Tuesday, January 26, 2010

Information standards in healthcare Part 1

The healthcare world has a headspinning proportion of standards relevant to information management. Getting useful information on internet about such things is easier said than done. My thanks to all those who had some genuine information out there for the reentrants like me.

Title II, Administrative Simplification of the HIPAA of 1996 called for efficient and electronic transaction for administration and finance in healthcare. It impacted all "covered entities". American National Standards Institute (ANSI)standard was preferred by the federal regulators. Some of the key ANSI standards are Accredited Standards Committee(ASC) X12, National Council for Prescription Drug Program (NCPDP), Health Level Seven (HL7). An episode of health care may involve several HL7 messages and X12 transactions running sequentially or concurrently, all communicating about the the same health care “objects” or events. This may raise the issues of interoperability id data semantics to not match.

New version of current transactions and new transacation are being worked upon.The currently used formats being upgraded from X12 Version 4010A1 to 5010 and from NCPDP 5.1to D.0 (Refer to http://www.cms.hhs.gov/Versions5010andD0/downloads/5010_Provider_Natl_Conf_Call_06092009.pdf for more information). Jan 1, 2012 is the cutoff for all old transaction.
An over view of the interaction of X12 messages and HIPAA cross reference is given below:
HIPAA Transaction X12.
Claim 837
Eligibility 270/271
Auth. Request 278
Claim Status 276/277
Enrollment 834
Remittance 835
Premium Pmt. 820
Attachment 275
ACK TA1/997




Note: The UB04, CMS 1500 are standards to align the paper form to the electronic format.The CMS-1500 is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

In terms of the the contents of the electronic message, some other terms are relevant.
Diagnosis Related Group (DRG) is essentially categories under which reimbursements are sought for diseases classified under International Classification of Diseases (ICD-9). ICD-9 is used for inpatient and outpatient diagnosis and inpatient procedures (ICD-9-CM). Current Procedure Terminology (CPT) is used for outpatient services rendered.

Tuesday, January 19, 2010

EMR - Where are we and what's in it

The Health Information Technology for Economic and Clinical Health Act has pushed the EMR agenda into reality. An interesting handshake between Walmart, eCW and Dell is worth noting (http://www.nytimes.com/2009/03/11/business/11record.html?_r=4&hp).
Walmart plans to team its Sam’s Club division with Dell for computers and eClinicalWorks. Wal-Mart says its package deal of hardware, software, installation, maintenance and training will make the technology more accessible and affordable, undercutting rival health information technology suppliers by as much as half.The Sam’s Club offering, to be made available this spring, will be under $25,000 for the first physician in a practice, and about $10,000 for each additional doctor. After the installation and training, continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, the company estimates. Wal-Mart says it had explored the opportunity in health information technology long before the presidential election. About 200,000 health care providers, mostly doctors, are among Sam Club’s 47 million members.The company’s test bed for the technology it will soon offer physicians has been its own health care clinics, staffed by third-party physicians and nurses. Started in September 2006, 30 such clinics are now in stores in eight states. The clinics use the technology Wal-Mart will offer to physicians

How ready is the heatlhcare sector in terms of EMR adoption: A quick preview from HIMSSanalytics.org (The State of U.S. Hospitals Relative to Achieving Meaningful Use Measurements By Michael W. Davis Executive Vice President – HIMSS Analytics)

Short Primer on HIT data

As i trudge along unlearning and relearning fundamentals in my class, i thought it might be a good idea to pen down some of it.

Some key terminologies
Data: Empirical observations, symbols, numbers. They simply exist with no structure. A "know nothing" stage
Information: Data organized with relationships. No necessarily useful but is the building block for eveything else.. A "know what" stage
Knowledge: Information that has a pattern and is useful. Enables decision making. A "know how" stage
Understanding: Allows use of the known based on principles and fosters new knowledge. A "know why" stage

The types of information in a typical healthcare setting are as follows:
Internal , External and Comparative
Internal information may relate to
Patient encounter (patient-specific or aggregate) & (clinical or administrative)
General Operations
Exernal information is knowledge based
Comparative information - Outcome measure (over a period of time or against standard)
Common categories of benchmarking are patient satisfaction, practice patterns, health plans, clinical indicators, population measures.

A few key standards to note
ICD-9-CM is also known as international classification of disease Clinical modification. It is used to determine diagnostic related group. Critical to accurate institutional reimbursement
CPT - Current procedural terminology. It is used to provide information on medical and surgical services.
CMS 1450 and CMS 1500 are 2 common billing standards

A health executive needs to be sure of the source of the information, its accuracy and semantics. Given multiple standards agencies and multiple forces acting upon the healthcare organization, it is important to have a common understanding of the terms. A good reference is the document embedded below. It is taken as from the hhs.gov website as a reference.
Some key takeaways from a definition standpoint are given below:

EMR - Electronic medical record - Maintain within organization boundaries and owned by the provider
EHR - Interoperable data maintained to be shared across organizations in conformance with national standards
PHR - Personal heatlh record - Individually owned and maintained

Health Information Exchange is the entity that will facilitate the EHR exchange nationally. They will work with Regional Extension Centers (Health Information Organization). HIOs will collaborate with Regional Health Information Organization which are collaborated network between providers in a specific geography.

