In this guest post, Judy Rich, president and CEO of Tucson Medical Center, shares the innovative ways her teams are leveraging technology to support improvements in care transitions. Tucson Medical Center is also part of Arizona Connected Care, which was recently selected to participate in the Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organization (ACO), sponsored by the Centers for Medicare and Medicaid Services (CMS).

Every hospital executive and clinician today is working to effectively manage what we call the “white space” – the place where patients exist between episodes of care, after a doctor’s appointment, surgery or procedure and before their next touch point or follow up. While it’s challenging to connect with patients once they leave the hospital and are out of our control, doing so is critical to both increasing quality of care and controlling healthcare costs. Mastering the “white space” plays a key role in helping patients stay on the road to recovery and ultimately reduce hospital readmissions.

At Tucson Medical Center, we’re spending more time on readmission prevention than ever before. While the goals we’ve set for our health system around care transitions are only made possible with the help of the right technology, I have a nursing background and know there are many other factors to consider. Leveraging electronic medical records that enable clinicians to easily access specific patient histories and care pathways at the moment it matters, as well as reveal critical data about the broader patient community, is just the tip of the iceberg in terms of what technology can do for us. But we still need a range of caregivers and clinicians to engage and connect with patients directly – whether by reinforcing what we’ve told them during hospitalization with clear instructions or by following up with patients after they leave to ensure they’re taking their medications and following care protocols properly. Here are a few examples of where we’ve combined the best of both worlds – technology and clinical – to improve care transitions:

• Access to Nurses After Discharge – Patients can reach nurses live via phone for guidance even after they’ve left our facilities, which we’ve found helps them avoid making another trip to the hospital. This service is especially critical for elderly patients who might not have consistent access to transportation. Even more importantly, this needs to be a “warm call” – one with someone who can quickly access the patient’s specific history so that the patient doesn’t feels the person on the line is remote and disconnected. The coordination between the hospital care management team and the Arizona Connected Care transition nurses provides the patient with a seamless and continuous resource to reach out to until they are stable and back in the care of their primary care physician.
• Put me in, Coach – Our system assigns each patient a transition nurse or “coach” who visits them in the hospital, conducts a home visit within three days of discharge and follows up via phone at regular intervals. The coach is responsible for answering questions, reviewing medications and identifying any red flags with patients that may cause a relapse or issue that sends them back into the hospital.  They have access to the provider’s EMR and communicate closely with them, while still making sure the patient is empowered to communicate directly with their primary care physician.
• Home is where the help is – The Hospital to Home (H2H) model, in collaboration with our outpatient care advocacy, is designed for mostly elderly patients with chronic conditions (CPOD, diabetes, Parkinson’s, Alzheimer’s) who are facing a number of life restrictions due to their illnesses. The team in this instance provides ongoing emotional and physical support, including screening for depression, educating patients on ways they can improve their quality of life and engaging with pharmacists and dieticians, etc.  By bringing resources to the home, they offer alternatives to ED visits and help prevent unnecessary hospitalizations.

Regardless of the model, nurses and caregivers providing transition support across Tucson Medical Center have gone through very specific training to be able to provide this type of intensive, case-based and interactive care. With more of a focus on the patient’s health and success outside of hospital walls, health systems can keep both quality outcomes and costs on track.

– Judy Rich, president and CEO of Tucson Medical Center

Judy Rich was recently featured in Becker’s Hospital Review discussing her “Top 5 Tips for Embracing Accountable Care.”

Whenever the regulation goes into effect – currently proposed for October 1, 2014 – the expectation is that ICD-10 will be overwhelmingly complex for coding professionals. The sheer increase in the number of new codes in the system – a five time increase in diagnosis codes and a 19 time increase in procedure codes – may be daunting to even the best of coders. However, most do not realize that the code explosion comes from a handful of additional attributes that are being applied to codes they already know. Hospitals and health networks increasingly rely on computer-assisted coding (CAC) systems driven by natural language processing (NLP) technology, but not all NLP engines are created equal.

