What Does Cerner’s Purchase of Siemens mean for the Soarian EMR?

A few weeks ago Cerner announced that it was purchasing Siemens Health Services for $1.3 billion. Although the real boost to Cerner is likely to come from its acquisition of Siemen’s expertise in medical devices and advanced imaging capabilities, Cerner will have to decide the future of Siemens EMR—Soarian.

Siemens originally developed Soarian not to compete directly with the largest players in the market, but to fill a gap in its core IT services business. Unveiled in 2002, Soarian developed a reputation for being “too slow to achieve reliable go lives at customer sites, too slow delivering code fixes and upgrades and too slow evolving their portfolio” according to KLAS research.

Cerner officials have said that the company will continue to support Soarian, but it seems unlikely that Cerner would continue this support indefinitely. The Soarian platform did not gain enough market share to warrant its continued attention from Cerner, which is the second or third largest player in the EMR marketplace (depending on the metric used).  According to CMS, only 81 hospitals have used Soarian as their EMR vendor to attest to meaningful use for reimbursement between April 2011 and November 2013. This compares with 532 from Cerner. This acquisition will only add a modest number of new hospital sites to Cerner’s portfolio, but will quickly advance Cerner’s ability to integrate their services with various medical devices and advanced imaging systems.

The purchase of Soarian also represents a bit of a defensive move for Cerner as 12 of the 16 hospitals that decided to leave Siemens last year contracted with Epic, one of Cerner’s main rivals.

So will Soarian survive?  Maybe. But the more likely scenario is that Cerner will slowly transition its newly-acquired Soarian sites to one of its own EMR products. Soarian’s expertise in integrating medical hardware systems could significantly boost Cerner’s competitive edge in the market by increasing Cerner’s ability to embed information from the EMR inside advanced diagnostic and therapeutic technologies. But it is possible that hospitals will not be able to purchase a product called Soarian in the next two to three years.

-Amber Altemose, J.D.

Resources:

The Wall Street Journal – Cerner Corp. to Acquire Siemens Health Information Techonology Unit

KLAS – EMR Market Share by the Numbers: The Cerner/Siemens Acquisition

Becker’s Healthcare – Top EHR Vendors by Meaningful Use Attestations

ICD-10 Update

After the implementation of ICD-10 was delayed another year through the enactment of the Protecting Access to Medicare Act of 2014, the Department of Health and Human Services is expected to issue an interim final rule in the near future regarding the use of ICD-10.

According to the Act, the Secretary of Health and Human Services could not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets.  Prior to the Act, the implementation date was October 1, 2014.

The interim final rule issued by the Department of Health and Human Services will require the use of ICD-10 code sets beginning October 1, 2015.  The rule will also require HIPAA covered entities to continue to use ICD-9 through September 30, 2015.

– Amber Altemose, J.D.

Resources:

Health Data Management – CMS Inches Toward Establishing ICD-10 Deadline as October 1, 2015

 

House Passes Bill that Includes ICD-10 Delay

While healthcare providers have been preparing to transition to ICD-10 by the October 1, 2014 deadline, the House of Representatives passed a bill today that would delay the ICD-10 transition until at least October 1, 2015.

HR 4302 was introduced yesterday to repeal a twenty-four (24%) percent cut in reimbursements for physicians treating Medicare patients.  Although the primary purpose of HR 4302 is to prevent Medicare payment reductions to physicians under the Sustainable Growth Rate formula, Section 212 of the bill will delay the October 1, 2014 transition to ICD-10 code sets for another year. Specifically, Section 212 states:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

The Senate is schedule to vote on the bill tomorrow, March 28, 2014.

– Amber Altemose, J.D.

 

Resources:

H.R. 4302, Government Printing Office

House passes ‘doc-fix’ bill; measure delays ICD-10 implementation, Modern Healthcare

It’s Almost Time for Stage 2 of Meaningful Use

Despite the continuing outcry for a delay in the start date, Stage 2 of Meaningful Use may be less than a week away for some providers. Eligible hospitals may begin their ninety (90) day reporting period as early as October 1, 2013, while eligible professionals may begin as early as January 1, 2014.

How is Stage 2 Different?

