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Meaningful Health Care Informatics Blog

August 25, 2010  10:29 PM

Hidden secrets for improved efficiency in the Billing department

Posted by: RedaChouffani

Similar to many other industries, the larger groups seem to have the answers and have automated every major workflow or process that had complex steps or unnecessary ones.  Similar to how some fast foods mastered the art of creates burgers in record times, it is important to seek to learn from other’s experiences.
In healthcare the same should apply.  Whenever considering new ways to reduce cost and increase efficiently, we should look to what some of the larger organizations are utilizing and how some of those technologies can be applied at the small to mid-size level.  What has been a surprising facilitator for this, is the continuous drop in technology costs. 

One particular area that has some interesting solutions surrounding it, and is spreading throughout some of the mid-size organizations and it is the shrinking of FTE billing staff. 
Traditionally, a practice would review the overall national or MGM reported Provider to billing staff ratio and use that to hire for the billing department.  However, that model can no longer be used an accurate representation of what really a physician will need in terms of staff.

In most cases a billing department will ideally spend a significant amount on specific tasks or job roles.  These tasks would range from Coding, billing, Workers Comp specialists, Medicare Specialists, Collections, Claim follow-up, or simply authorizations.  However, depending on the size of the practice, one person may be responsible for all the above.
But let’s for a second discuss what technologies are available out there that can facilitate and assist this billing team reduce their work load or help them become more efficient.

Implement a Document Management or use Electronic EOB: This would significantly reduce the amount of time it takes to retrieve an EOB to review denials or simply to re-file a previously rejected claim.  This also can be combined with an indexing solution the will facilitate searching within the documents.
Implement electronic remit and auto posting for all insurance payments which would eliminate the majority of the time needed to post manually an EOB.  This process requires a clearing house that supports 835 X12 formats Scan to deposit checks: With the high number of checks coming into the practice, having a staff member drive to the bank and wait in line may seem as it is a waste of resources.  With many banks offering remote scan and remote deposit an organization can now deposit their checks without even leaving their office.

LockBox: This is another useful service that can be provided by your financial institute.  In this service a practice can have all their patient payments (from their website, checks, credit cards, ..etc…)Insurance payments to be all automatically posted to the system electronically in batch mode.  Basically no staff will need to manually the charges from a Kiosk, or a bank deposit, credit card transactions one line at a time.  So, if you calculate the time it requires one staff member to enter one patient payment and multiply it by the total amount of checks you are receiving daily, you will notice that eliminating this manual process will have a tremendous impact on the bottom line.  The way this works is simple,  the bank of a Revenue cycle Management firm will supply you with a utility that will generate a lockbox file (several standards available and PMS vendor must be consulted to ensure compatibility with the software), once all the transactions are received or totaled, a file is generated and submitted to the EHR/PM system.  The system then processes the file and posts all the payments by attempting to match the payment to the patient using identifiers such as (patient address, name from checks, Credit cards or other means).

August 22, 2010  9:41 PM

North Carolina Providers may be getting closer to a state wide HIE

Posted by: RedaChouffani

With the recent federal grants awarded for the state of North Carolina health information exchange and EHR training programs, this state has been very busy planning and preparing for a state wide health information exchange platform.

In just the last 8 months, 4 separate HIE initiatives have been established.  From the east coast under CCHIE (Coastal Carolinas Health Alliance), NCHEX (North Carolina Hospital Association) ,
Sandhills HIE (Sandhills Community Care Plan) , and Southern Piedmont Community Care Plan HIE (Southern Piedmont Community Care Plan).

This will mean that participating clinicians will be able to review and access patient records electronically and view admission information, lab results, radiology reports, Medication list, History and Physicals, Progress Notes, transcribed reports.

One August 20th, of 2010 one local non-profit organization NCHICA (North Carolina Health Information and Communications Alliance) in collaboration NC Health and Wellness Trust Fund (who has been nominated by NC State governor Bev Perdue to manage the NC HITECH awarded federal grant) have released to the public the draft for operational plans for the NCHIE.  This can be accessed via the following link: here.  Although there are only 5 days until the deadline to submit comments, the public is encouraged to provide input on the proposed 183 page long document for the NCHIE.

