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.

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.

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.

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.

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?

This post originally appeared in Wired magazine’s Cloudline blog.

In 1990, when I got my first health care job driving ambulances, not a soul in the New Orleans EMS department had a cellphone. Not even the head of the service. The mayor, his chief of staff and the police chief each had one. That was about it. These phones weighed like 15 pounds and were hardwired to a car battery. And we ambulance drivers documented our care on “run sheets” found on metal clipboards but, since so few people bothered to read them, we also wrote key vital signs and other metrics on a three-inch-wide piece of white tape smacked across the patient’s abdomen.

Today, everyone in New Orleans — and everywhere else — has a cellphone. These cellphones have the computing power to find, and add to, and direct everything that anyone would need to know about a patient anywhere in the world… but they don’t do it! Today’s “do-everything” cellphones are the size of your wallet, yet most ambulance crew run sheets are still paper, found on metal clipboards. And most good patient data is still found on those three-inch-wide pieces of tape.

Why? I’ll give you one good reason and one bad one.

A countless number of companies and technologies and ideas were harmed — and, in fact, blown up completely — between the days of the brick Motorola cellphone and the iPhone of today. Remember “DSL” companies that connected houses to the internet over copper wire? Remember “booster antennae”? Remember when we all thought the “flip phone” was the shizzle?

There are many corpses scattered in the wake of the Internet and cellphone renaissance that has occurred over the past 20 years and we are all fine with that. The young engineers and designers that were part of exploding companies simply took their backpacks and mini-fridges and went to the next cool company. When the company worked out, the options for these young engineers and designers were worth millions. When it didn’t work out, they moved on.

But there’s a big difference when it comes to health care. If each of these companies had been dealing in critical patient information in an EMR and lives were at stake, this would have been a dangerous game. The innovation would have been faster but the collateral damage would probably have been too much for our social values.

OK, now here is the bad reason:

The market for exchanging information in health care, specifically for sending referrals, is, in many cases, not legal. I’m not kidding. A few years after we nationalized health care coverage for seniors (Medicare) and for those in need (Medicaid) in 1965, we also made it illegal for the sender of a patient to be given anything of value by the receiver of that patient.

There was a good reason for it as we were afraid of kickbacks driving up federally funded care. Well, federally funded care has gone up quite a lot since it was originally funded, but no supply chain emerged.

Cellphone carriers can pay retailers who hook up folks to their network, but specialists can’t pay primary care doctors for the effort required to send clean electronic clinical info over to them that would improve care and reduce duplication.

If they could, there would be a lot more than, like, six Wired readers using their engineering talents in health care. (Hi! Please come work at athenahealth.) Instead, the only information systems that people pay for are those that work within their own controlled environments. There are legacy, non-cloud software systems that are only useful for exchanging information within the institution that owns that particular IT system. Weird, right?

As a result, in the last three years, we have hospitals that bought an EMR under the HITECH Act (and Meaningful Use) that have also bought the practices of the doctors that use them! We have gone from some 22 percent of docs employed by hospitals in 2008 to about 44 percent employed by them today. Making people work for you in order to exchange information with them is not exactly New Age. And most of those doctor acquisitions will fall apart in the next three years. You heard it here first.

The good news is that, even despite these obstacles, the obvious benefits of cloud computing, especially through electronic medical records, are driving health care into the 21st century. We at athenahealth are growing like crazy and we serve all our clients on one single instance of our web-native application. We are also being asked by our clients to move information in and out of legacy systems that don’t communicate well. We have even gotten the federal government — the Office of the Inspector General in the Department of Health and Human Services, to be exact — to bless a small ($1) interchange fee as “NOT a kickback” in order to attract more entrepreneurial energy into the efficient exchange of clean health information.

All of this makes me feel like heady times are ahead in health care. Even though we are watched by a nervous, panicky government that doesn’t quite get the deets, enough good seems to be getting done for Uncle Sam to continue letting us move about the cabin. And the government is getting behind the cloud — or, at the very least, not getting in the way of it.

So, people of Wired, come to health care! The water is, well, a little chilly, but it’s getting warmer all the time. In fact, I’d say spring really is here!

Originally, the 10th revision of the International Statistical Classification of Disease and Related Health Problems–aka ICD-10–was slated for adoption here in the United States on October 1, 2011 by all “covered entities” under HIPAA.

As early as January 2009, the deadline was pushed out to October 1, 2013 and with it, migration to ANSI 5010 moved to January 1, 2012 in order to support ICD-10 codification. If, like me, you have become so immersed in the politics of such timing, just remember that the ANSI 5010 standard and ICD-10 code set updates are intended to be helpful, streamlining and improving transactions and improving diagnosis reporting and analysis.

