Addressing EMR-Related Issues with A Care Management Platform

Introduction to cliexa’s Care Management Platform

There is a need for additional digital health and care management platforms to alleviate some of the burdens of the electronic medical record (EMR) through enhanced customization, streamlined data collection, and integrated compliance algorithms into a digital patient intake and remote monitoring platform, like cliexa.

cliexa’s care management solution is designed to increase clinical efficiency by providing digitized intake forms and qualifying patients for reimbursements automatically. This process aims to streamline the documentation and data collection procedure so that providers spend less time documenting, and more time with their patients.

Through an automated process, clinical metrics and quality data, via patient-reported outcomes, integration into the Merit-based Incentive Payment (MIPS) quality reports can be done in the EMR to maximize compliance and reimbursements. This technology empowers clinicians to make intelligent correlations between: 

  • Medical History
  • Clinical Assessments
  • Surveys and Questionnaires
  • Connected Device Data
  • Payor Claims Data
  • Medication Adherence

How are the barriers to EMRs for the physicians addressed by cliexa?

Coordinating care for better diagnosis 

Patients can check their progress from their handsets or tablets, which is subsequently sent to their physicians in a consistent and objectified approach in order to measure their disease activity scores. This information is then passed through the cliexa Cloud into the provider’s existing EMR system.

Along with serving as a chronic care management system, a care management platform like cliexa, are employed for clinical trials, to process digital forms which are sent to an existing EMR system, for the remote management of patients’ progress.

Improved accuracy and reproducibility of data

Patient-reported outcomes (PROs) measure any phase of a patient’s condition and health status directly from the patient, regardless of the analysis of the patient’s responses by a clinician or anyone else. This naturally advances the precision of how, why and what the patient is going through and can be interpreted into disease activity scores to evaluate the severity of the disease. 

Reduced external pressures on Physician-Patient relationship

Physician burnout, compressed clinical grids, greater medical complexity, EMR coverage, increasing costs, variable medical data, reduced reimbursement, advertisement and marketing are the identified external pressures on the physician-patient relationship. Smart systems like cliexa, address these issues through the implementation of PROs.

Clinicians have found PROs to be a useful mechanism for shared decision-making in the right environment with the right workload. This facilitates achievable endpoints that promote the physician-patient relationship by better time management, a common platform for patients and clinicians to trace and envision their disease activity and simplified documentation.

Less time consumption and ease of implementation 

Flawless integration into the current workflow, customizable evaluation and questionnaires configure effortlessly with your EMR system. The cliexa Cloud passes the information responded by the patients in the care management platform directly to your EMR, customized depending on your preference.

The system sets in with no disturbance in your workflow and requires approximately one day to set up without any IT commitments. The information is sent to the clinicians’ files in the formats of your choice to verify data quality before full integration.

Customizability is how cliexa deals with all the reservations over implementation. The platform is structured according to the requirements of the physicians, patients, and the healthcare composition, without the need for an on-site IT team. The staff training can be done in a day along with minimally invasive implementation, meaning simplicity throughout the course of implementation.

Cost-effectiveness and reimbursements 

The healthcare systems are known to have the following reservations with PROs; high capital investment needed, physician engagement, information management requirements, integration of knowledge, privacy considerations and the management of critical or missing information.

cliexa attends to these considerations through a reimbursement structure and flawless integration. Although investment is one of the key considerations, the software links providers and payors to rationalize the process of Content Management System (CMS) and payor compensation.

cliexa has formulated the ROI calculator on the platform for the people who choose to go for its reimbursement structure. The physician engagement and management requirements are addressed by focusing on time management and easing the procedure as per the interest of the physicians.

Better patient experience and versatility of use

cliexa is a free-to-use care management platform for patients, available on the App Stores for all mobile platforms. This includes devices such as smartphones or tablets that consist of the app store for download. Unlike other patient platforms, cliexa is independent of clinics or healthcare offices. This means that it is available for the personal use of the patients.

Even if the physician’s office does not use the software, patients can still track their condition and its progress by using this versatile software. With the application storing your history, you can have your data accessible when switching over to a new clinic or healthcare provider simply but updating the care treatment plan.

Privacy and confidentiality

All the rules of privacy and security laid down by HIPAA guidelines are followed in order to protect your information. It is further ensured that any data is not being shared with anyone other than your healthcare providers. The software in the clinics and on patients’ devices is updated automatically by a remote device management system.

