These are important questions for home health care organizations. While it may be safe to assume that all home health care professionals need to stay abreast with technologies that can promote their organization’s success, it is not always as obvious that they also need to learn to differentiate among products that promise to improve care quality, patient and employee satisfaction and the ability to effectively compete.

This summer, Home Care Technology Report (HCTR) invited readers to participate in the Home Care Technology Report 2011 Technology Utilization Survey in order to learn what technologies are currently in use and what near-term acquisitions are planned across the industry.

Sponsored by Magnolia Prime, a new telehealth services company profiled by HCTR in July, and conducted in conjunction with an independent consultant, the study provides a look at how diverse home health care organizations use technology and provides insights into their expectations and experiences to date.

Positive response to the survey indicates significant interest in technology among HCTR readers. A complete report on the survey, published this month, summarizes responses of nearly 200 home health care owners and employees, including executives, nurses, clinicians, administrative personnel and others involved directly or indirectly in providing patient care. Responses from vendors and consultants were not included in the analysis.

The findings are revealing. HCTR readers, with their answers, provide insightful and useful information to home health care organizations striving to differentiate their organizations and deliver quality care that is cost-efficient, responsive and effective.

Among the key findings:

• All of the technologies addressed in the survey offer home health care providers significant benefits on multiple dimensions, according to respondents whose organizations have adopted or plan to adopt them.
• Despite the potential benefits of all the technologies covered in the survey, adoption rates vary considerably, ranging from 10% – 94%.
• A majority of respondents whose organizations use these technologies report a moderate to high degree of satisfaction and/or benefit realized by their organizations and/or patients.
• Half or more respondents say their organization has no future plans to purchase, replace or upgrade any of the technologies addressed in the survey.

Survey results imply that many home health care organizations not yet investing in automation technologies would benefit by catching up with their colleagues. The majority of respondents who are utilizing the technologies examined — point-of-care software, home telehealth systems, remote patient monitoring and interactive voice response systems — report significant benefits and satisfaction.

Notable observations

• Just under half (49%) of respondents who say they use point-of-care software report moderate to high satisfaction with their current system.
• In a significant contrast, 80% report moderate to high benefits from using point-of-care software
• The same dichotomy appears in answers about home telehealth systems. 56% report satisfaction compared to 80% acknowledging benefits
• At 74%, HCTR readers seem to use point-of-care systems more than the traditionally estimated national average of 50%
• The same is true for home telehealth systems and other forms of remote patient monitoring, used by 51% of those completing the HCTR survey as opposed to the 20% to 25% reported by recent, more scientific surveys conducted with broader ranges of home care agencies
• Least surprising are the reasons given for not investing in home telehealth systems. 55% of respondents who have not already begun some type of remote patient monitoring say they are deterred by “insufficient perceived benefit” of the technology. 52% believe their patients may not be receptive and a full 71% name cost as their primary obstacle.

Following is a summary of survey responses from HCTR readers. To read a complete report of survey findings, click here.

Who participated in the study?

The nearly 200 HCTR readers who participated in the survey came from all home care job descriptions: executives, technical and administrative staff, nurses and clinicians working in rural and urban locations for organizations of varying sizes, specialty and technology utilization.

Respondent Profile

Job function:

• 20% owner/president
• 20% director level and above
• 20% technical staff
• 16% administrative staff
• 13% nurse
• 5% clinicians

Organization’s annual revenues:

• 40% more than $6 million
• 11% $3 million – $6 million
• 25% $1 million – $3 million
• 13% less than $1M

Geographic region:

• 29% mostly rural locations
• 29% mostly urban locations
•  42% mix of rural, urban.

Ownership:

• 40% hospital-owned
• 37% freestanding
• 4% government-owned
• 25% for-profit
• 51% non-profit
• 13% VNA

Member of a collaborative provider group or Accountable Care Organization:

• 7% yes
• 35% no
• 58% under consideration

Services provided by organization:

• 93% Skilled nursing
• 88% therapies
• 43% non-medical home care/private duty
• 49% hospice
• 43% palliative care
• 14% home medical equipment
• 45% home IV
• 16% other

Average number of patients served per day:

• 25% Less than 100
• 17% 100-199
• 8% 200-299
• 21% 300-500
• 28% more than 500

Payor mix:

• 93% Medicare
• 82% Medicaid
• 87% Private insurance
• 58% out of pocket payments by patients
• 9% other

Percentage of non-English speaking patients served:

• 65% less than 5%
• 24% 5%-24% patients
• 11% more than 25% patients

Key sources of technology information:

• peers in the home health care industry (76%)
• HCTR (63%)
• industry conferences (62%)
• internet (42%)
• colleagues at respondents’ own organizations (25%)
• general media (8%)

Current Technology Utilization Reported by Respondents

• 94% Software application to submit electronic claims to Medicare
• 74% Point-of-care system to collect patient data in the patient’s home
• 36% Telephony software for electronic visit verification
• 71% OASIS checking and analysis or benchmarking software
• 32% Home telehealth (two-way communication) technology
• 19% Remote patient monitoring (one-way communication) technology
• 10% Fall detection device technology
• 20% Medication Management Technology

Respondents Who Report Moderate to High Satisfaction with Current Technology

• 49% Point-of-care system
• 72% Telephony system
• 56% Home telehealth technology
• 60% Remote patient monitoring technology
• 53% Fall detection device technology
• 53% Medication management technology

Respondents Who Report Moderate to High Benefits Realized from Technology

• 82% Home telehealth
• 80% Remote patient monitoring
• 74% Fall detection device
• 81% Medication management technology

