One thing recently became increasingly important to Metro Imaging and Radiology, an independent radiology practice with five locations throughout St. Louis, Missouri: meeting meaningful use.
In 2012, Metro Imaging added an electronic health record after having used NextGen’s billing system for several years. Along with the EHR, the chain added the Anoto digital pen.
With more than 100,000 annual patient visits, the practice sought a viable solution to help streamline the intake process and reduce some practice inefficiencies, like scanning and filing paper patient forms.
“We knew it was going to be difficult to reach meaningful use, and we needed something that was going to be very efficient,” said Christine Keefe, chief financial officer at Metro Imaging. “We couldn’t have anything that slows us down too much.”
The Anoto pens seemed like the best solution. The pen stays charged for 10 hours and can hold 200 pages filled out top to bottom.
The practice was sold on the pen because of its ability to capture the information being entered onto paper forms, especially the patient intake forms. According to Keefe, the pens were only considered based on a recommendation from it NextGen representative, but since implementing it, they have completely done away with any manual scanning of patient forms.
On top of that, the clinic has completely gotten rid of paper (except for the patient in take forms used at the front of house) and it no longer keeps papers files.
The first week following implementation was the most difficult, she said, but since everything has settled back to normal and there have been no hiccups. The EHR was probably a more significant change than adding the pens. After all, the patients rarely notice there’s something different about the slightly larger ball points.
The pen captures the data entered into the fields of the paper forms by the patient through a small camera on the pen. It snaps 70 images per second as a patient enters the required data, storing until the pen is docked on a charging station, at which point it downloads all of the information contained into the practice’s EHR through a USB port.
“A great thing about the pen is that you can dock it, ignore it and by the time you’re done doing other things, everything is downloaded and you can use it again,” Keefe said.
An immediate benefit, other than reducing the amount of manual input required of clinical staff is that the forms that are used by the practice are customized and capture data in a structured manner.
Staff that previously focused on transcription, scanning and filing now have had their resources reallocated to claims and billing administration and patient relations. For example, staff has more time to follow up with patients and address any billing and claims issues that come up.
The practice currently uses 25 pens; five per practice. Each costs $385 and there is a $1,000 license fee. Additionally, the practice pays a regular maintenance fee. The pens can be used for hours without re-charging and can capture multiple people’s records without needing to be docked.
The pens are also Bluetooth-enabled and can transmit information wirelessly back to a healthcare setting, making them appropriate for home health workers and others that work outside the four walls of the practice.
They are the ideal technology too, since today more than 80 percent of physicians still rely on traditional pen and paper to capture patient information. Finally, digital pens offers a simple, alternative way to capture data and transfer it into an EHR, especially for physicians concerned about a computer or tablet PC getting in the way of their patient’s experience.
“We like the flexibility the pens have created for us,” said Keefe, “anything to cut down on work at the front desk.”
Metro doesn’t use them in the clinical setting yet, Keefe said, but there has been some interest in bringing them into the exam room. If things continue to go as smoothly as they have, that decision would be like hand meeting glove.
Dr. Juergen Fritsch, co-founder and chief scientist of M*Modal Inc., discusses the company, how it is used in the care setting, the market trends and where it is going.
What is M*Modal?
M*Modal is a leading healthcare technology provider of advanced clinical documentation solutions, enabling hospitals and physicians to enrich the content of patient electronic health records (EHR) for improved healthcare and comprehensive billing integrity.
As the largest clinical transcription service provider in the U.S., with a global network of medical editors, M*Modal also provides advanced cloud-based speech understanding technology and data analytics that enable physicians and clinicians to capture and include the context of their patient narratives in a single step into electronic health records, further enhancing their productivity and the cost-saving efficiency and quality of patient care at the point of care.
Why is it disruptive and important to the community?
M*Modal’s technologies are disruptive because they empower physicians with the ability to make informed decisions at the point of care, one of the most critical factors in reducing healthcare costs and improving patient outcomes.
M*Modal’s solutions are important because they are designed for healthcare by healthcare experts. As such, the solutions understand multiple dialects, accents and cadences, pull from a repository of more than 200,000 physician voices in the cloud and are only medically focused.
What is its potential?
M*Modal has the potential to transform the way the entire healthcare industry leverages advanced clinical documentation technologies and services, ensuring that all stakeholders across the healthcare spectrum, from the patient to the coders on the back end, benefit from the advanced clinical documentation workflows available in today’s and tomorrow’s healthcare settings.