Like Stage 1, the required objectives for Stage 2 of Meaningful Use fall under two categories:  Core Objectives (required) and Menu Set Objectives (selected from a list).  While a handful of Stage 1 objectives have been eliminated, the majority of Stage 1 objectives have been carried forward, slightly tweaked, or have been combined with other objectives for Stage 2; of course, there are also several new objectives for Stage 2.

CMS has issued several resources to help organizations and/or providers gear up for Stage 2, including two comparison tables which outline the specific changes that were made with regard to the objectives for eligible professionals and eligible hospitals, with links below:

Stage 1 vs. Stage 2 for Eligible Hospitals

Stage 1 vs. Stage 2 for Eligible Professionals

As an example, the threshold for the CPOE objective (which requires direct order entry by a licensed healthcare professional) has increased from 30% for all medication orders to 60% for all medication orders, while also expanding to include 30% of all laboratory and radiology orders for Stage 2.  Several other Stage 1 objectives have been slightly tweaked for Stage 2 by increasing the required completion thresholds, including the objectives for recording patient demographics, recording of vitals signs, recording of smoking status, among others.

Particularly of note, several new objectives for Stage 2 will require a change to IT infrastructure to allow for certain required functionalities.  For example, under Stage 2, eligible physicians must have the ability to use a secure electronic messaging system to communicate with patients and 5% of unique patients must actually utilize the system.   Similarly, eligible hospitals must have the capability to automatically track at least 10% of medications ordered within the hospital’s inpatient or emergency department, from the time of order to the time of administration.  This objective not only requires specific software functionalities, but may require hardware upgrades too.  As both objectives fall under the Core Objective category, providers or organizations without the requisite technology upgrades will not be able to begin Stage 2 (thus the outcry to delay the start date by one year or more).

How Can Scribes Help?

Whether you are targeting Stage 1 or gearing up for Stage 2, so many of the Meaningful Use objectives are simple documentation components with which our scribes may help.  For years, we, at PhysAssist Scribes, have stressed the importance of understanding the various Meaningful Use objectives and have implemented strategies to help our clients meet their goals.  For more information on our innovative training or for information on other ways our scribes can help, please visit www.iamscribe.com.

- Brittany Baine Walker, J.D.

ICD-10: Are you ready for the transition?

Meaningful Use, PQRS reporting, and Core Measures: each one of these causes an increased documentation burden upon healthcare providers, as each program brings its own set of documentation requirements.  Now, add to the mix ICD-10 compliance.  With a looming compliance deadline of October 1, 2014, how are physicians going to shoulder this additional documentation burden?  Scribes might be the answer.

What is the ICD?

The International Classification of Diseases (ICD) is an official publication of the World Health Organization (WHO) for the purpose of epidemiological tracking of illness and injury and has been in use in the Unites States since 1949.  ICD is used by all HIPAA covered entities to report diagnoses and inpatient hospital procedures.  Over the years, the ICD has been continuously updated, with the 9th version (ICD-9) adopted in the U.S. in 1979 – which is the version still utilized by all healthcare operations in the U.S. today. However, on January 15, 2009, the U.S. Department of Health and Human Services (HHS) announced the adoption of a new generation of diagnosis and procedure codes for healthcare transactions, known as ICD-10, by October 1, 2014.

Why the switch to ICD-10?

The current classification system, ICD-9, has been in use in the U.S. for over 30 years.  ICD-9 is grossly outdated, with a limited ability to accommodate the addition of new procedures or diagnoses, as the code set is running out of available codes.  ICD-9 categories consist of three digits and can only accommodate up to ten subcategories.  Furthermore, the codes lack specificity and include inconsistent terminology.  For example, according to AAPC, coding for fractures in ICD-9 does not include an indication of laterality; in other words, if a patient is treated for successive wrist fractures, there is no way to indicate between the right or left wrist.  In addition, there are no ICD-9 codes to differentiate between episodes of care (initial versus subsequent visits) for injuries.

To put things in perspective, the U.S. is the last developed country in the world to be using ICD-9.  All other countries have already made the transition to ICD-10.

