ICD10 and the 80/20 Rules

Whether you're a multi-hospital system or small physician practice, chances are, you've got good docs and bad docs.

ICD10, as you've probably been told 50,000,000 times now, is going to affect everything and everyone.  But what most people don't tell you is that it doesn't effect everyone and everything equally.

We know that ICD10 has big changes for Orthopaedics and GI and OB, but for opthalmology?  Maybe not so much.  So if you're going to try and figure out which specialties need the most training, you need to look at 3 things:

First: Financial impact.  Different specialites have different potential impacts on facility reimbursement.  You obviously want to spend the most time and effort training and tracking on these groups.  

Second: Volume.  Sure, GI may have some large shifts, but if that's a tiny sub-set of your business, why would you waste that time and effort to affect 3% of your overall business?

Third: Documentation from doctors.  We know that some doctors document better than others.  OB has large changes, but they also might have the best doctors at your facility in terms of EHR use and documentation quality.  If that's the case, maybe you can focus your efforts elsewhere.

The gist of all this?  The old 80/20 rule, that is, 80% of your impact will be the result of 20% of your specialties/providers.

You can't boil the ocean and you can't hit everyone equally with ICD10, so apply the 80/20 rule and really find your risk area and focus most of your effor there.

To understand our 80/20 impact, we brought in an outside firm to do a claims analysis and documentation review.  We could thus see potential DRG shifts, volume of cases and see where documentation gaps existed.  A little statistical analysis later, and we could pinpoint who/what we needed to focus on.  In some cases, it was a whole specialty.  In others, it may be 4 providers in a specialty.

Doing this type of work helps both narrow the focus and avoid the concern that some leaders have about this conversion being too big.  If you can do an analysis and show that you only have this 20% to really dive into and put all your resources on, it allievates fear.

This doesn't mean that everyone doesn't get some training or analysis, just that the heavy duty efforts go to the 20%.

There isn't much time left before 10/1, so you have to be smart and specific.

HIM Should Take Ownership of HIE, Patient Portal

HIM is changing, we all know this.  The world of paper-based - or even hybrid-based - medical record departments are joining the Dodo birds and dinosaurs in extinction.  One day, a lot sooner than we may think, museums will display ugly paper charts and people will be shocked to think we got our healthcare off of scratched on pieces of paper.

In this new EMR-based world, HIM has to find new avenues to lead.  We have to adapt and change to stay relevant, or we'll fall off and get left behind.

One emerging area that HIM must lead, is in the area of HIE and patient portal.  At their core, these functions are really just the latest methods to drive the release of information process.  As such, HIM professionals and their staffs are more than able to drive this and have the backgrounds to make them successful and compliant. 

Patient portals are very important as it relates to meeting Meaningful Use Stage II requirements and Patient Centered Medical Home criteria.  MU requires that at least 5% of the organization's unique patient population view, transmit or download their health information from a portal; PCMH requires that at least 10% of each surveyed area's unique patient population views, transmits or downloads their PHI.  Obviously you need to focus on the more stringent of the two, and HIM can help drive this.

A workgroup should be put together, chaired by an HIM professional, to govern each organization's PHR.  This group should include at least one physician or nurse practitioner, someone from PR, someone from training, a nursing representative, someone from IT and clinical unit/clinic directors.  They should help make design decisions, review data on usage of the portal and help keep it relevant and focused.

To be successful with a PHR, hospitals will need to have their own staff participate.  Organization's should incentivize their staff to sign up to help meet their required numbers.  They also need total buy-in from all staff to promote the PHR to their patients so that they enroll and use this wonderful tool, you can't have the nurse enroll the patient and then have the doctor say it's a piece of junk.  Also, look into having every touch point sign up your patients: Guest Services, Nursing, Providers, HIM/ROI, Patient Access, etc.

As for HIE's, the same principle applies.  HIM should help drive the converstaion about which HIE an organization chooses and what documents are posted to it.      

What's The Value in Value Based Purchasing

Starting next October, CMS is going to reduce all discharge inpatient payments by 1% to create a VBP pool.  Over the next few years, that rate will increase until 2017 when the pool will hit a cap of 2%.  Based on a complicated calculation that includes scores on clinical outcomes and HCHAPS, an organization may receive their full payment back, may receive less than that amount or may receive more than that.

