Doctors Use EHRs To Do ‘Chart Biopsies’
Adoption of EHRs helps physicians to get up to speed on incoming patients before handoffs from the emergency department.nnAs the number of hospitals with electronic health record systems grows, a new study finds that inpatient physicians who receive patients from the emergency department have begun to do “chart biopsies” of electronic records to prepare for the handoffs.nnAlthough the study in the Journal of the American Medical Informatics Association (JAMIA) doesn’t reach any conclusions about whether chart biopsies are an improvement over traditional handoff methods, it points outs that “chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions and the quality of care.”nnThe study defines a chart biopsy as “the activity of examining a patient’s health record to orient oneself to the patient and the care that the patient has received in order to inform subsequent conversations about or care of the patient.” To understand how this process works, the researchers studied general internal medicine physicians and surgeons who received patients from the ED at the University of Michigan Health System (UMHS) for a two-year period.nnAt UMHS, hospital physicians had access to two EHRs: one was for inpatient and outpatient documentation, and the other was used in the ED. When ED doctors and nurses entered data into their EHR, the inpatient doctors could view that data immediately. Over time, they began to review the ED charts before having a conversation with the ED physician who admitted the patient.nnThe three main functions of chart biopsies, according to the study, are getting an overview of the patient, preparing for handoff and subsequent care, and defending against potential biases.nnAccording to Hilligoss, every UMHS physician that he observed did some kind of chart biopsy. But they didn’t do one in every case–sometimes they were too busy–and every doctor did them differently. Hilligoss did point out, however, that doctors in hospitals other than UMHS were also starting to perform chart biopsies; fellow academics at other institutions have told him this. “It isn’t something that anyone has preplanned for, but because the EHR is there, they’re naturally doing it,” he said.nnSource: www.informationweek.com; Ken Terry; September 17, 2012.
Today, hospitals and doctors use a system of about 18,000 codes to describe medical services in bills they send to insurers. Apparently, that doesn’t allow for quite enough nuance.nnA new federally mandated version will expand the number to around 140,000—adding codes that describe precisely what bone was broken, or which artery is receiving a stent.nnIt will also have a code for recording that a patient’s injury occurred in a chicken coop.nnIndeed, health plans may never again wonder where a patient got hurt. There are codes for injuries in opera houses, art galleries, squash courts and nine locations in and around a mobile home, from the bathroom to the bedroom.nnSome doctors aren’t sure they need quite that much detail. “Really? Bathroom versus bedroom?” says Brian Bachelder, a family physician in Akron, Ohio. “What difference does it make?”nnThe federal agencies that developed the system—generally known as ICD-10, for International Classification of Diseases, 10th Revision—say the codes will provide a more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment strategies and care guidelines. “It’s for accuracy of data and quality of care,” says Pat Brooks, senior technical adviser at the Centers for Medicare and Medicaid Services.nnBilling experts who translate doctors’ work into codes are gearing up to start using the new system in two years. They say the new detail is welcome in many cases. But a few aspects are also causing some head scratching.nnSome codes could seem downright insulting: R46.1 is “bizarre personal appearance,” while R46.0 is “very low level of personal hygiene.”nnIt’s not clear how many klutzes want to notify their insurers that a doctor visit was a W22.02XA, “walked into lamppost, initial encounter” (or, for that matter, a W22.02XD, “walked into lamppost, subsequent encounter”).nnWhy are there codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting—but not while shopping, wonders Rhonda Buckholtz, who does ICD-10 training for the American Academy of Professional Coders, a credentialing organization.nnCode V91.07XA, which involves a “burn due to water-skis on fire,” is another mystery she ponders: “Is it work-related?” she asks. “Is it a trick skier jumping through hoops of fire? How does it happen?”nnMuch of the new system is based on a World Health Organization code set in use in many countries for more than a decade. Still, the American version, developed by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, is considerably more fine-grained.nnThe WHO, for instance, didn’t see the need for 72 codes about injuries tied to birds. But American doctors whose patients run afoul of a duck, macaw, parrot, goose, turkey or chicken will be able to select from nine codes for each animal, notes George Alex, an official at the Advisory Board Co., a health-care research firm.nnThere are 312 animal codes in all, he says, compared to nine in the international version. There are separate codes for “bitten by turtle” and “struck by turtle.”nnU.S. hospitals and insurers are bracing for