All of the aforementioned points are promising ways through which the EMR-related issues can be potentially addressed. However, cliexa or any other smart software is not a direct and the most precise way of diagnosis, rather it is a means to follow the health progress, functioning alongside primary care. Thus, if you are experiencing consistent symptoms of a chronic condition or a health issue, make it your first priority to visit your healthcare center for a checkup by the primary care provider.

Doctor looks at the patient's electronic chart on the tablet. Health care concept. 3d isometric. Concept for web design-01

Overview of the Physician Burnout Problem

The demanding work pace, time constraints, and emotional fatigue are the aspects that make physicians vulnerable to burnout. Symptoms caused by long-term stress such as depersonalization, low sense of accomplishment and emotional disparity due to work-life imbalance make the doctor prone to exhaustion leading to a feeling of quitting.

The WHO terms burnout as an ‘occupational phenomenon’ which, in its latest update of the definition, is referred to as a ‘syndrome’ that occurs due to chronic work stress that is not effectively managed.  The physician burnout is metaphorically referred to as the bank account of energy.

There are three main types of energy; physical, emotional and spiritual energy that keeps on adding up and depleting with time and circumstances. The highly demanding doctors’ profession and the workplace norms generally have a downward trend towards energy levels that puts clinicians at a high risk of burnout. 

According to a study published in the Annals of Internal Medicine in 2019, Physician burnout costs around $ 4.6 billion to the United States. Dr. Lotte Dyrbye of Mayoclinic opines that whoever enrolls in medicine is aware of the fact that it is a demanding and stressful profession.

Over the past years, the sprouting cases of physician burnout have led to cynicism about its repercussive effects on patient access to care, care quality as well as patient safety. Burning out inflicts the doctors to quit their jobs making access to care, less likely. Lack of attention and focus, as well as memory constraints, hamper patient safety and quality of care.

According to several studies, 1 out of every 3 physicians is suffering from burnout at a time. Thus, every physician precisely is at risk of burnout and it rightly needs to be dealt with as a crisis. Although the physicians can take the necessary steps themselves to improve the work-life conditions and keep the burnout symptoms at bay, big changes are needed at the institutional level to bring forth evident outcomes.

A recent report from Harvard states that physician burnout is a public health catastrophe that urgently needs a solution. Among the recommendations stated by the report, changes to the practice of Electronic Medical Record (EMR) or Electronic Health Record (EHR) are declared to be a significant measure to provide a medium-term solution for physician burnout.

Problems that are focused on EMR-related issues

The patient record used to be written on paper for ages and has consumed an ever-increasing space and remarkably deferred access to proficient medical care. As of today, EMRs collect individual patient data and clinical information electronically, facilitating immediate accessibility of this information to all healthcare providers. It is thus said to assist the provision of coherent and regular care.

Electronic Medical Records (EMRs) are automated medical information systems that assemble, store and present patient information. They are a way to produce reliable and structured recordings to access clinical data about patients. Hence, EMRs have replaced paper-based medical records which most practitioners have been long familiar with.

There are a number of potential advantages EMR is known for. These include

  • Optimizing the records of the patients
  • Improving communication of patient data to clinicians
  • Improving access to patients’ healthcare information
  • A substantial decline in errors
  • Optimizing payments and advancement in reimbursement for services
  • Formation of a data storage area for research and quality enhancement
  • Reduction of the use of paper

EMRs are envisioned to have great potential for enhancing quality, stability, protection, and efficacy in healthcare. These are the reasons why they are being implemented throughout the world.

In spite of the high expectations and focus on the technology worldwide, there are several EMR-related issues associated with them that have kept their overall implementation rate relatively low. They are viewed to oppose a physician’s customary working style and also entail the following barriers to acceptance by physicians.

  1. Financial Barriers

    EMRs necessitate a greater competence in dealing with computers. Further, installing a system entails significant financial resources; high startup expenditure, high maintenance cost as well as uncertainty about Return on Investment (ROI).

  2. Technical barriers

    Lack of computer skills of the clinicians and the other staff, deficiency of technical training and support, complexity and limitation of the system, etc. are the factors considered as technical barriers to EMRs.

