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No wound center is an Island. Part of pharmacy Part of medical staff Part of materials management Part of housekeeping Part of Infection control Part of risk management Part of quality assurance Part of business office Part of claims processing Part of medical records

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no wound center is an island
No wound center is an Island
  • Part of pharmacy
  • Part of medical staff
  • Part of materials management
  • Part of housekeeping
  • Part of Infection control
  • Part of risk management
  • Part of quality assurance
  • Part of business office
  • Part of claims processing
  • Part of medical records
  • Part of patient access/registration
why wound centers fail
Why wound centers fail
  • Wound centers fail because of LACK OF INTEGRATION
  • Inward within the facility
    • Pharmacy
    • Physician to physician
  • Lack of integration outside of facility
    • Local care givers
    • Nursing homes
    • Social services
    • LTACs
    • Case managers
the typical management company approach
The Typical Management Company approach
  • Sets you up as an outpatient “tertiary department”
    • Hopes to reduce hospital in-patient length of stay by providing treatment options for discharged patients
    • Hopes to benefit surgeons by getting patients out of “global fees”
how to create a doomed wound center
How to Create a Doomed Wound Center
  • Minimal attempt at integration into the rest of hospital in patient and outpatient services and the community
  • JCAHO does not like islands of care
  • Hospital inpatient and outpatient services NEED to be integrated across the entire service line
a few things you need to open a wound center
A few things you need to open a wound center
  • Business Plan development
  • Feasibility Study
  • Layout and floor plan, Blue prints and specs, safety guidelines
  • Training, handbooks, library references
  • Physician Billing guidelines
  • How to set up your clinic charge master
    • To do this you must know how the service rendered to the patient will be transmitted into a computer system which generates charges in relation to financial cycles (this is unique to every hospital)
  • Wound center facility billing guidelines from all third party payors
  • Economic realities of various wound care products and services
  • Staffing models
  • Staff training in processes and methods
  • Policy and Procedures, integrated into your hospital setting
  • Formulary
  • Inventory Development (many unique issues for wound care products)
  • Housekeeping issues unique to hyperbarics and wound center
  • Specific Human resources issues
  • Staff education
  • Marketing plan
  • Data management
  • CPT coding review, chargemaster review
  • Benchmarking
and there is another storm on the way
And there is another storm on the way

The Perfect Storm of Facility Reimbursement

background
Background
  • Federal Register, 4/7/2000, Medicare Prospective Payment System for Hospital Outpatient Departments
  • Codes 99201 – 5 and 99211 – 5 were to be used by non-Emergency Departments.
  • “. . . . each facility should develop a system for mapping the provided services or combination of services furnished to the different levels of effort represented by the codes.”
facility billing by time
Facility Billing by Time

Pros

  • Simple system to develop.
  • Fairly easy to calculate.

Cons

  • Inadequate surrogate as a measure of work.
  • Rewards inefficiency.

ThenMedicare Announced it’s plan in 2005 . . . .

cms proposed plan wound size

Stamps, 22.44 cm2

Approx. Level 2

Quarter, 4.44 cm2

CMS Proposed Plan – Wound Size

Playing Card, 56.45 cm2

Approx. Level 3

Level Two

25.1 cm2 to 50.0 cm2

Level One

0 cm2 to 25 cm2

Level Three

50.1 cm2 to ∞

billing by wound size
Billing by Wound Size

Pros

  • Simple system to develop.
  • Fairly easy to calculate.

Cons

  • Inadequate surrogate as a measure of work in non ER scenarios.
  • Does not relate to actual work involved in providing care.
what would have happened if these 5 108 visits were billed by wound size as proposed by cms
What would have happened if these 5,108 Visits were billed by Wound Size as Proposed by CMS?