Future Plans to Invest in Technology within Next 12 months

• Home telehealth: Buy 19%, Replace 13%, Upgrade 10%
• Remote patient monitoring: Buy 12%, Replace 5%, Upgrade 5%
• Fall detection device: Buy 4%, Replace 1%, Upgrade 1%
• Medication management: Buy 6%, Replace 0, Upgrade 0

Future Plans to Invest in Technology within 1-5 years

• Home telehealth: Buy 11%, Replace 5%, Upgrade 6%
• Remote patient monitoring: Buy 7%, Replace 2%, Upgrade 1%
• Fall detection device: Buy 5%, Replace 1%, Upgrade 1%
• Medication management: Buy 5%, Replace 1% Upgrade 2%

Dione Chen is an independent consultant who provides marketing, research, communications and strategy services. Her personal experiences as a family caregiver led to a strong interest in the importance of technology and innovation in aging services. She worked with HCTR and Magnolia Prime to develop the HCTR 2011 Technology Utilization Survey and resulting report.

Quinn reports that the objective was to test whether adding coaching provided via a software application running on a smart phone, coupled with patient/provider web portals to community primary care, to standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes more than standard management procedures alone.

Research Design and Methods

The University of Maryland School of Medicine “Mobile Diabetes Intervention Study” was a 12-month, cluster-randomized clinical trial. Researchers randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group.

A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels (HbA1c) over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile and web-based self–management patient coaching system and provider decision support.

Patients received automated, real–time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patients’ glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options.

Conclusion

Mobile phone management is efficacious in patients whose glycated hemoglobin levels are above desired levels as well as patients whose glycated hemoglobin levels are less egregiously elevated.

Although there were mean declines across all groups in lipid values and blood pressure readings, Diabetes Distress, Diabetes Symptoms, and PHQ-9 Depression, none of the 12-month changes comparing the UC to any of the active interventions were significantly different (P>.05).

Research Team

Charlene C. Quinn, RN, PhD

Michelle D. Shardell, PhD

Michael L. Terrin, MD, MPH

Erik A. Barr, BA

Shoshana H. Ballew, BA

Ann L. Gruber-Baldini, PhD

“Telemedicine and telehealth have the potential to transform aspects of rural health care, improving accessibility, quality and affordability,” the summary of the paper’s sixth chapter declares. “This working paper discusses the current technological frontiers and likely advances, together with new survey data on current usage of telemedicine by rural and urban doctors, and what they perceive as barriers that need to be overcome.”

Continuing from the synopsis of Chapter 6: “To make full use of telemedicine’s potential, a number of practical changes are now required. These include: building on work by the Federal Communications Commission and others to expand rural broadband capacity (estimated at around 60 percent of rural areas versus 70 percent of urban areas); introducing new public and private payment models for telemedicine, perhaps linked to the move away from traditional fee-for-service reimbursement models; and continued action by the Food and Drug Administration and others to remove outdated regulatory barriers to adoption.”

The complete, 84-page report is available for download from unitedhealthgroup.com/reform. The rest of the Executive Summary contains additional insight into the report’s scope and conclusions.

Three quarters of rural U.S. residents live in the South and Midwest, compared to only one-quarter in the Northeast and West.

Though five million people live in isolated and remote locations, around 31 million people who technically live in rural counties actually live close to an urban area.

Chronic conditions such as cardiovascular disease and diabetes are more prevalent in rural populations than in urban or suburban areas. This is worst in the South, especially among rural minority communities, for whom obesity rates and other risk factors are markedly elevated.

The paper sets out to answer five questions:

1. What are the health challenges confronting rural Americans?
2. How is the care delivery system currently organized to respond?
3. What do we know about the quality of rural health care?
4. What will the expected Medicaid and insurance coverage expansions from 2014 mean for rural areas?
5. Are there practical solutions to these health, access, and quality challenges?

In remote rural areas there are fewer than half the number of primary care physicians per 100,000 population than in urban areas, yet there are slightly more hospital beds per 100,000 residents in rural than urban areas. Nevertheless, about a third of hospitalizations for rural patients occur at urban hospitals.

The paper also includes:

• new empirical research on rural versus urban quality of care
• new projections for rural Medicaid and insurance exchange 2014 coverage expansions
• new state-by-state and county-level analysis of future pressure on primary care capacity
• new models for rural care delivery and care coordination

Outcome quality evidence is mixed

This paper finds new research suggesting that quality scores for urban and suburban areas are higher than those for rural areas in 75 percent of the hospital referral regions (HRRs) for which representative data are available. In a further 20 percent of HRRs there is no statistically significant difference in rural/non-rural measured performance, and in 5 percent of HRRs rural quality scores are higher.

Both rural consumers and rural primary care physicians rate the quality of local care lower than do their urban and suburban counterparts. For example 49 percent of rural consumers rate the quality of local care as ‘very good’ or ‘excellent’, compared to 64 percent of non-rural consumers who do so. Twenty-four percent of rural consumers think their local care is only ‘fair’ or ‘poor’, compared to 12 percent of urban and suburban consumers who believe that.

Healthcare reform

UnitedHealth finds that, by 2019, there could be an increase of around eight million rural residents in Medicaid and state insurance exchange plans, compared with what would have happened without the ACA legislation.

Five million rural residents already live in designated ‘shortage areas,’ defined by the federal government as counties with fewer than 33 primary care physicians per 100,000 residents. Attempting to identify locations where the pressures will be greatest, this paper finds that these areas tend to be in the South, and often have some of the tightest scope-of-practice restrictions on nurse practitioners and other non-physician health professionals.

