Healthcare IT Software Solutions

Baylor Grapevine Recieves the Texas Quality Award

Recently I had the opportunity to attend the Texas Quality Foundation Annual Conference and Awards Banquet. The conference is made up of a medley of learning sessions including organizational improvement and quality-focused concepts. However, these are not the main purpose of the conference; the main showcase of the event is the organizations who have managed to exceed expectations and drive results through performance excellence. These organizations have reached specific goals set forth throughout the year. The honored organizations capable of achieving such designations receive the Texas Award for Performance Excellence. The Texas Award for Performance Excellence is very prestigious and not easily obtained - "A role model organization demonstrating exceptional performance in all areas of organizational management – leadership, strategic planning, customer and market focus, measurement analysis and knowledge, workforce focus, process management and business results"(Qualtiy Texas). 

The organization achieving the highest of honors at this particular event was Baylor Regional Medical Center at Grapevine (BRMCG). "Baylor Regional Medical Center at Grapevine, a subsidiary of the Baylor Health Care System, is a licensed Acute Care Hospital serving more than 20 communities in the Grapevine, Texas area" (Quality Texas). The facility is mostly known for its 20 minute ER wait time...that is right, 20 minutes (WOW!). BRMCG is also known for the amount of babies delivered. Most importantly though, they are known for high customer service and quality care.

As I listened to the President at BRMCG explain the joys and struggles his team faced through the journey I was highly impressed. One overwhelmingly obvious quality the President and his team siezed was the ability to drive organizational improvement despite the most difficult of situations. In my opinion, this effort could have not been accomplished without a dedicated and focused leadership team and the team at BRMCG certainly posess those characteristics. Overall, the team at BRMCG is doing a terrific job delivering amazing patient care, which is why they truly deserve this award.

As my organization is highly engaged in the hospital space performing IT consulting, and, application and systems integration (interfacing), one of the questions which ran through my mind was, "How much of the barriers for obtaining the award were a result of such services and technologies offered by organizations like mine?" I did get a chance to ask my question and the consensus was that such technology services played an integral role in creating an environment capable of delivering more efficient processes and more streamlined operations.

"Mounting evidence that health information technology (IT) can improve health care quality and patient safety - reduce unnecessary expenditures - is spurring a flurry of activity in the public and private sectors, setting the stage for what some describe as a transformation of health care delivery." American Hospital Association, Health Information Exchange Projects, 2006

Overall, it is great to hear that organizations like mine are providing service and support to efforts such as these. With improved technology will come better patient care. However, I do realize that sometimes it is taking one step back to take five steps forward; especially when introducing new technology and causing a change in the way people perform their everyday jobs. History has proven that the pros do outweigh the cons, though.

Great Job to Everyone Who Was Recognized for Performance Excellence.

For more information on the Texas Quality Foundation visit: www.texas-quality.org

 

A Physicians Perspective on EMR Implementation

On Friday May 29th I attended the local HIMSS chapter meeting which was devoted to a physicians perspective of an EMR. I was amazed by the implementations being performed by physician groups without current incentives from the stimulus. In fact, one of the physician who had implemented an EMR within his clinic was able to explain in full detail the joys and pains of this process. The story was an inspiration for all physicians looking for the right way to do it.  

As a marketing and salesperson within Healthcare IT space, I really enjoy learning how our products and services can improve the quality of life for so many people - i.e., physicians, physicians family's, patients, payers, etc. In fact, at the HIMSS local chapter meeting one of the physicians who had done a full-blown implementation of EMR stressed the fact that he and his family were so much happier today because of its added value to their lives. This is only a guess but I am willing to bet that a happier and more well rested doc delivers much better patient care.

The advantage of patient care is also an extremely important topic within the subject of EMR. And, patient care was drastically improved as a result of the EMR because as the physician explained, now he and his fellow physicians could pull patient history in situations where it was needed quickly. Prior to the implementation the physicians would have to grab a chart to find important patient information; not to mention that navigating through the patient record could take quite a bit of time.

The speaking physician also brought cost savings after the implementation to the table. In fact, I was shocked that at one point he had 18 front office staff; again, this was a small clinic. Also funny, because after implementation he has less than 5 front office staff. The doctor showed all of his savings in a very well laid-out fashion, and, provided real data with metrics showing how he is now saving close to $500,000 annually; this savings even after paying for maintenance and support. Wow!

I hope to be engaging in more conversations with this physician in the near future.

Electronic Health Record: Moving Toward the Future

Recently I had the honor of attending the HIMSS Southern Chapters Regional Conference. At the conference I encountered a tremendous amount of information pertaining to various perspectives on EHR (electronic health record), RHIO's (regional health information organization), and various IT solutions designed for the health care industry. I also had the opportunity to engage extremely bright professionals regarding the advantages of EHR's, RHIO's, and healthcare IT solutions.