So what’s the point?

The goal is to move towards better consumer driven healthcare where outcomes and quality matter most.  It’s time to put away the phrases of “Well we’re a safety net provider” or “Our patients are just different” and move towards acknowledging this coming change and that we need to see this institution for what it is: a first rate hospital for all patients, not just those in need.

Maybe you think that’s not fair, that there should be a way to level the playing field between the top and the bottom, but to do so would mean we would have to acknowledge that we cannot compete with the “big boys” in terms of quality or outcomes, and that just isn’t the case.  We embrace this challenge to improve our HCHAPS scores and have publicly reported data that shows how great our institution is.

Everyone impacts the score.  From saying “Hello” to everyone in the halls to picking-up trash or helping a stranger find their way, it creates the kind of culture we need to succeed. 

While those are indirect influences, HIM has some direct:

·If we are behind on scanning and a doctor goes to access PowerChart and a note isn’t there and he gets mad and his frustrations may be visible to our patients who then have a bad experience

·If we don’t release the right records or release them timely, even though there isn’t an ROI question on the survey, our patients would score the hospital lower because they are going to dock us for that

Everyone plays a part.  From the top-executives to the front-line staff. 

There is value in VBP, it just is up to us demonstrate the highest values.

Healthcare Is More Than Healing

Been a while, my apologies...

Customer service and its relation to healthcare seem to be front and center these days (that is, if you happen to be a healthcare institution, the public probably couldn't care less right now).  The question needs to be asked, what does customer service mean in relation to treating someone?

For most people, we think of customer service when we go out to eat, stay at a hotel, get on an airplane or purchase something.  Those are generally positive experiences (we want something) and barring a problem, we expect to be treated with respect and from a personable employee.  But in healthcare, almost the opposite is true.

Even for the most mundane events, who really wants to go to the doctor.  Everything they do hurts.  Even a simply shot pierces the skin and can cause pain.  Think about that flu shot that made your arm hurt for days.  What about if you have surgery?  My wife has a heart condition and has had two open heart surgeries.  Each time they crack her body open and inflict pain in order to save her.  This is not an indictment of that process, but merely pointing out that after someone hurts your body, do you really want to then be asked to rank them on a scale of 1to 10?  Is that even fair?  Hospitals aren't hotels (as a New York Times op ed piece pointed out recently) and to think otherwise is unfair.

But having said that, organizations do need to remember that it's all about the patient and sometimes going the extra mile pays off.  Making people feel welcome is a huge point.  It's why Children Mercy hospitals are dolled up like play lands or why some hospitals include art in the hallways.  The hospital shouldn't be seen as a bad or scary place to be, but they aren't a week long vacation on the beach either.  Value Based Purchasing my do more harm that good for some institutions where they see sicker patients or perform more risky surgeries, because even under the best circumstance, the pain you feel can make you score them negatively, which can lead to lower payments.

ICD10 Delay, aka, And Now We Play The Waiting Game

When CMS and HHS announced the intent to delay ICD10, I highly doubt they thought they were opening the flood gates as badly as they have.

If they had properly thought this through, I have to imagine that they wouldn't have announced an intent to delay without a, ya know, new date in mind.  Not just a press release thrown out there to throw critics a bone, but with a bona fide idea of she this new deadline will occur.  Without, everyone is left in limbo.

At the heart of the delay is the quesiton on delay is this: What is the ultimate goal of changing the deadline?

If the answer is to allow for a leeway on enforcement, then adding a few months (3-6) on the backend like with what happened with 5010, doesn't really do much.  If the the compliance date is February 1, 2014 now, what's the big deal?  Is the AMA going to be happy?  Is that truly changing much of anything?

If the answer is to give additional years on prep work, then everything done up until is wasted time and capital.  If you went out and got an ICD10 certification from AHIMA and will pay the annual fee to keep said credential, are you really going to keep paying if the new date is 2015?  If you won't be using all that knowledge?  What about rushing all these IT upgrades and the costs associated with it.  Boom, down the drain.