  3. Time constraints

    The physicians find it too time-consuming to select, purchase and implement the system, to learn the system, to enter data, to convert the records and requiring more time per patient. 

  4. Psychological barriers

    Based on their personal reservations, understanding, and perceptions, clinicians have concerns about using EMRS. Their observation of the uncertain quality improvement associated with EMRs and doubts about the loss of specialized autonomy lead to a lack of belief in the EMR.

  5. Social barriers

    The social barriers include uncertainty about the vendor, lack of support from external parties, from other colleagues and from the management. Also, the physicians find EMR to be a system that interferes with the doctor-patient relationship.

  6. Legal barriers

    Clinicians think that keeping the patient records and medical information safe is vital to avoid legal issues. Nonetheless, there is a lack of clarity about the security standards to keep the patient records safe and confidential. 

  7. Organizational size and type

    A small practice is estimated to face greater difficulties in working out the financial issues than a large practice.

  8. Change process

    Implementation of EMRs in the medical practices demands a major change for clinicians who have their own working styles developed over the years. This renders them unwilling to adapt to variations in their methodology of work. Therefore, the change process is a challenge as well as a problem at the same time. Problems that occur during the change process include a lack of suitable organizational culture, lack of incentives, lack of leadership and reluctance in participation from physicians, nurses and other staff members.

According to a study, the slow rate of EMRs adoption implies the fact that resistance amongst medical doctors is strong. This is because the clinicians are the frontline users of EMRs and whether or not the other user-groups like nurses and administrative staff support and use EMRs, largely depends on EMR’s acceptability by the clinicians. Consequently, doctors have a great influence on the adoption level of EMRs. 

Additionally, a study found that most of the physicians who are stressed out are due to the work conditions and time pressures. The family responsibilities, time demands, chaotic environment at workplace, lack of control of the pace, unfavorable institutional culture; all are attributes associated with dissatisfied and stressed out doctors who inculcate a feeling of switching fields. However, these factors, not necessarily translate into poor patient care by the doctors. However, when a drop in the patient care quality was seen, it was rather due to burnout caused by the organization than by the doctors themselves.

The study also found that the implementation of the EMR contributed to burnout instead of reducing the stress levels as it was hoped. It was claimed that practices that implemented EMR caused an increase in stress to the doctors, the levels of which then reduced as the use of EMR matured. However, the stress level was never found to drop to the lowest. Furthermore, it was found that the fully established EMR systems, particularly coupled with shorter visits caused burnout, stress and an intention to leave the practice.

Causes of the EMR-Related Issues

Like all other technologies, EMRs can be used in a variety of ways for a variety of purposes. In regards to our current healthcare structure, one important performance requirement of EMRs is to generate clinical revenues. This means that it should support physicians’ billing and documentation to produce as much revenue as possible for each medical service. Moreover, EMRs should also help clinicians meet regulatory necessities that may have monetary or endorsement implications.

This implies that existing EMRs are not designed in a way so as to support many of the matters that clinicians, patients, and policy-makers value including improved care experiences, decreased cost, improved care quality, and inhabitants’ health management. Current EMRs have not been created to facilitate the physicians to improve in their diagnoses or become more cost-effective prescribers. This is because the present-day health care system generally does not compensate for these actions.

Having said so, EMRs have very minimum capacity pertaining to clinical decision making (which increases the quality of care), for the data collection on duplicate and needless tests, or on the collective health of the patients.

Simply put, the advancement of the EMRs will necessitate the changing of prime considerations regulating their design. This includes moving towards risk-sharing by clinicians and eventually, some form of potential reimbursement rather than the current fee-for-service culture. Till then, optimizing the usability and worth of EMRs will be an ascending effort.