Here are two things providers need to look for in NLP to ensure it can manage the demands of ICD-10:

• Compositionality – Suppose someone told you that you had to learn 10,000 actions, and then all of a sudden they increased that to 30,000 actions. That sounds bad. But, if they then tell you that all you really need to know is whether those same 10,000 actions happened left, right or unspecified, then it seems less overwhelming. This is called factoring out laterality, and is an aspect of compositional approaches to NLP. Compositional approaches identify complex coding concepts by recognizing and combining their simpler pieces of meaning. This approach already exists in ICD-9 solutions, and will simply be applied more frequently across the ICD-10 code base. If providers have a CAC solution with an NLP engine that can already recognize laterality for ICD-9, this is readily translatable to ICD-10. More than 24,000 ICD-10 code distinctions can be taken off the table just by factoring out laterality – reducing the effective code count dramatically in one fell swoop. Sigh of relief – and laterality is just one of many concepts that can be factored out of the code bases in a compositional approach.
• Robust medical concept knowledge base – Coders now recognize left and right, the concept of a lung, the concept of a joint, and the concept of a removal procedure, but medical documentation doesn’t always use the same words to describe these things. For example, with left and right, someone might abbreviate LT and RT in their documentation, lung may be pluralized as lungs, knee might be specified for a joint condition, and removal might be inferred from a specific procedure, such as cholecystectomy. Saying coders recognize any of the base concepts, such as laterality, doesn’t mean they (or their NLP engine) can get away with just knowing a few simple words. Your NLP has to be driven by a robust set of dictionary resources that provide information about medical terms and how they relate to each other. This is particularly important with body part terminology. A huge percentage of the increase in procedure codes come from greater specificity as to exactly where a procedure is performed.

There is an assumption that since an NLP engine automates what a coder is doing, at least on the surface, that if a coder is going to have a more difficult time with the number of ICD-10 codes that exist, so will the NLP engine. This is not necessarily the case, and knowing what your NLP engine is capable of now in ICD-9 will say a lot about how it’s going to be able to manage ICD-10.

– Mark Morsch and Brian Potter

There is substantial variation in how healthcare is organized and delivered from one community to another. For example, in some communities there is vigorous competition between organized provider systems, and in others providers are fragmented and unorganized. Hospitals and physicians collaborate well in some communities, while they compete in others. Healthcare access and delivery also varies tremendously between urban and rural areas. Other examples of these variances include:

• Fully integrated healthcare delivery and financial systems led by well-known organizations – i.e. Kaiser Permanente, Group Health of Puget Sound and Intermountain Healthcare.
• Strong multi-specialty group practices – like the Marshfield Clinic in Wisconsin or others – have developed strong single-specialty groups with affiliated ambulatory diagnostic and surgery centers.
• Integrated delivery networks that contract with multiple payers, such as Sutter Health.
• Academic medical centers as the core of integrated delivery system – like Partners HealthCare System in Massachusetts, the Mayo Clinic in Minnesota and Dartmouth-Hitchcock Medical Center in New Hampshire and Vermont.
• Physicians organizing into ACOs – such as HealthCare Partners in Southern California.

The point is that we need to avoid a “one-size-fits-all” approach, as many differences exist in local delivery systems. We need to test and optimize a number of different local healthcare delivery system models if we are going to make broader transformation a reality. Before any progress can be made, each community needs to understand the population it serves and their unique needs for healthcare, as well as differences, such as the types of insurance they have. For each segment, baseline measures of health status, utilization and costs should then be compared with best practices to establish specific health improvement objectives.

In order to make a transformation happen at the local level, we need to look at all information available from each healthcare constituent in the local community – including clinical, self-reported, claims and satisfaction data – so that providers can implement programs to achieve the objectives that make the most sense for each community; payers can align incentives and reimbursement with these provider initiatives, and can design insurance solutions that encourage patient engagement and adherence to provider initiatives; all parties can monitor emerging results; and finally providers can optimize programs and initiatives, redeploying enhanced programs where needed to the populations they serve. By necessity it will be an iterative process.