possible hiccups when the move to ICD-10 happens on Oct. 1, 2013, even though they’ve known it was coming since early 2009.nn”You have millions of transactions flowing in the health-care system and this is an opportunity to mess them all up,” says Jeremy Delinsky, chief technology officer for athenahealth Inc., which provides billing services to doctors.nnMedicare officials say they believe many big insurers and hospital systems are making preparations, but there may be some issues with smaller ones that won’t be ready.nnWith the move to ICD-10, the one code for suturing an artery will become 195 codes, designating every single artery, among other variables, according to OptumInsight, a unit of UnitedHealth Group Inc. A single code for a badly healed fracture could now translate to 2,595 different codes, the firm calculates. Each signals information including what bone was broken, as well as which side of the body it was on.nnSome companies hope to grab business from the shift. One medical-coding website operator, Find A Code LLC, has created a series of YouTube videos with the tagline, “Yeah, there’s a code for that.” Snow White biting the poisoned apple, the firm says, may be a case of T78.04, “anaphylactic shock due to fruits and vegetables.” On April 1, the company posted a document with the secret “X-codes” to describe medical conditions stemming from encounters with aliens.nnOther coding cognoscenti spot possible hidden messages in the real codes. The abbreviation some use for the new system itself, I10, is also a code for high blood pressure. Several codes involving drainage devices end in “00Z.” Then there are two of the codes describing sex-change operations that end in N0K1 and M0J0. “You could see it ripple through the room as people said, ‘nookie and mojo!'” says Kathryn DeVault, who has been teaching ICD-10 classes for the American Health Information Management Association. “Was it purposeful? We don’t know.”nnNo, it wasn’t, says the Medicare agency’s Ms. Brooks, who says the codes are built according to a consistent pattern in which each digit has a meaning.nn”I couldn’t if I wanted to insert a cute message,” says Ms. Brooks, who admits that she could be described by Z73.1, “Type A behavior pattern.”nnMedicare and CDC officials say codes were selected based on years of input from medical experts in various fields. Codes describing the circumstances of injuries are important for public-health researchers to track how people get hurt and try to prevent injuries, they say.nnBeing able to tabulate risks tied to locations such as chicken coops could be “important as far as surveillance activities” for public health research, says Donna Pickett, a medical systems administrator at the CDC. She says the current code for a badly healed fracture is so vague it isn’t useful.nnAnother CMS official, Denise M. Buenning, compares ICD-10 to a phone book. “All the numbers are in there,” she says. “Are you going to call all of the numbers? No. But the numbers you need are in there.”nnThis 
elp providers and health plans spend less time filling out paperwork and more time seeing their patients,” Secretary Sebelius said.nnCurrently, when a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format. As a result, health care providers run into a number of time-consuming problems, such as misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility. The change announced today will greatly simplify these processes.nnThe rule also makes final a one-year proposed delay – from Oct. 1, 2013, to Oct. 1, 2014– in the compliance date for use of new codes that classify diseases and health problems. These code sets, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include codes for new procedures and diagnoses that improve the quality of information available for quality improvement and payment purposes.nnThe rule announced Friday is the fourth administrative simplification regulation issued by HHS under the health reform law:n
HHS, on August 14, issued a final “blueprint” that states can use to operate their own health insurance exchanges. The blueprint details the functions that state-based exchanges will perform, how exchanges operated as partnerships between the federal government and states will perform, and what actions states may take in “federal facilitated” exchanges.nnFor example, a state-based exchange may opt to use the federal government to determine the advance premium tax credit (APTC) and cost-sharing reduction, the individual responsibility requirement and payment exemptions, reinsurance, and risk adjustment. States seeking to operate a state-based exchange or electing to participate in a state partnership exchange must submit a complete exchange blueprint no later than 30 business days prior to the required approval date of January 1 (November 16, 2012, for plan year 2014). The blueprint is available 
The rising tide of electronic health records (EHRs) in hospitals is lifting many other boats, ranging from clinical analytics apps to private health information exchanges. Another beneficiary is medical device integration (MDI) software, which connects medical device data output to EHRs.nnAccording to a new Capsite survey, 44% of the nearly 300 responding hospitals said they had purchased an MDI application in recent years. The majority of those purchases were made in 2011 and 2012. 