READ NEXT: cliexa Partners with the athenahealth Marketplace Program

Digital Health Solutions for Compliance and Reimbursement
Digital health solutions

The Problem

With healthcare reform sweeping our nation, many hospitals and clinical practices are prioritizing compliance to rules, regulations, and laws of healthcare, in order to streamline operations while providing safe, high-quality patient care. Oversight of compliance is managed by the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG). Physicians and their staff face increasing scrutiny when it comes to documentation, coding compliance, and the auditing process conducted by Medicare Recovery Audit Contractors (RACs) and private payers. The combined effects of a national shift towards value-based care and reducing costs have inevitably led to payers auditing more aggressively to identify potential overpayments. In the 2018 Comprehensive Error Rate Testing (CERT) report, the Medicare fee-for-service program documented an improper payment rate at 8.12 percent, representing $31.62 billion in improper payments (5). Common causes of improper payments include:

  • 58% due to insufficient documentation
  • 21.3% due to unnecessary medical proceeding
  • 11.9% due to incorrect coding
  • 2.6% due to lack of documentation
  • 6.3% due to other

Physicians and healthcare providers now face increasing pressure to get documentation right while delivering quality patient care. This shift creates a need for a robust cross-communication platform like cliexa, to foster collaboration between patients, providers, payers, and key stakeholders involved in the healthcare system in order to quantify and qualify patient-reported outcomes (PRO). As seen in the breakdown above, over 70% of improper payments are due to documentation errors or services deemed medically unnecessary.

Documentation Issues

Any healthcare professional who uses electronic medical records (EMRs) with auto-populating templates such as, but not limited to, a quick click-through of a review of organ systems (ROS) template that may not have been fully reviewed or has a default entry, is at risk for audit. For example, a patient can be seen professionally for having back pain, yet the musculoskeletal ROS was documented as negative when it should have said “low back pain.” This is a red flag to the auditor and prompts them to look for other inconsistencies. Errors can also occur during billing and coding, however, CPT and ICD-10 coding errors are less prevalent when documentation is adequate (6).

With cliexa, a substantial portion of the ROS, medical history, family history, and social history can be streamlined into the EMR from the comfort of the patient’s home or shortly before the physician sees the patient. This function will close the gap in clerical errors and serve as a safety net for when a provider forgets to elicit additional questions from the patient during the encounter or enter it into their notes.

It only takes on average 30 encounters of an ICD-10 code reported that was not supported in the physician’s note, or coding one level higher than they should have, to be audited. Medicare or the insurance company (payer) will ask for approximately $45,000 back, yet the actual amount paid will amount to over $1 million after accounting for interest, extraneous fees, and penalties (6). Those who code for a lower level of services or have smaller practices may believe they will not be audited since they are taking the low-risk approach, however, that is far from the truth. Auditing occurs because they identify the physician as an outlying practitioner compared to colleagues in the same specialty nearby. For example, a physician consistently bills level 4 and 5 services, while colleagues are billing mostly level 3 care, raises a red flag.

Even with an active body overseeing clinical documentation improvement (CDI) in the hospital and frequent educational sessions, these errors still persist. The demands on physicians and mid-level providers can get overwhelming, splitting their time between treating patients at increasing volumes and endless documentation despite the adoption of EMRs. Eventually, something gives. The trends show physicians improve significantly in the immediate 6 month period after billing training sessions, and unfortunately, often revert back to the same pattern of minimally edited or rushed medical notes (6).

As shown above, in the CERT report, services deemed medically unnecessary falls in the second most common cause of payment retraction. Having a strong patient medical history component in the physicians’ note lays the foundations for justification for office visits, labs, or imaging services rendered. It will naturally defend the need for such services. This is where cliexa comes in, allowing patients to fill out clinical assessments outside the hospital or clinic walls. This is especially important for chronic care management (CCM) patients because we can capture the trend of the patient’s disease progression, using reliable and objective data. As data accrues while a patient documents their symptoms improving or worsening, clinicians can intervene or change management as necessary. When further lab work or imaging is necessary, it will already be justified and deemed “medically necessary” with trending data, thus decreasing the potential for billing rejections from payers. This real-time data is sent directly to the Cloud and then to the clinician’s EMR system, with no disruption in workflow.

Another common issue occurs during documentation of the chief complaint and history of present illness (HPI) in the patient’s medical record. For example, a CCM patient with rheumatoid arthritis has been under your care for a couple of years. It is not sufficient to say “patient is here for a follow-up visit” as the chief complaint. The status of the patient must be further explained, such as comparisons made to previous visits: are they improving, worsening, stable, or well-controlled, as a result of any medications? The HPI is a section in the patient’s medical note that requires the physician to document, not ancillary staff such as nurses or medical assistants. An auditor will review the HPI and grade it in two levels: brief or extended.

