HHS says that this is the first time it has compiled a comprehensive list of the quality measures in a single location. It intends the inventory as a step in the effort to advance collaboration and synchronization within the quality measurement community. The measures and specifications in the inventory were self-reported by HHS divisions.

The list is available as a spreadsheet, sortable through dropdown menus. HHS says it will be adding more sorting options in the coming months.

An overview of industry activity around data quality, quality management, and data content standards is available on AHIMA’s Web site.

In the latest memorandum, dated October 24, CMS writes that the Conditions of Participation:

“do not prohibit the use of rubber stamps in a hospital setting, when properly controlled, for authentication of medical record entries. However, as a point of information for surveyors and providers, we are taking this opportunity to add an information-only statement to the interpretive guidance for §482.24(c)(1) to note that some payers, including Medicare, may not accept such stamps as sufficient documentation to support a claim for payment.”

The Center for Information Technology Leadership (CITL), a nonprofit IT research center based at Partners HealthCare System in Boston, offers the projections in the study “The Value of Personal Health Records.” The study describes an evidence-based model that estimates the industry costs and benefits of four different PHR architectures. The study is the first of its kind to examine the different PHR architectures and show their direct cost savings to healthcare providers and payers, CITL officials say.

PHRs provide patients with greater access to their health information and, depending on the individual product, give them an opportunity to add their own information. Many PHRs put patients in control of who can access their records, allowing them to share their information with providers, payers, and caregivers.

A PHR is different from a provider or payer’s record, which the organization controls for business and legal purposes. PHRs have the potential to improve care by sharing patient information among authorized providers. They can also increase a consumer’s awareness of his or her health and help in making informed health decisions.

Savings Vary by Type

Blackford Middleton, MD, MPH, MSs, is chairman of CITL and director of clinical informatics research and development for Partners Healthcare. He says that CITL believes electronic health record systems—implemented and maintained by providers—are a part of improving care and lowering cost; however, “we believe that the PHR is perhaps an equally important or maybe even more important part of the solution as well.”

Published November 12 and presented at the American Medical Informatics Association annual symposium, the CITL cost-benefit model assumes 80 percent of the US population actively uses one of four emerging PHR architectures: payer-tethered PHRs, provider-tethered PHRs, third-party PHRs, and interoperable PHRs. A panel of healthcare experts organized by CITL synthesized hundreds of articles on healthcare and PHRs to build the model.

Provider-tethered PHRs are tied to a healthcare organization’s internal record system. Payer-tethered systems are tied to a given payer’s system. Consumers use third-party PHRs to aggregate data from different, unconnected sources.

Interoperable PHRs represent a “future type” of record “populated with data from all regional data sources via standards-based automated data exchange. The connections with these sources would create a record that is more complete than any individual repository (e.g., [electronic health records], other PHRs, payer claims databases),” according to the report.

While the implementation and steady use of each of the four PHR architectures would result in vast cost savings, some architectures produce greater savings than others, according to the study.

The model projects that mass use of the interoperable PHR architecture could lead to the highest savings by streamlining healthcare operations and decreasing administrative and clinical costs, such as preventing duplicate medical tests and reducing adverse drug interactions.

The projected annual savings by model are:

• Interoperable PHRs: $21 billion
• Third-party PHR: $16 billion
• Provider-tethered PHR: up to $14 billion 
• Payer-tethered PHR: $13 billion

Highlighting the Value of Data Sharing

The  model assumes that PHRs in each category have certain functionality, including the ability to share test results and medication information. Other, more specialized functions include electronic appointment scheduling and e-visits. Middleton hopes the study will help policy makers and the general healthcare industry understand which PHR models can best improve healthcare and reduce costs.

“The PHR architecture and what data is accessible—and to what degree data is interoperable—that really defines the value of a PHR,” Middleton says. “Our intent is to model a what-if scenario; [for example,] what if everyone had a provider-tethered PHR or an interoperable PHR. And the goal is then to highlight the differences so that we can inform policy makers and the industry about what is valuable.”

