HIMSS 2010 – Monday

We may be in the middle of a major recession, but they forgot to tell the organizers and attendees of the 2010 HIMSS Conference in Atlanta. The Georgia World Conference Center is bursting at the seams, and teeming with activity. If you didn’t know any better, you’d think the government was about to pump a few billion dollars into the healthcare industry.

So far, most of the energy seems to be around Meaningful Use (and, by extension, EHRs and interoperability in general), ICD-10, and 5010, in that order.

Meaningful Use is, of course, a very broad topic, since it covers requirements ranging from clinician workflow to interoperability to patient communication, and beyond.

Patient Portals

I attended a very interesting presentation by Dr. Eric Liederman and Jan Oldenburg of Kaiser Permanente this morning, explaining why and how they built a “transactional patient portal” and deployed it to all of their members (the last hospital to implement the system will go live this week).

Kaiser Permanente has the largest civilian EHR deployment in the world.

Some no-brainer points of interest:

• According to a 2009 Deloitte survey of healthcare consumers, 57% of patients want a secure website to “access their medical records, schedule office visits, refill prescriptions and pay medical bills.”
• Among Kaiser Permanente members, the retention rate is 2.6-4.6 percentage points higher among patient portal users than the rest of the population.

Some surprises (at least to me):

• The most popular feature on KP’s patient portal is lab results.
• Initially, only “normal” results were available to patients via the portal. Eventually, though, most KP regions started posting all results (that can be provided legally) on the portal, because they got more from people wondering why some of their results were missing than they would from people worried about abnormal results.

Patient portals (or something very close) will be required in 2013, so it’s inevitable that most doctors will need to find and implement a solution pretty soon.

5010/ICD-10

I also attended a great round table session on 5010 and ICD-10 migration. As we’ve known for a while, there is a lot of anxiety out there around these requirements and—surprise!—healthcare providers expect software and clearinghouse vendors to solve their problems for them.

In fact, there is a lot that technology can do (and providers will absolutely have to leverage technology to address the issues), but clinicians, coders, billers, office managers, front desk staff, etc., will all be heavily impacted by 5010 and ICD-10, regardless of what their software and clearinghouses do for them.

Much of the angst right now is centered around providing training and education to staff. Providers are looking to HIMSS, AHIMA, WEDI, and CMS for guidance.

Incidentally, a Product Manager from RealMed was sitting at my table and said that around 40% of their customers are still sending claims as print image files (PIFs) of HCFA 1500 forms and NSF files, and RealMed is translating them to 4010s. He anticipates that he’ll have to continue to convert those archaic file formats to 5010. Yikes!

"Free" PMS and EMR software

Every few months, I get an e-mail or see a blog post about a new Open Source, "free" EMR or PMS. Usually, the e-mail is entitled something like, "We'd better keep our eyes on this..."

(By the way, I intentionally capitalize Open Source, because, as far as I'm concerned, it's a brand name. Or, if it's not a brand name, it's a movement. Or a religion. Or a political party. Whatever it is, it's a proper noun, and consequently requires capitalization.

For evidence of this, look at the Wikipedia entry for Open Source. As of this writing, it has the disclaimer, "The neutrality of this article is disputed" at the top. Of course it is! It's difficult to write about your religion and stay neutral.)

But I digress. I don't want to rehash the worn-out debate between Open Source and commercial software. That's about as interesting as Microsoft vs. Apple, Microsoft vs. Oracle, and Microsoft vs. Mozilla. The fact is, if Open Source works for your project, then you should use Open Source. If a commercial package meets your needs, use it.

Having spent most of the past 15 years of my career in the medical practice management software arena, I believe there are two broad categories of medical practices:

Open Source		Commercial Software
Sophisticated internal IT staff		Everyone else
Doctors = Technologists
High threshold of pain
Interest in or need for heavy customization
Equal/greater interest in tech innovation vs. treating patients

I honestly can't see where Open Source projects compete with commercial software like AdvancedMD. First of all, AdvancedMD and other SaaS-based software (is there any other kind?) are essentially free. The only up-front cost is for training and implementation. With commercial software, those services are available directly from the vendor, or from their authorized VAR. With Open Source, you'll have to find someone to provide those services, or you're working with a consultant. Either way, they're not free.

The real cost of software comes in the ongoing maintenance and support. With AdvancedMD, you pay a reasonable, fixed monthly cost. The software is maintained by the same team of IT professionals that maintain our other 3,000 customers. Help Desk support is provided by the same team of Support professionals that serve those same 3,000 customers.

If you choose Open Source, someone has to install and maintain the software, and provide end-user support. The software was free...these services are decidedly not.

That's not to say that there is no place for Open Source. There certainly is, and I'm certain that there are dozens if not hundreds of success stories.

The point is that it is very, very easy to determine whether you are a candidate for Open Source PMS and EMR software or not: If you fall in the left side of the above table, you should consider it. If you're one of "everyone else", well, welcome to AdvancedMD. (Sorry, that really was a shameless plug.)

Why does EDI have to be so hard? (Or, "Healthcare EDI is a freak show!"*)

Okay, let me be the first to ask:

Why are EDI transactions always so difficult???

• Why is it that we always have to put quotes around the words "healthcare EDI standards"?


• Why is it that we have to conform with absolute precision to a each of a variety of specs for outgoing transactions (270, 837, etc.), but payers can send us whatever crap they want (particularly in 835 remittance files), and we have to adjust our systems to interpret them?


• Why is it that we can't send test claim files to payers to ensure that we're meeting their wacky specs? Why do we have to wait until one of our customer actually sends a claim to the payer before we can know with any certainty that our claim generation system works?


• Why can't Medicare and Medicaid intermediaries be forced to comply with HIPAA transaction standards?


• Why can't state payers (primarily Medicare, Medicaid, and the Blues) conform to their own standards?

If it sounds like I'm a bit miffed...well, I am. Partially because it takes so much of our time to keep up with shifting requirements, but mostly because I'm convinced that it's on purpose!

I just finished watching a DVD that was produced by Healthcare IT Transition Group, whose stated mission is (in part) "to reduce the cost and improve the quality of healthcare through the development and implementation of robust IT standards." A worthy cause, by any standards...unless you're a healthcare insurance vendor. The video is called "Defeating the Denial Engine", and it describes new tools that enterprising vendors have created and are selling to payers to help them reject more claims and, consequently, pay out less money.

Here's the idea: This new class of software allows a payer to dial up the percentage of claims that are denied, using a huge array of rules that can, to varying degrees, be reasonably justified as valid rejection reasons. If the payer sets the dial too high, resulting in a flood of complaints from providers, then they can dial it down a bit until the protests become manageable.

That's a complicated way of saying, "Insurance companies will make it as difficult as possible for a caregiver to get paid...without dramatically reducing the number of providers that are willing to contract with them."
For those of us whose mission it is to help our customers get paid by insurance companies, it means that we need to redouble our efforts to understand exactly what it takes to successfully submit a claim to every payer in the nation, and abstract as much of that away from our customers as possible.

I foresee a world where all a biller has to do is ensure that patient encounters are coded correctly (according to the common best practices of the specialty for which he is billing), and the billing software (presumably AdvancedMD for smart billers) will address all of the carrier-specific idiosyncrasies automatically, behind the scenes.

AdvancedMD certainly goes a long way towards that utopian vision--perhaps further than any of our competitors, if you believe what our customers say--but we still have a long way to go. We are actually doing some pretty exciting work right now to take us even further down the road, which I'll write about as we get closer to release.

*The association of the word "freak show" with healthcare EDI was originally made by Steve Lewis, our own EDI guru, also known as "Morpheus".