Who’s using it? Why? What is the ROI?
M*Modal provides hospitals and physicians with the healthcare industry’s most advanced clinical documentation solutions. These stakeholders use our solutions to enhance how healthcare professionals capture and manage clinical documentation for improved quality, cost savings, reimbursements, compliance and patient care. Examples include enriching electronic health records for patient care quality and comprehensive billing integrity.
In terms of ROI, our technologies can identify documentation deficiencies and address them via closed-loop workflows, which improve the quality of the clinical patient note and increase the efficiency of documentation processes. Our advanced clinical documentation tools drive adoption of electronic health record systems, saving providers time & expenses.
How did it start? What is it doing to advance?
M*Modal grew out of research performed at Carnegie Mellon University in the late ’90s. The company’s founders developed a radically new technology for understanding conversational human interactions on the telephone. The technology proved to be an even better match for dictated clinical notes as created by healthcare professionals throughout the United States and elsewhere. Today, M*Modal processes millions of hours of verbal healthcare documentation for more than 200,000 physicians each year.
To advance our impact we are also focused on forging partnerships. We just announced several new partnerships with major industry players such as 3M, Optum and Intermountain Healthcare and we have established partnerships with top providers of electronic health record systems, including Epic, Allscripts and Merge. We are constantly working with partners to develop and address industry challenges as they arise.
How is it used in the care setting?
Our advanced speech and natural language understanding technology is used in a wide variety of clinical and administrative healthcare workflows, for example enabling physicians to interact with their clinical systems via voice anytime, anywhere, using their preferred device. This enables instant access to critical information for patient care, allowing providers to spend more time with the stakeholder that matters most – patients.
Additionally, hospitals and practices are using our solutions to analyze vast amounts of unstructured clinical documentation, identify documentation deficiencies and close care gaps. Traditional electronic health record systems do not provide this level of insight and so our solutions fill a critical need that becomes more and more important as we progress from a fee-for-service to a value-based reimbursement and accountable care model.
Tell me something about transcription tools that nobody seems to know.
Our advanced speech and natural language understanding technology has made the process of turning dictated physician notes into structured clinical documents roughly twice as fast as a traditional transcription workflow. On top of that, transcription services are slowly but steadily evolving to also include data validation services. That trend will continue as hospitals seek to lower their cost and free-up physicians to spend more of their time caring for patients rather than dealing with technology.
Should patients care about speech recognition?
Many patients are already familiar with speech recognition technology through their use of off-the-shelf consumer products that some of them are using at home. In my view, it is less the speech recognition technology that they should care about, but the significant advances that we have made in the past few years around computers understanding natural human language. That technology together with the vast and ever growing amounts of “big data” that are being created in healthcare is allowing physicians and other care providers unprecedented insights into healthcare outcomes and ultimately will be a key driver of improved healthcare.
What do you see as the most important health IT trends currently affecting the market? Why?
The most important health IT trends that’s affecting the market today is the move toward a more outcome- and prevention-based reimbursement models. Rather than paying for services provided, the market will shift rapidly toward paying fixed budgets to manage different types of diseases, particularly the costly chronic ones such as heart disease, diabetes, etc. Healthcare information technology is adjusting to this and is developing new solutions that are focused on personalized medicine to prevent diseases rather than just supporting the treatment of them once they occur.
Where are we going as a market?
As I noted earlier with the new outcomes-based focus, I would say that we are rapidly moving toward a more sustainable healthcare cost model, with a much improved focus on disease prevention and personalized treatment plans.
What is the number one complaint you hear regularly from caregivers?
By far the number one complaint is that outdated, inefficient technology is bogging them down, requiring them to spend more time in front of the computer, leaving less time to take care of their patients. In part, this stems from the fact that many hospitals have bought into decades-old electronic health records systems with inefficient workflows that slow down physicians, particularly in today’s world of increasing data capture requirements. But there is also a generation of newer information technology on the market now — such as speech and natural language understanding technology — that actually help improve physician productivity while also providing better insights into their patient population. The bottom line is: physicians and hospitals need to closely follow the healthcare IT market to identify the tools that can drive their efficiencies and improve their outcomes.
What are caregivers most excited about?