August 20, 2010  11:00 PM

North Carolina faces More reimbursement cuts

Posted by: RedaChouffani

This week North Carolina maybe the next victim to state cuts made to Medicaid.  This further increases the presses on physicians and Hospital organizations.
This week, it was clear to many physicians in North Carolina that further cuts in Medicaid are bound to become reality.  This will add more to the already shrinking reduced reimbursements and cuts.  But state lawmakers and governors are already facing some of the toughest budgets since the great depression and deep cuts to social services, public safety and health care are inevitable.
The State of North Carolina Administration is planning a cut in Medicaid provider rates at approximately $27 million in state funds; this will total in over $100 million in payment reduction.
Clearly, it is not just the physicians who will suffer from these cuts, but also hospitals and patients.  With an anticipated increase in Medicaid patients due to the recently passed Healthcare Reform and the Medicaid expansion, more patients will find it difficult to get providers to accept their insurance.  This would force many to seek Community health centers, or hospitals.
Then hospitals will then suffer from increased patient volume with insurance that has already a reduced reimbursement rate.  Patients will be frustrated by the reduced amount of practices.
Unfortunately there is no simple or easy solution to this.  If State law makers do not make the cuts necessary, then the deficits of the state increase.  Despite the recent federal funds awarded to NC as part of the Budget Act in July 2010, the state will still face the challenge that many other states face in this economy, and unfortunately so will the physicians in the state.

August 15, 2010  11:57 PM

Speech recognition in healthcare

Posted by: RedaChouffani

In recent weeks, I have been talking to few physicians that have finally made the jump to Dragon.  Many of them realized the potential costs savings that they can achieve simply by exchanging the digital records with a USB microphone.

What I was not prepared to see is how challenging the task of training the system to receive a good accuracy where you don’t have to spend hours correction the notes. In addition, one of the biggest concerns as more and more start adopting this technology is the simple fact that most of the data capture is not structure. This means that if you were to run a query on the system for a meaningful use requirement, chances are that not of that data would be queried or mined.  But what makes some of the technology makers like Nuance different, is that they are offering SDK (Software Development Kits) for EHR software makers to integrate the dictation system so that a physician can simply dictate an encounter, or SOAP notes just by simply using natural language processing.  This would enable specific parts of the content such as Exam findings, History, and such stored as structure data.

In addition, several EHR vendors have incorporated additional advanced workflows and functionality into their solutions.  For Epic, if physicians are not able to dictate immediately, they can record their findings into the chart and an automated workflow routes the audio file to the transcriptionist or automated transcribing server while still preserving the audio file right inside the chart.

So to make the best use of your dictation system, and identify new ways to further reduce your costs.   it is most definitely worth spending time training the system and correcting any errors that arise.  This will increase the accuracy in the long run.

August 8, 2010  9:43 PM

Identifying and measuring staff productivity

Posted by: RedaChouffani

For many health organizations attempting to reduce costs usually means cutting staff schedules.  But the reality is that with reimbursement cuts and healthcare premiere constantly on the rise, the highest expense is payroll and that means it will be the first to suffer.  In most organizations this is a very sensitive subject.  No one wants to let go individuals, but at the sometime the CFO or an administrator is responsible for maintaining the organization operational while maintaining a high level of quality and care delivery.

So, is there an easy way to reduce costs and ensure that you are only making minor adjustments?  In working with several practices, many are taking a different approach to this.  The plan executed was to identify what everyone is spending time on, and based on the findings reorganize the resources to increase efficiency.  However, while most organizations simply ask their staff to write out what they do during the work hours and what different tasks they are involved in, some groups are taking a more direct approach by utilizing legal monitoring tools that can see everything you are doing from how long you are staying on a site, personal passwords, emails, files copied and more.

For some these spy applications do provide a quick and easy way to regain some of the lost time spent on no business tasks during working hours.  And it is very attractive solution especially when some of these solutions describe the following ROI (Return on Investment).

One product that is commonly found in the market provides a Return on investment calculator that claims for an organization with 100 employees,  and an average of 90 minutes spent online of which 30% of it for personal use, an average hourly pay rate of $20/hour this would result on this application saving over $108,000.00 in one single year.

While the savings sound terrific, some side effects are bound to exist.  Some of the questions being raised with this method are:
how would the big brother concept affect morals?
Also now that a system admin, or an administrator knows a little too much information about a specific staff how is that going to impact the interoffice relationships in the organizations?
Should employees have a disclosure of who sees their information?
If a Patient is reviewing their PHI and it is exposed to a supervisor or manager, is that considered a HIPAA violation?
Is this big brother setting force administers to spend more time policing their staff?
Would it be more affective to have a third party firm review those logs and discuss findings with staff anonymously?

August 5, 2010  10:33 PM

The top ten steps to do prior to de-installing an EHR

Posted by: RedaChouffani

For many healthcare organizations that have made the commitment to paperless and implemented an electronic health records the road has been challenging.  Some have at some point contemplated the de-installation of the entire system, and others worked through the pain points and found new ways of making work..

