional health information organizations as a means of centralizing patient data exchange for communities.”

Community health integration strategies are the keys to reaching this interoperability, said Marino, with the goal of electronically connecting hospitals, IPAs, physicians, patients, payers, labs, and pharmacies into secured digital networks. Although there are many stakeholders, hospitals and physicians will take the lead of creating the information exchange that allows for a secured, efficient transfer of medical information between entities and provides patients with new healthcare conveniences through the use of technology (eg, Web portals, e-mail, text messaging). All in all, hospitals will be looked to as the driving force of electronic health connectivity for physicians, patients, and the community, because of their improved software capabilities and higher funds.

It is these higher funds that will allow physicians to take advantage of the hospitals. But what’s in it for the hospitals; why should they help the private physician? They can use technology as a means of building a strategic relationship, in which they’ll begin to appreciate the convenience of technology as physicians are incorporated into the network; they can negotiate quality outcomes within payer contracts; their patients will begin to understand and rely on technology and equate it to higher quality care; they’ll see a reduction in redundant tests; and they’ll see improved patient access and accuracy of information.

Marino next explored making the investment in an electronic community, explaining that a viable community health integration strategy begins with choosing the right ambulatory EHR and data-sharing model; that one must identify the total coast of ownership (software license, software maintenance, network connectivity, servers/server hosting, implementation services and end-user training, interface/interoperability costs, and physician office hardware/cabling); and estimate the total cost of ownership by provider and practice to amortize cost over time.

Focus of the session then moved to three major components of data-sharing, which Marino said are:

• Enterprise Data Sharing —created around a unique patient identifier or MPI #

• Centralized Data Repository Model —physicians have the ability to access information through a secured web portal

• Distributed Model -creation of a single, unified view of the patient record based on data from different systems without the necessity of having a central data repository

Aside from help provided by a hospital, practices can seek out grants from HHS, the National Institute of Standards and Technology, the Department of Agriculture, the Department of Commerce, or one of many health information exchange regional grants.

Even with more than enough funding, the key to the success of any community health initiative is ensuring that the physicians use the technology, and it begins with the EMR, said Marino. The problem is that many physicians haven’t adopted EMRs, because they feel costs are too high, the technology may interfere with their office workflow, the EMR will slow them down and cause them to see less patients, they’re going to wait to see the direction that the hospital with which they are aligned goes in regards to technology, and/or they feel it is a huger under taking and they’re not going to be practicing much longer, according to the speaker.

However various revenue opportunities exist for providers who use an EMR system, stated Marino, including: •Improved accuracy of documentation most of the time leads to better coding, more revenue

•Increases in charge capture of services and improved accuracy of claims

•The ability to negotiate quality performance outcomes within payer contracts

•Assistance for providers in understanding stimulus money, e-prescribing, and PQRI incentives

Further, providers can save money by using an EMR, by cutting back or eliminating transcription costs, chart creation, physical storage space, medical records FTE, encounter forms, and time spent looking for lost charts or transferring charts.

Has Marino convinced you to use and EMR? Well, you’ll need to know the key components of implementing one, which he said are:

• Review the implementation plan for your vendor

• Identify a physician champion and super user

• Document current clinical workflow processes

• Maximize physician input in EMR development and design

• Develop a thorough understanding of the new EMR system

• Ensure proper training

Knowing these key components is just the beginning, explained Marino, who went on to review the criteria for a successful implementation:

•Design EMR technology to allow physicians to incorporate “easy-to-retain” functionality as well as clinically intuitive pathways

•Redesign clinical workflows that promote automation and efficiencies

•Don’t forget your revenue cycle

•Adopt an incremental deployment strategy in order to increase comfort level and build confidence in EMR

•System should be built to ensure physicians use the technology; if not, nothing else matters

That’s not all; you’ll need to design an implementation strategy, said the presenter. “Look at your current processes and determine what will change in the move from a paper-based environment to an electric one,” he continued, explaining that a practice should consider the handling of paper forms, transcription and the incorporation into the EMR, e-prescribing, charge capture, and claim scrubbing. He also said not to try and fit current processes in a new environment; “go through a total workflow redesign that addresses every aspect of the revenue cycle,” Marino added. Also, look at how information will flow from the practice management system to the EMR—particularly, what functions will be maintained in the practice management system—and what processes will be needed to manage each function with the added technology. Lastly, look at what additional hardware and software is needed to support an electronic environment.

When looking at physician involvement, continued Marino, avoid these common mistakes:

• Moving too fast with the implementation without consideration of the network’s growth strategy

• Overestimating physician confidence with electronic solutions

• Under-involvement of physicians in the EMR selection and the consensus building process

• Limiting the physician involvement in the design and implementation phases

• Designing the electronic process around the technical process without enough focus on operational flow

• Not using templates and tasks that support your specialty and instead using generic electronic notes

Document conversion must also be considered, noted Marino, stating that you’ll need to create a plan for the conversion of records and incoming information, consider how far back in time to begin the patient record conversion, and determine how much of each patients chart will be converted.

Marino next provided a brief overview of “managing through metrics.” Key areas, he said, for monitoring system utilization are scheduling, registration, scanning, transcription, and coding and charge capture. Practices also need to look at their practice management system and EMR, and missing charges and coding/claim edits. “Develop daily, weekly, and monthly reports to help manage the electronic environment,” he explained. Look at sample EMR metrics, the number of active users, the number of documents scanned, the number of charges billed, the number of dictations created, and the number of orders authorized.

The presentation ended with Marino offering advice on “where do you go from here.” He said to talk with colleagues and networks to assist with decision making; recognize that decisions will come based more on when to implement and not if you should implement; understand that stimulus money and other government incentives are important components of the EHR return on investment; begin thinking about your organization’s strategic goals, IT objectives, and implementation initiatives; and realize that “when it finally comes down to moving forward, it’s really not about the technology, it’s about the clinical processes and workflows that drive success.”