Benefits of ICD-10

As with ICD-9, ICD-10 will have two versions in the U.S.: ICD-10-CM (Clinical Modification), used for diagnosis coding and ICD-10-PCS (Procedure Coding System), used for procedure coding in the inpatient setting.  All ICD-10 codes will be very different than those currently used.  ICD-10 will consist of alphanumeric codes up to seven characters in length, with such characters representing more detailed information than what can be gleaned from ICD-9 codes (which only consist of 3 or 4 numeric digits).  Overall, ICD-10 will expand to include over 140,000 different codes, as opposed to a mere 13,000 codes (approx.) with ICD-9.  These new codes will allow for more specificity with regard to the circumstances surrounding the injury or illness, as well as more defined laterality (or anatomic location).  The new code set is designed to foster better reporting, which will support the value-based purchasing model of reimbursement; to ensure more accurate payments for providers; to facilitate disease surveillance and medical research; and to reduce payer requests for additional information before payment.

How will ICD-10 affect providers?

The most substantial day-to-day impact upon providers will be the fact that all documentation will require a level of detail that can support the increased specificity required by the ICD-10 codes.  For example, the injury chapter of ICD-10-CM is one section that received significant revision.  In order to determine the appropriate codes for outpatient treatment for an injury, the medical record will need to include such information as the facts surrounding the encounter which caused the injury, the external cause, the activity engaged in by the patient at the time of injury, and the location of the patient at the time of injury (such as the specific room of the house), among other information.

For most providers, changing the way they document will not be easy.  It will be a behavioral change that will not occur overnight.  Hours of training and preparation is recommended, as well as continual auditing of records to uncover any documentation gaps.

One solution that providers may consider is the use of scribes.  Scribes are trained to provide real-time documentation– which means they are physically present in the exam room as the physician is interviewing the patient.  The scribe is able to listen and document all the detailed information, such as the details surrounding the cause of the presenting injury, as stated by the patient.  Without a scribe, the provider may or may not be able to later recall all the seemingly insignificant details, which will now be required within the record in order to be coded correctly within ICD-10. With a properly trained scribe, the impending ICD-10 documentation burden may actually be something to look forward to, as opposed to dreading.

For more information on the specialized training provided by PhysAssist Scribes at I AM SCRIBE University, please visit www.iamscribe.com.

– Brittany Baine, J.D.

 

Resources:

Preparing for ICD-10-CM in the Emergency Department, AHIMA

ICD-10 Final Rule Press Release, Centers for Medicare and Medicaid Services (CMS)

ICD-10 FAQ, American College of Emergency Physicians (ACEP)

ICD-10 Transition: An Introduction, Centers for Medicare and Medicaid Services (CMS)

ICD-10 FAQ, AAPC

Improving the Patient Experience with the Use of Scribes

Since 2002 (the year the first national program to survey patients was adopted), patient satisfaction has become one of the primary, day-to-day concerns of a treating physician.  One of the original initiatives behind the survey mandate was to publish patient satisfaction results, thereby improving physician accountability and arming patients with information to make more educated decisions with regard to their own health care.

Measuring patient satisfaction makes sense; after all, physicians want patients to be happy with their experience.  However, there is more and more debate surrounding the efficacy of current survey methods and whether or not the increased focus on surveys has a negative effect on patient care.  A recent article by Forbes (found here) recognized the benefits to measuring patient satisfaction, but cautioned against the excessive pressure being placed on physicians to improve satisfaction scores.  This excessive pressure could lead to influencing medical decision making (a physician may be more inclined to order unnecessary tests, prescribe stronger pain medications, and give into other patient demands in an effort to avoid low satisfaction scores).  Furthermore, naysayers have, for years, argued that current survey methods do not adequately reflect actual patient satisfaction levels.  Sample sizes are often too small or are misrepresentative.

Putting recent criticisms aside, the concept of focusing on the overall patient experience and the improvement thereof is still important.  Health care professionals are continually finding new ways to make an impact upon the patient’s experience, and the introduction of scribes could be one of them.

