Patient Identification and Matching Report Released by ONC

The Office of the National Coordinator for Health Information Technology (ONC) released the final version of the Patient Identification and Matching Report. The report evaluated best practices and current trends in using electronic health record systems to accurately identify patients and exchange information between providers, patients, and caregivers. Mistakes in properly identifying patient health records put patient safety at risk and has resulted in too many patient deaths. 

The drafting process for the report included an industry environmental scan with input from stakeholders at meetings, on calls, and requests for submitted comments and recommendations. NAHAM was an active participant throughout the drafting process and provided recommendations focused on improving patient safety that are featured in the report. NAHAM's recommendations can be found on page 76 of the report. 

The report resulted in 10 findings that ONC will use as they move forward with the process of improving electronic health record systems and patient matching to improve patient safety.The findings are below.

Findings

1. Standardized patient identifying attributes should be required in the relevant exchange transactions. 

2. Any changes to patient data attributes in exchange transactions should be coordinated with organizations working on parallel efforts to standardize healthcare transactions. 

3. Certification criteria should be introduced that require certified EHR technology (CEHRT) to capture the data attributes that would be required in the standardized patient identifying attributes.

4. The ability of additional, non-traditional data attributes to improve patient matching should be studied. 

5. Certification criteria should not be created for patient matching algorithms or require organizations to utilize a specific type of algorithm. 

6. Certification criteria that requires CEHRT that performs patient matching to demonstrate the ability to generate and provide to end users reports that detail potential duplicate patient records should be considered. 

7. Build on the initial best practices that emerged during the environmental scan by convening industry stakeholders to consider a more formal structure for establishing best practices for the matching process and data governance. 

8. Work with the industry to develop best practices and policies to encourage consumers to keep their information current and accurate. 

9. Work with healthcare professional associations and the Safety Assurance Factors for EHR Resilience (SAFER) Guide initiative to develop and disseminate education and training materials detail best practices for accurately capturing and consistently verifying patient data attributes. 

10. Continue collaborating with federal agencies and the industry on improving patient identification and matching processes. 

No Extension for ICD-10 Implementation

Marilyn Tavenner, Administrator for the Centers of Medicare & Medicaid Services, announced today that there will be no extension of the October 1, compliance deadline for the nationwide conversion to the ICD-10 diagnostic and procedural codes. Speaking at the Healthcare Information and Management Systems Society convention in Orlando, Florida, Tavenner also explained that CMS was not changing compliance requirements for Stage 2 despite extensive pressure on the agency. 

Stage 2 of the electronic health record incentive payment program requires providers to electronically exchange healthcare records with each other to improve the interoperability of CMS' value-based payment programs. Eligible hospitals must commence 90 consecutive days of meeting the meaningful-use criteria on schedule. The starting date for most hospitals was October 1, 2013. However eligible professionals and physicians which operate on a fiscal year must begin compliance on April 1 or July 1, 2014. 

CMS will consider extensions on a case-by-case basis for providers and health IT vendors to obtain a "hardship exemption" that will extend the deadline for that facility. Tavenner does not expect the exemptions to delay full Stage 2 implementation by 2015. 

Timing is Crucial for Effective ICD-10 Education

The ICD-10 billing code system will expand the number of billing codes in the ICD-9 from 18,004 to 155,000 codes. This change will take place by October 1, 2014. The expanded codes create a need for the biller to have a more in-depth understanding of the medical conditions and diseases to accurately bill the patient. If billers are untrained or improperly trained it will create havoc for practices. Practices across the country are wrestling with the questions of 'when' and 'how' to train employees.

Several training methods are available. The depth of the training ranges from self-paced online modules to certification courses that require dozens of hours of in-person instruction. With the huge increase in individual codes and variety of training programs many administrators are left scratching their heads at the decision of how to train their staff. There seems to be a consensus that an online training module provides the flexibility and informational value that best suits the educational needs of many practices. 

Experts recommend that the training material used is centered around billing codes most commonly used in the practice. For example, the employees of a cardiologist practice should focus their training on the medical billing codes for heart-related disease and conditions. 

The experts also suggested that practices begin training now by assessing how well the staff works with ICD-9. The practice should address any bad practices and frequent problems before moving to the more complex ICD-10 system. 

Many experts suggest waiting to train employees until about three months before the transition to ICD-10 to avoid workers forgetting how to use the new coding system since they will be still be interacting with the older system daily.

CCHIT Will No Longer Test or Certify Electronic Health Record Systems

After almost a decade of testing and certifying electronic health record systems (EHR) the Certification Commission for Health Information Technology (CCHIT) will no longer provide these services. CCHIT was the first provider of testing and certification services, and is still the most commonly used provider in the nation. Nearly half of the health IT systems on the Office of the National Coordinator for Health Information Technology at HHS'  Certified Health IT Product List have been certified by CCHIT.