  • Brief HPI, 1-3 HPI elements
    • “Patient is here for arm (location) pain that started a week ago (duration)”
  • Extended HPI, 4+ HPI elements
    • “Patient is here for waxing and waning (timing), arm pain (location) that started a week ago (duration). He states it is a constant ache (quality) type pain that worsens when he wakes up (provoking factor).

Leaving out important parts of the documentation will lead to a lower level of service in billing and lower reimbursements. To mitigate this issue, cliexa offers screening and compliance tools that are already integrated on the platform.

Evaluation & Management Audit

A major pitfall in an audited record of high concern for the HHS and OIG stems from EMRs “assisting” physicians and mid-level providers with coding and documentation prompts. Most EMRs come with a feature that supports accurate evaluation and management coding, yet they can also cause inaccurate coding. Often times, the EMR does not have the ability to identify key data elements related to complex medical-decision making (MDM), which is alarming when it comes down to identifying the most accurate E&M code to use. Common mistakes made by the EMR system include:

  • Inaccurate level of service calculation (E&M codes) based on content in the documentation
  • Inability to create content and set system defaults
  • Inability to automatically detect a conflict between the information in the HPI and the ROS section

Understanding the inner workings of the EMR as well as optimizing its billing elements requires extensive time that physicians and HCPS do not have. As such, an over-reliance on the EMR’s suggested E&M code develops, which leads to unintentional upcoding or down-coding. Many providers believe that using the EMR-provided code would protect them from coding at a level not supported by documentation or medical necessity. Compensation may rise at first, but end up in payment retractions from payers or increase their risk for fraud. For example, if a patient comes for a follow-up visit, it is not necessary to include the 12-system ROS or family history of this patient, as it was already detailed in the initial consultation note. This can trigger the EMR to suggest a higher coding level, which is not justified. Physicians need an automated process that can quickly categorize the nature of the visit, which is offered in the cliexa platform with our coding compliance programming.

Medical Decision-Making (MDM)

The MDM portion of the E&M record makes up the criteria for the visit code physicians bill. In other words, it is more important than the history and exam portion of the physician’s note. MDM constitutes the complexity of the diagnosis and/or creating a management plan. From the desk of the auditor, these factors include:

  • The number of possible diagnoses and/or the number of management options that must be considered
  • Amount or complexity of medical records, diagnostic tests, and/or other information that must be ordered, reviewed and analyzed
  • The risk of complications, morbidity, or mortality and associated comorbidities related to the patient’s presenting chief complaint, diagnostics and management options (6)

In order to qualify for a given type of MDM (Straightforward, Low Complexity, Moderate Complexity, High Complexity), at least 2 out of the 3 elements listed above must be met. Each tier has its own designations under each element. For example, straightforward has a minimal or established problem that is stable and improved for a number of possible diagnoses. Whereas low complexity would have a low number of possible diagnoses or established problem that is worsening. cliexa has compliance measures built into the platform to ensure patients actually qualify for the right codes. You can also build in custom screening tools, such as a CCM patient with 2+ chronic conditions. At the same time, the physician can collect clinical metrics and compliance data through our system that directly integrates to your MIPs quality reports in the EMR. MIPs, which stands for Merit-based Incentive Payment System, is CMS’ largest value-based care payment program, which was adopted to shift the healthcare industry from fee-for-service to pay-for-value. There is a public reporting aspect of MIPs that impacts a clinician’s reputation as well as reimbursements: better MIPs score results in higher payments. It’s important to note that if one does not submit data for MIPs, there will be up to 5% reduction of Medicare reimbursements; this process is automated in our platform.

The compliance aspect of a clinician’s life cycle is complicated and frustrating, to say the least. That is why our platform can offer solutions to maximize your patient-facing time. Many aspects of the office visit require filling out surveys or patient information that ends up taking more time than the visit itself. cliexa brings increased efficiency to your practice by:

  • Streamlining the documentation aspect via integration with EMR for audit protection and compliance
  • Improve physician-patient communication
  • Allow customizable built-in surveys and questionnaires to improve your MIPs score

References

 

Mobile Health Applications - Value Based Care

In today’s healthcare system, there is a focus on creating a value-based care system to foster a standard of effectiveness, and efficiency when it comes to patient health outcomes, and reduced costs. Through this model, healthcare providers are incentivized to deliver high quality care and this value is derived from measuring health outcomes over time. There is significant pressure that many providers face to be able to quantify their patient’s health outcomes in order to show they are in fact delivering “value-based care.” A value-based model creates a need for a fruitful cross-communication system that extends to patients, providers, payers, and all involved in the healthcare system in order to quantify and qualify health measures.

