A medium-sized physician group operates multiple ambulatory care centers since its inception in 2001. Each care center has different uses of medical records that range from paper records, homegrown specific databases, paper calendars, and Google calendars. Each ambulatory care center operates independently with no EHR (Electronic Health Record) that connects the center’s data. Furthermore, each care center has different operational standards and ways to execute their data. This is shown with one center utilizing handwritten notes and another employing a 15-year-old nephew of one of the physicians to program a database of their own to schedule appointments. According to Science Daily, 61% of medication errors are due to illegible handwriting and transcription errors (Science Daily, 2007). The same study found that when US hospitals switch to electronic systems 66% of prescription errors were reduced. Furthermore, with a lack of continuity with calendars within each center costly scheduling errors are inevitable. This increases wait times for the more popular centers and takes away valuable time for the employees that could be working on other tasks. Similarly, this is also a waste of productivity for the centers as they do not operate exclusively with one system which will create economies of scale and increase productivity, by employing one person instead of numerous for each center. In conclusion, the issue at hand is the lack of uniformity and interface between the care centers which is creating inefficiencies which are resulting in fewer profits.
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To increase profitability the ambulatory care centers will need to take advantage of creating and implementing an EHR. There are two reasons why an implementation of an EHR will be beneficial for the care centers. The first reason is that it will streamline calendars, medical records, billing, coding, and data sets. This will be more efficient and will allow the centers to operate with added information. The second reason why the implementation of an EHR will be beneficial is that of the federal government incentive. This incentive is provided to ambulatory centers that provide care to Medicare “eligible providers” that are EHR certified.
On February 17th, 2009 the American Recovery and Reinvestment Act of 2009 (ARRA) was enacted (Himss, 2018). Apart of the ARRA, the Centers for Medicare and Medicaid services was tasked to create an EHR incentive program, also known as meaningful use. The incentive program was established to accelerate the use of qualified EHR’s and to be “meaningfully using” the EHR (Incentive Program, 2018). The Medicare incentive that is given when all requirements of the EHR are being met is a maximum amount of $44,000 (Incentive Program, 2018) which is given across five years of program participation.
With all the talk of the ambulatory care centers and the benefits of centers creating an EHR, it is important to know what an EHR is. An Electronic Health Record (EHR) allows healthcare providers to record patient information electronically instead of using paper records. However, EHRs are often capable of doing much more than just recording information. The EHR Incentive Program asks providers to use the capabilities of their EHRs to achieve benchmarks that can lead to improved patient care (Incentive Program, 2018). This improved patient care is the ultimate goal and reasoning for the incentive program. Furthermore, EHR systems provide immediate electronic access to person and population-level information by authorized users. Provide knowledge and decision support that enhance patient care, while creating an efficient process for healthcare delivery (Giannangelo, 2015, p. 336).
Code Sets Implemented
Within the EHR that is implemented, there will be code sets that will help organize the data sets that will be created from the input of data. “A data set is a method to capture and organize certain data elements in order to turn data into information” (Giannangelo, 2015, p.249). With the organization of information that will be input from the centers, the operation will be more efficient with patient’s medical information. The different code sets that will be vital to gaining “meaningful use” and will need to be implemented within the centers EHR is ICD-10, SNOMED-CT, NDC, HCPCS, CPT, and HL7.
First, ICD-10 is the tenth revision of ICD which was implemented in 1983 from the World Health Organization. ICD stands for International Classification of Diseases and is used to communicate healthcare information for services so that they are able to be reimbursed (Giannangelo, 2015, p.19). In the US, ICD is able to assist in coding and classifying diagnoses from the following: Inpatient and outpatient hospitals, Physician offices, Long-term care facilities, and home health agencies. Furthermore, ICD was developed as a way to collect data on the causes of death, and today ICD-10 is used to record both the morbidity and mortality data by many countries (Giannangelo, 2015, p.19). By having this coding system, data can be collected analyzed, interpreted and compared. ICD-10 consists of three volumes, twenty-two chapters, and uses alphanumeric codes. The three volumes are divided into a tabular list, instruction manual, and alphabetic index. Lastly, ICD-11 which will be the eleventh revision to ICD is set to start being reported in January 2022 following endorsement (World Health Organization, 2018, para. 8).
