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January 7, 2008

Healthcare 2008: The Shape of Things to Come
By Annie Macios
For The Record
Vol. 20 No. 1 P. 8

Industry experts crack open the proverbial fortune cookie to forecast what lies ahead.
Ten years ago, one might not have believed that HIT would evolve to the point where it is now. With the face of health information continually changing, it’s hard to predict where technology will take HIM professionals in the coming year. Whether you use a Magic 8-Ball, a fortune cookie, or just old-fashioned common sense, the future always seems to hold as many “knowns” as “unknowns.” Helping For The Record predict the hottest issues of 2008 are leaders in their fields who have seen countless trends come and go in the healthcare industry.

It’s no secret that “cash is king” in maintaining a smooth-running healthcare facility. What reimbursement issues may HIM professionals encounter in the coming year?

“I think we’ll see Medicare’s Physician Quality Reporting Initiative [PQRI] on a larger scale,” says Sheri Poe Bernard, CPC, CPC-H, CPC-P, vice president of member relations at the American Academy of Professional Coders (AAPC).

Currently a voluntary program, the PQRI has few healthcare organizations participating because the 1.5% payment is not a “big enough carrot.” But Bernard believes that by the end of 2008, providers will understand that the financial carrot is going to become much larger. “It will also soon become required rather than optional. It is a big deal because it requires a lot of additional reporting, which can be difficult if an organization is not using an electronic medical record [EMR],” she adds.

As such, she predicts that more physician offices will be pushed toward using an EMR because those with pay-for-performance data capture in their functionality make it easier to generate the codes required in the PQRI.

In turn, practices must plan for the EMR, as that will be a big part of increasing pay-for-performance participation. “Coders are not always high up on the totem pole when decisions regarding EMR choice are made,” says Bernard, adding that a facility may select an EMR with great clinical data capture, but it may not be adequate for coding compliance. Therefore, it is vital to involve HIM staff and coders in the EMR selection process.

Bernard says participating in the PQRI at this stage in the game is a great “dress rehearsal” for Medicare and can be viewed as a way to eliminate glitches before participation is required.

As technologies evolve to support accurate and timely reporting, where will the focus be in 2008?

Brenda J. Hurley, CMT, FAAMT, director of industry relations and compliance at Medware, admits with jest that there is a fine line between what she believes will happen in 2008 and what she hopes will happen. Nonetheless, she sees definite trends that point to improvement in reporting and quality of care.

Hurley believes the electronic template in new EMRs will be more critically evaluated to ensure a useful product. “People jump on the bandwagon so quick for saving costs and completing reporting that now the problem is the information input starts to look like cookie cutter reports,” she says. This provides limited value to patient continuity of care, and agencies such as the Centers for Medicare & Medicaid Services (CMS) are now reviewing templates because physicians are complaining that information in the reports is vague or doesn’t apply to a patient’s current condition.

“Evaluation is appropriate because what is the goal of reporting? To generate a report with useful information,” says Hurley. In the end, it comes down to weighing the value of the information gleaned vs. cost. She says it is too easy to integrate these things to save money even if it doesn’t provide quality of care to patients.

With patient safety and accurate reporting in mind, Hurley also predicts there will be a trend toward evaluating the use of abbreviations and content of information. “There is not enough emphasis on what information needs to be on the report. We need to generate essential components,” she says, adding that there needs to be report standardization, and while the American Society of Testing and Materials International has standards, they are not embraced as they should be.

What about EMRs and other technologies?
“I believe that we will see a continued increase in the number of [EMR] installations both in hospitals, as well as physicians’ offices,” says AHIMA President Wendy Mangin, MS, RHIA, who is also director of medical records at Good Samaritan Hospital in Vincennes, Ind. The recent relaxation of the Stark law permits hospitals, under certain circumstances, to supply an EMR to physicians. “I believe there will be a groundswell of installations in the next year or two,” she adds.

Mangin also cites continued work defining the legal e-health record. “AHIMA is working with HL7 [Health Level Seven] to come up with the definition, with a draft currently published,” she says. Because of the volume of information available, how the legal electronic record is defined has become increasingly important.

Hurley says institutions and medical transcription services will continue looking at speech recognition (SR) technology in 2008. “In the transcription world, that’s OK. We look to use technology for better efficiency,” she says. “But don’t put transcriptionists in a world where we’re just correcting the same errors every day and then expect increasing productivity.”