We all know about the direct impact of scribes, such as the potential for providers to see more patients in the same amount of time; a potential decrease in Left Without Being Seen (LWBS); and an overall improvement in physician efficiency and organization.  All of these things have the potential to improve the overall patient experience, as wait times (even just perceived wait times) are huge determining factors in satisfaction. But what about some of the more indirect effects of scribes on the patient experience?

  • Pulling the provider away from the computer and allowing the scribe to document, gives the provider the opportunity to engage in more interpersonal communication with the patient.  Scribes allow the provider to sit down, make more eye contact, and convey other positive nonverbal cues to show the patient that they are listening.
  • By offloading documentation onto the scribe, the provider has more time at his or her disposal to spend with the patient, answer questions, and summarize the plan of care.
  • Managing the workflows and keeping the provider more organized has a positive, indirect impact upon other ED staff.  Having happier ED staff members gives way to a better work environment and potentially happier patients.
  • Prepping the provider before each encounter, reminding them of the particular patient’s name and chief complaint, reassures the patient and conveys a message of provider engagement and interest.
  • Telling the scribe what to document within the record while standing in front of the patient allows the opportunity for the patient to ask questions or seek clarification.  The patient will leave with a more clear understanding of their diagnosis and the plan for their care.

Lastly, here is some food for thought:  Scribes not only have the potential to help improve the experience of the patients actually seen by the provider, but the use of scribes also has the potential to improve the experience of the patients that would have NOT been seen by the provider. Consider the amount of patients that leave the ED every day without ever being seen due to wait times. If scribes have the potential to decrease the number of patients that leave without being seen, this means that scribes also have the potential to increase the number of individuals who get to have a patient experience at all: being treated in lieu of leaving without being seen by a provider is the first step in improving a patient’s experience.

- Brittany Baine, J.D.

HIPAA Compliance & Medical Scribes

Let’s talk about HIPAA privacy and security as it relates to scribes.  The very nature of the scribe job description requires access to Protected Health Information (PHI); scribes enter information into the patient’s record at the direction of a provider and retrieve patient information from various sources on behalf of the provider.  For this reason, it is imperative that HIPAA compliance is made a top priority during scribe training and continually monitored from a management perspective.

For the purposes of this blog post, we are going to focus on two main aspects of HIPAA compliance with regard to scribes: proper training and proper access.

Proper HIPAA Compliance Training

As with all other types of healthcare personnel, scribes should undergo structured HIPAA training prior to working in any healthcare facility. Training courses vary in the manner of presentation (whether it is a classroom setting or an online learning module), but the materials should at least focus on the following:

  •    History and purpose of HIPAA regulations
  •    What type of information is protected and in what formats?
  •    The “minimum necessary rule” and the definition of a breach
  •     Best practices: examples of appropriate use and misuse of PHI
  •     Consequences for violating HIPAA
  •     How to report violations

Another topic that is wise to include is the application of HIPAA regulations to the online environment.  As our personal and professional lives continue to become increasingly more electronic and with the growth in use of such social media outlets as Facebook and Twitter, it is important to educate healthcare workers that the principles taught during HIPAA training also apply to the online world.  There have been many recent cases involving HIPAA violations and social media, which can serve as real-world examples of “what not to do.”  For example:

Rhode Island ER Physician Terminated for Posting Patient Info on Facebook

Nurses Fired for Discussion on Facebook

Nurses Terminated for Posting Cell Phone Pictures of X-Rays

Proper Access to Electronic PHI (e-PHI)

With more and more healthcare facilities switching to electronic medical record systems, it is important to ensure that scribe access to such EMRs is compliant with HIPAA security requirements.  First and foremost, each individual scribe should be issued a unique login or user identification with a secure password in order to gain access to any electronic system housing electronic PHI.  Generic scribe logins or shared logins are not permissible, as unique identifiers are required in order to track each user’s activity and system access in accordance with the HIPAA Security Rule.

While this seems simple enough, it is important to keep this principle in mind, especially under special circumstances, such as scribe training.  During any type of on-site training, both a “trainer” scribe and a “trainee” scribe need to have their own individual logins or user identification.  Additionally, as with all healthcare workers, scribes should be instructed to never share login information or passwords and to regularly change their passwords in conjunction with hospital policy.