Anyway, the “best-laid schemes of mice and men oft go awry”… unless you’re living in France, or one of the Nordic countries…circa 1997.

The industry transition to ANSI 5010 has been less than smooth and the Centers for Medicare and Medicaid Services (CMS) recently extended the enforcement start date to July 1, 2012. In response to feedback from organizations like the American Medical Association (AMA) regarding the administrative burden and cost of the ICD-10 transition, CMS announced in February that the agency would also consider postponement of ICD-10 implementation.

No lack of points of view

Finally, on April 17, the Department of Health and Human Services (HHS) published a Notice of Proposed Rulemaking (NPRM) in the Federal Register to propose a one-year delay to the implementation of ICD-10 until October 1, 2014. Prior to the release of the NPRM, policymakers and thought leaders weighed in with a wide range of opinions as varied as: “Don’t delay!”, “Make it a 2 or 3 year delay”, “Let’s just move on to ICD-11”, “Do we even need ICD-10 or can SNOMED suffice?” (While this last idea may seem a bit radical and unlikely, we tend to agree with its potential to simplify—removing the administrative burden on providers and avoiding redundancy.)

But at this point, the length of a delay doesn’t really matter. What does matter is that delays continue for everything—ANSI 5010, Meaningful Use, ICD-10, the Sustainable Growth Rate resolution. And with each delay, the innovative doctors, vendors, patients, health systems and payers aren’t rewarded for their speed and efficiency.

I understand the thoughtful arguments of advocates on all sides and I know we’re collectively tackling monstrous issues. But, the culture of delay is really beginning to keep our industry stuck in a rut. The discussion seems to be increasingly focused on “When will we?” rather than “How can we?”

As always, we’d love to hear your thoughts and, more importantly, encourage you to share them with the feds, who take the comment process very seriously.

You can review the NPRM at the Federal Register. The rule also includes proposals for the adoption of a standard for a unique health plan identifier (HPID), a data element that would serve as an “other entity” identifier (OEID) and a National Provider Identifier (NPI) requirement. Comments are due no later than 5 p.m. on May 17, 2012 and instructions regarding submission can be found on page 22950 of the rule.

When Florida Woman Care was looking for physician billing services and an EMR that would support its growth goals, the leadership wanted a solution that allowed them to drill down into data, get paid efficiently and avoid running the practice like a patient conveyor belt.

Find out how Florida Woman Care has made the most of athenahealth’s cloud-based services to satisfy these needs.

And we like that. It shows progress.

It also means we are experiencing an acceleration of the paradigm shift from the “Old World” of paper-based health records to the “New World” of EMRs.

None of it feels like a small adjustment; more like a tectonic paradigm shift for the health care industry. Even as the Old World recedes around us and the New World emerges, Old World concepts of health records and record ownership do persist. They manifest themselves in some unusual ways, too, and with surprising staying power, persisting in laws, regulations, the way we think about records, the way we do business and, often, even in EMR offerings themselves.

EMR systems that have not fully transitioned to the new paradigm represent a “Middle Path” that slows down change and innovation. To move forward successfully from the Middle Path to the New World, we will ultimately need to resolve the conflicts between the paradigms.

Ownership vs. Use

So, what about these conflicts? In the Old World, records are regarded principally as physical items–paper files that contain information. Therefore, the Old World focuses on custodianship of the record, which then translates into the question of who “owns” the record and, therefore, the items (information/data) contained within the record. This is a property-based approach to health information. In the New World, the interest is the data itself and, more important, aggregated data across multiple records that:

• provides meaningful insight about what care protocols work
• enables caregivers to communicate better with patients
• enables researchers to more expediently identify patients to participate in studies
• achieves better public health reporting and analysis, among other uses…

Therefore, in the New World, how the data can be used and how it can be leveraged is more relevant than who owns it.

Are you still living in the Old World? Did you make the leap to the New World? Tell us about it.

Next week, we will explore static records vs. real-time records and ways that software-based EMR systems often represent the inertia of the Old World paradigm.

Okay, forget being in the health care business—we are all patients sometimes, too. Do you feel like an actual human in the exam room or a numbered paper gown with dollars signs attached to it? Has trying to get well ever nearly bankrupted you?

Well, you’re not alone.

This is a tough time to run a medical practice—or be a patient—and we all know that is why, in fact, athenahealth exists. We are here to make it suck less.

For a light-hearted look at your plight—and ours—we have a little video. It’s a parody of a song from the Tony Award-winning musical “Avenue Q.”

Hang on. Things get really great at the 3:29 mark….