Yes, as of this writing, the ICD-10 compliance deadline has been proposed for a delay to Oct. 1, 2014.

With that in mind, we have devoted an entire section of our website to ICD-10 knowledge for physicians, practice managers and anyone else who needs a clear picture of what it takes to manage the leap from some 13,000 to about 68,000 diagnosis codes.

As the year goes on, we will add updates to the section and let you know about each one. If you have questions that aren’t reflected in the FAQs, please comment here and we’ll get your answers.

In response to the request from Congresswoman Renee Ellmers—a fellow North Carolinian—to exempt soon-to-retire doctors and small medical practices from the federal requirement to use an electronic health record (EHR), I say ‘Not needed.’

I am 66 years of age and I adopted an EHR in January 2011, when I was 64. The upfront cost was reasonable and training was done without interrupting my schedule. In addition, since my vendor—athenahealth—is only paid if I am paid, they have a vested interest in making certain that claims are filed and paid in a timely manner.

For the first three months in 2011, I learned to use the system. During the next three months, I fulfilled all the requirements for Meaningful Use and I attested at the end of June. A few months later, I received my check for $18,000 without any significant hassle on my part—the attestation was all done by my vendor. 

I find that using the athenahealth electronic health record has greatly improved my documentation, virtually eliminated claims denials or resubmissions, facilitated communications with other health providers and patients, and has even reduced postage and office supplies. It did not impact my workflow because the system is easily modified (by me, not the vendor). Moreover, some of the requirements of Meaningful Use helped me deliver better patient care–like the requirement that I provide a clinical summary to patients after their visit.

Physicians of my age went to medical school during the ‘60s and ‘70s. The application process was very competitive and, as a result, they are all smart people. To imply that we are incapable of adopting and learning to efficiently use an EHR is nonsense. To the good Congresswoman, I would reply that her time could be better spent concentrating her efforts on bringing Medicare reimbursement in line with private insurance carriers.

Dr. Eubanks is an athenahealth client.

If you read the athenahealth blog regularly, you know we tend to write about and discuss Meaningful Use.

Often.

We have a good reason. We have approached Meaningful Use the way we approach everything we do—by working with our providers to get them paid for doing the right thing. To that end, we offered the industry’s only incentive guarantee, established a Meaningful Use Resource Center for clients, held a multitude of MU webinars and created a cross-functional team to tackle each problem clients might face. And our CEO, Jonathan Bush, pulled a Full Monty (of his data) while in Las Vegas for the MGMA convention last October.

Our approach worked! We helped 85% of our eligible, participating physicians attest to the Stage 1 measures and receive their incentive payments.

With so much blood, sweat and tears invested in the Meaningful Use of our EHR by providers, we jumped at the opportunity offered by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) to provide comments in response to two sets of rules: The Meaningful Use Stage 2 Notice of Proposed Rulemaking (NPRM)—“CMS Rule”—and the 2014 Edition EHR Standards and Certification Criteria Proposed Rule—“ONC Rule”. In future posts, we’ll dig into key topics in greater detail but, for now, we thought it’d be helpful to summarize what we submitted on May 7th.

General Thoughts on the CMS and ONC Proposed Stage 2 Rules

We are highly encouraged by the inclusion and expansion of objectives and measures related to the exchange of health information, patient engagement, and quality reporting. The increased focus on these critical areas will lay the foundation for providers to leverage health IT to promote better care for individuals, improved population health and increased value in health care (aka the health care “Holy Grail”.)
Because there is often a variance between standards and their implementation, we believe a high degree of harmony between the ONC Rule and CMS Rule is fundamental to the Certified EHR Technology (“CEHRT”) vendors’ ability to help providers achieve Meaningful Use. We also think it’s vitally important for the ONC and CMS to create enough rules flexibility to encourage continued innovation. (PLEASE!)

In the specific case of health information exchange, we hope the ONC will consider the certification criteria as the minimum, baseline standard upon which existing and new means of electronic exchange can support providers in achieving Meaningful Use.

Last, we greatly appreciate the many ways CMS and the ONC have fostered a transparent rule-making process: public access to the Federal Advisory Committee meetings and recommendations; presence at industry events like the HIMSS12 conference; and, opportunities to participate in private-public collaborations. The efforts made by CMS and ONC representatives to educate the public on comment-making best practices have been great too.