SNOMED-CT is the most comprehensive, multilingual clinical terminology in the world. Its controlled medical terminology has comprehensive coverage of diseases, clinical findings, etiologies, and procedures and outcomes used by doctors, nurses, dentists, and other health professionals (Giannangelo, 2015, p. 104-106). The clinical terminology gives clinical consent and expressivity for clinical documentation and reporting. Because of the comprehensive coverage that SNOMED-CT is able to describe, the communication and accuracy that is given to EHR’s are able to provide greater clinical care to patients. SNOMED-CT was first released in January 2002 in Pathology and quickly was used in other medical fields. SNOMED-CT is broken down into the following main components: Concepts, descriptions, relationships, reference sets, cross maps, and other resources (Giannangelo, 2015, p. 107-108). The main component is the concepts which can be thought of as the basic units of SNOMED-CT. The concepts cover disorders, findings, body structures, procedures, pharmacy products, and other encompasses related to healthcare. With the broad scope that is covered in SNOMED-CT, it is the largest of any of the codes and contains over 300,000 active concepts, almost a half a million descriptions, and one million relationships (Giannangelo, 2015, p. 106).
The national drug code was designed and implemented to serve as a universal product identifier for frequently prescribed drugs. These product identifiers are only for use as human drugs and biologics (Giannangelo, 2018, p. 83). NDC was originally created to serve as an essential part for out-of-hospital drug reimbursement program for Medicare but has since increased its scope. The code is a unique three segment ten digit code that is present on all nonprescription (OTC) and prescription medication packages and inserts in the US (Idaho MMIS, 2018, para. 1). The three segments that make up the NDC are labeler, product code, and package code. The labeler is any firm that manufactures, repacks, or distributes a drug product. The product code identifies the specific strengths, dosage form, and formulation of a drug for a specific manufacturer. Lastly, the package code identifies the package size.
Introduced in 1983 and published by the Centers for Medicare and Medicaid Services, HCPCS stands for Healthcare Common Procedure Coding System. “HCPCS is a standardized system for healthcare providers and medical suppliers to report professional services, procedures, and supplies” (Giannangelo, 2018, p. 70), which is required in healthcare settings for reimbursement of ambulatory services. There are two levels of HCPCS codes. HCPCS level I codes comprise the CPT coding system. The level I codes are comprised of five characters and two-digit modifiers. Additionally, “CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals” (Giannangelo, 2018, p. 71). The second level of HCPCS is HCPCS level II. Level II codes began in the 1980’s and are referred to as alphanumeric codes. This is because they consist of a single alphabetical letter then by four digits. The level II codes are a coding system that is used to identify products, supplies, and services that are not found in the CPT codes. Lastly, the level II codes are not used for billing and HCPCS are made independent of the process for making determinist regarding payment and coverage.
CPT which stands for Current Procedural Terminology is a medical code set that is used to report surgical, medical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations (TechTarget Network, 2018, para 1). CPT is used in coordination with ICD-10 for medical billing and reimbursement. CPT is a part of the Healthcare Common Procedure Coding System (HCPCS) which was described above. There are three parts of CPT which are broken down into category I, category, II, and category III. Category I covers procedures and contemporary medical practices that are performed. The six sections that are covered in the category are evaluation, management, anesthesiology, surgery, radiology, pathology and laboratory, and medicine. Category II consists of supplementary tracking codes that are used for performance measures and help measure the quality of care delivered. Lastly, category III contains temporary codes that cover emerging technologies, services, and procedures. Category III codes are different from category I codes in that are not performed frequently or ones that are not FDA approved.
Health Level Seven International (HL7) is a consensus standard development organization recognized by ISO and accredited by ANSI. HL7 was founded in 1987 and is “dedicated to providing a comprehensive framework and related standard for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services (Giannangelo, 2018, p. 279).” HL7 helps create interoperability standards. Interoperability means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered (Giannangelo, 2018, p. 338)”
Interpretation and Implementation
The implementation process for the EHR is done in three stages. Each stage has different benchmarks that will need to be met. If the benchmarks that are made are met in the three stages then the center will be eligible to receive the full incentive of $44,000 that was stated above. The entire incentive program is voluntary. However, if a hospital or center chooses not to be a part of the incentive program and fails to meet the required criteria by 2015 then there will be negative adjustments to their Medicare/Medicaid fees starting at 1% reduction up to 3% reduction by 2017 which will continually go up (CDC, 2017, para 2). Since the centers can possibly see a reduction in their reimbursement it makes logical sense to implement the new EHR. If the centers are not successful or fail to implement an EHR they risk to receive less money which will further hurt their profitability. The first category which is called meaningful use stage 1 was released on July 13, 2010. This release contained the objectives, measures, and standards that need to be met. The rules that are located within this contain 15 core set objectives, and 10 menu set objectives (CDC, 2017, para 3). An example from an objective in stage 1 is “implement drug-drug and drug-allergy interaction checks (Centers for Medicare & Medicaid Services, 2018, p. 29).” This objective will then have a measure and criteria that will be met.