Level 1 89.42% 4,589

Level 2 4.42% 226

Level 3 6.16% 310

acuity scoring system components all the stuff you do for which there is no procedure code
Acuity Scoring System Components (all the stuff you do for which there is no procedure code)
  • Method of Arrival (ambulatory/stretcher)
  • Additional Resource Utilization (isolation, translator)
  • Patient Assessment (history, general physical exam, risk, etc)
  • Patient Process (coordination of care, education)
  • Problem Focused Activities
    • Wound Care (measuring, dressing application)
    • Edema Management
    • Ostomy
  • Other Focused Interventions
    • Diabetes Management
    • Nutrition
  • General Procedures (injections, cast removal)
  • Testing (hand held Doppler, culture, blood draw)
  • Departure Instructions
  • Departure Disposition (to home, to ER, etc)
billing by acuity score
Billing By Acuity Score
  • Pros
    • Actual measure of work performed
    • Yields a normal data distribution
    • Integrates well with an EMR
    • Punishes inefficiency
  • Cons
    • Difficult to calculate by hand
    • No consensus guidance on relative value of points
how would the 5 108 visits have been billed if acuity had been used a normal distribution curve
How Would the 5,108 visits have been billed if Acuity had been used?A Normal Distribution Curve

Mean: 95.6

Standard Deviation: 30.0

Correlation Coeff.: 0.881

Level 1 0 – 35

Level 2 36 – 65

Level 3 66 – 125

Level 4 126 – 155

Level 5 156 – 200

data analysis summary
Data Analysis Summary
  • We agree with CMS that time is not a surrogate for work
  • Data analysis clearly shows that wound size is an equally unrepresentative method for measuring work and will result in over 85% of wounds being billed as Level 1
  • An acuity scoring system is a more accurate and reproducible method of measuring actual work
what does that mean for wound centers
What does that mean for wound centers?
  • Facility reimbursement will change
  • Will likely be based either on wound SIZE or on some as yet to be determined scoring system
  • DOCUMENTATION will be more important than ever
  • Despite the burdensome documentation, the alternative is 89% Level 1 visits!
  • The Alliance of Wound Care Stakeholders has recommended that CMS adopt the Intellicure Acuity Scoring system for Facility Billing and many wound centers are using it now, either calculating by hand or in the Intellicure EMR
would you like to do this by hand
Would you like to do this by Hand?
  • Not only would you have to fill in this sheet on every patient, but you would have to have all the documentation to support whatever you filled in!
  • However, an EMR would automate this so that the acuity scoring is built in!
documentation challenges
Documentation Challenges:
  • Documentation quality varies among wound centers.
  • Quality of care varies among wound centers:
    • Dependent on experience of staff
    • Delays in implementing HBOT, VAC, etc.
  • Suboptimal Revenue – Physician and Facility revenue is dependent on documentation and quality of care.
  • Changes in Reimbursement on the horizon. . . .
problems in delivery of care not unique
Problems in Delivery of Care (not unique)
  • Inconsistent Care
    • Quality of care dependent on experience of practitioner
    • CPGs can have minimal impact because they are not immediately available at time of care
  • Delays in clinical decision making
    • Negatively affects patient outcomes
    • Negatively affects revenue (fewer HBOT treatments)
how can we improve quality
How can we improve Quality?
  • Physicians cannot keep track of everything they need to do for every patient.
  • We must have a “systems” approach to help reduce errors, improve care, and prevent patients from “slipping through the cracks.”
  • We must have data systems to help us.
  • We must reduce errors, reduce hassle, reduce cost, improve care, and improve efficiency.
  • HOW CAN WE ACCOMPLISH ALL THIS?
improving performance and quality
Improving Performance and Quality
  • One approach: chart review
    • VERY labor intensive
    • Sort of punitive (punish poor performance)
    • Try harder to educate
  • Another Approach: “Quality Improvement”
    • Works to a point
    • Labor intensive
    • Limited application: can usually only tackle one problem at a time
paying for quality
Paying for Quality
  • There are over 100 programs involving health plans and medical groups covering 10’s of millions of patients, all basing reimbursement strategies on QUALITY of CARE.
  • Medicare is implementing “Pay for Performance” which it calls, “The right care for the right patient at the right time.”
  • It is likely that in 10 years, the majority of providers will not pay by procedure or encounter, but for OUTCOME.
  • How can wound centers on this wagon?
how do these programs work
How Do These Programs Work?
  • Doctors install Electronic medical Records systems in their offices.
  • Carriers and physicians decide on parameters to follow (e.g. % of diabetics who get a HgbA1C).
  • Medical information is transmitted to the Carriers from the Doctors Office.
  • Carriers reward the physicians for providing the care that was agreed upon.

