Ready or not, Electronic Health Records are coming. Like death and taxes, EHRs are inevitable. As part of the Recovery Act, The Centers for Medicare and Medicaid Services have implemented a 3 stage “Meaningful Use” program for Medicare and Medicaid providers that will be implemented over the next 5 years. The CMS website describes the program’s objectives this way: (CMS website – Meaningful Use)

To realize improved health care quality, efficiency and patient safety, the criteria for meaningful use will be staged in three steps over the course of the next five years. Stage 1 sets the baseline for electronic data capture and information sharing. Stage 2 (est. 2013) and Stage 3 (est. 2015) will continue to expand on this baseline and be developed through future rule making.

Insurers know that as goes Medicare so goes the rest of the nation’s health care system. Insurers that prepare to take advantage of the new electronic billing and record mandates will have a distinct competitive advantage over those that do not.

EHR Opportunities and Potential

In the area of claims handling the move to electronic health records will provide a vast opportunity for insurers to capitalize on the correlation between medical specials and fully digitized medical records that include reports, chart notes, images, examination and treatment documentation, and even prescription records. EHRs have the potential to provide the claim handler with unprecedented abilities to reconcile the medical specials with injury causation, providing that they have the tools and data platform to take advantage of these digital representations of what traditionally was a paper / image driven process.

The greatest impact of the EHR transformation will be in the traditional medical bill transcription workflow. The delays and errors inherent in most carrier’s current system of manual transcription will be a thing of the past. This will speed up the entire claim handling process.

To fully realize the potential savings that EHR’s can provide, insurers will need to ensure that their medical management and cost containment systems are fully compliant with EHR data and security standards, and that those systems provide their claims handlers the flexibility to fully utilize the EHR data.

Since EHR data standards are still evolving, insurers planning for their future implementation will need to make sure that the tools and systems they are considering are standard-aware and ready for implementation when final standards are determined. Of course any systems and tools being considered must also support current image based standards since the transition to an EHR system will occur in phases over the course of many years. It is critical during the planning stage, to question both internal IT and perspective vendors as to how they are prepared to leverage these standards as they transition from the current system to a fully implemented EHR system.

EHR Standards and Interoperability Requirements

As noted above, EHR standards are evolving. One key factor for a universal EHR system is the interoperability of the system between healthcare providers, payers, government agencies, regulators, vendors and other stakeholders. Health Level Seven International (HL7) is a non-profit, ANSI-accredited international standards developing organization that is playing a key role in developing the standards that will be used to meet the “meaningful use” criteria outlined by the CMS. An HL7 press release describes the process of creating these standards: (Health Level Seven Background Brief)

The enactment of the American Recovery and Reinvestment Act in the U.S., which has earmarked $19 billion in federal funds to support the spread of health IT, has provided new opportunities for HL7. One of the criteria for showing “meaningful use” of an EHR-a requirement for receiving government financial incentives-is to exchange electronic data with other healthcare providers. The HL7 standards already in place, and those that HL7 is developing or bringing online in the U.S., will be instrumental in achieving the interoperability that will enable providers to exchange data easily across healthcare communities. In fact, the Office of the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services selected HL7 Version 2 and the HL7 Clinical Document Architecture (CDA) / Continuity the Continuity of Care Document (CCD) in its initial set of standards, implementation specifications and certification criteria for EHR technology.

The HL7 Clinical Document Architecture (CDA) is an important step to achieving interoperability. The CDA is an ISO approved standard that provides an exchange model for clinical documents (such as discharge summaries and progress notes) and brings the healthcare industry closer to the realization of an electronic medical record. There are large-scale CDA implementations in North and South America, Europe and Asia Pacific. The Continuity of Care Document (CCD) is a CDA implementation of the continuity of care record (CCR), created by the American Society for Testing and Materials (ASTM). Disparate information systems can employ the CCD to exchange clinical summaries that contain key data about individual patients, such as diagnoses, medications, and allergies.

Stage 1 of the Meaningful Use program initially contained two requirements that included billing and administrative transactions, – first that a user be able to determine through the EHR system a patient’s insurance eligibility, and second that a user was able “to electronically submit claims to public or private payers in accordance with the standard and implementation specifications specified in 45 CFR 170.205(d)(3).” (Federal Register Vol. 75, No. 144 p.44612). Due to time constraints and technical difficulties these requirements were subsequently removed from Stage 1. However the Department of Health and Human Services has made it clear that the requirements will be reinstated in Stage 2 and beyond:

“Therefore, we intend to include for adoption, administrative transaction standards and certification criteria to support meaningful use Stage 2 rulemaking, and expect health care providers and Complete EHR and EHR Module developers to take this into consideration leading up to 2013.” (Federal Register Vol 75, No 144 p 44613).

EHR standards and requirements are set forth in the Code of Federal Regulations – “Health Information Technology Standards, Implementation Specifications, And Certification Criteria And Certification Programs For Health Information Technology.” (45 CFR Part 170) They specify criteria for ambulatory (170.304) and in-patient (170.306) settings. For an ambulatory setting the requirements include:

• Computerized provider order entry – medications, laboratory, radiology/imaging
• Electronic prescribing
• Patient demographics recording
• Electronic patient reminder generation
• Clinical decision support including real time notifications of contraindications
• Electronic copy of health information – generation and retrieval
• Problems – ICD-9 Vol. 1 and 2 and ICD-10 code sets
• Laboratory Test results
• Medications
• Timely access
• Clinical Summaries
• Exchange clinical information and patient summary records with other providers and organizations

As noted above, administrative transaction data (CPT and billing data) is not yet included in the requirements – however with the implementation of Stage 2 and beyond, this information will be included as part of the EHR data structure. To effectively use EHR information insurance medical cost containment and liability management systems must be able to extract the relevant claim data from the enormous amount of data that will be part of EHR records. In effect medical management and cost containment systems must be able to isolate the trees from the forest.