A range of approaches are discussed that states and the federal government can take to confront the question of how to ensure there are enough high quality health plan choices and rural provider networks to serve rural residents.

These include: recognizing the role that nurses and other suitably qualified health professionals can play in meeting network adequacy standards, alongside mobile and telemedicine-enabled providers where appropriate; taking care in designing insurance market and exchange rules explicitly to recognize the distinctive population and provider characteristics of more rural parts of each state; using the state’s purchasing power to provide incentives to participation by rural providers, as states such as Georgia have done; driving greater transparency on quality; and ensuring new federal initiatives on Medicare reform are tailored for rural communities.

The paper concludes that the next few years will be times of considerable stress on rural health care, but also times of great opportunity. “Across the country there are already impressive examples of innovative new care models providing high quality care, tailored to the distinctive needs of their local community. The challenge for all involved in rural America now is to build on that track record of innovation and self-reliance, so as to ensure that all Americans — wherever they live — can live their lives to the healthiest and fullest extent possible.”

In a keynote session at last week’s McKesson home care and hospice customer meeting, Melanie Duerr, RN, a Fazzi Associates partner, and her sister Kathleen O’Donnell, CPA, a professor at Onondaga Community College, offer stern warnings that now is the time to begin to prepare for the ICD-10 conversion and that your project must include every department.

We plan an extensive interview with Melanie and Kathleen soon but a brief summary of their excellent presentation will provide some background and lay the groundwork for that future article.

How complex will ICD-9 to ICD-10 conversion be?

Canada was presented as a good benchmark. With one single nationwide healthcare payer, one-fifth the population and one designated training firm, Canada completed its conversion in five years. Measurements indicated a dip in productivity that return to pre-ICD-10 levels after six months.

How is it possible that Canada was able to begin that long ago?  Isn’t ICD-10 brand new? Actually, no. ICD-10 was endorsed by the Forty-Third World Health Assembly of the World Health Organization (WHO) in May 1990 and came into use in WHO member states beginning in 1994. Most industrialized countries, including the Republic of South Africa the presenters pointed out, completed their conversion long ago. Is the United States ready to meet the government’s October 1, 2013 deadline? Is the U.S. healthcare community taking the task seriously yet?

The presenters offered one possibly telling indicator:

• The American Health Information Management Association (AHIMA) has made a three-and-a-half minute video available on YouTube recapping its Second Annual ICD-10 Summit and providing resources to gather information. To date, YouTube reports about 900 views of that video, posted May 6, 2010. In the video, AHIMA reports conference attendance was just over 400, double last year’s Summit.  http://www.youtube.com/watch?v=DqunZSM2RXo
• For comparison, a YouTube video of a baby laughing hysterically at paper being torn up has been viewed more than 16 million times since posted two months ago.

Challenge and opportunity

Duerr and O’Donnell do not pull any punches when describing ICD-10’s full implication for the entire U.S. healthcare industry. “This is an opportunity,” they contend. “The wise provider will use it to clean house. That means everything. Clean up operations, personnel, processes and technology and improve efficiencies.”

“This is not an IT project,” Ms. Duerr reiterated. “Your Strategic Imperative Team, which ought to be in place by now considering that you have less than two and a half years to prepare, should consist of representatives from your coders, QA, field staff, trainers, operations, supervisors and  your CEO and CFO. Your software vendor and your IT staff should be involved but the bulk of your activities will extend far beyond their areas.” In other words, do not look to your software vendor to “do ICD-10” for you, they emphasized.

To those who have grown accustomed to the federal habit of moving deadlines, the Duerr and O’Donnell reminded their audience that CMS has been quite adamant that this deadline will be different. It will come to pass on October 1, 2013, right on schedule. “They cannot put it off any longer,” O’Donnell said. “First of all, the rest of the world has already converted.”

The second reason cited is that, “As complexity of diagnoses increases, more detail was needed to translate several descriptive paragraphs into a line of numbers that can be read by a machine,” Duerr explained. “By matching the complexity of the classification system to the complexity of today’s diagnoses, we can improve care quality, documentation accuracy and payment reliability.”

Summary of basics

• ICD-9’s 24,000 codes will be replaced by about 9 times as many. The exact number is impossible to pin down, and largely irrelevant, as there is no one-to-one correlation. One coder training and certifying body, AAPC, estimates the change as going from 17,000 codes to 141,000
• ICD-9 has five numerical places plus an alpha column that can be one of two letters
• ICD-10 will use seven distinct entries, beginning with an alpha column that makes use of 24 letters and including a column that can be alpha or numerical and a new category to identify the episode count
• Early research indicates that newly trained coders score higher on tests after training than do coders with 30 years of experience
• To prepare for the 2013 conversion, updates to ICD-9 will cease following the scheduled 10/1/2011 update
• Recent research indicated 12% of U.S. healthcare providers have budgeted for ICD-10 transition planning
• Two years is considered the minimum time it will take most providers to be ready for October 1, 2013.

A good place to start reading is a document published by CMS, “ICD-10 Myths and Facts,” and available on the CMS web site.

In Medicare’s Home Health PPS system, and to a certain extent within the hospice world as well, clinicians hold all the power. Clinical decisions determine patient care plan and establish Medicare payment dollar amount.

To the exact extent that such documentation is accurate, payments are correct. Errors can subject the agency to overpayments and accusations of fraud or underpayments, which the government generally accepts with unvoiced gratitude. Ensuring clinical documentation skills is therefore a critical enterprise for every Medicare provider.

