Despite gains in medical technology and the use of electronic health records (EHRs), medical errors related to patient identification continue to pose significant, and in some cases, fatal risks for patients across the U.S.
Medical errors are the third-highest cause of death in the U.S., with 250,000 deaths per year, according to a Johns Hopkins University report.
Mismatched patient records and duplicate patient records are the two biggest forms of error that can lead to misidentification, according to a study by the Pew Charitable Trusts and Massachusetts eHealth Collaborative. Misidentification may result in the wrong surgery or medication, duplicate or unnecessary testing, unintended surgery, inaccurate prescriptions, and higher medical costs. The study also found medical errors occur more frequently within urban health systems where patients are more likely to be seen at more than one medical facility.
The Pew study cited patient misidentification as a nationwide crisis, with matching rates as low as 50 percent in some healthcare facilities.
We must do better.
The collective outcry of our patient population demands we do more. Our patients deserve more. As CEO of the American Health Information Management Association (AHIMA), and with the full support from our Board of Directors, I will continue to advocate for the adoption of a nationwide patient identification solution that addresses the need to accurately identify patients as they move through our healthcare systems.
We are not there yet, but help is on the way.
In June of last year, the U.S. House of Representatives passed an amendment to the Labor-HSS Appropriations bill that removed a ban prohibiting federal dollars from being used to adopt a national patient identifier. In December 2019, when Congress passed the 2020 spending package, language was included to address patient safety, and efforts in furtherance of a nationwide patient identification strategy:
Patient matching: The general provision limiting funds for actions related to promulgation or adoption of a standard providing for the assignment of a unique health identifier does not prohibit efforts to address the growing problems faced by health systems with patient matching. The agreement encourages HHS to continue to provide technical assistance to private-sector-led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information.
The news that Ascension and Google are working together on a system using machine learning, called Project Nightingale, at first seems like a step forward toward better patient care. Because it’s challenging for any healthcare provider to exchange information about patients and patient care, it only makes sense that the healthcare industry would look for technology solutions that could solve some of these obstacles.
The design of a new software system that could suggest changes in care and make medical records easily accessible to any doctor treating a single patient would help alleviate many of the challenges our healthcare system faces today.
However, it’s important that these two entities move through the process with great care and consideration. Google is no stranger to controversy regarding data privacy, machine learning and ethics. In April, the tech leader vanquished its AI ethics board after a public outcry over board members and the potential misuse of Google’s AI systems. Further, Google has been accused of inappropriately using data to personalize online marketing and advertising. While it is true that Project Nightingale doesn’t break any laws under the Health Insurance Portability and Accountability Act (HIPAA), what is most concerning is the potential misuse, release or breach of the data without patient permission.
As a senior consultant for an IT security and risk management firm, I have spent years guiding government health agencies toward common-sense approaches to data management using technology. In order to ensure the greatest transparency for Project Nightingale, it is crucial to give patients an option to opt-in or -out of the program namely because of the risk for data to be breached or misused.
First, Google and Ascension should be tasked with clearly outlining how this project will progress in the future, or who the intended users are. Is it only for healthcare providers? If Google has access to patient data, will it be marketed in the future? While Google may say it will not share or sell user data, we don’t know how Ascension plans to use this data set in the future.
Using the information as part of a medical study that could help improve patient care is much different than using patient data to better market or advertise healthcare solutions or pharmaceutical products. Without this information being publicly available, how are patients and the public supposed to know safeguards were set up at all? This is one reason that so many in the technology industry, including myself, are hesitant to support this project.
Second, any technology is at risk for a data breach, no matter what kind of security is in place. Any device can be hacked, whether by a nefarious organization or a person living in their mother’s basement. Therefore, it is vital to stay a step ahead while anticipating vulnerabilities and risks.
As industry economics change, health care organizations are increasingly being pressured to provide financial transparency while improving the patient experience. Patient financial clearance (PFC) departments are increasingly under pressure to reduce costs and improve their own performancemetrics.
Yet it is difficult to improve baseline PFC key metrics such as days outs, denials, patient escalations, and write-offs without adding staff, an additional expense.
How can PFC departments reasonably achieve performance and productivity goals while still fulfillingtheir core functions? The first step toward PFC improvement is to understand how most PFC departments work, then sequentially adding measures to enhance PFC performance.
PFC departments, usually operating within a provider’s revenue cycle division, are typically resource challenged to curtail internal costs. A PFC department’s greatest cost is staffing, since most authorizations require staff-conducted phone calls to payers. Furthermore, authorizations are often complex for PFC to obtain, since they are based on specific payer rules and valid for only a set period of time.
