Raghu Vir

Front End Speech Recognition: A case of dime wise and dollar foolish?

A new study sponsored by Agency for Healthcare Research and Quality (AHRQ) identified the frequency with which errors occur when physicians use front end speech recognition.

” Critical errors were found in 15 percent of data entered into patients’ electronic health records by physicians using computerized speech recognition technology, according to a pilot study funded by AHRQ. The study evaluated front-end speech recognition technology that allows dictation and editing in an electronic record’s text field. The study examined speech recognition errors based on 100 patient notes by attending emergency department physicians in Boston from January to June 2012. Findings showed that there were 128 errors, or 1.3 errors per note, and that of the 71 percent of notes that contained errors, 15 percent contained one or more critical errors that could potentially lead to miscommunication affecting patient care. Annunciation errors were most common, followed by deletions and added words. Study findings represent the first estimates of speech recognition errors in dictated emergency department notes, researchers said. The study, “Incidence of Speech Recognition Errors in the Emergency Department,” and abstract were published in the International Journal of Medical Informatics.”

As you know for years EHR vendors and speech recognition technology vendors have been pushing front end speech recognition as an alternative to dictation. With fancy demos and presentations, they have been able to convince CFOs how hospitals can save millions by avoiding transcription. But by avoiding transcription and pushing the burden of documentation onto physicians, hospitals definitely saved money but in that process had to accept incomplete and inadequate documentation by physicians. To overcome the new problems with documentation they had to spend a lot more on clinical documentation improvement programs employing highly paid CDI specialists.

Due to this overwhelming burden of documentation, physicians are not only extremely frustrated as recent surveys have shown but are also financially impacted as they are able to see far fewer patients than before.  With hospitals owning more and more physician practices, the cost of their physicians seeing fewer patients is very high.

In conclusion, such high error rates in documentation are only expected because the medical records are now being asked to be completed by physicians who are fully frustrated, not trained at all in such a task and they are under continuous pressure coping with the ever changing rules and regulations of healthcare.

Hospital readmission rates are falling across the country

Potentially avoidable hospital readmissions that occur within 30 days of a patient’s initial discharge are estimated to account for more than $17 billion in Medicare expenditures annually. Not only are readmissions costly, but they are often a sign of poor quality care.

To address the problem of avoidable readmissions, the Affordable Care Act created the Hospital Readmissions Reduction Program, which adjusts payments for hospitals with higher than expected 30-day readmission rates for targeted clinical conditions such as heart attacks, heart failure, and pneumonia. The Centers for Medicare & Medicaid Services has also undertaken other major quality improvement initiatives, such as the Partnership for Patients, which aim to make hospital care safer and improve the quality of care for individuals as they move from one health care setting to another. 

The data show that these efforts are working. Between 2010 and 2015, readmission rates fell by 8 percent nationally. Today, CMS is releasing new data showing how these improvements are helping Medicare patients across all 50 states and the District of Columbia. The data show that since 2010: 

·        All states but one have seen Medicare 30-day readmission rates fall. The rate in Vermont virtually remained unchanged. 

·        In 43 states, readmission rates fell by more than 5 percent.

·        In 11 states, readmission rates fell by more than 10 percent.

Here are 10 questions to ask before you buy CDI software

1)      Does the software minimize data entry? If your CDIS have to enter all the codes and DRGs manually and also analyze that data for reimbursement manually it severely hampers their productivity. You want your team to be more efficient and productive.

2)      Does it come with built-in ICD-10 compliant query templates or do you have to manually enter them? Manually creating query templates is a time consuming task and you need to spend a lot of time and resources in creating these queries and making sure that they are ICD-10 compliant. You also need to ask if the vendor updates the provided queries periodically to incorporate all the changes like sepsis definitions etc.

3)      How easy is it to customize the query templates to meet the needs of your hospital? Can you do it yourself or do you have to depend on the vendor? Many times the queries that are available out of box do not meet the needs of your hospital. In such cases, you want the process of query template customization to be easy and quick. You do not want to depend on the vendor to do this for you because that will be too expensive. Also once you customize the templates you should have the ability to roll it out to the entire CDI department.

4)      Does the software provide for education and training of CDI staff and the physicians? Ideally whenever you query a physician the relevant educational information should be included as part of the query so that the physician can document better going forward. Similarly, the CDI specialists and the coders also need to be continuously informed and kept up to date about CDI information.

5)      How easy is it to run any reports that you want – CDIS productivity, CMI, CC/MCC capture rates, Query Response Rate, HACs, Physician compliance etc.? As a manager you want to run all type of reports to monitor performance, productivity and efficiency. Such reports should be available easily and on-demand.

6)      Can you run the reports or do you have to depend on the vendor to run the reports? You do not want to wait on the vendor to run the reports and then get on a conference all so that they can explain the reports back to you. You want the reports to be informative, insightful and easy to understand.

7)      How easy is it to navigate the software? Is the workflow intuitive or too cumbersome? The more complex the software the slower the learning curve and lower the productivity. If a new CDI cannot become productive in a couple of days, that software is too cumbersome. If the software has limitations on browsers, operating system versions etc it is not easy to manage.

8)      Does the software support in-house as well as remote CDI specialists? Many hospitals have hybrid work environments – some of the staff are in house while others work remotely. You want to make sure that your software can easily adapt to such an environment.

9)      Can the software be integrated with our EHR? Many hospitals want the queries to be pushed into the inbox of the physician in the EHR. Make sure your software is capable of doing that.