Though interoperable PHRs presents the highest potential savings in cost, they are still a work in progress. But CITL’s cost-benefit model indicates that PHR development should lean toward an interoperable architecture, Middleton says. Interoperable PHRs act as a hub for patient information, connecting multiple payers and providers to each other through a patient-controlled record.

While PHR use does offer savings, establishing the products and the networks takes money. The cost-benefit model also adjusts to reflect the savings after deducting the cost of implementing each PHR architecture. Providing interoperable PHRs for 80 percent of the US population could cost an estimated $3.7 billion to acquire and $1.9 billion annually to maintain, the study estimates. After cost, and based on a 10-year roll-out of infrastructure, the interoperable PHR could still save $19 billion annually in healthcare costs.

CITL hopes several things come as the result of this model, Middleton says. Third-party PHR companies like Google Health and Microsoft HealthVault can use the study to recognize the value of standards that will make their products more interoperable. Providers and payers can recognize the value of PHRs and pledge their support for PHR adoption. Finally, policymakers can recognize the value of PHRs and address issues that will allow nationwide health IT adoption, Middleton says.

The brief explores that need for collaboration through three domains: confidentiality and security, data use and maintenance, and terminology asset management. Seven Web-only extras offer tools to help with that alignment.

The extras are available as appendixes to the online version of the brief, and they’re also available as a separate file for download. All seven are bundled into a single PDF:

• A: Roles and Job Elements that Support EHR Management
• B: Critical Success Factors for Fostering Convergence 
• C: e-HIM Privacy and Security Responsibility Matrix
• D: Terminology Map Resources
• E: Terminology Implementation Checklist 
• F: Roles and Relationships of HIM and IT in New Terminology Implementation: Identifying Stakeholders for Strategic Planning and Successful Transition
• G: Suggestions for Further Reading

Also take a look at the feature story “Health IM and Health IT: Frequent Traveling Companions” appearing in the same issue. Authors in that story offer examples of converging HIM and IT roles and how the need evolved at individual facilities.

Members may read all stories online in the AHIMA FORE Library: HIM Body of Knowledge. Select features and practice briefs also are available publicly.

November-December 2008

Features

• Record Limbo, by Chris Dimick
• Planning Forms Automation, by Cynthia S. Hyde, RHIA
• Minimizing Hybrid Records: Tips for Reducing Paper Documentation as New Systems Come Online, by Teresa M. Hall, RHIT, MHA, CPC, CAC
• Health IM and Health IT: Frequent Traveling Companions, by Beth A. Acker, RHIA; Deborah A. Adair, MPH, MS, RHIA; and Betsy Sweeney, MS, RHIT

Practice Briefs

• HIM and Health IT: Discovering Common Ground in an Electronic Healthcare Environment
• Management Practices for the Release of Information

Working Smart

• Tools of the E-Discovery Trade, by Sandra Nunn, MA, RHIA, CHP
• Releasing Records from Other Providers, by Barry S. Herrin, FACHE
• Help in Setting Access Controls, by Margret Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS
• Is Document Imaging the Right Choice for Your Organization? by Elizabeth Liette, RHIA; Chris Meyers, RHIA; and Keith Olenik, MA, RHIA, CHP
• CMS Bans Use of Physician Signature Stamps, by Gloryanne Bryant, BS, RHIA, CCS

Coding Notes

• The ABCs of Medicare Advantage, by J. (Jeanette) Stacey Hernandez, CCS-P
• FY 2009 Hospital IPPS Final Rule, by Linda Schwab, RHIT

The red flag rules require businesses that extend credit to their customers to develop and implement written identity theft prevention programs. Healthcare organizations fall under the rule, say attorneys.

The FTC released the final rules in November 2007. The requirement calls for a creditor to “provide for the identification, detection, and response to patterns, practices, or specific activities—known as ‘red flags’—that could indicate identity theft.” The rules apply to “financial institutions and creditors with covered accounts.”