HIPAA compliance is certainly not unique to the scribe industry, for these regulations apply to all healthcare workers in the U.S.  It is recommended that medical scribes receive HIPAA training upon hire (and before working in the facility) and annually thereafter.

For information on the training curriculum offered by PhysAssist Scribes, please visit the PhysAssist Scribes website, here.

 – Brittany Baine, J.D.

PQRS: Haven’t started reporting yet? Your scribe can help.

As the end of 2012 draws near, eligible professionals who have not already begun reporting PQRS measures will soon decide whether or not they will begin in 2013.  As you know, the Physician Quality Reporting System (PQRS) was launched in 2006 (originally named the Physician Quality Reporting Initiative or PQRI) in order to provide a financial incentive to eligible professionals for voluntarily reporting data on designated quality measures with regard to Medicare patients. For 2012, eligible professionals who satisfactorily report on at least three (3) measures could receive an incentive payment of 0.5% of their total estimated allowed charges for Medicare Part B Physician Fee Schedule (PFS) covered services provided during the reporting period.  The same incentive payment will be available to eligible professionals (which includes physicians, physician assistants, and nurse practitioners, among others) for 2013 and 2014.

While the program is technically voluntary, eligible professionals who do not satisfactorily report PQRS measures will experience a negative payment adjustment, which is based upon the professional’s total Medicare charges during the reporting period, beginning in 2015.  It is important to note that the negative payment adjustment of 1.5% for 2015 will be based upon the measures reported during 2013; in other words, to avoid experiencing any “penalty” adjustments, eligible professionals must begin reporting PQRS measures in 2013. See chart below.

From an emergency provider standpoint, there are 16 measures out of over 300 measures that apply to the emergency department setting:

#28 – Aspirin at Arrival for Acute Myocardial Infarction (AMI)

#31 – Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage

#54 -12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain

#55 -12-Lead Electrocardiogram (ECG) Performed for Syncope

#56 – Community-Acquired Pneumonia (CAP): Vital Signs

#57 – Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation

#58 – Community-Acquired Pneumonia (CAP): Assessment of Mental Status

#59 – Community-Acquired Pneumonia (CAP): Empiric Antibiotic

#76 – Central Venous Catheter (CVC) Insertion Protocol

#91 – Acute Otitis Externa (AOE): Topical Therapy

#92 – Acute Otitis Externa (AOE): Pain Assessment

#93 – Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

#252 – Anticoagulation for Acute Pulmonary Embolus Patients

#253 – Pregnancy Test for Female Abdominal Pain Patients

#254 – Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

#255 – Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

Eligible ED-based professionals should report on at least three (3) measures during the reporting period (typically January 1 – December 31 for ED-based professionals) in order to receive the incentive payment.  While there are several ways in which to submit PQRS measures to CMS, the two main methods for ED-based professionals are claims-based submissions and registry-based submissions.  Regardless of the method used, the most important aspect of PQRS measurement is ensuring that the required data elements for each measure are properly included in the medical record; conversely, it is equally as important to document the patient, medical, or health system reasons why a particular measure was not met for a specific patient in order to still get credit for the measure (ex: aspirin not given on arrival due to patient refusal or aspirin allergy). For claims-based submissions, coding professionals can assign a designated code and modifier in order to report the measure to CMS based on the information in the medical record.

Specially trained medical scribes can help physicians document PQRS measures.  As an advanced training topic, scribes can learn the data elements necessary to include in the medical record in order to get credit for a particular PQRS measure.  Scribes can prompt physicians to include additional, necessary information, such as providing the medical or patient reason for not meeting a certain measure.  While the eligible professional is ultimately responsible for all information entered into the record, it is invaluable to have a scribe trained in recognizing the type of patient encounters for which the physician will be able to report on the quality of care provided.

For more information on scribe training innovations as provided by PhysAssist Scribes, please click here.

- Brittany Baine, J.D.

 

PQRS Incentive Payments or Payment Adjustments by Calendar Year

2011: 1.0% incentive payment

2012: 0.5% incentive payment

2013: 0.5% incentive payment

2014: 0.5.% incentive payment

2015: -1.5% payment adjustment

2016 and beyond: -2.0% payment adjustment

 

Resources:

Information on PQRS can be found on the CMS website, found here.