It’s tempting to focus on the country as a whole and look for ways to make monumental change across geographies, but a local approach to transforming the delivery and financing of healthcare is critical if we’re going to make positive change. We need to keep evolving, learning and improving one community at a time to achieve our goals on a national level, rolling-out and repurposing learned best practices from one like, local community to another. The “yellow brick road” to a nation of sustainable health communities is paved with the local healthcare delivery system!

– Joel Hoffman

Rich Rogers is vice president of information technology and chief information officer at

While we’re all trying to demonstrate meaningful use and achieve financial incentives, ICD-10 is still a major regulatory issue that hospitals and health systems have to prepare to support. For providers, ICD-10 is the equivalent of switching the entire U.S. to the metric system, impacting every part of our lives from footwear to the gas pump to baking ingredients. ICD-10 will change healthcare organizations not only in how they will secure revenue, but also in how they operate across every aspect of their business.

In other countries that have adopted more complex coding protocols we’ve seen coding productivity decrease significantly – for example Canada saw coding productivity losses of 10 to 50 percent, while Australia saw a productivity loss of 25 percent – increasing the demand for experienced coding teams to make the transition smoothly. In the U.S., ICD-10 will require a complete relearning of what coders know, and in our facility like many others, many experienced coders plan to retire instead of learn a new language. Add to this the fact that we already aren’t graduating enough inpatient coders from our universities to meet the current demand, and you’re tripling coder demand issues for healthcare organizations here in the U.S.

In addition, physicians will need to be much more specific when documenting patient care to comply with ICD-10, but right now there is no incentive for them to do that. We’ll need to invest time and resources into educating them how to document properly under the new requirements and clearly communicate how their coding impacts revenue and reimbursement at the organization – more easily said than done in a world where their time is more precious than gold. Finally, if hospitals and health systems don’t prepare for ICD-10 now and postpone staff training, the potential backlog of coding inconsistencies will have tremendous impact on the organization’s cash flow problems.

For all the above reasons – and because we know the impact failing to prepare for ICD-10 will have on our bottom line – at Health First, we’re making changes now for the conversion. At the top of our list: Implementing a computer-assisted coding (CAC) solution to maintain our current coding staff and support ICD-10 without the need to hire another 50 coders. Even under ICD-9, the return has been immediate, and CAC is already having a real impact on an increase to our hospital Case Mix.

From the multiple IT systems each of us has in place that will need to upgrade, to the physician and coding of documentation in those systems, we all need to relearn what we previously knew about patient medical records under ICD-10. Regardless of the deadline, we need to prepare for the inevitable and can all benefit from the efficiencies gained from making changes now so we are ready. Whether measured in miles or kilometers, as an industry we need to move faster on this.

– Rich Rogers

]]> http://healthcare-exchange.com/2012/03/06/poll-which-initiatives-are-you-tackling-this-year/feed/ 0 healthcareexchange http://healthcare-exchange.com/2012/02/21/the-new-core-hcit-for-the-accountable-age/ http://healthcare-exchange.com/2012/02/21/the-new-core-hcit-for-the-accountable-age/#comments Tue, 21 Feb 2012 16:58:36 +0000 OptumInsight http://healthcare-exchange.com/?p=1242 ]]> In 2011, the health care industry went through some interesting changes – from Meaningful Use attestations and delays to ICD-10 – but one of the less publicized milestones was one that may have a deeper and longer lasting effect on how we care for patients and that was the CMS final rule on the Medicare Shared Savings Program (MSSP). I believe that this rule, and the types of new provider risk-bearing models it encourages, will spawn a whole new generation of health information technology. A generation that focuses not just on patients currently seeing doctors and being admitted to hospitals and appearing on a census, but on a much broader spectrum of analytics, clinical transformation tools, wellness/prevention solutions and automated care management systems for comprehensive management of patient populations.