Usually in an environment where physicians are making every attempt to not loose focus on providing the patient care needed, it is understandable to see the tensions and frustrations that can come for implementing an EHR.  So, prior to deciding when enough is enough and giving up on an EHR system what are the steps needed to be taken prior to finalizing the de-installation decision.

The top ten steps to do prior to de-installing an EHR:

1.Be objective: One of the most critical steps of identifying if the current EHR investment can be saved would be to identify what exactly is causing the frustration, bottlenecks in workflow or downtime.  Focusing on the situation not the application or vendor will help create specific items that could potentially be resolved through training and simple support calls.

2.Assign a team lead or champion:  Having a person that can be the point of contact to report system problems, an individual who can work with vendors, and a team member that is looking for a way to salvage the EHR installation would be a very helpful step.  This would enable the organization to properly identify tangible and specific system problems that may be causing the sour taste,  and create a positive atmosphere toward making an effort to resolving the challenges of the solution.

3.Get more training if needed:  Many of the vendors are more than happy to assist with additional training when requested.  So, an organization must accept the fact that they may need more training to properly perform certain actions.

4.Talk to your vendor: In most cases the vendors or Project manager that was assigned to you during the implementation stage assumes that you are a happy client when they don’t hear your feedback. And that your sole point of contact with the company is the support line or an individual that changes every time you make the call.  You must make an effort contact the vendor and express your frustration and challenges.  As many vendors, it is important for software companies to keep happy references and reduce if not eliminate bad PR.

5. Discuss your needs with a third party consultant: Unfortunately not all EHR vendors are able to assist in integrating all the different healthcare products to create a comprehensive solution.  Their expertise is usually based solely around their product.  While there are few vendors that do offer a wide spectrum of services that include consulting, interfacing and integration, it is important to seek assistance from consultants that have assisted other organizations identify issues associated with the EHR.

6. Identify the real source of the issues:  On many occasions, clinical staff run into performance issues on the system, and rightfully so, this has a direct impact on patient care, productivity and the bottom line.  But what seems to be a classic case of software issue, sometimes it is simply the infrastructure that may not be meeting the requirements of the solution.  From slow wireless connections, to slow workstations that barely browse the internet,   it is critical to identify the real source of the problem.

7.Involve everyone:  Whether all the vendors agree on the source of the trouble or not, it is critical to get everyone involved.  From IT, to clinical staff, software vendors and management, everyone must work together and be aware of what issues the organization faces.  This can assist in identifying at a much faster rate possible solutions to help.

8.Compare what you have gained thus far:  On many occasions, one would tend to ignore the positives that came out of the EHR.  Thus step would require you to compare your pre-paperless days and identify what you have gained in added efficiencies, collections, or even incentives from using the EHR.

9. Are the health records accessible:  With the enactment of the ARRA in 2009, and the final ruling on meaningful use,  software vendors are now required to use agreed upon interoperability standards.  But unfortunately for practices utilizing systems that may not adhere to the requirements of the Certified EHR,  extracting existing electronic health records in a standardized fashion would be the biggest challenge when considering de-installing the product.  This can be considerably more challenging if the model used is a web based solution.  Of course, no one anticipates needing to extract data from the new and existing EHR  package during the implementation phase, so many of those questions are never addressed upfront.

10.costs associated with the de-install:  The last step that is a must review is the costs that would be associated with the de-installation of the system.  Whether the organization is going back to paper and requiring staff to print all charts and file them as paper,  or simply maintaining the system and enduring more maintenance costs associated with keeping the system intact, the stakeholders must account for those added costs.

In most organizations having to decide if a system is sustainable or not is something that should take serious consideration, analysis and team work.  In some cases things can be corrected through retraining and reevaluating some of the workflows.  But with the steps listed above, it may help reduce de-installations and confusion associated with the process.

August 1, 2010  10:19 PM

Published Meaningful Use and Certification program

Posted by: RedaChouffani

On July 28th,  two of the most anticipated federal rules meaningful use and certification ruling have been trimmed down and published.   After careful review of the final ruling, many of criteria seem to have changed but eligible physicians, and payment structure remains the same.