CCHIT stopped taking applications from vendors in January. Executive Director Alisa Ray stated that they would wind down the remaining 70 systems scheduled for tests by April or May of this year. Ray explained that the delay for implementing meaningful use requirements lead to the decision to move away from certification and testing. 

The company will also stop private-label certification programs for other health IT systems. CCHIT is phasing these programs down as the organization shifts to a global focus. 

Consumers will have eight certification bodies to choose from with the withdrawal of CCHIT from the marketplace. Five of the companies are recognized by the ONC as Accredited Testing Laboratories. Three other companies are ONC Authorized Certification Bodies. All eight companies test and certify EHRs to qualify them for participation in the EHR incentive payment program established by the American Recovery and Reinvestment Act of 2009.

Healthcare Enrollment May Be Stifled By Federal Website Maintenance

Consumers attempting to complete health insurance applications through online healthcare exchanges before the February 15th deadline may be frustrated this weekend. February 15 is the deadline to apply for coverage that will begin on March 1. 

The Department of Health and Human Services (HHS) announced Monday that heavy maintenance to the Social Security Administration's website (SS) will result in the inability of HealthCare.gov to verify Social Security numbers and other personal details required for coverage under the Affordable Care Act. 

The maintenance is expected to begin Saturday, February 15 at 3p.m. and end Tuesday, February 18 at 5a.m. Those consumers that are affected by the website maintenance should phone the federal call center on Tuesday to arrange for coverage March 1. The number to the federal call center is 1-800-318-2596.

Centers for Medicare and Medicaid Services Begins Open Payments Data Collection This Month

The Centers for Medicaid and Medicare Services (CMS) announced last week the agency is taking the first steps toward publishing data collected from healthcare providers on payments from drug and device manufacturers and group purchasing organizations. CMS is referring to the data collection initiative as the Open Payments program. 

The Open Payments program is a result of the enactment of the Physician Payments Sunshine Act. The program was enacted to increase transparency in the healthcare industry and provide the public with awareness about the financial relationships between drug and device manufacturers, group purchasing organizations and their healthcare providers. The goal is to allow patients to make informed choices when selecting a healthcare provider and in treatment decisions.

Data collection will begin February 18, 2014.  Organizations will submit data to the CMS on payments made to healthcare providers. CMS states that payments includes gifts, consulting fees and research activities. The second phase will begin in May 2014 when manufacturers submit detailed payment information. 

Healthcare providers and manufacturers will have the chance to review and correct inaccuracies in the data after both phases of collection have been completed. Following the review process CMS will post the data on payments to their website. CMS will post this data by September 30, 2014. 

Obama Administration Announces Health Insurance Mandate Delay and Reduction of Percentage of Workers Covered Requirements

The Obama Administration announced changes in the implementation of the Affordable Care Act provisions related to the employer mandate for "medium-sized" businesses.  The provisions were originally drafted to go into effect this year. 

The changes in implementation deadlines do not affect most businesses. Companies with fewer than 50 workers remain exempt from the mandate. 

First, the deadline to meet the coverage requirements under the mandate for medium-sized businesses, companies that employ between 50 and 99 workers, has been delayed until January 1, 2016. The delay is conditional and requires companies to promise that the employer will neither cut an employees' hours nor let go of employees for the purpose of making their business qualify as a "medium-sized" business with 50-99 workers. Officials describe the verification process of this promise as "self-attestation" and the IRS has not provided information on how it will determine the companies' veracity. 

White House advisor Phil Schiliro explained the reasoning behind the change, "For the two-percent of American businesses that have between 50 and 99 employees, the Treasury Department concluded that a phase-in was the most common-sense way to implement the law." 

The employer provisions will go into effect for companies that do fall into categories covered by the employer mandate that do not have 50-99 workers. However, the requirement that the employers offer coverage to 95% of their full-time employees by January 1, 2015 has been reduced by 25%. The employers will now be required to offer coverage to 70% of their full-time employees by January 1, 2015. The Treasury Department's final rules state that the requirement for employers to offer coverage to 95% of their full-time employees has been delayed until 2016. 

Other changes affect seasonal workforces, adjunct faculty and volunteer firefighters and paramedics. Seasonal workers that work less than six months will not be considered full-time employees. The changes include a method for estimating the hours of adjunct faculty that accounts for hours spent working outside the classroom. The Administration's promise that volunteer firefighters and paramedics would not be considered full-time employees was formally implemented in the most recent changes. 