Last week, we offered evidence that the common practice of saving paperwork for the end of the day can have a disastrous effect on documentation accuracy (“From Bedside to Billing Part 2: Let’s Tell the Truth About Clinical Point-of-Care Systems” 1/26/11). This week, we consider the financial consequences of allowing clinicians to continue that dangerous practice.

There is universal agreement among all of the software companies that provide OASIS analysis and correction applications and/or services to home care and hospice providers that clinicians provide Medicare with a 10% to 15% discount, on average, on every HHRG they help calculate. Speaking with representatives from Home Health Gold, PPS Plus, SHP, The Analyzer (now owned by Sandata) and Acucare, we learned that 80% to 90% of OASIS assessments that require corrections end up with a payment increase.

Summary: on average, clinicians err on the side of caution, the opposite of what CMS calls “case-mix inflation.”

Your one and only solution: training
Far too many home care and hospice owners and managers regard clinical training as an expense. As can be seen from the above statistics, training that results in improved clinical documentation is not an expense, it is a revenue source. To skip on training is immeasurably expensive.
If that adverb seems exaggerative, or if a 10% to 15% discount to Medicare is not convincing, consider the more severe consequences:

Headline: Obama Using ‘Bounty Hunters’ to Root Out Fraud
In March of last year, before the Affordable Care Act was passed, the President promised to deploy high-tech bounty hunters to help solve the Medicare fraud problem. Motivated by commissions of up to twelve percent, these collection agencies that won the government contracts have aggressively gone after criminals who bill Medicare without providing services.

However, in their zeal, they and their counterparts on the non-bounty side such as RHHIs, MACs, ZPICs and the like, have not been doing a stellar job of differentiating between completely false claims and simple typos. The rate at which legitimate payments have been denied has been accelerating over the past year, leading some consultants and attorneys to suspect that these contractors may have been given quotas to fulfill.

Primary justifications for payment denials, ADRs and Focused Medical Review assignments are failure to demonstrate medical necessity for services rendered, excessive use of therapy and technical issues such as missing physician signatures or physician signatures with missing dates in the physician’s handwriting.

Fiscal intermediaries and other CMS contractors do not seem to be limiting themselves to just this new level of scrutiny over your clinical documentation. A tendency toward inappropriately aggressive enforcement has also been detected. According to NAHC Center for Health Care Law Deputy Director Denise Bonn, unusual incidents occurred in courtrooms during 2010 that were unheard of previously. Administrative Law Judges (ALJ) do not always stop after deciding to return a denied payment to a home care provider but occasionally take the time to emphatically scold RHHI and QIC representatives who brought the case to court for being so completely unfamiliar with the laws they are charged with enforcing.

The significance of this development is not to be missed. When payment denials are unjustified and the victim provider does not bother to file an appeal, the payment is forever lost and the error is never challenged. Unfortunately, it appears that appeals are filed in only about 16% of denial cases.

Immediate steps to take
#1 – Reduce your payment denial frequency by improving your clinical training program.
#2 – Unless you can see that an error is obviously yours or the amount in question is quite small, always file an appeal.

One brief comment about step #2 before designing your new training program. Never allow mistaken auditors to get away with a misinterpretation of the regulations you are required to follow. If you do not think you have the time to appeal, hire an attorney or other experienced consultant. There are many cases where investments in the tens of thousands of dollars recouped hundreds of thousands in denial reversals. One of the cases attorney Bonn described involved over $14 million.

How not to train adult professionals: the pep talk
Two years ago, then software company owner Jeff Lewis explained to his live conference audiences that the “Let’s All Try Harder” pep talk it the most popular and least effective strategy a manager can implement. A chart he compiled after examining data from nearly 7,000 home care agencies shows how well the strategy works in home care and hospice:

How not to train adult professionals: the shotgun approach
Requiring every staff clinician to attend the all-day Saturday workshop, whether you provide the donuts or not, creates more problems than it solves.

1. It pulls some clinicians away from patients.
2. It wastes the time of the 90% of staff that is already accurate 99% of the time. (These are the ones who will tell you at the end of the day they could have taught the class.)
3. It damages goodwill and employee morale, at least for that 90%.
4. It never achieves 100% attendance, which means dealing with repeating material for absentees at some later date.

How not to train adult professionals: the conference
This one is obvious. You cannot afford to fly everyone to Las Vegas for next year’s NAHC meeting. Nor can you take every clinician out of the field for two or three days to attend your state association conference. If you carefully select one or two clinicians to go to a state or national meeting, they are then obliged to take copious notes and relay everything they learned to the rest of the staff as best as they can remember it. They never deliver the material as well as or as accurately as the original presenter and where are they going to do it except at another Saturday workshop? See the list above.

Ockham’s Razor
As everyone knows, “Pluralitas non est ponenda sine necesitate.” For non-Latin readers, the 14th-century English logician and theologian William of Ockham was trying to say, “if it looks like a duck, walks like a duck and quacks like a duck, don’t overthink it.” More eloquently, “the simplest explanation is most likely the correct one.”

For the purposes of this discussion, the concept, also known as the law of succinctness, means that you should be training only those who need to be trained, and only on the issues with which they need help. Only new hires, and not necessarily all of them, need a complete OASIS course.

Do this:
Using tools that are probably already available in your primary software application, run reports that help you know exactly who is generating the most payment denials. Who has developed bad habits when completing an OASIS assessment? Who misunderstands one or two specific OASIS questions or company policies? If your software does not offer enough detail, talk to the 3rd-party services that do. (They are the ones listed above in reference to the 15% Medicare discount problem. If you do not know how to find them, use the tool mentioned in the ad at the right.)