In a effort to utilize patient-reported health status to improve care, cliexa is collaborating with the American College of Cardiology to develop technical modules targeting cardiology-specific diseases using remote patient monitoring. The first module, cliexa-PULSE, has been developed is for Atrial Fibrillation and includes patient-reported symptom tracking, medication reconciliation functions, connections to wearable data and claims data connection. This information will fulfill reporting needs for patients through visual tracking graphics in the application and to physicians in a summarized, customized manner. Moving forward we are looking to commercialize this product through the ACC’s 2,500 members and beyond.

Improved communication and reduced costs can be achieved by improving patient engagement, streamlining clinical workflow, and implementing a customizable technology that will automate clinical processes, analyze and simplify patient data, which can lead to improved care and health outcomes. By the incorporation of patients’ health status and value via patient-reported outcomes (PROs), providers can monitor the quality of health care delivery.

PROs can be used as absolute terms, or as a change from a previous result as well as a measurement in clinical trials. Physicians can better determine baseline status, clinical trial endpoints, monitor therapy effectiveness, assess change in stats and prognosis predictor, while the patient experiences positive impacts on daily activities, emotional wellbeing, psychological health, and social function. In addition, PROs can aid clinics to improve patient outcomes, quality of life and satisfaction by using the PROs to better inform their care. PROs prioritize the important details in a clinical encounter and aid a better understanding of the motivation behind patient behavioral change. With this information, the clinic can analyze the evidence, design clinical trials and change their practice and policy. In addition, PROs can aid clinics to improve patient outcomes, quality of life and satisfaction by using the data to better inform their care. PROs prioritize the important details in a clinical encounter and aid a better understanding of the motivation behind patient behavioral change. With this information, the clinic can analyze the evidence, design clinical trials and change their practice and policy.

Patient-centered data collection outside of a traditional clinical is the next frontier of modern healthcare. By digitizing and automating PROs, both patients and physicians benefit financially and through effective time management. PROs tackle the challenge of long surveys, care integration, multimorbid patients, and improving the relationship between patient and provider. Clinicians need instruments (surveys) to capture patient-reported measures of symptom status, functional status and health-related quality of life. PROs help quantify the disease from patients’ perspectives, makes disease- specific measures more sensitive and relevant, help meet all the requirements of performance measures and can improve the process of delivering clinical care while bringing the patients’ voices into care. Physicians have found that PROs, in the right setting with the right workflow, are a helpful mechanism for shared decision making and help tackle the treatment goals of patient survival, free of hospitalization, and increased quality of life.

Read more from ACC: //www.acc.org/latest-in-cardiology/articles/2019/04/14/12/42/innovation-at-acc-collaboration-using-patient-reported-health-status-to-improve-care

In 2018, cliexa was selected as one of Jumpstart Foundry’s portfolio companies. Jumpstart recognizes the value of recent healthcare industry trends including “Remote Patient Monitoring” and “Telehealth.” In their recent article, JSF featured cliexa in their discussion of these recent technological trends in healthcare.

One of the key challenges in healthcare that we are solving is being able to render results interpretable to patients and providers, while creating efficient, streamlined communication and workflow. cliexa’s Remote Monitoring platforms assist providers in making more informed decisions about treatment plans and enable them to respond more quickly to new data so their patients will have fewer complications or side effects. cliexa suite of products enables providers to deliver value-based care which translates to significant cost savings.

With clinically validated scoring models, our platform provides clinicians multiple reference points with correlations to identify the accuracy of patient reported data which will result in better patient and clinician experience and enables more responsive and preventive treatments.

Patients will play a greater role in their care with cliexa and will be able to make valuable correlations to causative factors for pain flare-ups through remotely reported outcomes. The discrete clinical data and patient-reported outcomes enable providers to improve clinical decision making, while reducing liability and billing concerns with payors. These algorithms help providers respond more efficiently to new data so their patients will have fewer complications or side effects.

Click here to learn more about cliexa’s Digital Solutions for Healthcare.