ACEP FAQ on PQRS and Emergency Medicine can be found here.

CMS Releases Final Rule for Stage 2 of Meaningful Use

Today, CMS has released the final rule for Stage 2 of the federal EHR incentive program known as “Meaningful Use.”  As a companion rule, the Office of the National Coordinator for Health Information Technology (ONC) has also released its final rule on certification criteria, standards, and implementation specifications for certified EHR technology. You can find each of the rules below:

Stage 2 of Meaningful Use – Final Rule

ONC Certification Criteria – 2014

Particularly of note, CMS has released its response to requested commentary on whether or not scribes may be utilized in the CPOE (Computerized Physician Order Entry) process and be regarded as having met the CPOE core objective.  A discussion on the commentary received by CMS, as well as the accompanying response, begins on Page 53986 of the published Final Rule.  If you’ll remember from a previous blog post (found here), we discussed the various concerns surrounding scribes and order entry and we proposed solutions to alleviate potential concerns.  One component of the CPOE definition as promulgated by CMS is the requirement that the order be entered by someone who could exercise clinical judgment in the event that the entry generates any automated alerts.

Some groups have found that with a properly structured EMR workflow, the alerts could be generated at two points: once at the time of drafting by the scribe and then also at the time of review and authentication by the provider.  With this workflow, it can be assured that a person who could exercise clinical judgment would be able to view the alert as a clinical support aide.

However, not all EMRs are created equal.  In the Final Rule, CMS states that it is conceivably possible that a scribe would be the only user to whom the alert would be viewable, due to the fact that not every EMR is capable of generating the alerts at the time the order is authorized by the physician (some EMRs are only capable of generating the alert once).  It is for this reason, that CMS states that orders should be entered by a licensed healthcare professional who could exercise clinical judgment (not the scribe).

This particular scenario is just one example of the need for EMR standardization. In fact, the 2014 EHR certification criteria as released by the ONC today is a step in the right direction. The new criteria are aimed to allow for greater flexibility, improved communication, and to promote a move towards greater system interoperability.

For an interesting read on the various hurdles to be overcome in order to achieve interoperability, check out Part 1 and Part 2 of this interview of one Health IT Researcher.

- Brittany Baine, J.D.

CMS Guidelines for Scribes

As you may know, Medicare claims submitted to CMS for reimbursement are processed by Medicare Administrative Contractors (or MACs).  MACs are private companies with whom CMS has contracted to administer all Medicare Part A and B claims within certain jurisdictions.  (Medicare Part A covers inpatient hospital services, among others; Medicare Part B covers physician services, outpatient care, and other medically necessary services).

Originally, CMS divided the country into 15 A/B MAC jurisdictions and awarded each jurisdiction through competitive procedures to various private companies.  However, over the next several years, the 15 A/B MAC jurisdictions will be consolidated into 10 larger jurisdictions for cost saving purposes.

Each MAC has the authority to issue its own documentation guidelines for all claims submitted within its jurisdiction, including guidelines on scribe use.  Each of the MACs listed below have issued guidelines, an FAQ, or bulletin with regard to the use of scribes (with links to each):

Generally speaking, the MACs state that scribes may document the words and/or activities as they are performed by the practitioner during a patient encounter (much like the Joint Commission guidelines).  While the practitioner is ultimately responsible for the record, scribes should be trained to have a basic understanding of the E/M Documentation Guidelines as set out by CMS.  Furthermore, several MACs have issued specific signature requirements to be used when scribes are utilized (for example, clearly indicating who performed the service, who recorded the service, the qualifications of each, and the date and signature of both the practitioner and scribe).  When adding scribes to your practice, it is important to consult the MAC guidelines for your jurisdiction in order to develop CMS compliant scribe workflows and policies.

For more information on MAC jurisdictions and to determine which MAC operates within your state, please visit the CMS website on A/B MACs found here.

- Brittany Baine, J.D.

 

Resources:

1. 1995 E/M Documentation Guidelines, Centers for Medicare and Medicaid Services.

2. 1997 E/M Documentation Guidelines, Centers for Medicare and Medicaid Services.