Many care givers are excited about mobile devices — mostly about tablets like the iPad Mini. It allows them to do many of their tasks more efficiently while on the go, even sharing a lot of information effectively with their patients. Virtual assistant technology is also of great interest to many physicians, particularly in combination with mobile devices. You will see many new mobile apps hitting the market in the next few years that will allow care givers to verbally ask complex questions about their patients’ health record and get answers within seconds.
What piece of regulation would you like to see abandoned? Adopted?
I’d like to focus on pieces of regulation that I would like to see adopted more readily or more expediently. The key ones for me are interoperability standards and the respective regulation found in the ARRA HITECH Meaningful Use program. Almost every other industry has embraced interoperability. You can get cash at virtually any ATM in the world — but you can’t transfer your electronic patient health record from one EHR provider to the next (at least, not without major effort). We need to change that, and we need to do it quickly. Regulation can help with that.
Dr. Juergen Fritsch is co-founder and chief scientist of M*Modal Inc. where he leads research efforts in the fields of speech and natural language understanding for clinical documentation. His work focuses on building and improving a medical language understanding system that is based on standardized medical ontologies and vocabularies while employing statistical algorithms to learn from vast amounts of linguistic data. He has published more than 20 peer-reviewed papers and has been granted five patents on original speech recognition and natural language processing research. Juergen received his Ph.D. (1999) and M.Sc. (1996) degrees in computer science from the University of Karlsruhe, Germany.
In light of recent reports that nearly 220,000 hospitals, office-based physicians and other eligible professionals have received more than $12 billion in federal incentive payments, I thought I’d highlight the top questions as featured on CMS.gov’s FAQ section.
But, a little perspective first. According to Modern Healthcare, to this point, 3,757 hospitals, or 75 percent of the 5,011 U.S. hospitals that are eligible to receive federal funds under the program, have received an EHR incentive payment.
Also, “215,500 physicians and other EPs, or 41 percent, of the 527,200 total physicians and other professionals deemed eligible to participate, have been paid. Some 85 percent of hospitals and 70 percent of physicians/EPs are registered under the programs, the CMS reports.”
So, back to the original story: CMS.gov’s Frequently Asked Questions and the answers. If you’re not aware of the resource, it serves a broad base audience with a smattering of questions and responses. For example, there a variety of topics including billing, e-health, data navigation, EHR incentive programs, well, you get the point.
Here’s a short list of some questions and their answers:
How and when will incentive payments for the Medicare Electronic Health Record (EHR) Incentive Programs be made? For eligible professionals (EPs), incentive payments for the Medicare EHR Incentive Program will be made approximately eight to 12 weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year. Payments will be held until the EP meets the threshold in allowed charges for the calendar year ($24,000 in the EP’s first year) in order to maximize the amount of the EHR incentive payment they receive. Medicare EHR incentive payments are based on 75 percent of the estimated allowed charges for covered professional services furnished by the EP during the entire calendar year. If the EP has not met the threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March of the following year (allowing two months after the end of the calendar year for all pending claims to be processed).
What is CMS? The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency which administers Medicare, Medicaid, and the Children’s Health Insurance Program. Provides information for health professionals, regional governments, and consumers. Additional information regarding CMS and it’s programs is available at http://www.cms.hhs.gov/.
When eligible professionals work at more than one clinical site of practice, are they required to use data from all sites of practice to support their demonstration of meaningful use and the minimum patient volume thresholds for the Medicaid EHR Incentive Program? CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demonstrating meaningful use must have at least 50% of their of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives. Therefore, States should collect information on meaningful users’ practice locations in order to validate this requirement in an audit.
How do physicians join or leave a group? If both the physician and the group are already enrolled with the same carrier, the physician and the group together are required to complete a CMS 855R showing the date the physician joined the group and reassigned benefits to the group. If a physician leaves a group, the physician or the group should complete the CMS 855R, showing the date the physician left the group. When leaving the group, the CMS 855R does not need to be signed by both the physician and the group. If either the physician or the group have not enrolled with the carrier, they must first complete the appropriate CMS 855 for either an individual (CMS 855I) or group (CMS 855B) before the reassignment can be effective.
Your smartphone a medical device? There’s a possibility that this could happen as Washington and its players continue to evaluate whether in the Food and Drug Administration should regulate mobile apps technologies, including health-related apps.