CMS

what is the solution
What is the Solution?
  • What tool can STANDARDIZE facility DOCUMENTATION?
  • What tool can STANDARDIZE physician DOCUMENTATION?
  • What tool can automate quality assurance and benchmarking?
emr the emerging medical requirement
EMR, the “Emerging Medical Requirement”
  • EMRs are not a luxury in the 21st Century, they are a REQUIREMENT.
  • Estimated that in 10 years all medical records will be electronic
slide29
“Healthcare Information and Management Systems Society”
  • Provides leadership for the optimal use of healthcare information technology and management systems
  • Frames healthcare public policy and industry practices
ehr attributes and essential requirements
EHR Attributes andEssential Requirements
  • Provides secure, reliable, real-time access to patient health record information.
  • Functions as clinicians’ primary information resource (i.e., it is THE medical record).
  • Assists with delivering evidence-based care (i.e., CPGs).
  • Captures data used for continuous quality improvement, utilization review, & risk management,
  • Captures the information needed for reimbursement.
  • Can support clinical research, public health reporting, and population health initiatives.
  • Supports clinical trials and other research.

If a system cannot do ALL of these things, it is NOT an EMR.

slide31

Web Based “EMR”

PatientRegistration

Web-Based

EMR

Handwritten

Notes, Nursing

Orders

Paper

Chart

RecordsCustodian

Dictation

Handwritten

Notes, Rx

Labs, Orders

Transcription

Scanner

Non-Searchable

PatientEncounter

FaceSheet

Communication to

Referring MD, DME

Home Health

Pharmacy

E H R

web based emr

Web-Based

“EMR”

E H R

Web Based “EMR”

Is it the “Clinician’s Primary Resource?” (HIMSS definition)

Where are the legal medical records in a Web based system?

Hospital

+

+

+

Wound Center

Paper

Chart

Wound

Photos

slide33

PatientRegistration

Web-Based

EMR

Handwritten

Notes, Nursing

Orders

Paper

Chart

RecordsCustodian

Dictation

Handwritten

Notes, Rx

Labs, Orders

Transcription

Scanner

Non-Searchable

E H R

Steps requiring Human Interaction

H

H

H

PatientEncounter

FaceSheet

H

H

H

H

?

Communication to

Referring MD, DME

Home Health

Pharmacy

H

H

H

H

Human

Interaction

web based emr34

Who is this guy?

Web Based EMR?

“Systems are 99.9% reliable and available in real-time.”

  • A snapshot of the internet traffic across the world shows that much less than 99.9% of data is reliably transmitted on the internet.
  • At this time, hospital IT department Record Custodians will not allow web-based EMRs.
web based emr35
Web Based “EMR”

128 Bit Data Encryption = Security?

Lack of adequate security is another reason why hospital IT departments will not allow Web based EMRs.

slide36

PatientRegistration

Web-Based

EMR

90

Handwritten

Notes, Nursing

Orders

Paper

Chart

RecordsCustodian

Dictation

Handwritten

Notes, Rx

Labs, Orders

Transcription

Scanner

Non-Searchable

CPGs?

