Well, good afternoon. I would like to thank
Rob and ONC and CMS for having me here today to talk with you, and
also for putting me last on the agenda on a Friday afternoon.
"[laughter] "I'm well aware that I'm in between you and your weekend,
but I am happy to be here and we're here talking about a very, very
important topic. I want to tell you a little bit about HIMS so that you
can understand our perspective. We represent more than 50,000
individual members, of which more than two-thirds work for a health care
provider, governmental or not-for-profit organization, and we also
include over 750 corporate members and more than 225 not-for-profit
members that share our vision of better health through improved --
through use of information technology. "So, we've been looking at this
issue for awhile. In fact, HIMS recently gathered some of our
stakeholders in an EHR coding integrity work group, and of course, this
was in response to public reports indicating that clinician's use of
EHRs may have contributed to inappropriate coding or over-billing,
including in the area of evaluation and management services. Our work
group performed a critical review of the underlying causes of coding
errors in EHRs. At the highest level I'd like to say it's important to
recognize that changes in reimbursements, practice patterns, and/or
technology can all create opportunities for coding issues. And the work
of this work group really informed our statement today. "So prior to
the widespread use of EHRs in clinical practices, providers were often
worried about claims of fraud and abuse. Many of our members
anecdotally report that their practice would under-code for the
encounter if they were not absolutely sure whether they met the complex
guidelines that must be followed to select the correct codes, codes that
are often also used by commercial payers. But coincident with many
other beneficial functions, today's EHRs can facilitate better
documentation, as well as direct selection of diagnosis or procedure
codes, and as well as capabilities for computer-assisted coding. So
based on the work of our work group and other anecdotal data, we have
the following observations regarding the complex factors that can
influence the impact of the use of EHRs for coding. First, HIMS members
tells us that they are able to code more accurately than in the past.
And this perhaps could increase health care costs to the payer, but not
to the system overall. That is, in the past, the provider may have been
absorbing those costs. Across the health care system, heath IT enables
earlier recognition of potential medical problems. So we are ordering
more follow-ups and preventative and screening tests. While these
efforts may increase costs in the short-term, there exists a potential
long-term benefit of decreased cost as we aim for a healthier
population, improve chronic disease management, and detect cancer and
other conditions at an earlier stage. "As we strive as an industry to
increase quality and manage overall health, it's important to also note
that clinical and primary care are evolving, even in our current
encounter-based system. For example, one approach, not invented by the
EHR, but perhaps made more achievable by EHR systems, is what is called
a shared agenda visit. This means that although patients come to the
physician as needed for sick care, the physician uses the EHR to
identify specific care opportunities and unmet goals. When appropriate
and feasible, they can expand the acute care visit to include whatever
preventative and chronic care needs the patient might have, depending on
the number of those conditions addressed and how they were managed.
Under the coding guidelines we have today we might expect that shifting
to an outcome-focused shared agenda model might lead to short-term cost
increases. "Challenges do exist today for the use of EHR for coding.
When the provider is -- while the provider is usually in the best
position to know the clinical details of a patient encounter, they are
often unfamiliar with the complex guidelines that must be followed to
select the correct codes. In particular, E&M codes. Still, because E&M
is a codification of the diagnostic process in clinical medicine, we
must facilitate functionality and interfaces that incorporate E&M
principles into optimal care. Our overall goal as a community is that
the clinicians are able to incorporate the complex E&M guidelines to
promote patient care excellence as one of the benefits of the
well-designed EHR. "Finally, challenges with EHR workflows and
clinician training may not optimally facilitate the capture of an
adequate medical history, including a clinician's ability to determine
accurate and trustworthy differential diagnoses. In the absence of
reliable clinical diagnosis, clinicians may often resort to increased
diagnostic testing, usually in order to discover a diagnosis rather than
simply confirming it or determining the extent. So with respect to
these challenges, HIMS recommends that health care community work
together in the following three areas: Integrate E&M documentation,
training, and oversight in the medical school and residency curriculum.
"Simplified CPT E&M codes will ultimately provide more granular and
specific guidance for E&M coding. Evaluate ways to specifically
identify functional requirements for EHRs that would help facilitate E&M
compliance, as well as better documentation and diagnostic work flows,
again, with the goal of using the EHR functionality for the benefit of
the patient. "As we look towards the future we can anticipate the
following. In the area of new challenges in coding, clinical quality
measures can lead to additional non-clinically related documentation in
the clinical workflow. Future payment models that are not
fee-for-service may also drive additional documentation. And with new
payment models, in order to say incent uptake of health information
exchange capabilities, we may see adoption of new coding capabilities.
An example of that is higher E&M coding for cognitive activities, such
as information reconciliation in the information exchange arena. "And
finally, as we realize new payment models that pay for outcomes or that
are bundled, the phenomenon of coding errors related to care encounters
may self-resolve. HIMS notes also that the IT market is already
providing solutions. Third-party products can provide coding
translation outside of the EHR as part of the billing cycle. For
example, some new products that are aimed at easing the ICD-10
transition could also possibly address the coding error challenge as
well. Companies that provide clinical interfaced terminology content
provide clinician-friendly, clear, unambiguous descriptions of diagnoses
and procedures, along with mappings to standardized coding systems,
ICD-9, ICD-10, CPT-4, et cetera, and these are done by professional
coders. This can allow for the best of both worlds, collecting
structured data from professionals that are closest to the clinical
reality while ensuring that diagnosis and procedure codes that are used
for billing are correct. "So, given the work that HIMS has already done
in our commitment to working on this issue going forward, we take the
issue of coding errors seriously, and we are convinced that convening
the community to discuss these issues is a very advantageous activity.
We very much appreciate the opportunity to participate here today. We
look forward to working with federal government and health care
community partners to leverage opportunities to maximize coding
efficiency and accuracy, all with the goal of facilitating the optimal
use of EHRs in the clinical workflow. So, with that I'd like to say
happy Friday. Thanks, again, to Rob, ONC, and CMS for having HIMS here
today, and we appreciate it. Thank you. [applause]