For the new year, Hurley is hoping to see SR implementation that incorporates two main cost-effective strategies: standardization of healthcare documents and following dictation best practices format. By applying these two factors, she believes greater efficiency will be achieved with traditional transcription, as well as the technological investment. “Why wait? Prepare now for technology to move ahead. Tackle the basics, and meanwhile, you can reap the benefits,” says Hurley.

Amber Doster, vice president of marketing at HealthPort, believes technology will be a valuable tool in the hands of healthcare organizations. “More and more, we are seeing that providers want access to an increasing detail of information,” she says. “In 2007, we experienced a spike in requests for product functionality and services that centered around pulling information from areas that have never before been accessed. Paper records don’t just need to be in the provider’s hands, they need the ability to quickly search through many types of documents for certain terms or procedures for patient care. In 2008, this need will only grow, and it will help drive solution development from a vendor perspective.”

The Effects of Consumer Empowerment
“I believe consumer-directed healthcare could hit physicians hard and heavy in the coming year,” says Bernard. With group insurance plans taking the approach of enlightening their clients to the cost of healthcare and changing the way reimbursement is handled, consumers will be more conscious of where they spend their healthcare dollars.

What does this mean to the HIM professional? For coders, especially those in physician offices, it is likely that consumers will ask for costs up front and comparison shop. “It creates a process of change and affects the flow of information in the office. It’s totally unusual for the front desk to ask the business office, ‘How much will this procedure cost?’” says Bernard. By comparison shopping and looking for the best deal, consumers will ultimately drive down prices, and the quality of care will be raised as physicians compete for business.
Perhaps more significantly, collecting from consumers who have more responsibility for payment will cause accounts receivable to swell as practices adjust to the changing rules of consumer-directed healthcare. Bernard expects collection and other administrative costs to rise as a result.

Personal Health Records
Mangin forecasts that there will be more companies offering online PHR storage. As such, she anticipates privacy concerns will continue to emerge as patients demand control over who has access to their personal information.

As the number of PHRs grows, healthcare facilities will have to prepare for patients presenting their health information on different kinds of media. For example, Mangin’s facility had a patient arrive with his information on a flash drive. “Facilities will have to think about how they will handle the information,” she says.

To raise public awareness of the PHR, the AHIMA has launched a campaign called “It’s Hi Time America” that promotes four components essential to a comprehensive health record: high technology, high quality, high security, and high standards. The campaign calls on HIM professionals to educate healthcare consumers on the subject and encourage them to begin their own PHR.

Elsewhere on the PHR front, Hurley says the Association for Healthcare Documentation Integrity (AHDI) is participating in initiatives that will help individuals capture their PHR. “As medical transcriptionists, this is absolutely consistent with what we do every day: data capture,” she says. While helping to expand the number of individuals who have created their PHR, AHDI members will explain the technology and assist individuals such as senior citizens in capturing their own data.

What legislative issues affecting HIM may arise in 2008?

Bernard foresees 2008 legislation that could set the date for ICD-10-CM and ICD-10-PCS implementation. “Code changes are fairly stable this year,” she says, noting that facilities that have adopted computer systems report tripled productivity from coders. But she also says coding is more complicated and intricate than in the past. “Specialties that have a good system in place are going to have great success,” she predicts.

On the informatics side, Don E. Detmer, MD, MA, president and CEO of the American Medical Informatics Association (AMIA), believes that after years of discussion, the legislature will implement one or more bills relating to HIT and informatics concerning workforce, standards, and quality.

Relative to quality, Detmer is delighted that the government is “finally facing the reality regarding America’s perverse disincentives to implementing electronic health records [EHRs] in small practice settings” with CMS finally subsidizing the entry of small practices into the EHR world. He says this could potentially become the event of the decade, since it was previously unclear whether the United States would ever attempt to catch up with the healthcare systems of other nations with regard to federal financial investment. From his perspective, the federal government must see itself as part of the solution to the financial barriers of the implementation challenge, primarily since the government pays such a large part of the nation’s healthcare financing.