Surveillance withWeb Based EMR

PatientEncounter

FaceSheet

Communication to

Referring MD, DME

Home Health

Pharmacy

Standard reports obtained from Vendor quarterly

E H R

Where are the CPGs in this system?

can a web based system qualify as an emr by the himms criteria
Can a “Web-Based” System Qualify as an EMR by the HIMMS Criteria?
  • “Real Time, point-of-care?” No.
    • Not if the data is not entered IN THE ROOM at the time you are seeing the patient.
  • “Reliable access?” No.
    • The Internet does not meet reliability standards for EMR
  • EMR must be the Clinician’s “Primary Resource:” No.
    • The medical records are in several places with a Web-Based system,
    • Not unless ALL health information is collected.
  • “Assists with Evidence Based Care:” No.
    • If the system does not provide evidence based help with management at the time the doctor sees the patient, it is not an EMR
  • Automates workflow? No.
    • There are many manual steps using a Web-Based System.
is there a wound care specific program which does qualify as an emr
Is there a Wound Care Specific Program Which DOES Qualify as an EMR?
  • Yes.
  • There is a wound care specific software program which meets ALL the HIMMS criteria for an Electronic Medical Record.
  • That is why it is NOT Web-based.
  • You control your own data, which can be accessed any time from servers in the clinics, and ALL medical information is collected.
how does intellicure the emr work
How Does Intellicure the EMR Work?
  • Data collected at point of service, during patient encounter
  • All clinical information is entered (physician and nurse)
  • Not retrospective (like programs where selected information is entered later)
  • Paper charts are not necessary (can print out the documents if desired). The actual medical record is ELECTRONIC.
  • This electronic record then generates ALL other clinical documents (nursing orders, physician letters, etc.)
slide41

Document Automation

Your Wound Center

Your Wound Center

physician communication
BEFORE

NOW

Physician Communication

Your Wound Center

intellicure and facility billing
Intellicure and Facility Billing
  • Intellicure designed the Acuity Scoring System Adopted by the Alliance of Wound Care Stakeholders
  • The Alliance proposed that CMS adopt this method for facility reimbursement
  • The Intellicure EMR automatically calculates the Acuity Score during the visit
  • Should CMS adopt a similar system, calculating this by hand will be very burdensome
  • Only Intellicure is prepared now for a change in Medicare policy.

Capturing charges by hand, for all you really do for a patient, will be burdensome

medicare and physician billing
Medicare andPhysician Billing
  • Payment for Evaluation and Management Codes (E/M) determined by complexity of care
  • Complexity based on key components (History, Physical Examination, Medical Decision Making)
  • 1997 Rules in 42 page document published by CMS
  • 6,144 possible combinations for a visit
  • EMR becoming the method of choice for most doctors because the decision making is so complex.
  • Intellicure calculates the Physician level of service during a wound care visit.
physician billing intellicure calculates it

Patient

Physical

Decision

History

Exam

Making

Intellicure

Algorithm

Physician Billing: Intellicure Calculates It
slide47

PatientRegistration

Automatic

Photo

Archiving

E H R

Intellicure EMR

Patient Encounter

Point-Of-Service

Documentation

CPGs

HL7 Interface

IN: Demographics,

Labs, Allergies

OUT: Documents

Hospital

Registration

performance improvement analyze that i e anything
Performance Improvement: “Analyze That” (i.e., anything)

Goal 1: Improve the accuracy of patient identification.

Goal 2: Improve the effectiveness of communication among caregivers.

Goal 3: Improve the safety of using medications.

Goal 8: Accurately and completely reconcile medications across the continuum of care.

intellicure emr the dividends
Intellicure EMR: The $ Dividends
  • Facility Billing
  • Physician Billing
  • DME orders
  • iHealthRecord
  • Quality Assurance
  • Pay for Performance (Medicare)
  • Data Analysis
emr is the answer
EMR is THE ANSWER
  • The Answer to QUALITY of documentation (completeness, legibility, consistency)
  • The Answer to quality of MEDICAL CARE (CPGs integrated in to EMR means consistent care)
  • The Answer for SURVEILLENCE of care (automated, real time)
  • The Answer for tracking and improving OPERATONAL EFFICIENCY
  • The Answer for DATA ANALYSIS (research and marketing)
  • The Answer for securing REIMBURSEMENT
emr and wound center functions
EMR and Wound center functions

Nursing documentation

Product Efficacy

Supply ordering

CPGs/Best practice

Clinical Research

EMR

Facility billing

Physician billing

Outcomes analysis

Management reports

Benchmarking

Physician documentation

Photo Archiving