Depending on the capability of your chosen application’s reporting function, you will find one or more of the following is true among your staff:

• Some of your clinicians use their own shorthand language, which often describes insufficiently either patient condition, medical necessity of all or part of the care plan, exact professional services rendered or all three. Auditors look for incomplete sentences and vague, obscure descriptions.
• Some of your clinicians have developed bad habits with OASIS assessment forms, leaving questions unanswered, omitting signatures, or providing conflicting answers to two questions, both of which cannot be true.
• Some of your clinicians fall into the ‘favorite answer’ syndrome. Your report should alert you if one nurse never (or always) has a patient with impaired vision or incontinence, or if one therapist marks every patient with the same ambulatory weakness. Some reports we have seen have revealed favorite answers marked 95% or even 100% of the time by one clinician for one OASIS question.
• Some of your clinicians simply misunderstand the intent of one or more OASIS questions.

Every one of these deficiencies can be corrected by a clinical supervisor in a one-on-one conversation in 10 or 15 minutes. Each correction will result in a noticeable uptick in your Home Health Compare scores and corresponding decrease in your payment denial count. In addition, your staff will have its Saturdays back, may eat fewer donuts, and will not have to sit through explanations of points they already know as well as their instructor. Employee morale — and retention — will increase.

Summary: the training manager’s mantra

You need to know:

• What subjects to teach
• Whom to teach
• Whom to leave alone
• How often to conduct training
• Whether your training efforts are working
• When to adjust your training topics on the fly

When you know these things, you are equipped to take action to improve your organization’s clinical documentation skills. This will, in turn, strengthen your protection against the government’s stepped-up payment denial activity stemming from fraud control efforts. The cash flow improvements that will result from fewer denials and fewer appeals that have to be filed will cover the costs of your new training program perhaps as much as ten times over.

As we asserted when this three-part series began, improving the health of your organization is not that different from improving the health of your body. Start with prevention, which is cheap. When necessary, resort to cures, which can be expensive. If you do the prevention correctly, you cannot help but come out ahead, clinically and financially.

In addition, we pointed out the complete power over agency revenue the Medicare payment system gives to clinicians. We noted this power occurs both up front, when clinicians establish a payment amount with an OASIS assessment, and at the end when they protect those payments from auditor denial by developing documentation that establishes medical necessity and justifies a treatment plan.

The wise manager, we concluded, empowers clinicians in six specific areas:

• computer-assisted clinical documentation
• quick, easy access to patient records, including archived historical records
• online OASIS accuracy checking services
• frequent, professional training opportunities
• HIPAA privacy and security protection and prevention technologies
• remote patient monitoring technologies

Telling the Truth About Point-of-Care Technology
This week, let’s take a closer look at Computer-Assisted Clinical Documentation Systems. Over the years, certain myths have grown up around point-of-care automation. The best way to attack mythology is with facts.

TRUTH #1: POC is not a panacea; it comes with roughly equal numbers of pros and cons.

In almost every case of a point-of-care implementation failure, the cause can be traced to inadequate staff preparation and training. Certainly, on occasion, software can be faulty or a vendor can miss the mark. However, those companies and their products do not survive long in a free market, especially a small one where agency owners regularly talk with each other.

Home care providers often react to sticker shock by looking for areas to cut corners and, far too frequently, it is training that suffers. The fact is that inadequate training is expensive in the long run, more expensive than the investment in doing it right in the first place. This includes pre-training for staff who are unfamiliar with computers and need to learn the basics before having a sophisticated clinical application thrust into their lives.

TRUTH #2: POC is not about laptop computers.
In addition to full-size, Windows-based laptop PCs, bedside data gathering can be facilitated by sub-notebooks, Tablet PCs and iPads, Netbooks,
PDAs and smartphones and Blackberries, the patient’s own phone and
paper-based Optical Mark Recognition scanning systems. At least 50 software vendors currently offer one or more of these solutions. (For a complete list of all known home care and hospice point-of-care companies, go to www.homecaretechnology.info.)

TRUTH #3: POC system do not, nor have they ever been intended to, increase clinical productivity
Though there was a day when the sales argument included a promise that point-of-care systems pay for themselves by giving clinicians
time to squeeze in an extra visit every day, no serious sales representative makes that claim anymore. Point-of-care automation does create efficiencies but not for the clinician in the field. At best, software is not slower than paper when completing an OASIS assessment or documenting a visit. At worst, many clinicians report, some applications are slower than documenting on paper.

Where an organization gains is in the office, and those gains can be significant. Clerical costs often plummet when personnel is no longer needed to retype what clinicians have already written. Data is available to management in real-time or, worst case, within one business day. Management reports can help financial decisions to be based on the most recent clinical information.

Many paper-dependent providers have policies requiring clinicians to deliver documents every day, which places a burden on clinician time and increases agency mileage reimbursement costs. Others allow three days or more, which means management report data can lag behind up to a week, since paper often lingers on a data entry clerk’s desk, sometimes for several days after field staff submits it and before it is entered.

As the industry has grown wise to Truth #3, management now rarely prepares field staff for a conversion from paper to computers with promises of additional leisure time or more visits per week. Rather, emphasis is placed on computer-assisted accuracy and fewer documentation errors, leading to fewer payment denials. Many agencies learned the hard way that staff disappointment with a new POC system often arises from unmet unrealistic expectations, not from difficulties using the system itself.