10)     How much does it cost and what is the total cost of ownership? The upfront cost of software is only one aspect of total cost. You also need to look at implementation costs, integration costs, IT infrastructure costs, annual maintenance costs etc.

If you are in the market looking for CDI software or if your current software license is expiring, please watch this 5 minute video that gives you an overview of Doc-U-Aide, the industry’s most intuitive, insightful and intelligent CDI software. Doc-U-Aide comes in three flavors – Enterprise, Lite and Network editions, to meet the budgetary needs of hospitals and health systems of all sizes.

Starting next week all hospitals have to start serving the MOON to patients

The Notice of Observation Treatment and Implication for Care Eligibility Act (the NOTICE Act), which was enacted on August 6, 2015 law requires hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours. This notification must be provided no later than 36 hours after observation services are initiated or sooner if the patient is being transferred, discharged, or admitted as an inpatient. CMS then details their proposal in the form of possible scenarios of when the MOON would or would not be given. if released from the hospital or CAH.

CMS expects there will be times when an individual has received more than 24 hours of observation services that has not yet received the MOON, and there are imminent plans for discharge to home, another facility, transfer to another unit or facility to receive care that does not include observation services, or admission to the hospital or another facility as an inpatient. In these cases CMS is proposing “that the MOON must be given sooner than the 36-hour time limit for delivery because the MOON must be delivered before the individual is discharged, transferred, or admitted. When there are no plans to transfer, discharge, or admit an individual who receives observation services for more than 24 hours, we are proposing that the MOON must be provided within 36 hours of the initiation of observation services.”

CMS also believe that in the “rare circumstances where a physician initially orders inpatient services, but following internal utilization review (UR) performed while the patient is hospitalized, the hospital determines that the services do not meet its inpatient criteria and the physician concurs with UR, orders the discontinuation of inpatient services and initiation of outpatient observation services (that is, a Condition Code 44 situation), the MOON would be delivered as required by the NOTICE Act (when outpatient observation services have been ordered and furnished for more than 24 hours).”

When a CMS reviewer determines that an inpatient admission was not medically reasonable and necessary after the beneficiary has been discharged making the stay not appropriate for Medicare Part A payment, “the beneficiary’s patient status remains “inpatient” as of the time of the inpatient admission. The patient’s status is not changed to outpatient because the beneficiary was formally admitted as an inpatient, and there is no provision to change a beneficiary’s status after he or she is discharged from the hospital.” In this scenario there would be no need to issue the MOON as the patient’s status remains inpatient regardless that it was an improper admission.

Similar to Scenario 3, when a hospital determines through Utilization Review after the beneficiary has been discharged that the inpatient admission was not reasonable and necessary there would be no need to issue the MOON as the patient’s status again remains inpatient. 

This proposed rule requires CMS to develop a standardized form known as the Medicare Outpatient Observation Notice (“MOON”).

CMS is proposing that hospitals and CAHs would be required to use a proposed standard notice (the MOON) for written notification. This standard notice would:

• Explain that an individual is an outpatient receiving observation services and not an inpatient, and the reason(s) for this patient status.
• Provide an explanation of implications of receiving observation services as an outpatient, such as implications related to cost-sharing requirements under Medicare and post-hospitalization eligibility for Medicare-covered Skilled Nursing Facility (SNF) care.
• Include a blank “additional information” section so hospitals and CAHs may add “additional information.”
• Be in “plain language written for beneficiary comprehension.”

The NOTICE Act sets forth that the written notice must be:

• Signed by the individual receiving observation services as an outpatient, or
• Signed by a person acting on the individual’s behalf to acknowledge receipt of the notice, or
• If the individual or person refused to provide a signature, “the written notification is to be signed by the staff member of the hospital or CAH who presented the written notification and certain information needs to be included with such signature.” The “certain information” to be included is the staff member’s name and title, a certification statement that the notice was presented, and the date and time the notice was presented.

Definition of Observation Services

“Services that are reasonable and necessary, specifically ordered by a physician or other non-physician practitioner authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services, and meet other published Medicare criteria for payment.”

At this point in the proposed rule, CMS makes the distinction that “individuals receiving observation services will always be registered as outpatients; however, not all outpatients receive observation services.”

CMS is set to release single star hospital overall quality ratings soon

More than 74% of the hospitals in the country score less than three stars in this new Five Star Rating system.

Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide care to their patients. This information can help consumers make informed decisions about their health care. In a major step to educate and inform consumers about hospitals’ quality rankings CMS has developed an Overall Hospital Quality Star Rating (Star Rating) that reflects comprehensive quality information about the care provided at our nation’s hospitals. The Star Rating takes 62 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars.

Here is a preview of the information CMS has released today:

Healthcare expenses expected to grow faster than GDP during the next decade

In a recent article published in Health Affairs, the authors (Office of the Actuary, Centers for Medicare and Medicaid Services (CMS)) have projected that healthcare expenditure in the United States for the period 2015 to 2025 to grow at an average annual growth rate of 5.8%, which is a full 1.3% higher than the projected GDP growth rate during the same period. The share of healthcare expenditure as a percent of GDP is expected to climb from 17.5% in 2014 to 20.1% in 2025!

As the effects of Affordable Care Act start to subside in the next two years, the key factors contributing to the growth of healthcare expenditure will be economy, growth in medical prices and aging population.