Our Comments to the CMS and ONC

So, what did athenahealth contribute to the conversation? In our comments to CMS, we focused on:

• Why the implementation of Stage 2 should not be delayed
• Health Information Exchange
  • A logistically feasible, cross-vendor-and-organization alternative to the electronic provision of summary care record at transitions of care
  • Supply chain issues with incorporating lab results as structured data
• Patient Engagement
  • An alternative to the proposed secure messaging measure
  • Considerations for the implementation of View, Download, & Transmit
• How to aggregate data and attest with an EHR conversion

We also commented to the ONC about their Proposed Rule:

In addition to the nitty-gritty, technical issues, at a high level we also covered:

• Reporting on Patient Safety Events and the vendor’s role
• Support of a flexible and process-based approach to Quality Systems
• Ideas on how to facilitate data portability
• The importance of maintaining “Complete EHR” as a concept

Finally, we urged the ONC and CMS to continue driving transparency by a) continuing to make vendor, specialty and state attestation data publicly available; b) releasing registration-by-vendor data to inform providers during their EHR purchasing decisions; and, c) private-public sector collaboration.

So, now we wait. CMS will review 230 comments and the ONC will review 400. And what a range of comments they have to consider. To cite a few:

• The American Hospital Association has expressed its opinion that the proposed rule sets the bar for Stage 2 too high.
• The Electronic Health Record Association has also shared some concern about reporting requirements.
• Rep. Renee Ellmers, R-NC, a nurse who is married to a surgeon, asked CMS to exempt doctors from the Meaningful Use program who are in small practices or are close to retirement.

What do you think? How did you weigh in? We’ll keep you posted as the comments get reviewed during HIT Policy committee and HIT Standards committee meetings over the next couple of months. But now, we’d like to hear from you.

With all the action in the health IT industry these days, an electronic transaction format conversion has to be one of the least sexy topics out there. But the latest transition has been fraught with danger.

Heading into the last quarter of 2011, the ANSI 5010 conversion had the potential to have a huge negative impact on providers. An unsuccessful conversion would have been disastrous for medical billing: Claims would have been unreadable by payers and payments could have been sent to the wrong locations. In an extreme case, the past decade’s successful migration to electronic transactions could have unraveled, forcing providers back to paper in order to get paid.  

Every month, 15 million electronic claim, remittance, eligibility and claim status inquiry transactions flow through athenahealth—and before the ANSI 5010 conversion, we knew the change would impact nearly every one of those medical billing transactions. So, we slated a gradual implementation over a full year.

And yet, despite our best efforts to push early adoption with payers, we had only three payers ready for claim submission in the 5010 format as we headed into the third quarter of 2011. Three payers, accounting for less than 1% of our volume.

Fast forward seven months.  

Although the Centers for Medicare and Medicaid Services (CMS) have twice postponed enforcement of these standards (currently scheduled for June 30, 2012), more than 97% of athenahealth’s transactions are now exchanged in ANSI 5010. We’ve since moved on, tackling our 2012 initiatives, including preparations for the massive ICD-10 code update. And those remaining 2.1% of transactions are awaiting payer or intermediary readiness. So, we’ll continue to move these payers and monitor them throughout this year, and probably into 2013.  

So, how did the ANSI 5010 conversion go?

It hurt, but it could have been so much worse.

We started Q4 2011 with less than 1% of claims submitted in 5010—by the first week of January, 2012, we had  more than 85% of claims in the new format. This rapid conversion wasn’t without serious impacts to our providers: 

