EHR and Meaningful Use: How it Impacts the Coder What you get …€¦ · Pros and Cons of EHR and Meaningful Use copyright, pswilson 2016 34. AAPC 2002 (pswilson) 18 PROS copyright,

AAPC 2002 (pswilson) 1

EHR and Meaningful Use: How it Impacts the Coder

What you get may not be what you expectPatricia S. Wilson, RT (R), CPC, PMP

AAPC HEALTHCON 2016

April 12, 2016

WIIFM

• History

• What is happening today

• What to expect in near future

• Why it matters to coders

copyright, pswilson 2016 2


What will not be discussed in this presentation• No specific product or company will be endorsed or

discussed

• How all the technology works


Once upon a time…….



“In attempting to arrive at the truth, I have applied

everywhere for information, but in scarcely an instance

have I been able to obtain hospital records fit for any

purposes of comparison. If they could be

obtained…they would show subscribers how their

money was being spent, what amount of good was really

being done with it, or whether the money was not doing

mischief rather than good…..”


Florence Nightingale 1863



Statistics on medical errors – truth or fiction?• 1999- ‘To Err is Human’ – 98,000 deaths due to

medical errors

• 2010 – Inspector General of HHS – 180,000 Medicare deaths due to bad hospital care

• 2013 – Journal of Patient Safety – medical errors are the 3rd leading cause of death in the USA


The problem“One in every seven primary care visits is affected by missing medical information. In a recent study, 80% of errors were initiated by miscommunication, including missed communication between physicians, misinformation in medical records, mishandling of patient requests and messages, inaccessibly records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems.”

Commission on Systemic Interoperability, “Ending the Document Game”

copyright, pswilson 2016



The Electronic Health Record (EHR)

• Started in mid 1960s, primarily by academic hospitals. Intended to:

• Provide clinical data as part of workflow

• Automate and streamline clinician workflow

• Generate a complete record of a patient encounter

• Directly or indirectly support other care-related activities:

HELP System: Origin goes back to 1954 (LDS Hospital’s Cardiovascular Laboratory). Developed by Dr. Homer Warner, first chair of the University of Utah Department of Medical Informatics, with Dr. Allan Pryor and Dr. Reed Gardner, and others.



Objectives as defined by IOM (1999)

• Support patient care and improve its quality

• Enhance productivity of healthcare professionals and reduce administrative costs

• Support clinical and health services and research

• Accommodate future development in healthcare technology, policy management, and finance

• Have mechanisms in place to ensure patient data confidentiality at all times


Barriers to adoption (from IOM)

• Design requirements

• Standards and systems development

• Demonstrate cost benefits

• Reduce legal constraints

• Coordination of resources

• Coordination for secondary uses

• Education and training



How we got to where we are today

HIPAA - 1996

• Health Insurance Portability and Accountability Act

• Portability• Provide continuity of healthcare coverage

• Administrative simplification• Reduce cost

• Standardization of information exchange

• Protect patient’s confidentiality

• Minimal set of security standards



Goals of standards

• Interoperability – ability to exchange information between organizations

• Comparability – ability to ascertain the equivalence of data from different sources

• Data Quality – measurement of completeness, accuracy and precision


Presidential Executive Order

• President George Bush – April 2004• Office of the National Coordinator for Health

Information Technology (ONC)

• Consolidated Health Informatics (CHI)

• Health Information Technology Standards Panel (HITSP)



Definition of an EHR

• Longitudinal electronic record

• Patient data

• Multiple encounters

• Any care setting


What an EHR should do

• Collect information

• Improve patient care

• Reduce costs

• Create more efficient use of time



How an EHR does this

• Automates and streamlines the clinician's workflow

• Generate a complete record of a clinical patient encounter

• Support other care-related activities directly or indirectly

• Evidence-based decision support

• Quality management

• Outcomes reporting


What an EHR contains

• Demographics

• Progress notes

• Problems

• Medications

• Vital signs

• Past medical history

• Immunizations

• Laboratory data

• Radiology reports



Limitations to EHR

• No system does all functionality

• Different standards used by each system

• Lack of interface capabilities between different systems


Administrative and financial systems• First to be implemented in an electronic format

• Study indicated that of physician groups who are given full functionality, only 9% use the total system

• 91% use only the scheduling and billing/financial portions of their system



HITECH - 2009

• Health Information Technology for Economic and Clinical Health Act

• Public health

• Improve health care quality

• Ensure privacy and security


Meaningful Use – use a certified EHR • Improve

• Quality

• Coordination of care

• Safety

• Efficiency

• Population and public health

• Engage patients and family

• Maintain privacy and security



‘Meaningful Use’ criteria• Includes patient demographics

• Contains clinical health information• Medical history

• Problem lists

• Has capacity to provide:• Clinical decision support

• Physician order entry

• Health care quality information

• Integrate with other sources


Key components of Meaningful Use

• Use of Certified Electronic Health Record Technology (CEHRT) to meet improvement and efficiency goals