Meaningful use stage 2’s final requirements were created on August 23, 2012 (CDC, 2017, para 5). The requirements that were created must be met for each hospital or center to be eligible for stage 2’s incentive. This stage included 17 core objectives and 3 of 6 menu set objectives for eligible professionals and 16 core objectives for hospitals. An example of a stage 2 objective is “Ensure adequate privacy and security protections for personal health information (Centers for Medicare & Medicaid Services, 2012, p. 82).” Again this objective will then have a measure and criteria that will be met to be eligible to receive the incentive.
Finally, on October 16, 2015, the CMS released the final rule for stage 3’s for meaningful use (CDC, 2017, para 7). This is the final requirements that must be met before hospitals, centers, and eligible professionals receive the final incentive. However, if the requirements are not met then this is when the negative adjustments start to Medicare reimbursement, starting at 1% reduction. For stage 3 hospitals and centers will need to attest to any combination of four measures out of six from the meaningful use final rules.
As you can imagine a huge undertaking as in implementing a new EHR for multiple health care centers will be a challenge. The biggest challenges will be the consolidating of past, current, and future data of records that had previously been written down, on google sheets, or just on a word document and interoperability amongst the multiple code sets that will be implemented in the EHR. In addition, the lack of consistency within each individual center and ways to streamline data amongst the centers will be a difficult challenge to overcome. Being able to accurately input existing, current, and future data into the new EHR will take valuable time and will need to be managed effectively. This can be done by hiring an outside company to input data, or by having current employees complete the task. When the data has then been entered the challenge will be how the code sets will be able to communicate amongst each other through varying operating systems and create interoperability. This is where HL7 and LOINC come in to play. As stated previously Health Seven International (HL7) is a code set that that provides a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information. Additionally, the Logical Observation Identifiers, Names, and Codes (LOINC) standard provide a set of universal identifiers for laboratory and clinical observations that can serve for information exchange between electronic systems (Giannangelo, 2018, p. 170). Because of these two codes the different code sets will be integrated amongst each other and be able to communicate effectively amongst the multiple care centers. In addition, to the difficulties in the coding challenges there will also be a challenge with the existing physicians, nurses, and medical staff with the care centers with the implementation of the EHR. This challenge is in regards to change and the difficulties that people in the workplace have with change. Being able for the leaders in the centers to show the benefit of the EHR will be beneficial to get all of the employees on board. This will be just as challenging.
Step by Step Integration
According to the AMA (Hodgkins MD, 2018, para 2), there are nine steps to a successful implementation of a new EHR. The nine steps are:
1. Create an implementation team
The team that will be in charge of the implementation will need to be made up of physicians, nurses, medical assistance, compliance, and administrative staff of the physician group. Having a team ready and in place is necessary because they are able to train other staff and raise awareness of challenges that are encountered. Furthermore, this will help in regards to change and the employees that are not as adaptable. By having a group of peers leading the training and implementation buy-in will be greater and overall lead to a better implementation.
2. Configure the software
This will require the help from internal IT or hiring an external IT team. Ensuring that the software used meets appropriate security measures is essential so that you are not failing to meet HIPPA requirements.
3. Identify hardware needs
Ensuring that the correct hardware is available to the centers physicians, nurses, and the staff is essential to creating efficiency. It is shown that having a printer in every room and a large screen for the computers saves 50 minutes of physician time per day (Hodgkins MD, 2018, para 10). Furthermore, the use of tablets will need to be considered as each physician will not need to log in and out upon entering each room which will further increase efficiency. This short-term investment will be beneficial in the long run with increased efficiency from all medical staff.
4. Transfer data
Making sure the migration of existing data is being accurately recorded into the new EHR is extremely important. By having existing staff or hiring an outside company to accurately transfer data such as demographics, past medical history, medication history, etc. will ensure that the EHR is being used effectively. Furthermore, by creating a checklist for the physician group to complete per patient will help make sure that all needed information is being inserted (Hodgkins MD, 2018, para 13). Lastly, knowing how much time it will take per patient to transfer is important, so that you are able to evenly distribute the patients and transfer the data on time without any unexpected delays.
5. Optimize pre-launch workflows
Making sure that all necessary workflows are completed before EHR implementation will help with the limited resources during implementation. Some of the questions that can be asked to ensure its necessary are: Does it add value, is it being done in the right order, and is it being done by the right person?