And it's not like healthcare costs are an issue right now, hospitals are just rolling in cash they can waste.

In all seriousness, while everyone has and should continue business as usual until a new date comes out, even that approach is ripe with danger for lost time and resources that if the delay is too big, you'll never get back.

Limbo....not the kind of play we need to be right now.

Rolling With The Changes: Rules for Change Managment

It sometimes amazes me that even now, here in 2012, with all the constant changes occurring around us with computing, healthcare, social media and a rapidly shrinking world, that people would have become agents of change overnight, but of course, that's hardly the case.

From the big overhauls such as ICD10 or moving up to a Stage 6 EHR on the HIMSS ladder to the small steps in between, getting people to adapt to the new reality of the workplace can be demanding and difficult, but necessary for a successful conversion.

Wanna succeed?  Give these a try...

1.  Be Up Front:  I'm sure your parents told you that honesty is the best policy, and when it comes to big changes, be up front early and often.  When I took our department through the conversion from a paper-based, traditional model to a fully electronic scanning one, we told the staff early on about the process and the big changes that would be coming.  By letting them in on these events during the early planning stages they can go through the fear and anger stages sooner and move on to being productive.

2.  Control the Story:  To some degree you have to be a PR expert and control the way information is presented, spinning the information positively whenever possible.  You need champions who are in the weeds, people who are front-line and can help dispel gossip or rumor-mongering.  Since you can't be everywhere at once, you need people on your side.  Create talking points and ways to deflect negativity.

3.  If The Change Calls For A Reduction In Forces, Be Fair, Be Honest:  Part of this ties back to #1, but, and this should go without saying, if the change calls for some staff to be let go, you need to work with HR on developing clean, fair methods to determine which staff should be retained and which should be let go.  Performance, years of service and adaptability should all be considered.

4.  Offer The Tools Staff Need To Change:  If roles will be changing, provide training or opportunities for education to allow them to learn the new process and succeed under it.

Integr8ting Productivity With Time and Facts

How many hours per day is the typical person really work and really is productive?

Well, you can start with an hourly employee.  They work, typically, an 8.5 hour day.  But of course, that .5 is for an unpaid lunch, so really it's just 8 hours even.

But they get breaks, two 15 minutes ones, and you can't really ask for production while they're on break, meaning now you're down to 7.5 hours.

End game: Production, true production that is, should be based on a 7.5 hour work day, but not an 8 hour work day.

As a side note, I tend to say that coders should work on a 7 hour work day so that they are given an extra 30 minutes per day for tough accounts or problem solving with their team lead/supervisor.


Next, how do you really know what their productivity is and what it should be.  Let's take the second part first.

There may be any number of ways to determine what the general production is.  Go on a list server or LinkedIn group and ask your peers.  Maybe read an article from a journal for your specialty.  But those tell you only what the general production for any given role is, without taking into account the nuances of your particular organization.  It's truly unfair to simply use the standard level for production.

What I recommend to Integr8tion partners is that they do two things to determine production:

1. Find out what the industry says their production should be
2. Time study your own employees to find out what it actually is

Next, I take the difference and add 5% (gotta aim high) and use that are our goal.

Now for the first part of the question, measuring production.  Here are my tips:

1: Automate: Humans are prone to error.  I know, big shocker, but that's why you need to automate as much of the process as possible.  Don't let staff manually track inches, pages, accounts, etc, since they could make an error either on purpose or mistake and throw off your calculations.  On the backend, who wants to waste the time manually adding up everything and also worrying about making mistakes.  Get the process online to save time and avoid confusion.

2. Set a policy and get HR's approval:  Always have a policy in place the explicitly explains what the production standard is, how it's calculated and what the consequences are for failing to meet it.  Work with your HR to ensure they believe in the policy and will help enforce it should that problem arise.

3. Be tough but fair:  Explain the policy and process to your staff, answer any questions they may have, but when push comes to shove, you need to be tough and enforce the standards.  Even if that means writing up "good" employees.  You need to administer the policy fairly and evenly, but let everyone know there are standards and they must be met.