TRUTH #4: Not all software is created equal
Brand matters. Not every well-intentioned software developer has released a product with features that match your specific needs. Remember that the purpose

of clinical software is to enable better clinicians. Software can be designed in such a way that it can guide nurses, therapists and aides toward home care and hospice best practices and away from bad habits and potentially harmful shortcuts. Better patient care, improved patient outcomes and fewer claims denials can be the result.

Though there was a time when it was thought software should be unobtrusive, should allow clinicians to operate exactly the same way they did on paper without disrupting the practices to which they had grown accustomed, today’s software developers are no longer merely recreating paper forms on a computer screen. Business intelligence and decision support have moved from the executive office to the bedside, joining best practice consultation and error prevention safeguards built into clinical automation tools.

Without naming names, suffice it to say here that the above is mostly true among today’s home care and hospice software vendors. Responsibility falls to the team evaluating software products to detect the difference between modern software with the potential to improve clinical performance and legacy products that still merely reproduce paper forms on the screen.

TRUTH #5:
The “point of care” is located inside the patient’s home

Most automated home care agencies and hospices we speak to have policies on the books that documentation is to be done in the home on the computer. Most of those also report that convincing clinicians to comply with that policy is their least successful endeavor. Though clinicians have good reasons — the laptop is too heavy, the software is too slow, the patient’s home is unsafe or unsanitary — there are equally good reasons not to delay documentation until the end of the day.

Sadly, a large number of agencies that are not automated report the same problem, leading to the conclusion that computers may not necessarily be the culprit. Nevertheless, mediocre documentation is expensive, for two reasons.

1. Human memories are fallible. Accuracy declines by the hour during a typical clinical work day.
2. Modern hard drives have the capacity to store thousands of patient records. A single lost or stolen computer can create a HIPAA Privacy violation large enough to bankrupt even a large home care agency or hospice.

Consultant and former California OASIS coordinator Michael McGowan conducts the following experiment when offering full-day seminars. He asks his audiences to complete an OASIS assessment on him, interviewing him and recording the conditions and complaints he presents as though he were a patient, at the beginning of the day. At noon, he asks them to complete another OASIS form but he does not remain in the room or answer their questions. Finally, he has them do a third one at the end of the day.

He determines accuracy by comparing the answers with each other. The results, charted below, show that participants’ OASIS answers are nearly 95% in agreement in the morning assessment, less than 80% aligned with each other at noon and barely 60% in agreement at the end of the day.

When a clinician’s computer disappears through a shattered car window or is lost, the HIPAA covered entity is required to notify every potentially affected patient. These mailing costs may not be unbearable if the lost computer stored only a current case load. Some agencies, however, do not have policies about the number of patient records a clinician should keep. Even if there is no good reason, some computer systems place every patient record on every mobile computer.

Next week
There is a sixth truth about point-of-care computing but it is complex enough to deserve separate treatment. In part three of this series, we will begin with evidence that clinicians, on average, undercode initial OASIS assessments to such an extent that it amounts to a predictable discount on home care services to Medicare and other payers. Following that evidence, we will discuss solutions, beginning with professional training programs.

The year that welcomes the first Baby Boomers to Medicare will also see:

• the first effects of the Patient Protection and Affordable Care Act (ACA)
• another string of Medicare pay rate cuts for home care
• tighter hospice regulations
• growing impact from private duty agencies
• almost all state Medicaid systems in the red; slashing eligibility, rates and services to cope
• many employers wondering, if the nursing shortage is said to be easing, where they all are
• ongoing, major government crackdown on Medicare fraud that frequently cannot tell the difference between criminal intent and typos

Issue One: Healthcare Reform

Since ACA, the healthcare reform law, will touch nearly every other item in our list, it will be enough here to say one thing about the law itself. It is important that healthcare organizations remember to look at ACA from three perspectives. You are a healthcare services provider but you are also a healthcare services consumer and an employer. ACA regulations will touch you in all three roles.

You have been hearing via the media mostly about ACA provisions listed in the left-hand column below. As a home care agency or hospice owner or administrator, however, your concern will be absorbed by the provisions in the right-hand column.

Issue Two: Understanding Your Value to the U.S. Healthcare System

The healthcare system needs home care so that there is a place for patients to go when they are discharged too soon and too sick from hospitals and there is evidence they are coming to you sooner and sicker than they did ten years ago. The best evidence comes from CMS contractor Abt Associates.

Every year, CMS asks Abt to perform a statistical analysis on patient condition in order to determine whether you are inflating OASIS assessments to increase HHRG scores. To compare actual patient condition with your reported case-mix, one of Abt’s tools is a detailed measurement of patient mortality risk at the moment of transition from hospital to home care. They set a baseline at the year 1999, the end of the Interim Payment System (IPS) era, and report any changes in each year’s report. The latest data reported by Abt is from 2008.

The annual report predicts case-mix growth to be expected due to patient condition and compares its own prediction with reported case-mix growth from home care clinical documents. Report author Henry Goldberg calls his prediction “real” growth and your reports “case-mix creep.”

Throughout Goldberg’s report, the operating assumption is that your clinical assessments were correct in 1997-1999 and have become less correct since then. Assessments written during the initial years of OASIS are not only Abt’s numerical baseline but their accuracy baseline as well. In other words, the report draws conclusions based on the assumption that clinicians were skillful at writing assessments when OASIS was new but have grown less accurate with a decade of experience.

Abt uses four categories to determine one aspect of “real” case-mix growth, risk of mortality: minor, moderate, major and extreme. In the process of analyzing case-mix “creep” since 1999, Abt used figures that reveal that today fewer hospital discharged patients are admitted to home care with minor and moderate mortality risk and many more arrive with major or extreme risk.

