November 22, 2010

Repositioned for Success
By Greg Goth
For The Record
Vol. 22 No. 21 P. 20

According to industry observers, the integration of EMRs and revenue cycle management is likely to change HIM’s role.

The final verdict may not be in, but early adopters of integrated clinical and revenue cycle management platforms say they are already seeing impressive results, whether they install the new systems piecemeal or enterprisewide in a “big bang” approach.
“To some degree, we are still on the early side of the curve as an industry on this,” says Ed Ricks, chief information officer (CIO) at Beaufort Memorial Hospital, a 197-bed not-for-profit in South Carolina. Ricks and his board opted for an incremental approach to implementation, beginning with the hospital’s emergency department (ED).

“There are certain areas where it’s just much more critical to capture that, particularly in the area of nursing documentation, and the [ED] is one of those areas,” he says.

Beaufort Memorial installed an ED information system (EDIS) and realized a $1.3 million increase in gross revenue just one month after going live in December 2009. Ricks says his organization’s experience may be an example for others still contemplating automatic charge capture and the integration of clinical and revenue cycle management applications.

Whether a hospital takes the incremental or the big bang approach to leveraging electronic clinical data to improve billing processes and reimbursements, Ricks and other industry experts say HIM professionals need not fear that wholesale job losses will accompany the shift from manual to dynamic coding and billing. However, they also say HIM staffs will need to adopt an enterprisewide and forward-thinking strategy as EMR adoption ramps up via the HITECH stimulus funding.

HIM’s New Role
Margret Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, president of Margret\A Consulting, says HIM professionals must reassess their skills and ascertain the likely direction of the technology-enabled clinical/financial chart to secure their place in a facility.

“I do think people are concerned about employment levels, and I have to say I’m a little concerned,” she says, “because I think that has been a fear for quite some time. And that fear has immobilized people rather than mobilized them. It has been around such a long time [that] people don’t tend to think about it anymore and, as a result, they also aren’t being proactive about what else they can do.”

Amatayakul’s sentiments are contrary to conventional wisdom about the future of HIM employment. The Bureau of Labor Statistics’ 2010-11 Occupational Outlook Handbook, for instance, estimates a 20% increase in the number of medical records and health information technicians through 2018, a projection it deems growing “much faster than average.”

But Amatayakul thinks such projections, whether from government or trade association sources, are “doing the profession a disservice because that really signals to people ‘My job is secure.’ I don’t think those jobs are secure. There probably is a need for a better-skilled workforce in general. Whether the profession as we know it will step up to the plate is a big question.”

The Association for Healthcare Documentation Integrity has recommended stronger educational opportunities for HIM workers, recognizing that “medical transcriptionists possess a unique set of skills that when mastered and paired with additional training in technology, management, and data analysis could create a knowledge worker that would allow greater collaboration with the software engineers developing EHR systems and tools for evidence-based medicine to meet the needs of all allied health professionals.”

Lou Ann Wiedemann, MS, RHIA, FHIMA, CPEHR, the AHIMA’s director of professional practice resources, says the concern over HIM workers losing their jobs and finance department projections that coders can be eliminated to save costs as clinical and billing data integrate electronically are off the mark. Nevertheless, change is coming.

“I think [automation] will change the way they do their jobs, but I don’t feel that it is going to totally eliminate positions,” she says. “Realistically, in the long run, some positions may not be filled through attrition; I think that’s going to happen no matter what. I think it’s very misleading to implement an automated process and assume the biggest gain or ROI [return on investment] will be a full-time equivalent position cut because, even with computer-assisted coding, somebody has to work a rejected report.

“So the coder who was coding to begin with now works a smaller list of accounts that were rejected. You’ll gain efficiencies because coders who were spending their entire day coding now are working smaller reject lists and bills get out the door faster,” she adds.

Job Stability
In theory, implementing an integrated EMR/revenue cycle management platform could, in time, yield enough data that more charts could automatically flow from the attending physician straight through billing without any intermediate intervention from HIM. However, even organizations that have successfully made the jump to the integrated platform say the rate of change in contracts such as reimbursement rates and preauthorization procedures—and a more likely chance of audits—means there is still a lot of human analysis necessary.

“Could you set up some triggers and workflows and rules to have those codes automated? Absolutely,” says Rick Mohnk, CIO of HealthAlliance Hospital, a 150-bed facility in Fitchburg, Mass., that went live with an integrated Siemens Soarian platform in December 2005. “I don’t think, quite honestly, that there’s enough agreement among the payers that they would be willing to accept that. That’s not derogatory; everybody changes the rules too often. For instance, from one contract period to another, procedures that were not preauthorized before now need it or you don’t get paid.

“The capability’s there,” he continues. “If it’s consistent and you can write the workflows that state an ‘if, then’ kind of deal, I could do it, but they don’t really exist. We’d end up with compliance issues because you can’t keep up with the changes. We have two full-time people who just manage our contract engine alone.”