Based on the interpretation of the current administration’s perspective of mobile health innovation and regulation and how those innovations benefit patients will likely determine whether regulation, and ultimately, taxes are assessed on them.
Mobile health apps can range from an iPhone app that monitors diet to mobile or wireless technologies used in hospitals and home-care settings.
Obviously, developers and those producing the apps want more clarification on the issue. As expected from a federal agency, the FDA has issued draft guidance in 2011 according to Modern Healthcare about how it plans to oversee mhealth apps, but nothing final has been released. So, what we’ve seen may not ultimately be what we get.
Some people believe health apps will help solve the overwhelming cost crisis in healthcare; thus, shackling them with additional oversight, taxes and regulation will stifle a burgeoning industry. As such, according to Modern Healthcare, there needs to be “’predictable, transparent and risk-based regulation,’ the value of interoperability, and reimbursement policy that aligns stakeholders.”
I couldn’t have said it better myself, and I agree with the fear that some lawmakers have about a concern that FDA regulation of smartphones, tablets and apps could mean those technologies are subject to the medical device excise tax, a 2.3 percent tax on the sales of certain devices that went into effect in January.
The tax is part of the Patient Protection and Affordable Care Act and is considered the device industry’s contribution to financing healthcare reform.
In a March 1 letter to FDA Commissioner Dr. Margaret Hamburg (PDF), the House committee leading testimony asked the FDA to clarify whether the smartphones and mobile health apps will be subject to the tax. No response as yet. Not surprising. Additionally, leadership also requested that the agency provide information about when it plans to issue final guidance on how it plans to oversee mobile medical apps.
“Most Americans have no idea that their smartphone, tablet or the mobile apps that have become part of their daily lives could be subject to added red tape or a new tax under Obamacare,” Energy and Commerce Committee Chairman Fred Upton (R-Mich.) said in a news release.
According to the Washington Post, “In 2012, Congress gave the FDA the green light to define which medical apps would require its attention. The agency has asked for comment on a proposal that would give it regulation authority over accessories to existing medical devices, such as apps that show MRI scans, as well as apps and accessories that transform mobile devices into regulated medical devices, such as attachments or apps that turn smartphones into heart monitors.”
For those with an interest at stake here, they should feel some level of concern, no matter the side of the isle they happen to sit. Further regulation, and definitely taxation (especially at the app user level), will destroy the momentum gained by these tools to the market since they’ve been developed.
In the very least, the seemingly unending and elusive patient engagement game that plays on may find itself put on pause as this has the potential to once again remove personal control of tools designed to help manage and improve one’s health and to regulate it.
In many ways this seems like a sin tax. High taxes are used to get people to quit bad behavior, like smoking. When the prices gets too high, they (ideally) quit.
Skype and unbridled communication between caregivers and their patients has opened a great many opportunities for care to be offered the world round, from a variety of locations within our own communities to remote and unconventional places in other areas of the world.
In a nutshell, Dr. DeShan spends several months in Russia each year leading an international medical mission where he serves some of Moscow’s most needy, as well as delivers care to some of the world’s remote people through journeys into the wilderness.
When he’s in Moscow serving patients, she’s able to stay connected to his practice in Midland Texas, where he’s a partner at a thriving OBGYN. Aside from relinquishing a few of his daily duties, such as delivering, he’s able to maintain a full patient load and he does that in part using the web and tools like Skype to maintain contact with them and with his practice.
Personally, I believe the work DeShan is doing is fascinating. He’s using his talent and skill to follow his passion and his calling in life. His practice and his patients are in support of his work and in no way does he keep it from them. Those patients that were not comfortable with interacting with him part time through the web were assigned to other practitioners.
However, I’ve always wondered if Skype is a tool that can be trusted for such work. Despite his good deeds, I always wondered he’s in HIPAA compliance.
According to a recent article in Medical Office Today, I’m not the only one. According to the article, “Notwithstanding the fact that Skype is ubiquitous, its use may be inappropriate for healthcare providers as web-based platforms raise a number of significant HIPAA privacy and security issues:
Many platforms are proprietary, meaning that healthcare providers have no way to determine if and what information is stored
Users cannot reliably develop and verify an audit trail
There is no reliable way to verify transmission security
Users have no way to know when a breach of information occurs
There is a lack of integrity controls to ensure that electronic protected health information is not altered
Also, according to the piece, HIPAA and its resulting regulations pertaining to privacy and security require covered entities such as healthcare providers to protect the confidentiality of protected health information and guard against unauthorized access, use, and disclosure of such information.