Since 1999, about 5% fewer are admitted to home care with Mortality Risk Level 1 (minor) and nearly 11% fewer with Mortality Risk Level 2 (moderate). Compare that with Mortality Risk Level 3 (major) increasing more than 14% and Mortality Risk Level 4 (extreme) increasing nearly 80%.

The Abt report added that home health care patients in 2008 spent 31% fewer days in acute care hospitals than they did in 1999. If you suspected patients leave the hospital in much worse condition today than they did ten years ago, you are correct. (For more detail, see our story on Abt’s 2009 report at http://homecaretechreport.com/article.php?id=986)

If there is a question asked far too infrequently of hospitals and healthcare payers, it is, “Where would patients go for care if home care were not here, and what would it cost you?” Actually, that answer can be calculated.

According to Abt, from 1999 through 2007, average hospital expenditures for Medicare beneficiaries who are discharged to home care decreased 18%. Using the average cost per admission to healthcare payers, both governmental and private, that 18% is worth about $4,000. According to Abt, “case-mix creep” costs Medicare approximately $200 per PPS episode.

Remembering that the title of this section is “Understanding Your Value to the U.S. Healthcare System,” let us dare to continue down this logic path.
If the quality of home health care services does its job and prevents a hospital readmission, the entire cost of that avoided admission, on average, $22,000, is saved. Perhaps it is forgiveable here to repeat, again according to Abt, “case-mix creep” costs Medicare approximately $200 per PPS episode.

What Is Your Sales Argument to Hospital Discharge Planners?

The Abt report asserts that the 18% decrease in hospitals costs can be attributed to shortened hospital stays for patients discharged to home care but a closer look calls this into question. Though home care does make shorter hospital stays feasible, it turns out not to be exactly accurate that 18% less time direct equates to 18% less cost.

Hospitals do not allocate all of their costs that way. In fact, only a fraction of a total hospital bill is based on length of stay. It turns out that hospital overhead, more than 50% of the amount charged to the payer, is fully amortized at the moment of admission. Direct patient care costs account for nearly 40%, leaving 10% or less to be divided by the number of days the patient was in the hospital. Therefore, discharge day, the day home care might shave off for the payer, only actually saves the payer about $300. Clearly, length of stay is not home care’s sales argument.

Instead, look back at the total cost of an admission. If your skillful services keep a patient out of the hospital when he or she would otherwise have deteriorated and gone back, either the hospital (within 30 days of discharge) or Medicare (more than 30 days post-discharge) saves the full price of admission, on average, $22,000. Therefore, avoided admissions is what your database software tracks and that data is what you present to referral sources.

To become the hospital recidivism prevention hero in your service area

There are tools home care and hospice ownership must acquire and staff must skillfully use:

• Data-rich intake procedure
• Inter-disciplinary patient care coordination
• Fall avoidance programs
• Remote patient monitoring systems

But the number one, most important, sink or swim, do-or-die strategic tool home care providers must have in order to compete for hospital and physician referrals is the highly-skilled, well-trained, technology-equipped clinician.

You do not just hire a highly-skilled clinician, you nurture him/her. You provide training and technologies, no matter the cost, because your agency’s survival is in his or her hands. Though it may be different in private duty home care, in Medicare home care, clinicians are in 100% control over:

• company revenue
• regulatory compliance
• ADR rate
• payment denials
• overpayment recoupments
• whether or not the agency owner goes to jail

In Medicare hospice, the same is true for:

• care quality
• regulatory compliance
• payment denials
• RAC audit vulnerability
• and, yes, that jail issue

Management’s role is to provide the tools and training to empower clinicians to excel in each of these areas. No matter how powerful their skills when hired, nurses and therapists need ongoing corporate support in these six areas:

• computer-assisted clinical documentation
• quick, easy access to patient records, including archived historical records
• online OASIS accuracy checking services
• frequent, professional training opportunities
• HIPAA privacy and security protection and prevention technologies
• remote patient monitoring technologies

Next week: Let’s tell the truth about clinical point-of-care systems

We pick up our discussion at this point, exploring clinician training, clinical automation systems, and the dangers of sending clinicians out without them, or with the wrong ones.

• GPS Navigation system
• Personal Digital Assistant
• Flip Video Camera
• MP3 Player
• Digital Camera
• Handheld Video Game
• Notebook PC
• Cell Phone
• Wrist Watch
• TV & Stereo Remote Control

Yes, they all run on batteries but this story is a bit more important than that.

It has been predicted by Wall Street watchers, such as Douglas A. McIntyre and Charles B. Stockdale, that every one of these technologies is about to be replaced by smartphones. Applications running on the iPhone, RIM (Blackberry) and Android operating systems can turn those platforms into respectable simulations of each of these separate devices. (The only argument technology fortune tellers have been getting is about the camera. Even with phone-based cameras reaching double-digit megapixel rates, real photographers know that real cameras will always be around, they say.)

Today, we can add an eleventh gadget that may be on its way out. A Canadian company, Tether, has released a smartphone app for Blackberry and Android that serves up the phone’s data connection to an attached PC. Company founder Tim Burke told HCTR he and his partners are not yet fully familiar with home care in the U.S. but have an idea that it will be well received.

We tend to agree.

Many visiting nurses and therapists today prefer the advantages of pervasive connectivity when it is available, over storing a day’s work and synchronizing it with servers in the office at the end of the day. Management appreciates the advantages as well, as patient data and time and mileage reports are recorded in real time, streamlining data entry and payroll activities.