Contributing to this issue for Americans, Detmer observes, are serious issues surrounding the safety and quality of care, concerns for which EHRs with clinical decision support can significantly improve performance while mitigating care costs that continue to rise at an unsustainable rate.

With the current decision to eschew financing for EHRs, the government is standing by while wasting billions of taxpayers’ dollars, according to Detmer. He points out how media coverage in Europe is becoming more positive about their IT systems now that the benefits are starting to emerge. In addition, multinational research supported by The Commonwealth Fund documents both the value of robust systems and how the United States lags behind.

Detmer also says it has become apparent that our nation is not properly prepared for dealing with health information in the case of natural or manmade catastrophes. “September 11, SARS, and [Hurricane] Katrina were an insufficient signal to the U.S. government to see that EHRs and an IT infrastructure are essential for our nation’s day-to-day healthcare, as well as its long-term security and care in times of disaster. Only time will tell how this turns out, but prospects today appear dim to grim,” he says.

Doster says to expect Washington to be busy this year. “Over the last year, we, as a company, have seen a large movement toward government regulations for healthcare IT and data exchange,” she says. “With increasing momentum for Medicare bonus payments for e-prescribing, increased discussions on universal healthcare, and various other regulations coming from Washington, D.C., we believe 2008 will be a year in which more defined roles are set for major portions of healthcare IT.”

With technology taking off the way it has, healthcare informatics has come to the forefront. What will be the key issues in this area?

Detmer is keen to see what transpires with American Health Information Community (AHIC) version 2. Clearly, he notes, progress has recently been made in the area of standards and greater interoperability through the efforts of the AHIC and the Office of the National Coordinator. However, the financial viability of regional health information networks remains a major issue of concern, as does confidentiality, security, and the genuine threat to legitimate medical research if this issue isn’t understood sufficiently by the American public and their representatives. In addition, Detmer believes the informatics workforce needs additional funding to address growing demands.

Detmer predicts that large industry players such as Microsoft and Google will continue to wade into healthcare. “The issue here,” he posits, “is how much Americans will really benefit by corporations seeking their own closed approaches over an open-systems approach to such health-related issues. Maybe we’ll be better off and maybe not.”

What’s in the 2008 forecast for the HIM profession?

In the coming year, Hurley sees medical transcription becoming more diverse. “Our world is changing and evolving,” she says, predicting an increased role for transcriptionists that will continue to change as the year progresses.

“I may be biased,” Detmer says, but he believes more people are acknowledging AMIA’s larger influence. “AMIA is now much more visibly engaged, nationally and globally. A formal trilateral arrangement of AMIA with the European Federation for Medical Informatics and the Asia Pacific Association for Medical Informatics with the support of the International Medical Informatics Association is one sign of this,” he says.

He also notes examples of AMIA’s rising visibility at the national level as well, citing new funding from the Centers for Disease Control and Prevention, the National Center for Research Resources, and Telemedicine and Advanced Technology Research Center. “Basically, we have gone from push to pull, and this will continue into the future,” says Detmer.

According to Mangin, job security for HIM professionals is very good; however, she believes there will be a shortage of qualified HIM professionals. “This makes it harder for all the successful implementations of systems and technology,” she says, because it is essential to have staff that know about process redesign and difficult to implement systems without skilled, knowledgeable staff. The AHIMA is trying to increase the number of students going into its programs, “but that remains a continued challenge for the coming year,” according to Mangin.

A shortfall of HIM professionals could lead providers to lean more heavily on outsourcing. “More responsibilities are being placed on the medical records community, and their knowledge of new areas in the healthcare IT marketplace has expanded as well,” Doster says. “This means there is less time to focus on day-to-day operations and the work that affects both bottom-line revenue and patient care. Outsourced services for these tasks that typically influence these critical areas will most likely grow in 2008. Experienced staff with the credentials to handle these services is becoming harder to find and outsourcing the services is becoming a decision that is needed to keep up with organizational goals.”

The concept of health information exchange (HIE) is also making its presence known. “A lot of areas are involved in health information exchange, and there is definitely a role for HIM professionals in making those come to fruition,” says Mangin. The AHIMA has created a practice council that will examine existing research, develop mission statements, and recommend agendas for research to help implement HIE. “It’s an evolving area, and our members are getting involved,” she adds.

— Annie Macios is a freelance writer based in Doylestown, Pa