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

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

medical-error-picA 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.

CMS launches ‘Pick Your Pace’ options for physicians as part of Quality Payment Program

money-tighteningAs part of CMS’ move to link physician payments to patient outcomes, the Quality Payment Program put in place by CMS is set to begin on January 1, 2017. CMS has shared plans for the timing of reporting for the first year of the program. It allows Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019.

First Option: Test the Quality Payment Program

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

Saince offers healthcare providers a suite of solutions and services to improve and protect reimbursements in an rapidly changing environment. For more information, please call (888) 472 4623.

Here are 10 questions to ask before you buy CDI software

blog_2015_08_25-11)      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.

Four reasons why hospitals have to start outpatient CDI programs now

graph1-hospital revenues are shifting from inpatient ot outpatientHere are four reasons why hospitals have to start their outpatient CDI programs now and not later.

1) Hospital revenues are shifting from inpatient to outpatient
Historically, 92 percent of Medicare revenues to hospitals have come from inpatient and outpatient services. Over time, however, the share of revenue coming from the outpatient setting has increased, and the share coming from the inpatient setting has decreased.

From 2010 to 2014, the share of revenues coming from the outpatient setting increased from 21 percent to 27 percent. The increase resulted from several changes: a shift in services from the inpatient to the outpatient setting, a general increase in beneficiary outpatient service use, a shift in the billing of physician office services from the physician fee schedule to the OPPS, and changes made to the outpatient payment system that packaged many lab services into outpatient payment rates that were previously paid on a fee schedule rather than the OPPS

The share of revenues coming from the inpatient side fell from 71 percent in 2010 to 60 percent in 2014. This decline results from (1) a shift in services from the inpatient setting to the outpatient setting, as just discussed, and (2) changes in Medicare DSH payments.

As hospitals see increased revenues from outpatient services, they need to put in processes and procedures in place to protect their revenues.

2) Rate of growth of outpatient visits far outpaces inpatient discharges
CMS data shows that between 2006 and 2014 outpatient visits per beneficiary have increased by a whopping 44% while inpatient discharges per beneficiary have decreased by almost 20%. And projections show that this trend is going to continue well into the future.

As hospitals see a faster rate of growth in outpatient visits, they need to put processes in place to maintain revenue integrity.


3) Hospitals have aggressively acquired physician practices to offset the decrease in inpatient revenues.
This is resulting in increase in hospital revenues as payments shifted from Physician Fee Schedule to OPPS which generally pays higher. Now CMS is working aggressively to streamline the payments and make the payments equal for Hospital Outpatient Departments and Physician offices. CMS has already moved some of the clinical laboratory fee schedule services into OPPS resulting in a saving of $2.4 billion in a year. Now CMS is also working on bundling more services into Comprehensive-APC to further reduce reimbursements under OPPS.

As hospitals see the outpatient revenues get more and more streamlined, and as they lose the advantage of seeing increased revenues from OPPS compared to Physician Fee Schedules, they need to focus on outpatient CDI programs to protect revenues.

4) The HCC Risk Adjustment Model under the Affordable Care Act
The Hierarchical Condition Categories for risk adjustment has also become complicated from jumping from 3000 codes in ICD-9 to over 11000 in ICD-10. This degree of specificity requires appropriate documentation and as the CMS moves to value based reimbursement models, this aspect of documentation becomes critical for revenue integrity.

Hospitals have to out in place outpatient CDI programs to ensure that the physician documentation is truly reflective of the acuity and the chronic conditions of its patient population.

Most of the hospitals have a mature CDI program in place to take care of their inpatient population, but over 90% of the hospitals still haven’t put in an outpatient CDI program. Outpatient settings is where all the action is. Hence the time to think of outpatient CDI is now and not later.

PracticePerfect CDI from Saince is the industry’s first fully featured outpatient CDI solution that integrates, CMS and HHS HCC capture, risk score calculation, integrated querying, dedicated ER workflows, PQRS measures and many more.

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

templatesThe 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.

No respite to patients from increasing medical costs




Consumer Price Index (CPI) numbers from June 2016 which were released today show that prices for medical care have started to go up again after a lull for a couple of months. At 0.4% the price for medical care increased twice as much compared to all other items. Prices of hospital services increased by 4.3% compared to June of 2015 while in-patient hospital services prices jumped by 5.1%!

Prices of prescription drugs also increased quite significantly by 4.4% compared to June 2015.

Over the last 12 months, the price of medical care has increased over four times faster than the prices of all other items.

Looks like there is still no respite to patients from ever increasing medical costs.

Survey finds that EHRs many times do not catch medication errors

A recent survey report released last month by Leapfrog Group found that many EHR systems do not catch medication errors. Almost 40 percent of potentially harmful drug orders weren’t flagged as dangerous by the systems, Leapfrog found. These included medication orders for the wrong condition or in the wrong dose based on things like a patient’s size, other illnesses or likely drug interactions. Meanwhile, systems missed about 13 percent of errors that could have killed patients.

Medication errors can often times cause serious harm to patients – and even death. Many hospitals try to prevent them with the use of electronic health records (EHR) systems. But these methods are far from foolproof, according to this new report.

According to 2015 figures from the federal Agency for Healthcare Research and Quality, about 1 of every 20 patients in hospitals suffers harm because of medications. Of those, the agency estimates, half are avoidable.

Meanwhile, in a push to improve patient safety and health care quality, the federal government has been encouraging hospitals to adopt electronic health records — particularly with medication ordering systems — thanks to parts of the 2009 stimulus package and 2010 health reform. But there’s been pushback from many doctors and advocates, who say design issues can make the software difficult to use or even counterproductive.