Ricks says keeping abreast of the multitudinous payer rule changes is just one of three main areas in which the role of HIM staff will change as clinical and billing applications are more tightly coupled.

“There is still a lot of coding to be done and lot of learning to be done on the coders’ side because the regulations change all the time,” he says. “Another area is that HIM will involve more of a coaching aspect. Provider education is continuous. Physicians often don’t think of the terminology to use from a billing perspective while they are taking care of a patient, and the coder can only code based on what the physician says.”

The third area Ricks sees growing in importance as platforms become more integrated is comprehensive chart review, especially as government and private payers place more emphasis on audits.

“We have to make sure we can validate what we’ve been billing,” he says, “reconciling the record of what was created electronically vs. what the coder has coded.”

Mohnk concurs, saying that in some cases multiple codes still require an experienced HIM person’s evaluation of a claim’s quality. “The doctor does the final diagnosis, but there are other codes underneath that not everybody can keep track of. That’s just a reality,” he says.

That reality is also bound to become even more complex with the introduction of ICD-10. Its fivefold increase in codes will require an HIM role change from what Ajit Sett, vice president of revenue cycle solutions at Siemens, calls administrative to a peer professional role—staff who can offer physicians guidance under the complexities of the new system.

“We need these people and they do not come easy,” Sett says. “You need to know this thing inside out.”

Better Documentation, More Money
In the not-too-distant past, physicians were uncomfortable with payers instituting more stringent evaluation and management (E&M) guidelines. The stricter the guidelines, many doctors said, the less leeway they had to practice the art as well as the science of medicine—not to mention how much lower reimbursements might be. However, Ricks says the experience at Beaufort Memorial has proven that tighter integration of clinical and financial systems has actually improved reimbursement.

Under its Medhost EDIS platform, charges are calculated as every element of care is documented, enabling Beaufort to more accurately determine E&M levels. A medication documentation tool has also enabled Beaufort’s nurses to more accurately record IV infusion start and stop times.

Improved E&M coding and IV infusion charges resulted in a net payment increase of $50 per ED patient within two months, and Beaufort expects that number to grow as more payments are received. Based on an estimated 40,000 patient visits each year, Beaufort anticipates that the EDIS will deliver $2 million annually in recurring net revenue.

Ricks says prior to the integrated platform’s implementation, ED physicians were billing off documentation “which for us had been dictation that was later transcribed. So while that can complete a very flowery and full record, the discrete data elements that are necessary should you be audited weren’t necessarily there. Now they will have actual data support for the claims they submit. I feel they have better compliance now that validates the billing they are doing.”

HealthAlliance has also seen substantial improvement in its bottom line since going with the integrated Soarian platform. For example, it has seen a reduction in average days of revenue in accounts receivable by 20-plus days, $1.1 million in payment rate improvements in the first six months of fiscal year 2008, a 99% accuracy rate for valuation of accounts receivable, and a 4.1% cumulative increase in net patient revenue.

So You Want to Be an HIM Star?
With results like those at Beaufort Memorial and HealthAlliance, integrating clinical and financial platforms may look like the default route of the future, giving HIM departments a chance to become more than coding experts.

“Historically, they put their heads down, counted charts, looked at charts, looked for signatures, and so on,” Mohnk says. “Now, with the electronic environment, they can really get in and look at the workflows and try to answer the questions ‘How can we help the physician? How can we help with patient care?’ Not just on the financial side, but how can they help with monitoring things like cosignatures—’Where’s our place in the puzzle that really makes a difference?’“

Wiedemann says HIM professionals must assert the discipline’s needs early in the planning process.

“The biggest challenge for HIM departments is that as you implement the new technologies you have to maintain a legal health record that demonstrates information integrity, that the record is created in the normal course of business and meets standards in the community or industry at large,” she says.

“You can’t assume the other people within the organization are looking at it from that standpoint,” Wiedemann continues. “The CFO [chief financial officer] may be looking at it from the revenue cycle standpoint, the CIO may be asking how many laptops or mobile devices they can get, and pharmacy may be trying to figure out how fast they can get medication orders. Somebody has to approach it from the information integrity position, and the HIM professionals have to make sure those are considered before they implement or as they implement and not as a retrospective. The automation is coming, and I wouldn’t want to sit back and let somebody else decide what HIM’s role will be in the new process.”

Susan L. Adams, a revenue cycle management consultant for the Healthcare Financial Management Association, calls the migration to integrated platforms “almost a ‘cleaning house’ opportunity” for HIM departments, from mapping existing processes to the new workflows to assessing whether hospital forms that patients have filled out for years are necessary or can be combined or eliminated.

“It’s almost a chance to start from scratch to review how to build processes,” she says.

— Greg Goth is a freelance journalist from Oakville, Conn., specializing in technology and healthcare policy issues.