EHRs and the Claims Handling Process

Once fully implemented a standardized EHR system will increase the efficiency of the entire claim handling process, including document review, bill transcription, and the review of injuries and the medical treatments provided. The mandated move to ICD-10 diagnosis coding and ICD-10 PCS (inpatient procedure coding), scheduled to occur on Oct. 1, 2013, along with the Jan. 1, 2012 move to the Version 5010 electronic claims standards set, will begin to put in place the EHR foundation that will eventually become standard industry wide. (CMS website – “ICD-10 Basics for Payers,” Sept. 2010)

Currently an enormous amount of time is spent by claim handlers in reviewing the medical documentation associated with a claim. Most of that documentation comes in the form of scanned images of handwritten forms, notes, charts, admission and treatment records, etc. Essentially the claim handler is looking at electronic representations of dozens, or in some cases, hundreds of paper documents. For the claim handler these documents can present substantial difficulties:

• Handwriting is often illegible, forcing the claim handler to spend large amounts of time in simply trying to decipher what the clinician was saying. In addition because these records encompass the totality of the claim, from initial presentation through all subsequent treatments, many individuals will have made notes often using shorthand and non standard terminology. This forces the claim handler to spend even more time reconciling these notes with bills and treatment codes.
• Documentation is often incomplete, forcing time consuming delays while claim handlers attempt to locate the missing records and update the claim file.

EHRs will do away with these problems and allow claim handlers to use their time in the most efficient way possible. Fully digitized EHRs will give the claim representative access to both the entire medical record of the claim (including notes, charts, histories, and images), as well as the claimant’s medical history. Rather than spending valuable hours interpreting and deciphering electronic versions of printed documents, EHRs will allow claims handlers to focus their attention on analyzing, investigating and clearing claims. This will enable claims handlers to close claims faster and increase the volume of claims handled by claims departments.

Within the claim handling process, medical bill transcription has always been costly in terms of both time and money. It is a labor intensive process that many insurers choose to outsource. Bills are subject to the same problems of illegibility as are other medical documents and, in addition, they can be miscoded by the provider either inadvertently or with the intent of up coding or unbundling. Additionally the bill transcription process itself can add many days to the overall claim settlement process.

Because EHR systems need to be interoperable with each other (so that patient records are fully and immediately accessible to any provider, using any system, anywhere in the country), they will impose a data structure that will eventually do away with the need for insurance companies to maintain either an in-house or outsourced medical bill transcription capacity. Since all records related to treatment will have been digitized for use in the EHR system either immediately or shortly after creation, insurance companies will be able to use those digitized records directly without the intermediate step of transcription. EHR structured data will also make the detection of up coding, miscoding or unbundling easier to detect. (Note – an interesting article covering this topic – “The Importance of Transcription In The EHR Age”, by Ken Congdon, can be found at the Healthcare Technology Online website.)

For the claim handler and the insurer, no single element of the claim review process is as important as reviewing the medical records for causality and the appropriateness of treatments provided. Ensuring that providers are treating and billing within accepted medical guidelines and only for those injuries covered under the claim, is key to containing medical related costs.

A major consideration for insurers in paying claim related medicals is the existence of undisclosed or disguised pre-existing conditions or injuries that are not related to the claim. For the claim handler, documentation is usually limited to the current claim. Unless a provider makes note of a pre-existing condition or injury, or the claimant mentions it to the adjuster, such pre-existing conditions may go unreported and result in payments for treatments unrelated to the claim.

A standardized EHR system, once in place, will greatly reduce the costs of insurers by minimizing inappropriate payments associated with pre-existing conditions. Because an EHR will contain the complete medical history of a patient/claimant, claim handlers will no longer have to play medical detective in attempting to link treatments to previous undisclosed conditions or injuries. Insurers are likely to see reduced costs in both man-hours and savings in inappropriate payments.

The Analytical Potential of EHRs for Insurers

We have outlined some of the potential benefits in medical management and cost containment that a standardized and universal EHR system can provide. However, given the wealth of detail inherent in EHRs there is the potential for an insurer to utilize that data (stripped of identification elements) in statistical models that can be used in analyzing medical trends in claims data.

Given where we are in the progression of electronic data – EHRs add an effective dimension to the data capabilities of carriers. Not only can the marriage between EHR data and auto physical data form the determination of causality, it can also serve as an exposure determinate and predictor.

More to come on those interesting topics in the future.

45 CFR Part 170
Retrieved from http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=5c04367d65136717775673a2c1e334de;rgn=div5;view=text;node=45%3A1.0.1.4.75;idno=45;cc=ecfr#45:1.0.1.4.75.3.27.3

CMS website – “ICD-10 Basics for Payers,” Sept. 2010
Retrieved from http://www.cms.gov/ICD10/Downloads/ICD10PayerFactSheetFINAL.pdf

CMS website – Meaningful Use – Retrieved from
https://www.cms.gov/EHRIncentivePrograms/35_Meaningful_Use.asp#TopOfPage

Federal Register Vol. 75, No. 144 p.44612 Retrieved from
http://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf

Health Level Seven Background Brief Retrieved from
http://www.hl7.org/newsroom/HL7backgrounderbrief.cfm

Congdon, Ken. (9/28/2009). The Importance Of Transcription In The EHR Age. Healthcare
Technology Online: http://www.healthcaretechnologyonline.com/article.mvc/The-Importance-Of-Transcription-In-The-EHR-Ag-0001

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