Among other things, the HIPAA rules require:
Person or entity authentication
Business Associate access controls
Device and media controls
Security management process
“The use of web-based platforms, especially those that are proprietary, makes it difficult for healthcare entities to meet many of their HIPAA obligations,” the article states. “As a consequence, telehealth providers carry a higher risk of potentially violating HIPAA rules when they use services such as Skype.
According to the Health Information and Trust Alliance, the organization recommends against the use of Skype and similar platforms for communications involving health information, concluding that web-based platforms are not secure, and are an inappropriate way by which to communicate with patients, especially when the communication involves health information. Their view was confirmed late last year when a security flaw was discovered in Skype that put users’ personal information at risk of disclosure.
“All of this does not mean a healthcare professional should not use Skype to communicate to patients, only that they be aware of the increased risk of violating HIPAA and think long and hard prior to using such technology.”
However, should a provider insist on using Skype, there are some steps they should consider to better protect themselves from potential HIPAA liability (all good tips, according to the magazine):
Have patients sign HIPAA authorization and a separate informed consent as part of intake procedures when using web-based platforms
Develop specific procedures and protocols regarding use of Skype, similar platforms
Train workforce on the use of these platforms
Exclude the use of these platforms for vulnerable populations
Limit to certain clinical uses (i.e., only intake or follow up)
Use secure platforms with audit trail, breach notification, other capabilities.
Only HIPAA-compliant technologies can truly protect a physician and a patient. These steps may help. In the long run, though, as I’m sure Dr. DeShan would agree, don’t let the cost of the work keep you from doing it.
A new report suggests that the average physician lost just as much as would have been gained had he or she received the full meaningful use incentive payment for the last five years — $44,000 – by implementing an electronic health record, which basically makes the whole thing null and void.
There’s a caveat, though. The practice that has implemented and is using the EHR, needs to make a few changes to the way the practice runs or else the saving is lost. Somewhat of a no brainer, according to study that’s published in Health Affairs, only 27 percent of practices achieved a positive five-year return on investment by implementing the electronic systems.
The trouble, according to the survey, is that practices “failed to make operational changes to realize the benefits of EHRs such as doing away with paper records after implementation of the electronic systems, adoption, as well as dictation, billing services and positions or staff members who were performing services no longer required after EHR adoption.
A reduction in the required workforce at the practice after the implementation of an EHR is a common problem. I’ve spoken with several practice leaders who cited it as such, and in many cases, staff whose positions were eliminated because of the software have been re-assigned to other areas. There are only a few practices in which I’ve spoken where employees were laid off because of the systems. I expect this number to grow as more systems come online.
According to MedPage Today, which published the results of the study, the study sought “pre- and post-adoption financial cost/benefit data from practices such as total revenue, total operating costs and total labor costs. Researchers also asked for information on areas that were impacted by EHRs, such as the cost of paper medical records, dictation services, and billing services.”
Their results of the study showed that the average physician lost $43,743 over five years. Primary care practices fared better than specialists. Practices that saw a positive return on EHR investment increased revenue by more than $114,000 per physician over five years, results showed. In comparison, practices with a negative return on EHR investment saw revenue increase by an average of only $9,200 per physician in five years.
“Even when adding federal incentives to use EHRs, the majority of doctors would have lost money,” MedPage Today reports.
Other results from the study include:
38 percent of practices with six or more physicians achieved a positive return on investment, compared with 26 percent of practices with one or two physicians
55 percent of practices reported a reduction in the cost of paper medical records after EHR adoption
22 percent of practices reported the most common ongoing cost was additional hours of practice time
10 percent of practices noted improved efficiency, allowing them to see more patients each day
18 percent increased revenue through improved billing
This is a bit surprising: Practices with a practice management system prior to EHR implementation in place to help with billing functions benefited less on average.
Seems like some of the unexpected consequences of EHR use are finally working their way to the top and a bit of the actuality of the situation is coming out; just because a system is implemented, doesn’t mean everything is going to be great. “Wide usage of EHRs was supposed to help doctors increase revenue through improved billing and efficiency gains that would allow them to see more patients per day. However, doctors have complained that EHRs are cumbersome and cause physicians to spend more time documenting patient visits,” the magazine states.