To get there, agencies furnish field staff with cellular modems, also known as air cards or air sticks. Some mobile PC manufacturers now build cell connectivity functions into laptop and notebook PCs, avoiding the breakable and easily misplaced USB attached version. The problem with this convenience is that cell phone companies charge anywhere from $40 to $80 per month for the service.

As smartphones gradually take over from plain cell phones, monthly plans that include a high number of minutes, or unlimited minutes, are becoming common. These plans often offer the user a low-cost incentive to bundle a data plan with the voice minutes. The entire package can range from $20 to $99, depending on deals offered to volume subscribers.

Management may balk at adding data plans at an extra $10 or $20 per month to an employee’s voice plan but, if a smartphone application can replace the need for a cell modem, the decision becomes much easier. Let’s take a look at the math, using a fairly typical cell plan as our base.

The annual savings of $550 per clinician grows when Tether’s volume pricing is factored in. The price of the application drops substantially from its $50 list price when purchased in quantities typical of the average home care agency.

As a footnote, let us point out that this is not the only application of its type. We tested both the Tether product and one called PDAnet, which sells for about $20. Both provide an Internet connection wherever a cell modem can. The difference is that the Tether connection is not severed when the phone rings. A nurse can work online while talking to the office at the same time.

About Tether

 
A privately owned company based in Halifax, Nova Scotia, Tether has already signed users numbering in the tens of thousands. The company was cited as one of the Top 10 Canadian ICT companies to watch and is in the process of becoming a ”
Blackberry Alliance Member.” Product versions for the Macintosh platform have been launched.

http://tether.com

The Hamilton CapTel 800i telephone is a new captioning telephone product from Hamilton Relay (a division of Hamilton Communications, Aurora, NB). It addresses communications obstacles that many elderly Americans struggle with on a daily basis. The need is greater than generally assumed.

According to CapTel’s literature, an estimated 30 million elders are completely deaf. Beyond the most severe needs, findings by the National Institute on Aging (a part of the National Institutes of Health), indicate that 30% of Americans ages 65-74 and 47% ages 75 and older have some degree of hearing impairment.

According to spokespeople at CapTel, frustration and depression over the inability to communicate by telephone with friends and family is widespread. It comes with a keen sense of loss of independence experienced by the hearing impaired when they either cannot hear voices over the ordinary telephone or require others, such as spouses or children, to interpret telephone communications for them.

The developers of the CapTel 800i telephone address these health and social issues by providing elders with an easy-to-use captioned telephone service. It operates this way: The CapTel 800i telephone combines screen captioning with a normal phone hand-set. Working in tandem with a home computer, the device displays callers’ words appear on users’ PC screens much like closed captioning appears on television screens.

At the recent AARP annual convention, a Hamilton presentation was cleverly titled, “See What You’ve Been Missing On the Phone.” The CapTel telephone service, the company representative explained, operates over existing telephone lines and Local Area Network Internet connections. These in turn link to a skilled transcriptionist, or “captionist.”

The captionist repeats the caller’s words into voice recognition software for display on the receiver’s computer screen in real time, word-for-word.  According to the session presenter, captioned output appears with 95% accuracy. There is a $99 cost for the tools to implement services but captionist services are provided free of charge, 24/7/365.

The service may not be suitable for everyone with hearing limitations. Users must have access to a computer, be literate and have adequate eyesight. Still, for hearing-impaired persons who do meet these requirements, the CapTel device can be a doorway to a more fulfilling life.

According to Oswald Melman, in his article “Hearing Loss Among the Elderly Today,” [available online at: http://www.articlesbase.com/hearing-articles/hearing-loss-among-the-elderly-today-1544399.html ], hearing loss is an inherent source of stress for people as they age, and it is perhaps one of the most common health problems to affect individuals’ well being. Melman mentions new technologies such as FM hearing aids and wireless hearing aids that minimize background noise. The CapTel system deserves a place alongside these more familiar technologies that enable people with hearing loss to once again become a part of the events and people affecting their lives.

www.hamiltoncaptel.com

_________________________________________

Audrey Kinsella, MA, MS, has written on home telehealthcare and new technologies for home care service delivery for 20 years, in 6 books, multiple web sites, and more than 150 published articles.  She can be reached at: telehealthcare@lycos.com or 828-252-8571.

“Humana Cares Chronic Condition Management” is in the process of filling 270 new St. Petersburg-based positions to coordinate medical and quality-of-life needs for Humana commercial health plan and Medicare Advantage members suffering with CHF, COPD, coronary artery disease and complex diabetes. The new associates, who will eventually number as many as 780, will include telephonic managers, onsite field care managers and community health educators, according to a Humana statement.

The new program will expand an effort that has already deployed a holistic approach with several thousand plan members to reduce hospital admissions by 36% and emergency room visits by 22%. Humana Cares teams work to help members with these chronic conditions remain independent and safe in their homes by:

• Installing safety items their homes and ensuring their transportation and prescription needs are met
• Providing education on self-care management, especially diabetes education
• Deploying home telehealth systems to monitor vital signs, provide education and identify events, such as escalating blood pressure, before they lead to emergency or inpatient admissions
• Assist members in navigating through a complicated health care system
• Put members in touch with community resources.

Humana Cares opened its doors in February 2009 with a mission to find new ways to reduce hospital utilization and lower overall healthcare costs. “Today, in the United States, 38 percent of Medicare beneficiaries live with three or more chronic health conditions,” said Humana Cares President Jean Bisio. “Our goal is always to keep members independent and…help them manage their health and improve their quality of life.”