• Without warning, in November, Medicare had unveiled 5010-only enrollment for providers. This meant conversions within each state needed to be completed before any new athenahealth providers could start submitting claims in 5010. If the associated intermediaries could keep up with the testing, and 5010 approvals were done in a timely manner, this could have been manageable. But many couldn’t keep up and some of our new providers suffered as a result. Despite this, we were live with most Medicare carriers by mid-November and fully live in all states before the conversion deadline, minimizing the impact on our providers.
• With internal communication gaps and the implementation of external tools, many payers couldn’t tell athenahealth how they were interpreting the standards in advance of moving to production. Because of this, athenahealth’s front-end rejection rate, which typically hovers around 1.5%, peaked at 2.4% in January, 2012. While we weren’t thrilled, the only other vendor we’re aware of that shared this metric was happy with their 5% rejection rate. We credit this manageable increase to our production testing process, which mitigated risk by submitting the bulk of claims in 4010 while gradually increasing the 5010 volume with each payer who supported it. 
• Payers and intermediaries who didn’t have careful controls processes in place were, at times, unable to answer basic questions about submitted claims: Who submitted them? How many claims are there? or What is their status? This widespread issue resulted in false compliance warnings, processing delays and reporting errors, and some providers were hit harder than others. Again, through vigilant monitoring and escalation of missing claim research with payers and intermediaries, we were able to resolve these issues. The situation then improved dramatically in February. Some of our providers had significant payment delays, which would have been more extreme had we not detected issues early, analyzed the available data and resubmitted affected claims once we became confident of the best way to move forward.     

Here’s why our cloud-based services ease transitions like these:

• Our cloud-based model allows unparalleled visibility into the financial health of our clients. We’re invested in the whole claim lifecycle—we don’t just pass through a claim and hope it gets to the payer. We confirm receipt, track claims’ progress and ensure remittance is received. And we’ve set up alarms to let us know when  claims don’t get on file as expected. Within a week of a claim submission, if we haven’t seen acknowledgement as expected, we begin escalating issues with the intermediary and payer. 
• We had a testing cycle that was so thorough it elicited ridicule from some trading partners early on. Yet, by the end of the implementation, several payers and clearinghouses were thanking us for our help in their implementation. As an early adopter, we were able to help them detect issues and address major problems before the rest of the pack was ready to start testing. For example, in January alone we encountered nearly 50,000 false rejections from clearinghouses or payers who needed to update their systems and reprocess our clean claims.
• We allocated the appropriate time, money and people to the change, monitored maniacally, and reacted quickly. Our “war room” processed hundreds of issues with our Development and Rules teams present in the room so that a new requirement or issue could be swiftly implemented as soon as it was defined.

We’re already working on preparations for the big switchover to the ICD-10 code set and tapping into the lessons we learned from 5010 to make it go as smoothly as possible. As always, we want to help providers focus on their patients by serving up the right information at the right time, in the right place.

We are always happy to see coverage of electronic health records (EHR) pop up beyond medical or health IT news outlets. As a cloud-based service to medical practices and health care systems, we spend our time talking to those audiences because we are, well, trying to share the distinct benefits of our services. But an EHR is ultimately about an individual patient—and every patient should know more about the future of medical records.

So, recent coverage in the Boston Globe about EHR adoption got our attention. (As a company with a mantra about going paperless, a headline that says “Goodbye Paper” is particularly apt.)

The story included this infographic about the spread of EHR technology and the disbursement of federal incentive dollars under the Meaningful Use program.

And while it’s not exactly going to make the evening news, the Government Accountability Office just published a report on the first year of the Meaningful Use program. 

One of athenahealth’s concerns about the Meaningful Use program has been the lack of a method to verify that physicians across the country have met the measures. Thankfully, that’s not an issue for athenahealth. Since we operate in the cloud, we can see even the smallest grains of data in the network. In fact, we have been able to regularly report out on the progress of our client physicians on their path to Meaningful Use of an EHR as they met and attested to the measures.

While we can verify what physicians on our network do, how can that be done with software-based solutions, when they don’t afford the visibility of a cloud-based network? We hold ourselves to a high standard of integrity and we want to be sure that that the truly meaningful users get rewarded. It turns out that the government seems to agree and the auditors at the GAO would like to see a better process for verifying performance.

The GAO made the following recommendations to the Centers for Medicare & Medicaid Services (CMS), which administers the Meaningful Use program:

• Establish time frames for expeditiously implementing an evaluation of the effectiveness of the agency’s audit strategy for the Medicare EHR program.
• Evaluate the extent to which the agency should conduct more verifications on a prepayment basis when determining whether providers meet Medicare EHR program’s reporting requirements.
• Collect the additional information from Medicare providers during attestation that CMS suggested states collect from Medicaid providers during attestation.
• Offer states the option of having CMS collect meaningful use attestations from Medicaid providers on their behalf.

What do you think? How has the experience with Meaningful Use treated you and your practice of medicine?