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.

ICD10 and Your Documentation Gap Analysis

With a project as large and potentially daunting as the looming ICD10 conversion (go-live date of October 1, 2013 for those of you living under a healthcare rock), one of ht major tasks you should have undertaken or need to, is a gap analysis on your documentation.

But, where do you being and where does it end?

First, believe in the mantra ALL CODES ARE NOT CREATED EQUAL.

There is only so much time you can devout to this analysis and any educational offerings thereafter to try and mitigate any large risks so you need to realize early that smaller specialties or codes aren't going to be able to get the kind attention that higher weighted codes may be.

For example, a hospital may not really focus on Podiatry patients as it may be low volume and possibly low weighted DRG payments, but a Podiatry practice would be the opposite.  So it all comes down to each individual facility.

So start with what you know...or better yet, what your coders know.  They should already be acutely aware of what DRGs or specialties have problems with documentation.

So start big, picks a few specialty or DRGs that you know your facility has a lot of and can be problematic.  Run some random reports to get patient lists and then try coding them using ICD10 (either through encoder or the book) and make notes as to where there are gaps that lead to a wide range of possible ICD10 codes.

This is great data to share with your doctors since it will help guide them on what they will need to do to expand the detail of their documentation (theirs an oxymoron for you).

Another piece to consider is contracting with a vendor to do the financial impacts.  While it may be possible to do this in house, the bottom line is that number of permutations and data that you'll be reviewing is so large that doing it in-house is probably use not feasible (also, consider the time constraints).

One great thing a third party can do is run the different variables on all your inpatient claims to see what possible DRGs they may roll up (or down) to in ICD10.  Since one I9 code will have many I10 code possibilities, these vendors can run all the permutations and different variables of those codes, so if you have a claims that has one code with 10 possible I10 codes, they can run it all 10 times and see how the final DRG plays out.

This isn't the end of your analysis...just the beginning.....

Form Design or Re-Design: Where Do We Start?

One of the most daunting undertakings for any organization, getting a true handle on forms can make even the strongest of managers feel like breaking down.

Whether it's developing, implementing and monitoring a process for new forms or working on re-designing them for an electronic world, it's very time consuming and thankless project, but one of the most important things you can do to ensure compliance, as well as it being a necessary first step.

Today, we'll talk about form design and re-design in the context of preparing for implementing a document imaging solution.  To achieve a successful outcome, you'll need the following 5 things.

1.  Time
That's right, the most important factor is the time necessary to complete the project.  At one of the hospitals I worked with, it took myself and my teammate almost a full business week to go through all the forms and create a document library of what forms the organization even had.  We did multiple 'asks' and meetings with all departments to obtain any and all forms they had.  Going one-by-one to enter them into a spreadsheet and capture the important information such as form name, department in use, etc was messy and long, but it was a key brick in the foundation for a successful go-live.

2.  Barcodes
The backbone of document imaging is barcodes.  Barcode the patient label, barcode the form, and let the system do it's work and take the guesswork and potential problems out of the human hands.  Barcoding forms is a fairly simple process, but there needs to be some logic behind it.  For example, on the off chance that the barcode is unreadable, or if you have to hand key in the form because it doesn't have a barcode, you want your most heavily used forms to have easy numbers so the staff can quickly ten-key them in.  For example, if you are using three digit barcodes, and your progress note form is very heavily used, you may want to make it 111 so that any staff could quickly key that in if need be.  If you have a detox form that is rarely used, making it 829 isn't as big of a deal because you don't see it enough.

3.  Fast Tracking Old Forms
Hopefully, you have some sort of forms committee or process in place, but as you do your forms library you may find that there are tons of forms that are old, outdated, pilots or home grown and are needed for continuity of services, however, you can't wait to send them through the monthly process of forms committee since they are already in use.  You need a way to ensure that you can quickly get these types of forms standardized and approved.

4.  Templates
Templates are key.  You need to ensure form standardization so that you can have better control over them.  This means not only that you should, to the best of your ability, have designated places on every form for where the barcode and patient label go, but also that the template for new forms is standard so that if the GI clinic wants to create a new form, they don't just try to make one out of Word, but instead have an organizational template that ensures the proper formatting.

5.  Patience
As I've said, all these steps take time.  Some take a lot of time and will require multiple reviews and reworks over days, weeks and months to ensure you have the right set.  For example, at one hospital, we started with over 800 forms after our initial pass, but by go-live we were down to only about 450.  Again, this is a thankless job, but incredibly important.

Welcome and Introductions

Welcome....to INTEGR8TION.

What is Integr8tion you ask?

Simply put, it's an idea, a concept, that the key to reaching our goals is through an integration of people, technology and resources.  Combing all these elements together creates a power greater than any that could be made by these parts alone.

A company may be founded by a driven, bright individual, but it succeeds because it has a great plan, it leverages the right technology, it hires the proper people and it remains focused on it's goals.

My goal for this venture?  To discuss HIM and healthcare IT related topics and how the integr8tion between these two concepts can maybe help drive you towards your goals and help focus our efforts on improving our great healthcare system.

I can't say I started out in this industry with this notion, but have grown into this way of thinking over my years of service.

Over time we'll discuss everything from implementing Document Imaging or organizational restructuring ideas to regulatory compliance issues like ICD10 and everything in between.  We'll talk about improving communication, placing people in roles and situations that allow them to succeed and how even the most daunting of challenges can be overcome with integr8tion.

Stay tuned my friends.....