EHR and Meaningful Use: How it Impacts the Coder What you get may not be what you expect Patricia 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 AAPC 2002 (pswilson) 1
What will not be discussed in this presentation No specific product or company will be endorsed or discussed How all the technology works copyright, pswilson 2016 3 Once upon a time. copyright, pswilson 2016 4 AAPC 2002 (pswilson) 2
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.. copyright, pswilson 2016 5 Florence Nightingale 1863 copyright, pswilson 2016 6 AAPC 2002 (pswilson) 3
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 3 rd leading cause of death in the USA copyright, pswilson 2016 7 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 AAPC 2002 (pswilson) 4
copyright, pswilson 2016 9 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. copyright, pswilson 2016 10 AAPC 2002 (pswilson) 5
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 copyright, pswilson 2016 11 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 copyright, pswilson 2016 12 AAPC 2002 (pswilson) 6
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 copyright, pswilson 2016 AAPC 2002 (pswilson) 7
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 copyright, pswilson 2016 15 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) copyright, pswilson 2016 16 AAPC 2002 (pswilson) 8
Definition of an EHR Longitudinal electronic record Patient data Multiple encounters Any care setting copyright, pswilson 2016 17 What an EHR should do Collect information Improve patient care Reduce costs Create more efficient use of time copyright, pswilson 2016 18 AAPC 2002 (pswilson) 9
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 copyright, pswilson 2016 19 What an EHR contains Demographics Progress notes Problems Medications Vital signs Past medical history Immunizations Laboratory data Radiology reports copyright, pswilson 2016 20 AAPC 2002 (pswilson) 10
Limitations to EHR No system does all functionality Different standards used by each system Lack of interface capabilities between different systems copyright, pswilson 2016 21 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 copyright, pswilson 2016 22 AAPC 2002 (pswilson) 11
HITECH - 2009 Health Information Technology for Economic and Clinical Health Act Public health Improve health care quality Ensure privacy and security copyright, pswilson 2016 23 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 copyright, pswilson 2016 24 AAPC 2002 (pswilson) 12
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 copyright, pswilson 2016 25 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 copyright, pswilson 2016 26 AAPC 2002 (pswilson) 13
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 copyright, pswilson 2016 27 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 copyright, pswilson 2016 28 AAPC 2002 (pswilson) 14
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 copyright, pswilson 2016 29 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 copyright, pswilson 2016 30 AAPC 2002 (pswilson) 15
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 copyright, pswilson 2016 31 Implementing standards in MU objectives Data 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-4 SNOMED 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 extension HL7 Pedigree Encounter Diagnosis N/A SNOMED CT +US extension ICD-10-CM 32 copyright, pswilson 2016 AAPC 2002 (pswilson) 16
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) 33 copyright, pswilson 2016 Pros and Cons of EHR and Meaningful Use copyright, pswilson 2016 34 AAPC 2002 (pswilson) 17
PROS copyright, pswilson 2016 35 copyright, pswilson 2016 36 AAPC 2002 (pswilson) 18
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 copyright, pswilson 2016 37 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 AAPC 2002 (pswilson) 19
CONS copyright, pswilson 2016 39 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) copyright, pswilson 2016 AAPC 2002 (pswilson) 20
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 copyright, pswilson 2016 42 AAPC 2002 (pswilson) 21
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 copyright, pswilson 2016 43 Specific examples of the impact on coding copyright, pswilson 2016 44 AAPC 2002 (pswilson) 22
Templates copyright, pswilson 2016 45 Computer Assisted Coding AAPC 2002 (pswilson) 23
How a computer decides which code Natural Language Processing (NLP) Clinical Document Improvement (CDI) Site specific rules copyright, pswilson 2016 47 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 copyright, pswilson 2016 48 AAPC 2002 (pswilson) 24
Issues with automating the coding process Consistency Size of content Maintenance Synonyms copyright, pswilson 2016 49 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 copyright, pswilson 2016 AAPC 2002 (pswilson) 25
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 copyright, pswilson 2016 51 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 copyright, pswilson 2016 AAPC 2002 (pswilson) 26
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 copyright, pswilson 2016 GEMS reverse map or ICD-10- CM to ICD-9-CM copyright, pswilson 2016 AAPC 2002 (pswilson) 27
SNOMED CT for Meaningful Use Problem List Current Active ICD-10-CM Within the patient summary record copyright, pswilson 2016 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 copyright, pswilson 2016 56 AAPC 2002 (pswilson) 28
NLM has other map sets ICD-9-CM to SNOMED CT (retired) SNOMED CT to ICD-10-CM copyright, pswilson 2016 57 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 copyright, pswilson 2016 AAPC 2002 (pswilson) 29
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 copyright, pswilson 2016 59 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 copyright, pswilson 2016 60 AAPC 2002 (pswilson) 30
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 copyright, pswilson 2016 61 Coding directly to ICD-10-CM 230744007 Cerebrospinal fluid leak (disorder) ICD-10-CM G96.0 Cerebrospinal fluid leak copyright, pswilson 2016 62 AAPC 2002 (pswilson) 31
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 copyright, pswilson 2016 63 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 copyright, pswilson 2016 AAPC 2002 (pswilson) 32
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 copyright, pswilson 2016 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 copyright, pswilson 2016 66 AAPC 2002 (pswilson) 33
Options for a coder Be alert Ask questions Communicate with your vendor, or the SDO directly Be patient with yourself and others copyright, pswilson 2016 67 Conclusion Automation is an efficient tool Guide to a result Not 100% foolproof Human factor cannot be removed copyright, pswilson 2016 68 AAPC 2002 (pswilson) 34
Questions copyright, pswilson 2016 69 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 copyright, pswilson 2016 70 AAPC 2002 (pswilson) 35
More References http://www.who.int/classifications/icd/en/historyoficd.pdf http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/downloads/M U_Stage1_ReqOverview.pdf http://endingthedocumentgame.gov/pdfs/privacy.pdf IHTSDO.org NLM.org RoadtoICD10.org copyright, pswilson 2016 71 AAPC 2002 (pswilson) 36