Wednesday, January 6, 2010

My Takeaway from Michael L George’s Lean Six Sigma for Services Final Part

The nature of service work makes it difficult to find out what needs change and how to transform. The work product is often invisible making it difficult to track the flow. Service industry is has a long tradition of being individualistic. People are protective about losing their creativity to standardization. It is vital to engage the people instead of enforcing compliance. Data in service industry is neither organized nor readily available. More often than not decisions are judgment or Delphi based. People do not respond to inputs/instructions as do machines. The sheer unpredictability of human behavior is daunting.
Recognizing waste in service is critical to a successful LSS initiative:
• Over processing – PMI calls it “Gold Plating.” It may also include inefficient iterations of work product, unnecessary handoffs, creation of cumbersome documentation, etc.
• Transportation and motion – A lot of effort goes in information chasing. The data or the person having the data is difficult to reach out. The lack of resources may be result in information waiting at desktops for being processed.
• Inventory and waiting time – Non-value added work upstream increases downstream wait time. Skill and resource bottlenecks are also contributors
• Defect – Lost communication, miscommunication result in work product being incomplete or contrary to customer needs.
• Overproduction – Poor prioritization or work qualification leads to over commit and under deliver
Some useful ideas for running initiatives in service industry:
• Be creative in meetings – Use the meeting times wisely. Collect data offline. Use meetings to analyze information, make decisions, and have concrete takeaways.
• Look for obvious quick hit opportunities – Pick up low hanging fruit and use the results of those initiatives to promote initiatives in more critical areas.
• Use improvement events like Kaizen (traditional or improvised) to generate energy and immediate gains.
• Reach out beyond team boundaries.
• Set realistic expectation – A single projects does not produce best in class improvements. Processes are generally littered with variation and not managed with even a general understanding of velocity and flow. These are 2 distinct deficiencies and need to addressed separately
• Pay attention to team composition – Dr. Belbin’s model offers a good guideline, manage expectation
• Be conscious of your audience – Improvise tools and method to suit the organization, lead by example.
DMAIC
A typical LSS project begins with a one-page charter with sufficient data to compute benefits, resource requirements, and ROIC estimates. Basic elements of DEFINE include
• Consensus on the problem
• Understand the project link to corporate strategy and ROIC
• Agree on project boundaries/scope of value stream
• Know the key metrics or indicators of success (people must be able to make sense of it)
MEASURE bases on data and separates Six Sigma from a general process tinkering activity. Common data gathering challenges include too little data, no data, too much data, and irrelevant data. Useful steps in measure are
• Establish baseline – Measure useful data like things-in-process, average completion rate, cycle time, first pass yield, approvals/handoffs, downtime/learning curve, defects that affect the customer, and complexity
• Impartially observe the process – Watch people, track emails, phone calls, set goals for observation, ensure consistent data collection
The purpose of ANALYZE is to make sense of the data collected so far. The key part is to stick to the data and not be colored by individual experience and opinions. It may use scatter diagram to correlate variables. Time trap analysis can identify improvement areas.
IMPROVE applies standard tools implement brainstormed alternatives. The tools include those for setup time reduction (learning curve, upstream batching), 5S (De-cluttering), and queuing methods for decongestion (Staff pooling/cross training, task slotting/triaging, back up capacity, variation reduction). In a philosophical sense, nothing really changes except that the universe rearranges to be more efficient. Things like sponsor support and communication are of essence in this stage
A standard rule says we must spend time on a task only 10 times as much as it takes to set the task up. Some important questions for setup time reduction.
• What is delaying the start of work
• What factors lead to work interruption
• What inhibits moving at full throttle
• Is there any redundancy
• Is there a possibility for rationalization/ task offloading/ streamlining
• How to apply statistical control
The aim of CONTROL is to preserve the gains made in improve till yet another generation of improvement happens. Key steps are
• Documentation – to ensure people don’t slip back into old habits
• Convert results into currency – Project need financial validation and verification not be mere feel good factor. Not all gains are financially tangible. Verify the results at later points in time to ensure consistent returns
• Set up alerting mechanism to catch when the process spins out of control
Control is the cross over point when the process owner will take charge.

The book is an amazing read.

Friday, January 1, 2010

My Takeaway from Michael L George’s Lean Six Sigma for Services Part 3

Implementation
For and organization considering LSS the biggest challenges are barriers in execution and interaction issues.
According to McKinsey, 80% of the failures in change management are due to
• No performance focus
• Lack of winning strategy
• Failure to have a good case for change
• Not distinguishing between data driven and behavior driven change
• Failure to engage and mobilize pivotal groups
• Over reliance on structure and system to change behavior
• Lack of skills and resources
• Inability to confront changes in organizational roles
• Inability to integrate and align initiatives
Major LSS opportunities lie in the white space between functions that transcend traditional boundaries. When key influencers appreciate the cross functional opportunities using LSS, the roll out becomes smooth. LSS training orients managers to be data centric in their problem solving approach. They are able to separate the outliers from the patterns and prevent “tampering” which often results in added variation. Cutting cost is not the same as cutting people. LSS projects need constant attention for possible course correction and retraining.

Health Management in India

http://www.ihmr.org/ - Institute of Health Management
http://www.iphindia.org/joomla/index.php - Institute of Public Health
http://www.who.or.jp/sites/bangalore.html - WHO, Bangalore
http://cghr.org/aboutcghr.html - Center for Global Health Research
http://www.hispindia.org/ - HISP India
- PHFI Newsletter
http://www.epos.in - EPOS India