PFC staff are also responsible for communicating the status of the authorization to not only the patient but also clinic staff. Given that a PFC department’s most important metrics directly pertain to patient health, it is imperative that PFC’s work is done in a timely manner and that financial status and payment are explained clearly to both the patient and provider, so that both parties can be educated in their decision-making process.
The organizational structure of a PFC department can assist or impede its overall productivity, based on the PFC team’s technology, workflow, and communication. For example, keeping teams in siloes may make team members specialized in their work but it can also create difficulty in achieving a streamlined overall process, due to the number of handoffs required to complete simple takes. Factors such as these illustrate the need for PFC departments to emphasize continuous improvement and workflow “optimization” which aligns technology, people and processes.
Improving PFC Performance
PFC performance improvement starts with understanding the department’s technology limitations an exploring potential options to automate PFC functions. For example, technology to verify insurance and benefits should be considered to reduce manual intervention as well as optimizing work queues to improve performance. Most EHRs have integrated insurance verification tools which can be configured to maximize the organization’s payers.
The Hospital Re-admissions Reduction Program took effect in 2012 with the goal of sustainably lowering hospital re-admission rates. Since then, the program has levied nearly $2 billion in penalties (in the form of reduced Medicare payouts) for hospitals with high re-admission rates.The intentions behind the program were good, but it hasn’t played out quite as expected — a 2019 study determined there was no significant change in re-admission rates of heart-failure patients since the implementation of HRRP.
The program also impacts safety-net hospitals more acutely because they serve all patients regardless of insurance status; their patient populations are generally older, sicker, and bring in less income.
A better solution to the re-admission problem might be for healthcare providers to focus more on educating patients — both on preventive care and aftercare — and shoring up these efforts through technological innovations that make education and awareness accessible to all.
How Tech-Enabled Communication Can Lower Re-admission Rates
Truly improving patient outcomes and decreasing re-admission rates is about more than just treatment. In fact, discharge is a critical point in a patient’s recovery as well. Without proper education on aftercare, patients are likely to end up back in the hospital without a better understanding of their current health or how they can improve it.
If healthcare providers can find more effective methods of patient education and communication, they can actively change the course of a patient’s future. Healthcare providers must do more than send out a pamphlet or quickly run through home care at the end of a doctor’s visit.
In an ideal world, all patients understand their conditions, know how to treat their symptoms, and can help prevent re-admission. In reality, however, only 12% of American patients are proficient in health literacy. This means the majority of people are either misinformed or completely uninformed about their health conditions and treatment plans.
Search engines haven’t helped matters, either. Another study determined that Googling symptoms not only stresses people out, but also causes them to misdiagnose themselves. When it comes to patient education, healthcare providers need to take the reins if they’re serious about long-term wellness. Otherwise, misinformation and anxiety will rule the day.
There has been a more in-depth exploration of technology in the healthcare industry. Every pioneering discovery is attributed to advancements in technology. What was not possible decades ago is now being implemented through various techniques, thanks to technology. Without a doubt, the core business of health today is anchored on digitally-enabled models. Technology has proliferated in the different industries that serve the healthcare segment. There are very many tech-enabled methods of research, drug production, treatment, and many more. Transformative digital technologies are aligning to come up with a powerful force for change, and market participant’s adoption is phenomenal.
It isn’t straightforward to predict the future, but at least, if technological trends continue in the current direction, many impactful technologically motivated innovations are to come. Digitization has been massively adopted in medicine, and it is well integrated into the detection and diagnosis of medical problems. It is even turning out to be a need rather than a necessity. Market participants are also wondering if artificial intelligence is going to replace doctors in the future – an ideology that is hard to rule out.
Today, disease diagnosis is being conducted remotely. Doctors are connected through centralized systems that allow them to monitor their patients remotely. Innovation has allowed telemedicine, where you engage with a doctor in the comfort of your home. Therefore, it is evident that artificial intelligence and the internet of things (all powered by technology) are going to alter how the healthcare system works. Most healthcare facilities have started adopting these changes, and they are becoming commercialized. Soon, receiving remote diagnosis and monitoring from your doctor will be a regular occurrence.
Better and Easier Treatment Using Advanced Medicine and Techniques
Imagine having a pocket-sized ultrasound device. Connect the device to your smartphone, and you can watch your baby move in your belly. You can also speed up your rehabilitation process using virtual reality. These are just a few of the significant innovative trends hitting the healthcare industry. They are making treatment faster, more relaxed, and more comfortable for many.