Many commentators are suggesting that the adjustments in implementation deadlines and requirements for businesses will increase pressure on the Obama Administration to extend deadlines for individuals so that they are not subject to the $95 or 1% of income fine for failing to purchase health insurance this year. Other experts counter that extending the deadline for individuals would result in fewer healthy individuals signing up now which could drastically shift the ratio of sick-to-healthy individuals enrolled. If too many individuals with significant health problems enroll without the balance of healthy individuals it could make the price of coverage more expensive. 

CMS Extends Medicare EHR Meaningful Use Attestation Deadline to March 31, 2014

The Centers for Medicare and Medicaid Services announced an extension for some participants in the Medicare Electronic Health Records meaningful use attestation deadline. The extension did not retroactively change any requirement for the date the criteria must have been met, it merely extended the deadlines for data submission for some physicians, eligible professionals and hospitals. The deadline extensions do not apply to the Medicaid portion of the Electronic Health Records incentive payment program. The Medicaid incentive payment program does not incorporate penalties.

Both the Medicare and Medicaid Electronic Health Records incentive payment programs were created in the American Recovery and Reinvestment Act of 2009. The programs have a significant impact with payments thus far in the amount of over $19 billion to more than 320,000 physicians and other professionals and 4,400 hospitals.  


Physician and Eligible Professional Extension

The Centers for Medicare and Medicaid Services (CMS) extended the deadline for eligible professionals to attest to Electronic Health Records (EHR) meaningful use in 2013. Physicians and eligible professionals will now have until 11:59p.m. on March 31, 2014 to submit their performance data. The new deadline, extended from February 28, 2014, does not change the requirement that the criteria for meaningful use must have been met by the end of the reporting period for the incentive payments, December 31, 2013. 

A CMS press release explained that this extension would allow more time for providers to submit their meaningful-use data, receive an incentive payment for the 2013 year and avoid the 1% penalty 2015 payment adjustment. 

EPs attesting for the Medicaid program or Physicians Quality Reporting Systems incentive pilot program did not receive an extension and must complete the attestation requirements by the original deadline. 


Hospital Extension

CMS is also offering what the agency is calling a "one-time" extension to hospitals "that may have experienced difficulty attesting" by the November 31, 2013 Medicare meaningful use attestation deadline. To be eligible to participate in the deadline extension hospitals must contact CMS by 11:59p.m March 15, 2014 for assistance. 

This extension will allow eligible hospitals to receive incentive payments under the program and avoid the price adjustments effective in 2015. 

Like the extension for physicians, the extension for hospitals does not change the deadline for the date the meaningful use criteria must have been met. The implementation deadline for the hospitals program, which operates on the fiscal year, was September 30, 2013. 


Resources
A Modern Healthcare article discussing the extension is available here.

A Medscape article discussing the extension and incentive payments is available here. 

A FierceHealthIT article discussing industry representative opinions on the extension is available here. 

A user guide for eligible professionals on meaningful use attestation is available here. 

A user guide for eligible hospitals on meaningful use attestation is available here.

The EHR Information Center is Open Monday-Friday from 8:30a.m.-5:30p.m. EST. The toll-free number to reach the center for assistance with meaningful use attestation is 1-888-734-6433. 

CMS' Two-Midnight Rule: Who Must Sign Off?

The Centers for Medicare and Medicaid Services (CMS) announced a clarification to the ‘Two-Midnight Rule’ this week that a physician must sign off on the admitting paperwork for Medicare beneficiaries. CMS published the two-midnight policy in an effort to explain when a Medicare beneficiary may qualify for overnight care versus outpatient care. This distinction is important to hospitals because the payment to the hospital is higher for overnight stays than for outpatient care. The rule initially established that a physician must have good reason to believe that a patient will require two nights in the hospital to qualify for the higher hospital rate from Medicare.

The clarification requires physicians to sign off on the admitting paperwork for Medicare beneficiaries before the patient is discharged. By signing the admitting paperwork the physicians are accepting responsibility for the determination that there is good reason the patient will require two nights in the hospital. Medicare's recovery auditors will not audit inpatient claims under the two-midnight rule until after Sept. 30, 2014.  

A hospital may still comply with the regulation if a non-physician staffer writes the admitting order into the medical record, even if the recording staffer does not have the independent authority to admit a patient. However, in all cases the physician must sign the admitting paperwork prior to the patient's release. 

For example, a hospital will be in compliance with the regulation if a nurse documents a physician's verbal order to admit a patient in the medical record if the physician signs the decision before the patient leaves the hospital. Similarly, residents, physician assistants and nurse practitioners may write the inpatient admitting order as a proxy for a physician so long as the physician signs the order before the patient is discharged. In every case the physician's signature represents that she approves and accepts responsibility for the admission decision.

