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No wound center is an Island

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Title: No wound center is an Island


1
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

2
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

3
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

4
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

5
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

6
How Are you going to Integrate all these
things????
7
And there is another storm on the way
The Perfect Storm of Facility Reimbursement
8
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.

9
Facility Billing by Time
  • Pros
  • Simple system to develop.
  • Fairly easy to calculate.
  • Cons
  • Inadequate surrogate as a measure of work.
  • Rewards inefficiency.

Then Medicare Announced its plan in 2005 . . .
.
10
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 8
11
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.

12
How big are wounds?Average Wound Size by Type in
5,108 visits
13
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

14
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)

15
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

16
How Would the 5,108 visits have been billed if
Acuity had been used? A Normal Distribution
Curve
Level 1 0 35 Level 2 36 65 Level 3 66
125 Level 4 126 155 Level 5 156 200
  • Mean 95.6
  • Standard Deviation 30.0
  • Correlation Coeff. 0.881

17
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

18
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

19
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!

20
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. . . .

21
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)

22
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?

23
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

24
Paying for Quality
  • There are over 100 programs involving health
    plans and medical groups covering 10s 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?

25
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
26
What is the Solution?
  • What tool can STANDARDIZE facility DOCUMENTATION?
  • What tool can STANDARDIZE physician
    DOCUMENTATION?
  • What tool can automate quality assurance and
    benchmarking?

27
All of these Issues Can be Fixed with the SAME
Tool
  • What is it?

28
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

29
  • 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

30
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.
31
Web Based EMR
PatientEncounter
FaceSheet
Communication to Referring MD, DME Home
Health Pharmacy
E H R
32
Web Based EMR
  • Is it the Clinicians Primary Resource? (HIMSS
    definition)
  • Where are the legal medical records in a Web
    based system?

Hospital



Wound Center Paper Chart
Wound Photos
33
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
34
Web Based EMR?
Who is this guy?
  • 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.

35
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.

36
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?
37
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 Clinicians 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.

38
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.

39
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.)

40
Nursing Notes
41
Document Automation
Your Wound Center
Your Wound Center
42
Physician Communication
  • NOW
  • BEFORE

Your Wound Center
43
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
44
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.

45
Physician Billing Intellicure Calculates It
46
Report Automation
47
Intellicure EMR
Patient Encounter Point-Of-Service Documentation
CPGs
HL7 Interface IN Demographics, Labs,
Allergies OUT Documents
Hospital Registration
48
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.
49
Intellicure EMR The Dividends
  • Facility Billing
  • Physician Billing
  • DME orders
  • iHealthRecord
  • Quality Assurance
  • Pay for Performance (Medicare)
  • Data Analysis

50
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

51
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
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