January 2011 will be the date that all programs will begin. And vendors are no longer required to have the certification prior to the start of the Stage 1 of meaningful use. A list published in a presentation from CMS summarized the changes from the NPRM to the final rule of the CMS incentive program in the following areas:

Hospital-based Eps
Meaningful use objectives
Medicaid acute care hospitals
Medicaid patient volume
Medicaid programs can start in 2011
More clarification throughout

Eligible physicians for Medicare Incentive program are:

Eligible Professionals (EPs)
Doctor of Medicine or Osteopathy
Doctor of Dental Surgery or Dental Medicine
Doctor of Podiatric Medicine
Doctor of Optometry
Eligible Hospitals
AcuteCare Hospitals*
Critical Access Hospitals (CAHs)

As Eligible physicians for Medicaid Incentive program are:

Eligible Professionals (EPs)
Nurse Practitioners (NPs)
Certified Nurse-Midwives (CNMs)
Physician Assistants (PAs) working in a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is so led by a PA
Eligible Hospitals
Acute Care Hospitals

More information can be found at the following presentation:

July 29, 2010  9:53 PM

What’s ahead of EHR software vendors

Posted by: RedaChouffani
Certified-EHR, NIST, test procedures

It is undeniable that our healthcare system is undergoing some major transformations. Many of which are aimed to improve quality of care and patient safety. Since the release of the Medicare and Medicaid EHR incentive program as part of the stimulus package, the technology sector is expected to see much needed growth and job creation due to the increased demand for technologies that will enable the transition.


While it may seem obvious at first to predict that most EHR software vendors would be the first to benefit from these federal programs. It is widely anticipated due to the complexity of the certification, that only a handful are expected to become what is referred to as Certified EHR.


In certain cases vendors are either acquiring other solutions to include as part of their portfolio and their strategic plans, and some are simply upgrading their product to ensure it meets the certification requirements.


As noted by the ONC, recently NIST (National Institute of Standards and technology) released the approved (pending) test procedures for evaluating conformance of complete EHRs and/or EHR Modules to the initial set of standards. That define the initial set of standards, implementation specifications, and certification criteria published on July 13, 2010.


These procedures of 49 different test measures are a first step for many EHR solution vendors to gauge the level of readiness their solution. It will assist in assessing what resources and timeline needed to ensure compliance with the first stage of meaningful use requirements.


The majority of these procedure released in tests contain some of the follow sections:


  • Definition
  • Certification Criteria
  • Informative Test Description
  • Referenced Standards
  • Normative Test procedures
  • Test Data
  • Conformance Test Tools


Organizations across the country are evaluating the business pros and cons in pursuing meaningful use. And with concerns of potential commercial payers at times following CMS initiatives, one must wonder if a certified EHR would eventually be a must have.

In some cases where the certification process may be a burden, the opportunity for all to seek standardization in interoperability and health information will only encourage collaboration, coordination of care and better medicine. This in most cases would prove to continue to improve care, quality and safety.



July 25, 2010  9:25 PM

The 10 critical steps to selecting an EHR

Posted by: RedaChouffani
EHR, selecting EHR, top 10 steps toward ehr

As many medical practices shift gears toward a paperless environment, it’s clear to many as they discover the newly flexible meaningful use requirements that they will further investigate the implementation and adoption of an EHR solution.

In selecting an EHR, most healthcare organizations face conflicting reports on products they are evaluating, some of which can be based on lack of proper product implementations. Others failed products that did not fit the practice’s workflow.  As an example; by knowing how to select an EHR product, and examining how some of the previewed products compare, the medical practice  will be able to properly identify its need and which products can successfully meet its challenges.

Practices have had plenty of time to make paper charts work for them since the early 20s, when the US saw the spike in private group practices grow. This provided ample time to perfect the efficiency of using paper based workflows.  While several software vendors come with a promise of a new world where no paper exists and practice’s revenues increase, it would be very naïve for any Practice Administrator to take their word for it.

Today’s technology is fully capable of automating and streamlining many clinical workflows, as long as it is the right solution with the right planning and readiness.

To avoid being just another statistic in the failed world of EHR, there are a few critical objectives that should be met to ensure a thorough assessment, smart selection and careful planning an EHR selection.

The following are the ten steps that can help you during your EHR selection stage:

1.      What are the organizations SMART (Specific, Measurable, Attainable, Realistic and Time bound) EHR Goals.

2.      Current State Analysis where an extensive review of current workflows and systems is performed.  In many cases this will assist in identifying all the steps that will need to be streamlined and replaced when going paperless.

3.      Identify all entities that will be integrated, or interfaced to the system>  Ranging from LIS (lab Information System), Imaging system (medical imaging), EKG machines, Lab companies and any other entity that retains medical information relating to a patient.