In part, the FTC defines a creditor as “any entity that regularly extends, renews, or continues credit; any entity that regularly arranges for the extension, renewal, or continuation of credit; or any assignee of an original creditor who is involved in the decision to extend, renew, or continue credit.” A covered account is one “used mostly for personal, family, or household purposes, and that involves multiple payments or transactions.” FTC notes that accepting credit cards does not necessarily make an entity a creditor.

The final rule and other guidance are available from the FTC.

• Recommends that the implementation of the two classifications and the related HIPAA transaction updates should occur over a three-year period, with the date of final compliance no later than October 1, 2012
• Supports a single compliance date across the entire US healthcare industry and recommends that the compliance date, once designated, not be extended, which would cause confusion and add costs
• Recommends that the ICD-9-CM, ICD-10-CM, and ICD-10-PCS code sets be frozen for one year prior to the compliance date; that is, the same set of codes would be used for the fiscal year before and after the compliance date
• Requests clarification on how Medicare PPS programs will be immediately affected at the compliance date
• Calls on leadership at Health and Human Services and the Centers for Medicare and Medicaid Services to ensure that the transition occurs across the industry—especially related to Medicare and Medicaid programs—and that sufficient testing takes place in advance of the deadline

AHIMA also commented on managing ICD-9 in the interim. ICD-9 will run out of codes before ICD-10 is implemented, perhaps as early as next year, and AHIMA recommends against using any unassigned ICD-9 code in any chapter for any type of procedure once the two open series of codes have been depleted.

AHIMA also commented on the proposed update to the HIPAA-related Transaction Standards, which is needed to accommodate the ICD changes and improve the transactions themselves.

AHIMA expressed its commitment to work with the healthcare industry and Health and Human Services to help ensure a smooth transition and a trained workforce.

All comments submitted to HHS are available at regulations.gov. Search on the code “CMS-0013-P” for the ICD-10-related comments and on “CMS-0009-P” for the HIPAA-related comments. HHS intends to review comments promptly, and there is some expectation that it will submit a final rule by the end of the year.

The Centers for Medicare and Medicaid Services no longer accepts signature stamps on any record. CMS attempted to clarify the scope of the ban this summer, but the message may not have percolated to all corners of the industry yet.

In July CMS stated that “stamped signatures are not acceptable on any medical record.” The prohibition applies to all providers and suppliers. Medicare will only accept “handwritten, electronic signatures or facsimiles of original written or electronic signatures.”

In spring CMS published a ban on signature stamps focused narrowly on the certification of terminal illness for hospice. The subsequent July notice explicitly included all medical records.

In the upcoming November-December Journal, Gloryanne Bryant, RHIA, CCS, recommends that HIM professionals ensure compliance with the ban by participating in documentation checks in areas that have commonly used signature stamps in the past. She suggests that hospitals handle this through teams that include case management, nursing, and HIM. Education on the ban may be needed. Any necessary corrective actions should be taken within a reasonable amount of time, she writes.

Bryant, senior director of corporate coding and HIM compliance at Catholic Healthcare West in San Francisco, notes that signature stamps could become a future target for future Recovery Audit Contractor audits, other investigations, or even the Joint Commission, so “striving for compliance now will pay off in the long run.”

A state law lowering the copy fees for electronic documents went into effect January 1, 2008. The law, the result of negotiations that tempered reductions in earlier proposed legislation, is already being countered with a bill to create a higher flat rate for all copying, regardless of record format.

In part, the tug-of-war highlights the gap between expectations over health IT’s potential and the current reality on the ground.

How Low Could It Go?

The flurry of bills begins in 2007, when the Illinois Trial Lawyers Association (ITLA) advocated for a bill that would change the Illinois Code of Civil Procedure and lower the copy fees for electronically available health records. Supporters argued that health information stored electronically is easier to access and can be produced by mouse clicks.