When a person is injured in an accident, because of the negligent actions of another it may take the injured party weeks or months to recover. After going to the emergency room for initial treatment, the injured person or persons could be faced with a number of additional visits to physicians including:
Orthopedic surgeons to treat any broken bones or fractures sustained in the accident
Plastic surgeons for skin grafting if the injuries are from a dog bite
Therapists to assist with general rehabilitation
Obtaining Medical Records is Crucial to Any Personal Injury Case
If the injured party retains an attorney, the attorney will be responsible for ordering and receiving detailed medical and billing records for their clients. This can be an arduous task depending on the hospital, facility or medical provider where the client treated.
Medical and billing records are crucial because they form the basis of the case an attorney builds for their clients. When an attorney, with the approval of their client presents a settlement demand to the insurance company, that demand must be supported with records that demonstrate the extent of the injury and the costs of treatment. A full recovery for the person who was injured is the primary goal.
Most medical providers, through their Release of Information (ROI) department, have similar processes in place. Generally speaking, it follows these steps in order:
A records request is made by the attorney, which includes a HIPAA form (Health Insurance Portability and Accountability Act) signed by the client
The request is received by the ROI department and entered into an electronic system or a hardcopy is placed in a manual filing system
The request is validated making sure that the patient information is correct and that the patient in fact treated at the facility
An invoice for records retrieval is created and sent to the attorney’s office
The attorney pays for the request with either a credit card or by mailing a check
Once payment is received by the provider, the records are released and sent to the attorney
The process sounds pretty straight forward but in big cities like Houston, with large hospitals and a medical center, there are literally thousands of requests made every day.
A physical fingerprint has been a standard identifying feature for decades. Our prints are completely unique to us, and they can reveal where we have been and what we have done, as well as to prove whether we have been the culprit or the victim of someone else’s wrongdoing. Every time your fingers touch a surface, they leave a mark, some evidence that you have been there.
We don’t tend to think about our computer or internet connection as having anything in common. Many people are aware of IP addresses, and how they are tied to individual connections. However, IP addresses are reused by internet service providers and can also be obscured relatively easily with a proxy server. This doesn’t mean that we don’t have truly unique digital fingerprints – just that they are a little bit more complicated than we might think.
What is Device Fingerprinting?
Many people are surprised to find out that this information is even available to the websites that they visit, let alone that it is being used to build a profile of them. When it comes to identifying devices online, the IP address is only one small part of the equation.
Fingerprinting is also more complex than well known methods called cookies. A cookie is something that is placed on a device so that websites can identify that specific device or user in the future. Fingerprinting, on the other hand, is about ascertaining whether one device with a particular set of attributes is the same as another device with those same attributes accessing the service on a different day.
Most of the time fingerprinting is used to detect bots, as their fingerprints do not look like real user’s fingerprints, but the technology has been seeping into marketing and data tracking circles and is used to identify individuals from seemingly anonymized data.
The health plan market is undergoing a drastic transformation. In the past, the competition had been lean with just a small number of payers. However, the market dynamics are changing. Since 2017, the number of MA plan choices per county has increased by 49%. The competition is said to grow even more in the coming years as more health plans are set to enter the market, owing to the fact that nearly 26 million baby boomers will age into Medicare through 2030.
Rising cost burden on health plans
With additional members, the “paperwork” and administrative costs are also increasing. A recent report revealed that there was almost a 6% increase in administrative expenses for MCOs in 2017. The substantial rise in membership with soaring costs means many health plans might find themselves in a financially untenable situation.
Along with the growing administrative burden, the compliance requirements are also weighing on the workload and costs. The push towards improving accuracy, completeness, and timeliness of the data is intensifying to “ensure that provider claims for actual health care spending matches the health plans reported financially,” said Seema Verma. To fulfill the reporting requirements and avoid financial penalties, health plans will have to improve their data submission process to align with the specific rules, formats, and regulations of a given state, which also ensures an increase in cost.
Payers don’t have much control or influence on the administrative and compliance costs. The member population will increase, and so will the requisites by regulatory authorities. The costs are likely to keep increasing on these fronts in the future.
The growing financial pressure has made it inevitable for payers to explore measures to contain costs from spiraling out of control. Since operations account for around 50% of an insurer’s base cost, reducing expenses on this segment can result in cost savings of significant proportions.
Resolution for cost pressures: Operational efficiency
There are certain operational activities such as claims adjudication, reprocessing, and post-call documentation which are highly repeatable and are executed manually. With the addition of more members each year, the burden of these tasks ought to grow even more. Automating these tasks can give a significant boost to operational efficiency; at the same time, it can help reduce overall costs. According to an article, automation technology can lead to an additional operational cost savings of up to 30 percent within five years for many payers.