• Electronic exchange of health information to improve outcomes

• Electronic submission of clinical and quality measures

• Implemented in stages

• Incentives for eligible providers



Stage 1 Meaningful Use• Meet 14-15 core objectives

• 5 out of 10 from the menu set

• 6 quality measures

• Core objectives include:• Computerized provider order entry

• Provide patients with electronic copy of record

• Record allergies, vital sign changes, problem lists, medications, etc

• Protect the data


Stage 1 Clinical Quality Measures

• 3 of 38 management scenarios to be met such as:• Diabetes management

• Heart disease

• Preventive screening

• Medication management

• Weight and nutrition management

• Immunizations and allergy management

• Behavioral health



Stage 2 Meaningful Use

• Everything in Stage 1 with an increase in percentage plus

• Family history

• Surveillance of syndromes sent to public health agency

• Electronic notes

• Problem list in ICD-9-CM, ICD-10-CM, or SNOMED CT

• Manage transition of care


Incentive requirements for Meaningful Use

• Reporting period is 90 days for first year and 1 year after

• Reporting through attestation

• Objectives and Clinical Quality Measures

• Reporting may be yes/no or numerator/denominator attestation

• To meet certain objectives/measures, 80% of patients must have records in the certified EHR technology



Incentive requirement impacts coders because…..• Codes are now being used to establish the quality

of patient care

• More codes and different types of codes are needed to provide specific clinical data to be measured


Implementing standards in MU objectivesData 2011 2014

Immunizations CVX – July 30, 2009 CVX – July 11, 2011

Problems ICD-9 -CM/SNOMED CT® – July 2009

SNOMED CT – July 2012 and March US extension

Procedures ICD-9 -CM/ CPT-4 HCPCS & CPT-4SNOMED CT

Lab Tests LOINC® 2.27 LOINC 2.40

Medications and Medication Allergies, E-prescribing

Any source vocabulary in RxNorm

RxNorm – August 2012

Race & Ethnicity OMB standards OMB standards

Smoking Status N/A SNOMED CT + US Extension

Preferred Language N/A ISO 639-2 constrained by ISO 639-1

Family History N/A SNOMED CT + US extensionHL7 Pedigree

Encounter Diagnosis N/A SNOMED CT +US extensionICD-10-CMcopyright, pswilson 201632


Future for Meaningful Use?


• January 2016 – CMS announced the end of Meaningful Use incentives

• Stage 3 October 2015 – exemptions and reductions

• Build on the needs of the provider not the government

• Use feedback to inform policy makers of need for more customization

• Tied to Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Pros and Cons of EHR and Meaningful Use



PROS




Benefits to EHR adoption by physicians as of 2013• 66% of all physicians plan to participate in incentive

program (up 18% since 2001)

• 80% reported overall, improved patient care

• 65% caught critical lab values

• 62% caught potential medical errors

• 81% accessed patient chart remotely


Data, Data, Data

• Clinical Care─Comprehensive and correct patient health information

─Improve care coordination

─Facilitate electronic health data exchange

─Improve population health through analytics

• Legal documentation to support standard of care in medical liability claims

─Billing and financial source of information

─Research


CONS


Man versus Computer

“[A] computer lets you make more mistakes faster than any invention in human history - with the possible exceptions of

handguns and tequila."

Mitch Ratcliffe

(quote from "The pleasure machine: Computers, Technology Review Apr 1992)



EHRs and MU

• Hard to meet MU requirements

• Dissatisfied end users

• Poor workflow

• Limited Vendor Support

• Lack of desired functionality

Challenges in making data meaningful Implementing and Integrating Standard

Terminologies

Integrating data from Multiple EHR vendors or EHR modules (e.g., inpatient to outpatient)

Collecting electronic Clinical Quality Measures

Enterprise wide collection and management of ‘Big Data’

Incorporate structured local data that does not ‘fit’ into a standard terminology

Data across state lines



Different types of standards• Messaging standards

• HL7 – Clinical data

• X12 – Financial data, HIPAA mandated transactions

• DICOM – Images

• Terminology standards• Drugs – NLM/FDA/VA collaboration (RxNorm, NDF-RT)

• Billing – CPT®, ICD-9-CM, ICD-10-CM/PCS

• Clinical – UMLS, SNOMED CT® , LOINC®, and others


Specific examples of the impact on coding



Templates


Computer Assisted Coding


How a computer decides which code• Natural Language Processing (NLP)

• Clinical Document Improvement (CDI)

• Site specific rules


Automated tools

• Manual review is daunting

• Many commercial tools for mapping and coding

• Institution developed tools for needs and use cases

• Feasibility and effectiveness of automation

• Dependency on use cases and heuristics that must be programmed into the software

• Level of confidence can vary from application to application



Issues with automating the coding process

• Consistency

• Size of content

• Maintenance

• Synonyms


No patient data in mapping

• Mapping does not involve any patient information

• The map is performed between source and target terminologies based solely on use case and heuristics

• No assumptions can be made when mapping, unless the assumption is clearly defined in the heuristics



Example of no patient information• Coder reviewing a patient’s medical record to select a code for

the diagnosis of stress incontinence. The coder will look at the patient’s gender in order to decide which code to choose:

• 788.32, Stress incontinence, male

• 625.6 Stress incontinence, female

• Mapper cannot look at a patient record for gender

• The term “stress incontinence” will rely on

• Heuristics

• Synonymy for non-gender-specific map


General Equivalence Maps (GEMS) is...