While in the RHIO panel discussion I heard a success story regarding the Ochsner Clinic which struck a particular chord with me. The story highlighted the importance of information exchange, and gave compelling testimony as to our need to drive change in the current healthcare system. The story told involved what happened to hospitals, physicians, and patients in New Orleans post Katrina. "Importantly, the executives at the Ochsner organization had planned extensively for a hurricane; and though ultimately the vast scope of Katrina did cause some system failures, Ochsner was among the few New Orleans hospitals able to function continuously during the storm and in its long aftermath" (Hagland, 2008). In fact, numerous lives were saved as a result of the efforts of the Ochsner team. I remember hearing of one woman that had went to a gym which had been established as a place for care. The woman held a wet paper bag in her hand, inside were 25 medications, all of which were unidentifiable. Fortunately, the woman was a patient of the Ochsner Clinic; this enabled doctors the ability to retrieve her medication information from a disc. The advancements made by Ochsner to deliver quality healthcare undoubtedly saved lives.

Great Job!

9 Out of 10 Claims Auto Adjudicated: Could this be True?

Up until this point I have been heavily engaged in reading numerous books regarding claims adjudication. I have also been studying the market, and, the entire claims adjudication process, or workflow. I continue to be fascinated by what I am discovering, and the complexity in adjudicating claims as a whole.

I would like to express some thoughts into processes in the pre-adjudication process. So far, from what I have gathered it is great to have auto adjudication…right? However, from what I understand about auto adjudication it is only possible in the narrowest context. How can some claim extremely high auto adjudication? Through auto adjudication a payer is taking risks of overpayment for reduced costs. I can see high levels of auto adjudication being used in a small book of business with small volume; at least in that context I would find feasible an auto adjudication rate in the ninety percentile. However, would payers let 9 out of 10 claims not touch human hands in ? Obviously, when thinking about auto adjudication in this context it seems a bit farfetched. Again, the important consideration is that auto adjudication is GREAT but leaves the payer somewhat exposed.

When is it OK to use auto adjudication? It is great to use auto adjudication when you can build decision rules for a narrow context – i.e. Medicare Secondary Reimbursement, drug screenings for new hires, etc. I find it hard to imagine auto adjudication being used for certain types of institutional (hospital) claims. Institutional claims tend to carry higher than average costs, and the auto adjudicating of some of these claims would leave the payer exposed to tremendous amounts of risk – i.e. overpayments on a large scale. This is not to say that institutional claims cannot be auto adjudicated though; the confines would just have to be narrow with a small book of business.

At my organization we always develop rules for auto adjudication when it makes sense. However, auto adjudication will only be used where the process allows the payer to gain more benefit from risk/reward. We would certainly NOT build auto adjudication into the system if it is going to leave the payer exposed to tremendous amounts of loss.

OCR: Is 96% Good Enough?

Optical Character Recognition: Is 96% Good Enough?

 

An organization we have been in conversation with was concerned about their ability to complete 60,000 claims a month accurately using OCR (Optical Character Recognition) technology. "Optical character recognition, usually abbreviated to OCR, is the mechanical or electronic translation of images of handwritten, typewritten or printed text (usually captured by a scanner) into machine-editable text" (Wikipedia). OCR is the industry accepted standard. This is a relatively simple answer in some regard. For instance, the first question I needed to uncover was what the organization wanted the error rate to be on 60,000 claims? Of course, the company was a little unsure how to answer that because the obvious answer was none, or 100% defect free. However, there is no perfect process; obviously there has to be some rate of error built into their costs. .

Two solutions were introduced to the payer, one of which was OCR technology. The OCR technology has an error rate of 4%. What? Four percent sounded great! As a consumer myself, I think that anything above 90% is just fantastic. However, the reality is 4% would cost this organization $720,000 a month in errors. Back up... where did I get this figure from... let me explain! The average claim mistake will cost an organization anywhere from $300 to $400, on average. However, if the form sent through OCR was a UB92 it could cost the organization up to $1,000 per mistake. I used a conservative $300 to base my analysis off of; and, I used the 60,000 claims for my model. The other solution positioned  to the provider was a double-blind key method. And based upon its 99% defect free rate, this would bring their cost of quality to $3,000 a month; a far better deal for the organization employing this method for converting paper claims to EDI.

 

 

Healthcare Auto Adjudication: The Robot Typist

Since becoming employed wtihin the Healthcare IT Software Solutions space, I find myself learning so much about healthcare, and the healthcare system – i.e., claims processing, adjudication, EDI (Electronic Data Interchange), and EDE (Electronic Data Exchange). I am continually fascinated with the solutions I am engaged in marketing and selling. For instance, the product I am working with now is a solution for claims processing. The solution is not adjudication software, rather software that works in conjunction with adjudication software.

I overheard one of the technical members of our team call eClaims "the robotic typist” today. A fascinating concept I thought to myself…one I asked him to elaborate more on for me.  As he began explaining how the software worked, and the decisions it made, I thought wow! I am a huge proponent of business process automation and love anything that makes life easier; he had my attention.

I was amazed at the decisions eClaims was able to make pre-adjudication. The software almost eliminates the need for human interaction downstream during adjudication. To elaborate on this, interactions and manual entry are necessary during adjudication when errors occur as the result of rejected files during processing. Errors during adjudication processing often occur as the result of human error upstream - i.e. the wrong number on a form, or missing information on a form such as: HCFA, CMS 1500, UB92. eClaims corrects any problems in processing pre-adjudication by scubbing the data.

All adjudication systems accept claims but some do it poorly or have problems with the format the provider is sending the claim in; eClaims eliminates this problem. eClaims also has an entire host of other features which make it a truly amazing product.

I look forward to helping automate and fine-tune a process which costs organizations tens of millions in lost revenue annually.