Let’s call this “The New Core,” vs. the basic EMR which will soon be the old core. It’s from these core tools focusing on managing the health of populations that the new age of care will be enabled.  Think of more provider-led health plans, consumers who get much more engaged in their care. Think of health systems that follow their patients from different risk categories as they migrate through the health system from pre-hospital/ambulatory settings to inpatient to post-acute and on into the home. Payers will still have an important role as efficient intermediaries and as government-sponsored healthcare expands so will the need to outsource the capabilities to manage the new lives covered. Think of a whole new world for physicians and other more empowered caregivers who get paid to take care of patients the way they were trained instead of being handlers of “care transactions” as in the past.

The momentum we’re seeing from CMS-designated Pioneer Accountable Care Organizations (ACOs) and the number of large physician groups seeking MSSP status is enough to showcase the HIT changes afoot. Today nearly 40 Pioneer ACO organizations – such as Sharp Healthcare, Allina Hospitals & Clinics, Partners Healthcare, Texas Health Resources, Atrius Health, and others – are taking on risk for large populations of Medicare patients that they weren’t previously responsible for. We’re seeing top-performing physician groups – including WESTMED and Cornerstone Health – applying for MSSP status and investing in these new tools, as they recognize the future of bearing and managing risk is inevitable. As we look ahead, I envision the impact of these changes to be:

1. Provider risk and integrated care models: By the end of 2012 I believe there will be a minimum of 50 major health systems and physician groups managing full risk on at least 10% of their patient population – a lofty goal perhaps but one that is already well underway. Whether the motivation for these new partnerships is cost reduction, market share, experiments with provider employee populations or payer-led efficiency programs, the end result will be the same – more provider organizations doing more than just dipping their toes in the risk-bearing water. I’ve talked to the C-suites of more than 200 health systems in the past 18 months and can assure you that there is no longer a question of whether they will become more accountable, but instead they’re looking at when and how to accomplish this.
2. Revenue cycle management: Hospitals leak revenue more than any other business in any other industry – with the average health system collecting only 33% of what they actually bill under the current fee-for-service (FFS) system. On top of this they will be burdened by the introduction of new fee-for-value (FFV) payments. Just meeting the basic requirements and maintaining status quo in this new environment will be challenging. As a result, 2012 will bring an emphasis for hospitals on closed-loop revenue cycle management, making it easier to adapt to new coding systems and offer long-term improvements, rather than quick fixes that are not sustainable. If they’re smart, they’ll act sooner rather than later to enable them to have the cash on hand to be ready for it all.
3. ICD-10: Less than 10% of healthcare providers are halfway to ICD-10 readiness, but with the introduction of up to 155,000 new reimbursement codes by 2013, ICD-10 could be an insurmountable challenge. Without preparation, hospitals face lost productivity and denied claims, which coupled with under coding, could deliver a financial hit of as much as $850,000 for an average 250-bed hospital. The implementation of computer-assisted coding systems that ease this transition takes time. The time to prepare is now, and in 2012 I see more hospital systems jumping on this critical bandwagon.

2010 was the year that the “Accountable Care” buzzword arrived en masse, 2011 was the year that government regulations were sorted out and private partnerships around shared risk were developed, and I believe 2012 will be remembered as the year the ACO translated into new models of care, with hospitals and large physician groups engaged and starting to manage risk and deliver care in a much more integrated fashion. This will also be a transformational year for health IT.  The New Core is here. From a new breed of analytics that help measure quality outcomes, to secure networks enabling physicians to share patient information in a more integrated fashion, to clinical actuarial tools that help caregivers manage cost and quality at the same time … Wait. What? Clinical people managing costs? Welcome to the new world! More on that in my next post.

– Todd Cozzens

An important consideration in the transition to ICD-10 is Clinical Documentation Improvement (CDI), which seeks to improve the quality of provider documentation, helping clinicians better reflect the services rendered and most accurately represent the complete patient encounter. The simplest type of CDI is educating providers about potential documentation weaknesses from both the clinical and financial perspective. While helpful, this is more impactful when coupled with specific examples of deficient documentation. Even so, retrospective analysis and feedback are limited to influencing future behavior and are dependent on follow-on audits to validate changes.