6. Consider the room layout
Afton overlooked in the implementation and design phase is the layout of the room. Creating an efficient layout will not only save money but create more trust from the patients. An example is the physician group should use the “triangle of trust” which puts the patient, physician, and computer at points of a virtual triangle which generates effective communication (Hodgkins MD, 2018, para 18). This eliminates the physician having to look over the computer or behind them to effectively speak to their patient. Furthermore, options to place computers on carts which can be wheeled and positioned in the most effective location have increased patient satisfaction.
7. Decide the launch approach
There are two ways that the approach can be implemented for the centers. The first is the “big bang.” The big bang means that the EHR functions will be converted for the patients and users on the same day at the same time (Hodgkins MD, 2018, para 19). The benefits to this will be that it eliminates confusion amongst physicians and staff since all tasks will be completed electronically at the same time. Additionally, the benefits of having the EHR will be seen sooner. However, the disadvantages of a big bang rollout are that small glitches can be amplified and that this rollout takes significant resources and staff support. The second rollout option is an incremental approach. This approach meaning turning on certain functions in a step-wise approach, such as starting with e-prescribing, and a few months later adding visit note documentation functionality (Hodgkins MD, 2018, para 22). Another incremental approach is to implement the EHR in certain sites or departments and slowly roll out to the rest of the organization, learning and tweaking the process along the way. The benefits to this approach are it reduces productivity loss and it allows the physicians and staff to gradually earn the EHR and its capabilities. However, the disadvantages are it requires a lengthy process of step by step implementation and requires awareness of the different phases that are being launched on certain days.
8. Develop procedures when your EHR is down
What will the centers do when there is a power outage or when the software/hardware is down? Creating contingency plans is essential to ensuring procedures are being followed in case of malfunction. Some practices have been known to file to do’s in easy to read three-ring binders with checklists to ensure standard and procedures are being met.
9. Initiate a training plan
Finally, creating a training plan is vital to ensuring that all key players are aware of the capabilities of the EHR and how to use it efficiently and effectively. The three steps to ensure readiness is to go slowly when training, arrange for colleagues to train each other, and to plan for ongoing training needs (Hodgkins MD, 2018, para 26). Going slowly will make sure that everyone is knowledgeable and not rushed during training. Arranging for colleagues to train each other works best because when physicians train physician and nurses train nurses they are better able to relate to what needs to be trained and how to effectively utilize the new EHR. Lastly, the EHR is forever changing and updating. Making sure that everyone that is utilizing the EHR is aware of these changes will once again make sure that the EHR is being used effectively.
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In summary, the new EHR for the physician group is a big deal! Being able to upgrade the multiple outdated systems and the individual systems that had no ways to communicate amongst each other will not only increase efficiency and productivity but will also make the physician group a Medicare-eligible provider and receive a $44,000 incentive. However, there are multiple challenges that are going to be difficult to overcome. These obstacles are code sets used, hardware and software configurations, communication between code sets, and the implementation process. Fortunately, when the physician group is able to configure the EHR and create the “meaningful use” from the EHR better efficiency will be made and the Medicare incentive will be granted.
- CDC. (2017, January 18). Meaningful Use. Retrieved from https://www.cdc.gov/ehrmeaningfuluse/introduction.html
- Centers for Medicare & Medicaid Services. (2012, September 4). Federal Register. Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf
- Centers for Medicare & Medicaid Services. (2018, October 4). Promoting Interoperability (PI). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html
- Federal Register. (2010, July 28). Department of Health and Human Services. Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17210.pdf
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- Himss. (2018). What is the Meaningful Use Incentive Program? Retrieved from https://www.himss.org/library/meaningful-use/what-is
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- Idaho MMIS. (2018, February 9). National Drug Codes. Retrieved from https://www.idmedicaid.com/Reference/NDC Format for Billing PAD.pdf
- Incentive Program. (2018). An Introduction to the Medicare EHR Incentive Program for Eligible Professionals. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/beginners_guide.pdf
- Science Daily. (2007, June 27). Computerized Doctors’ Orders Reduce Medication Errors. Retrieved from https://www.sciencedaily.com/releases/2007/06/070627084702.htm
- TechTarget Network. (2018). Current Procedural Terminology (CPT) code. Retrieved from https://searchhealthit.techtarget.com/definition/Current-Procedural-Terminology-CPT
- World Health Organization. (2018). Classifications. Retrieved from http://www.who.int/classifications/icd/revision/timeline/en/
- Zeng MD, X. (2016). The Impacts of Electronic Health Record Implementation on the Health Care Workforce. Retrieved from http://www.ncmedicaljournal.com/content/77/2/112.full
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