Outcomes of automating operational activities
Apart from cost savings and reduced utilization, automating operational tasks has multiple other advantages. Automating routine tasks can ensure that the tasks that previously took days to finish are completed in minutes. The accelerated service delivery can build more synergy between members, providers, and internal stakeholders.
There is tremendous pressure on health systems to serve more patients, particularly as the need for services rises and insurance disbursements decrease. Adding new facilities to accommodate demand is often not a feasible option due to budgetary/capital constraints nor is adding more doctors with nowhere to put them. As a result, healthcare leaders consistently ask whether they are getting all that they can out of existing resources.
Operating rooms are a prime example. They serve as the economic backbone for health systems, and organizations need to maximize the use of OR capacity if they want to achieve their fiscal and patient access goals. Yet effectively managing OR blocks and scheduling in the face of volatile weekly demand patterns can feel like trying to squeeze blood from a stone.
If a significant portion of OR time has been reserved as dedicated blocks for surgeons or service lines, unless time not needed is released efficiently, ORs end up both not being used during business hours and yet working late into the night. Patients wait longer than necessary for scheduling procedures and organizations lose revenue.
Additionally, poor OR utilization makes it extremely difficult to accommodate the new surgeons that health systems want to attract. Current providers have a lock on ORs far in advance, regardless of whether they may need the time or not and/or later release these blocks. Such practices leave few opportunities for new surgeons to secure time when needed.
To remedy the situation, health systems are turning to data to look for insights into what can be done to improve OR utilization. After all, small changes in utilization translate to big differences in patient access, revenue and profitability.
The Role of EHRs
As data insights move to the forefront in organizational decision-making, there is some confusion about what EHR systems do and the role that they play. In a nutshell, EHRs tell you what’s already happened. They are vital systems, absolutely necessary for describing problems within organizations and supplying the data to back up assessments.
Breaking this down further, the purpose of implementing an EHR is threefold:
Reservation system: EHRs provide health systems a way to reserve resources, whether it be rooms, infusion chairs, or clinic time. EHRs do this as well as enable scheduling of specific equipment or providers.
Single source of truth for patient encounters: Organizations need a way to maintain records for every patient encounter — a single instance for each enterprise deployment — and EHRs provide this.
Descriptive reporting: Health systems require reporting. EHRs generate reports based on what was done, sort of like how Charles Schwab tells you how your portfolio performed.
While these functions are all essential to running a successful health system, there are several things EHRs are NOT designed to do no matter how much teams may wish they could. For example:
By Valerie Barckhoff, principal and healthcare advisory practice lead, Windham Brannon.
Hospitals and health systems throughout the country are constantly looking for ways to streamline finances and fine tune operating margins. Many are now looking outside the box for solutions to help increase their operating revenue and combat the continued pressure to stretch budgets to include data security, attracting top talent and facility upgrades. Artificial Intelligence (AI), as an example, is showing promising results in healthcare to more effectively address revenue cycle inefficiencies.
AI has penetrated nearly every touchpoint in medicine, from the way emergency medical technicians (EMTs) are dispatched to assisting physicians during surgery. AI is enabling smart devices to detect cancer or a stroke, and consumers can even get help to quit smoking or address opioid addictions with the help of AI. So, it was only a matter of time to apply AI to tackle health revenue cycle inefficiencies. But how?
RCM Represents Prime Opportunities for AI
Even as revenue cycle management (RCM) becomes increasingly more complicated, there are a number of repetitive and predictable processes involved that make it an area perfect for the efficiencies that AI and intelligent automation offer?for instance, prior authorizations.
Prior authorizations, the process by which insurance companies and payers determine if they will cover a prescribed procedure or medication, are meant to help patients avoid surprise bills and unexpected out-of-network costs. However, this largely manual process is time-consuming and error-prone, resulting in $30 billion in annual costs for wrongful denials, inefficiencies and clerical errors. AI can reduce the need to assign resources to repetitive, “simple” pre-authorization requests, allowing healthcare leaders an opportunity to deploy staff to more complex, acute requests that require additional clinical information, peer-to-peer review, and/or other payer required information
Studies show that 84% of physicians surveyed said the burdens associated with prior authorization were high or extremely high, and 86% said the burdens associated with prior authorization have increased significantly (51%) or increased somewhat (35%) during the past five years.
The ability to apply AI to the revenue cycle provides yet another tool to identify inefficiencies, then allow hospitals to redesign their processes and re-allocate internal resources to maximize their net revenues going forward? to focus on more patient care instead of administrative burdens. There is a huge opportunity to gain 25- to 50-percent efficiencies for hospitals and health systems.