• an attempt to translate equivalent meaning from source to target

• one source system code linked to one or more target system codes



“ equivalent meaning” depends on...

• Use Cases• Purpose of the map

• Clinical mapping focuses on all possible meanings contained in source system code

• reimbursement mapping focuses on equivalent payment


GEMS ‘reverse’ map or ICD-10-CM to ICD-9-CM



SNOMED CT for Meaningful Use

• Problem List • Current

• Active

• ICD-10-CM

• Within the patient summary record


National Library of Medicine (NLM) Problem List• Subset of SNOMED CT for Clinical Observations

Recording and Encoding (CORE) project

• Nursing

• Veterans Affairs/Kaiser Permanente

• US extension to SNOMED CT

• Route of administration



NLM has other map sets

• ICD-9-CM to SNOMED CT (retired)

• SNOMED CT to ICD-10-CM


Consistency in applying rules

• 79688008 Respiratory obstruction (disorder)

• Map A to ICD-9-CM• 496 Chronic airway obstruction, not elsewhere classified

• Map B to ICD-9-CM• 519.8 Other diseases of respiratory system, not

elsewhere classified



Example 2

• 95883001 Bacterial meningitis (disorder)

• Map A to ICD-9-CM• 320.9 Meningitis due to unspecified bacterium

• Map B to ICD-9-CM• 320.7 Meningitis in other bacterial diseases classified

elsewhere


Example of ‘reverse’ map

• 230744007 Cerebrospinal fluid leak (disorder)

• Map A to ICD-9-CM• 349.89 Other specified disorders of nervous system

• Map B to ICD-9-CM• 997.09 Other nervous system complications



Throwing in ICD-10-CM (CS Fluid Leak) Map A 349.89 Other specified disorders of

nervous system─G96.8 Other specified disorders of central nervous system

─G98.8 Other disorders of nervous system

Map B 997.09 Other nervous system complications─G97.0 Cerebrospinal fluid leak from spinal puncture

─G97.81 Other intraoperative complications of nervous system

─G97.82 Other postprocedural complications and disorders of nervous system


Coding directly to ICD-10-CM

• 230744007 Cerebrospinal fluid leak (disorder)

• ICD-10-CM• G96.0 Cerebrospinal fluid leak



And its ‘reverse’ map is……

• ICD-10-CM G90.0 Cerebrospinal Fluid Leak• ICD-9-CM 349.81 Cerebrospinal fluid rhinorrhea

• ICD-9-CM 388.61 Cerebrospinal fluid otorrhea


Clarification of synonyms

• 3135009 ‘Otitis externa (disorder)’• Synonym of ‘swimmer’s ear’

• Map ICD-9-CM code 380.12• acute swimmer’s ear

• If the synonym was not present

• Map ICD-9-CM code 380.10• Infective otitis externa, unspecified

• Resolved



Another synonym issue

• 626004 Hypercortisolism due to nonpituitary tumor (disorder)

• Hypercortisolism not in ICD-9-CM index

• SNOMED CT is ‘Ectopic ACTH secretion causing Cushing’s Syndrome’

• Synonym is correct ICD-9-CM code

• Correct map is 255.0 ‘ Cushing’s Syndrome

• Resolved


Benefits for coders

• Tendency to record more complete information, thus increase revenue by 25 % to 40% due to more document-supported coding

• Can prompt for check-ups, screening procedures, etc that may be missed in previous documentation

• Affords more complete, accurate and consistent documentation to support coding



Options for a coder

• Be alert

• Ask questions

• Communicate with your vendor, or the SDO directly

• Be patient with yourself and others


Conclusion

• Automation is an efficient tool

• Guide to a result

• Not 100% foolproof

• Human factor cannot be removed



Questions


References and Resources

• www.washingtonpost.com

• www.modernhealthcare.com

• www.healthdatamanagement.com

• CMS Program Memorandum Intermediaries/Carriers Transmittal AB-01-69 May 1, 2001

• www.ama-assn.org/sci-pubs/amnews

• Charlene Marietti, ‘Will the real CPR/EMP/HER please stand up?’ May 1998


http://www.washingtonpost.com/

http://www.modernhealthcare.com/

http://www.healthdatamanagement.com/

http://www.ama-assn.org/sci-pubs/amnews


More References

• http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

• http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/MU_Stage1_ReqOverview.pdf

• http://endingthedocumentgame.gov/PDFs/Privacy.pdf

• IHTSDO.org

• NLM.org

• RoadtoICD10.org


http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/MU_Stage1_ReqOverview.pdf

http://endingthedocumentgame.gov/PDFs/Privacy.pdf

Documents

EHR and Meaningful Use: How it Impacts the Coder What you get …€¦ · Pros and Cons of EHR and Meaningful Use copyright, pswilson 2016 34. AAPC 2002 (pswilson) 18 PROS copyright,