4.      Create a Comprehensive Vendor Questionnaire and define all the elements that are more relevant to the practice’s specialty and challenges.  Some of the questions that must be prepared would be:

Some examples are:
* What is the cost per physician?
* Total cost of ownership, yearly fees, support costs and upgrades
* Can you design and modify the current system templates?
* Is your system true client/server or it is web based?
* How many installations do you have that are current?
* Is support local or outsourced overseas?
* Is your product a certified product (certification body to be determined)?  If not, do you plan on it?
* Can your product interface with another PMS application?

5.      Interview and evaluate the products according to your workflow.  This was a very successful method to really see the products in action.  This would be the step where you present your top commonly used workflows to the vendors and have them use those workflows during the demo.

6.      Request References From Vendors of Practices Such as Yours

At this step, a list of practices using the product that you can contact would be advisable.  This would shed some light on several components.

Questions to ask are:
* How long before the practice was seeing the same volume of patients?
* What specific items do the providers see as value with this package?
* What items does your clinical staff say is slowing them down?
* How would you rate the company support?
* Has this impacted your billing cycle?

There are several questions you should ask, but the main focus is to be specific. Get facts which will help you determine whether or not this package is a good investment.

7.      Review the Business Case

Whether the vendor provides you with a strong business case to justify the investment you are about to embark on or you take it upon yourself to create a financial analysis, it is a must to have some financial measurements such as return of investment (ROI), total cost of ownership (TCO), net present value (NPV) and discounted cash flows (DCF).  This will enable you to have a clear understanding on whether this solution will pay for itself or drain your practice of income during these difficult economic times.

Some of the items to review are:

Soft ROI: This is the element of your business that will have soft savings.  For example: First begin to perform time and motion studies.  This is where you measure the time it takes for the physicians to document a visit, prescribe or record the diagnosis and procedures on the encounter.  Then measure the time it will take for the same activity but with the EHR package (s) you are evaluating.  The difference in time gained will be one of the practice’s soft ROI.

Hard ROI: This can be associated with the cost savings from eliminating things like paper charts, folders, material, filling cabinets, and space leased for storing paper charts, transcription costs and such.

Risk Mitigation: The final section will cover the risks of using such a product.  It is clear that by digitizing paper charts, practices reduce the risk on misplacing or losing patient charts.  With the proper backups in place, a healthcare organization can rest assured that no matter what, the patient charts are protected.  In addition, some of the prescription modules enable drug interaction and allergy alerts.  This reduces the patient’s health risks dramatically.

8.      Visit Local or Remote Client’s Site

Being exposed to a live site using the product(s) you are evaluating is key.  This can help you get candid feedback, and will demonstrate how it is being utilized.

9.    Create a matrix, add the score each of the products based on each of the steps discussed above, then analyze the results.

10.      Decision Time

When you have considered your goals and challenges, what to resolve and what products to select, reviewed their existing install and had everyone on the same page, it’s time to evaluate your findings and use the attached checklist to assess which of the products will fit your need.

As the market and healthcare regulatory changes continue to affect medical organizations, executives are under pressure to reduce IT costs, automate current processes and increase revenue. Some of the changes can also determine if current implemented EHR will be a source of incentives or penalties.

July 21, 2010  11:01 PM

Solutions for cutting costs and increasing efficiency

Posted by: RedaChouffani
IT, kiosk, reduce costs, web portal

There are several proven and effective solutions that can assist medical organizations to improve efficiency and reduce costs. The following list outlines some of the available solutions to use in order to achieve some of the desired goals online and at the front desk.


  • Some of the services that can assist health organizations online are:
  • Web portal to capture patient registration (medical history)
  • Internet presences with SEO (search engine optimization) to capture new patients
  • Web portal to provide patients with available times (or use online services such as
  • Web portal to provide patients with their lab results (reduce incoming phone calls to the practice)

In the front desk

Cutting costs and increasing efficiency through solutions

  • Some of the services that can assist health organizations during registration:
  • Patient eligibility check (preferably done at the schedule level and display on the calendar the membership status on the appointment grids)
  • Patient packets and forms with bar code technology to speed document capture(eliminate valuable time spent on scanning documents)
  • Calling/texing system to confirm appointments (reduce no shows by reminding patients of appointments)
  • Kiosks (capture patient information, co-pays, confirm insurance, patient check-in and collect patient balances)
  • Tablets (you can always use iPad or Android tablets) for delivering education material pre surgeries,surveys or feedback.

Health-care technology seems to be dominated with EHR and going paperless and other solutions tend to get overlooked when organizations look for ways to reduce costs and improves efficiency. But with some of these simple solutions, medical organizations can accomplish tremendious savings, and increase new patients.

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