A more proactive approach to CDI works to identify potential documentation deficiencies while the patient is still at the facility. With this approach, CDI specialists, healthcare information management or care management teams work closely with clinical teams to review and help fill documentation gaps, ideally before or soon after the patient is discharged. This approach also has its downsides: it can be very labor intensive, requiring highly trained specialists to execute well; it is typically not possible to review every chart, but instead only to select patient encounters with the greatest opportunity for improvement to review; physician queries must also be communicated back to the provider, which can be difficult to integrate into the provider workflow.

Computer-assisted coding (CAC) technology is a valuable tool to support better clinical documentation and physician education efforts. CAC can help make the process more automated, accurate and measurable, but not all CAC solutions are created equal and the natural language processing (NLP) engine is the key to successful CDI. Accurate NLP can boost the productivity of CDI specialists, allowing them to review the results and quickly identify relevant information in the chart that could indicate missing or incomplete documentation. A specialized NLP engine can flag clinical facts that may indicate certain conditions that were present and services delivered, even if the full documentation is not present. This capability in particular will be very important in the transition to ICD-10, where codes are often more complex and require a compositional approach to combine information from multiple parts of the medical record.

CDI specialists face the same challenges as coders ─ limited time to completely understand complex medical records ─ and because CDI opportunities may involve more complex medical encounters, the demands are even greater. NLP can serve as the automated CDI specialist that reads every chart to find the ones with the greatest need for follow-up. As we’ve said here before, the time to act is now ─ rather than risk losing revenue, instead tackle the challenges of CDI today so that you survive the ICD-10 shift.

– Mark Morsch

Complicating this predicament is the fact that hurdle rates aren’t easily calculated ─ they are not necessarily a straightforward extrapolation from the Medicare fee-for-service experience in an ACO’s proposed service area. The recently released MSSP hurdle rate formula requires a blending of multiple years of baseline Medicare fee-for-service experience, trended to the contract year at national experiential trend rates, with adjustments for attributed members and decedents. Simply put, hurdle rates are not easy to calculate – not even with access to the appropriate historical Medicare baseline experience. Thus, absent CMS providing the hurdle rate, an MSSP ACO can’t easily work-up a proxy.

Modeling ACO rules now is critical to understanding the opportunities for success as well as the potential roadblocks that may lead to failure in the future. So what can a budding ACO do now to understand the most important variable ahead – what they will be measured against to decide their success?

Now more than ever, aspiring MSSP ACOs need to tap into expertise in these CMS rules with access to Medicare research databases that can actually estimate a specific MSSP ACO’s hurdle rate. There is clearly an arbitrage opportunity in CMS’ ACO hurdle rate calculations ─ based on the rules, some ACOs will have savings already built into their hurdle rates (i.e., hurdle rates greater than a traditionally determined, projected unintervened baseline) while others will have a more difficult road ahead (i.e., hurdle rates less than a traditionally determined, projected unintervened baseline) to get to a gain share position with CMS. These embedded savings/losses have proven to be not at all immaterial.

It makes sense that an ACO would appreciate the benefit of understanding their hurdle rates now ─ that is, will they be starting out in a favorable or unfavorable position ─ as they decide whether to contract with CMS and prepare and execute their operating plan.

– Joel Hoffman, ASA, MAAA, FCA

This week’s guest post comes from

The idea of implementing bundled payments can be intimidating for any hospital CFO. But, as a way of paying providers that combines all the services needed to treat a patient, bundled payments are an inevitable step for both payers and providers as the industry heads toward accountable care.

The challenges of implementing bundled payment models are more operational than conceptual – improving the flow of information between provider and payer, collecting and delivering the right information about services delivered to these patients across multiple care providers, and ensuring consistent reimbursement. It’s obvious how the task can seem overwhelming – as most providers are much more comfortable focusing on the appropriate care model for specific clinical conditions like diabetes or hip fractures – but here’s how every provider can prepare to make the shift:

• Get Organized – Providers need to determine how to assemble claims into bundles, how much a specific bundle actually costs, and which requirements for treating a patient have been met as part of that bundle. They need tools to notify payers that a patient is covered by a bundle and when the package of services begins and ends. Finally, they need to bundle data across multiple providers in a single claim for payers, and tools to properly distribute reimbursement funds.
• Divide and Conquer – Payers need to learn how to identify bundled claims within the stream of thousands coming in the door on a daily basis. To do this, they need tools to help understand which providers are involved with each bundle and enable communication with them. They also need a mechanism for identifying services with special exemptions and determine payment details (how much to pay for a bundle and to whom).
• Crunch the Numbers – Finally, to really change the way care is delivered, both parties need to track how the patient has been treated in different provider settings, and what appropriate care looks like. A database with the ability to query the shared data from both sides, close to real-time, will improve coordination and enable more effective patient management.