Hospitals may still be compensated in cases when a doctor later refuses to sign the admitting order.  However, they will be compensated at outpatient rates. The hospitals must send the bills through Medicare's Part B system for outpatient care.  


CMS' Two-Midnight Policy can be found here. 

"Balance Billing" from In-Network Hospitals Leaves Patients Shocked

In emergent situations paperwork is often the last thing on a patient's mind. Patients that have the wherewithal to remember to choose an in-network hospital to avoid large bills for treatment assume that they may be treated by any physician in the hospital and their insurance will cover the treatment. Unfortunately, many find out this is not true several weeks later with the arrival of a hefty "balance bill."

Balance billing is a common practice that bills the patient for the remainder of the cost of treatment that the insurance refused to pay because the treating physician was not out-of-network, even though she practices at a hospital that was in-network.

These unexpected bills can have huge consequences on patients and their families. NBC 5, in Texas, recently ran a story about Melinda Allen, a patient at the Texas Harris Methodist Hospital emergency room. Allen woke up on a Saturday with intense abdominal pain. She had her husband take her a hospital she knew was in-network. Several tests later Allen was diagnosed with an ovarian tumor large enough to require surgery.

The billing was less straightforward than her treatment plan. Allen paid nearly $5,000 out-of-pocket for her treatment, in addition to her $1,500 monthly premium. Allen assumed her insurance would cover the rest since she was treated at an in-network hospital. Allen was shocked when she later received a bill for nearly $700. 

The amount of the bill Allen received  was the balance left over from the price of the treatment charged by the emergency room doctor and the price her insurance company felt was appropriate. 

This practice leaves the patient to sort out the claim with their insurance company. "People are really vulnerable when they go into an emergency room," Stacey Pogue of the Center for Public Policy Priorities explained. "It's unfortunate, again, that we're put in that position because insurance companies and doctors can't decide what is appropriate reimbursement."

In situations like Allen's where does the blame fall? Allen chose an in-network hospital. Physicians, by law, are not allowed to ask about insurance and must treat all patients regardless of their ability to pay. Should the in-take process include a list of in-network and out-of-network physicians? 

Congressional Gridlock Stalls Hopes for National Patient Identifier and Meaningful Use Stage 2 Delay

Many in the health IT field believe that implementing a national patient identifier and a deadline extension for stage 2 meaningful use requirements would ensure a more cohesive operation of patient access and identification systems and increase patient safety.  Both of these problems require congressional action to solve, but with a Congress that fails to pass even the most basic pieces of legislation and appropriations it is unlikely there will be any legislation addressing these issues in the year to come.

National Patient Identifier

A national patient identifier would go far to improve patient safety by improving the accuracy with which patients are matched with their medical records.  Ideally, a national patient identifier would be a unique number for each patient with a two-digit checksum at the end of the number. In practice this would allow a patient’s data to move completely through multiple data systems without comingling with other patients’ records that may contain similar names, addresses and other identifying factors.

However, the likelihood of legislation requiring a national patient identifier is very slim after Congress voted to overturn a HIPAA provision that would have required a patient identifier in 1998. Congressional opposition focused on privacy concerns and the capability providers have to identify patients with several different identifying factors. Former national health IT coordinator Farzad Mostashari, M.D., explained that he believed the odds were very low for a national patient identifier and that it would require the industry proving they are unable to keep patients straight by cross-checking a patient’s identity with other identifying factors available to the provider.

Meaningful Use Incentive Program

The electronic health records meaningful use incentive program was created to advance the adoption of health information technology nationwide. Beginning in 2014 eligible hospitals and professionals will have to comply with stage 2 of the regulatory standards in order to receive corresponding incentive payments. 

Senator Alexander and Senator Thune, along with 15 other Senators, wrote a letter to HHS Secretary Kathleen Sebelius requesting more time for implementation of stage 2 standards. Their letter stated, “If the goal is to improve care by achieving broad and meaningful utilization of EHRs, providing sufficient time to ensure a safe, orderly transition through Stage 2 is critical to having stakeholder buy-in, a necessary component of long-term success.

However, former national health IT coordinator Farzad Mostashari, M.D., does not think that this extension will be granted.  Without speaking to the merit of the request, Mostashari recently told a group gathered at the CHIME Fall Forum that the extension would take up to a year to approve, and the extension requested is a year. The overlap would through U.S. health IT into “total chaos” due to the uncertainty during the rulemaking process to amend the schedule.

 Resources

Don Fluckinger’s article, “Shut down thoughts of a national patient identifier,stage 2 extension,” 

A podcast discussing the benefits of a national patient identifier can be found here. 

Alexander-Thune Letter from 17 Senators to Secretary Kathleen Sebelius requesting a meaningful use stage 2 delay can be found here.