The bill would have lowered the rate that facilities can charge from 86 cents per page for printed-off electronic documents to a combined single charge of the facility’s normal processing fee plus 75 cents. The 75-cent charge was intended to cover the cost of the CD or DVD used to transfer the information to the requester.

That rate structure didn’t make sense to those close to records systems, who argued that producing electronic records is more labor-intensive than the legislation’s supporters portrayed. The Illinois Health Information Management Association (ILHIMA), the Association of Health Information Outsourcing Services (AHIOS), and Illinois Hospital Association all opposed the bill. Just because information is stored electronically, they argued, doesn’t mean it is easier or less expensive to produce in a request of records.

“Regardless if [a record] was one page or if it was 1,000 pages, [ITLA] thought that all you do is push a button and it downloads—this is all they want to pay,” says Colleen Goethals, MS, RHIA, an HIM consultant with Midwest Medical Records Associates and past-president of ILHIMA.

The bill also proposed that information stored electronically must be produced electronically—saved onto a CD, DVD, or other electronic storage device—for release of information requests. ILHIMA officials argued that the EHR systems in use in many hospitals today are not capable of copying records onto an electronic disc. Instead the facilities must print out those records to share them.

A New Law and an Alternate Bill

After negotiations, a new bill was drafted proposing that healthcare and release of information organizations could charge 50 percent of the paper copy rate for all documents stored electronically. If a facility could not produce their electronic documents in an electronic format as requested, a formal letter must be sent to the requestor explaining why the facility cannot fulfill the request.

The bill was passed into law and has been in effect since January 1, 2008. Still, HIM professionals have reacted negatively to the changes, Goethals says, which have created confusion and financial loss in some healthcare organizations.

ILHIMA and AHIOS immediately helped propose SB 2458, introduced in February 2008. The bill would set the standard copy rate for all documents at $1 per page regardless of the record’s medium. The new bill also proposes that it is the facilities discretion whether or not to release documents in an electronic format.

The bill has sat in the Senate Rules Committee since March as sponsors and opponents await the scheduling of a negotiation meeting to discuss it. Goethals said ILHIMA is still hopeful the meeting will take place this year, but SB2458 will likely not be voted on until the 2009 session.

The bill’s progress may be tracked at the Illinois General Assembly Web site.

The October issue explores the HIM jobs of tomorrow and how current roles will evolve in the future. Other features report on medico-legal issues in electronic records, HIM specialty tracks and associate degrees, new Joint Commission standards and processes, and successful recruitment strategies.

Members may read all stories online in the AHIMA FORE Library: HIM Body of Knowledge. Select features and practice briefs also are available publicly.

October 2008

Features

• HIM Jobs of Tomorrow, by Chris Dimick
• Taking the Specialty Route, by Gina Rollins
• e-Record, e-Liability: Addressing Medico-Legal Issues in Electronic Records, by Michael Vigoda, MD, MBA; Jill Callahan Dennis, JD, RHIA; Michelle Dougherty, MA, RHIA, CHP
• New Joint Commission Standards Ahead: Improvement Initiative Takes Effect Janurary 1, by Gina Rollins

In Addition

• Successful Recruiting Strategies, by Kayce Dover, MSHI, RHIA

Practice Briefs

• Managing an Effective Query Process
• Enterprise Content and Record Management for Healthcare

Working Smart

• Applying Legal Holds to Electronic Records, by Sandra Nunn, MA, RHIA, CHP
• Raising Awareness of Medical Identity Theft, by Laurie Rinehart-Thompson, JD, RHIA, CHP
• Updating Long-Term Care’s Health IT Course, by Michelle Dougherty, MA, RHIA, CHP
• Quality Impact of the Master Patient Index, by Vicki Wheatley, MS, RHIA

Coding Notes

• Coding in the Coming Decade, by Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, CIC
• Outpatient and Physician Reporting of Biliary Procedures, by Jackie Miller, RHIA, CPC