Providers need to think carefully about the costs associated with the care decisions they make to successfully implement bundle payment programs. By aligning the incentives between payers and providers to deliver high-quality care to patients, bundled payments are a necessary step to success in any accountable care model. Follow the steps above, and the transition should seem more manageable.

–Dean Farley, PhD

In this week’s guest post Dr. Miles Snowden, chief medical officer at OptumHealth, offers tips for stimulating patient accountability in the age of accountable care.

While payers and providers are usually in the spotlight when it comes to accountable care, the most successful models will be the ones that place a strong focus on patient accountability. More and more frequently patients are selecting doctors with the best outcomes, asking proactive questions, and taking an active role in their lifestyle and behaviors. Empowering patients with the support and tools to be responsible for and more involved in their own health is critical to improving outcomes and reducing costs as part of any accountable care environment.  In fact, Optum found that when given more information about a planned elective surgery, 1 of every 15 patients change course – either deferring, choosing a less intensive option, or changing facility or proceduralist.

Currently, patients navigate the medical system to achieve the best outcome in the shortest amount of time, but physicians are incentivized to provide more services. If the decision-making process of the physician and patient are not fully aligned, then it is not reasonable to deploy a strategy focused solely on stimulating greater accountability in the patient. An alignment of goals for the highest quality and most financially efficient care can help to ensure patients are never in a position to make a health decision against the advice of their physician. The burden of responsibility has to be directed equally at all stakeholders. Once alignment is established, strategies to stimulate greater patient accountability can be deployed.

Establishing a primary care relationship is key for patients because it provides them with the opportunity to view care more holistically, gain a better understanding of medical alternatives, and feel supported by an advocate for better personal health. Group visits can also encourage patient accountability by allowing patients to connect with others who have similar conditions, and providing physicians with an opportunity to educate and promote better overall patient health. In addition these strategies, tools to enable patient engagement are paramount. We’ve bucketed these accountability enablers into three categories:

• Demand Management: Stakeholders too often demand a greater intensity or frequency of service than necessary to achieve clinical success—experiencing more readmissions, ER visits, and MRI or CT scans than needed for example. It may sound simple, but asking discharged patients questions such as “Where will you go post discharge?”, “Are you certain any equipment or physical therapy has been arranged?” and “How can we reach you?” counters some of the system inefficiencies and better moderates unnecessary demand in the medical system. In fact, such efforts can cut in half the readmit rates.
• Population Management: According to a commercial insured 2010 population analysis, half of high cost claimants had minimal to no engagement with the delivery system in the prior year, indicating that providers need to better engage with individuals who are not active in the system, not just at the point of care. This is a significant challenge that can be overcome by partnering with organizations that specialize in identifying and engaging individuals who will become future sources of medical costs. It is particularly important for providers to reach out to individuals with a low intensity of need that don’t consider themselves patients and individuals with immobility or lack of access to care.
• Network Management: Oftentimes, individuals choose to access care at the wrong place. Transparency of information on physicians and specialists ensures that patients are receiving the best care at the lowest cost. By facilitating transparency providers can influence patients’ decisions, increase patient involvement and open the door for better communication across the care continuum.

All patients across the care continuum need to be participants in their own care, and providers should be implementing strategies to encourage this accountability both at the point of care and, more importantly, once the patient goes home. The focus should not be directly on changing a physician’s practice or reducing a hospital’s patient load, but instead on implementing an accountability model that aligns both physician and patient expectations to improve the health care system as a whole.

–Dr. Miles Snowden