Gender Equity in Global Health

Initiating my career internationally outlined so many of my decisions over the years from academic focuses to my draw towards the connectivity that technology provides. A three-year stint in China bouncing between high volume cities and quaint villages set the tone for how I viewed the world and human capacity to be so similar despite our vast cultural differences. Years later when I headed off to finalize my Public Health Master’s practicum in Vietnam with FHI360’s Alive and Thrive program, I was still unsure of how all my interests and experiences would quite intersect.

Through this experience I was given the opportunity to work with a group of fantastic public health professionals to outline the connection between Social, Economic and Political events and how they have impacted gender equity in China, Nepal and Nicaragua using a Matched, Interrupted Time-series study. Using the Gender Gap Index, we assessed and compared how major national events have impacted these countries’ gender equity. This was measured through economic participation and opportunity, educational attainment, health and survival, and political empowerment1 as compared to a matched baseline model (matched, interrupted time-series methodology). We observed that our studied and matched countries’ gender equity trends projected as aligned until identified events occurred and caused a deviation. Overall, we found that social and political events are key to ensuring better health outcomes and more opportunities for women.2

Almost two years after we embarked on this research, I now have a new lens on how to apply this information and how health and social connectivity can be supported through the use of technology, as the Director of Product with cliexa.3 Using the knowledge and insights from this research and our multi-disciplinary team, I try to bring this understanding to work with me every day. My focus over the years has shifted from the traditional public health sector towards the impact that innovative tools can make on our own understanding of our health as well as the ability to better communicate to our care providers about key pieces of information impacting our health.

Undoubtedly the scale of my work has transitioned away from the national level toward to the individual but all with the intention of lending to that overall goal of protecting that which so clearly defines our essential right to be equal, equal in opportunity, equal in health, and equal in the ability to live our best lives.

1 https://reports.weforum.org/global-gender-gap-report-2018/measuring-the-global-gender-gap/

2 https://www.tandfonline.com/doi/full/10.1080/16549716.2020.1712147

3 https://www.cliexa.com/

Combatting the Opioid Crisis with Pain Management Technology

Introduction

The treatment for chronic pain has long been debated as its management offers a wide array of options for both clinicians and patients to choose from. Medicines for depression have the potential of becoming addictive due to their calming effect on the patient. While conventional treatments have become outdated, the administration of prescription-based and over the counter drugs has exploited susceptible individuals to the harmful effects of opioid overuse. It is vital that clinicians find a solution to monitoring the use of opioids to help bring the drug epidemic to its demise and simultaneously encourage non-pharmacological options to their patients. 

Monitoring chronic pain and depression 

Traditional Methods 

Depression and chronic pain can overlap due to them possessing a few common neurotransmitters that are responsible for delivering messages between neurons. They also have similarities in their pathways of the brain and the spinal cord. Chronic pain has the propensity of eliciting signs and symptoms of depression. Its severity and impact on a person’s life are what contribute to depression manifesting. With underlying chronic pain, a person begins to experience struggles in how they handle losses, more extended periods of inactivity, a decrease in sociability, diminished interest in relationships, and poor work performance. People who are susceptible to depression and are simultaneously managing the effects of a chronic illness are treated for both conditions simultaneously.

Traditional medicines and management are regarded as safer and there are ample choices a doctor can implement. Conventional medicines for the management of pain are based on the many theories and beliefs of different cultures that are targeted at reducing or improving pain. Among the many opted treatment regimes, the few common ones are acupuncture, herbal medicines, and Ayurveda medicines, which have been regarded as the most common and recognized treatments universally. Regardless of their effect or cultural support, these treatments aren’t evidence-based, and their underlying mechanisms aren’t common knowledge. This limits their use by doctors in their clinics.

There has been a notable rise in the treatment of pain and depression through the use of opioid medications. The opioid epidemic brought the attention of the masses in 2017. Many federal agencies, including the US Food and Drug Administration (FDA), the Joint Commission, and the National Academies of Sciences, Engineering, and Medicine (NASEM), have begun advising clinicians to regulate prescription-based opioid drug administration and to offer more options than just medications.

Overview of the Opioid Crisis 

It’s inevitable that with many drugs being conveniently available over the counter, patients have taken to self-medicating themselves. More importantly, due to the potent effects of opioid drugs, immune-deficient or overly busy people, rely on opiates to help them get through a tough day. The use of chronic opioid therapy for non-cancer related pains has taken risen exponentially in just the previous two decades. This was noted to occur concomitantly with the increase in prescription-based opioid use as well as abuse or accidental overdose using these drugs. Opioids are sometimes even called narcotics. Some of the strongest prescription-based opiates are tramadol, hydrocodone, fentanyl, and oxycodone. Even heroin, which is an illegal drug, is an opioid. Opioids are both human-made and synthetic. Regardless of what combination of a drug is made available, they all promise to act as immediate pain relievers.

The relationship between depression and opioid abuse is a two –way relation, meaning that when a person is suffering from depression or opiate withdrawal, he will likely develop symptoms of the other condition as well. Opioid drug abuse refers to the use of this drug without the use of a prescription. It’s either used in a non-medical context or is taken in larger quantities than is required, and this inadvertently is linked to higher rates of depression, bipolar disorders, and anxiety.

Current problems associated with a standardized method of treating pain 

Currently, pain management within the oncology department, its effective pain-relieving abilities, and there were limited alternatives for relieving pain in severe conditions have increased the reliance patients, and doctors have for these potent drugs. With an increase in drug reliance, even the risk for aberrant and inappropriate behavior has risen. Also, standardization in treating cancer-related pain lacks among the clinicians who prescribe it. It’s recommended that residents and doctors who practice medicine should vary in misuse and abuse of drugs.

Coping skills for patients dealing with chronic pain

Patient Education 

Non–pharmacological pain management means managing pain without the inclusion of medications. This mode of treatment targets the mind of the patient and hopes to influence and encourage positive thoughts or alter thoughts to reduce the effect of pain felt anywhere in the body. There are many non-pharmacological options that one can subscribe to. They include:

Educational and psychological conditioning of the mind

Many people are entirely in the dark about what to expect when dealing with depression or chronic pain. It is quite stressful for them, and it is their caretaker’s responsibility to educate them about their condition to make it easy for them. If a patient has been made prepared for what they’re about to endure, it helps reduce cortisol levels and thereby reduce the amount of stress they can experience. To decrease their anxiety, the clinicians should consider engaging the patient in conversation and explaining to them vital pathological signs regarding their debilitating pain or their depression. Even explaining treatment options thoroughly might allow them to make a more well-informed decision. The use of pictures or diagrams will help everyone understand the pathway of their illness properly. Any questions that the patient has should be written down and answered diligently.

Alternative treatments to pain medication (opioids)

Among the variety of treatment options available to patients, some critical and recognized suggestions are:

  • Hypnosis

A psychologist or doctor helps guide the patient into a state of altered consciousness, and this helps reduces the pain experienced by the patient by narrowing their thoughts. The method for such treatment involves guiding the patient’s thoughts through mental images based on sight, smell, taste, and feel. This helps deviate their thoughts from the pain they are experiencing. If a child or adolescent is experiencing chronic pain or depression, then various methods of distraction should be employed. Videos, songs, and storytelling are among the multiple techniques that can be applied. Many relaxation techniques are also used, such as deep breathing and stretching, which can also help ease the discomfort.

Among other options available to the patient and doctor are comfort therapy, occupational therapy, physical therapy, psychosocial counseling, and neuro-stimulation. These can be utilized instead to help relieve pain, and many patients find comfort in them instead of ingesting large amounts and frequent doses of medications. To further elaborate, these therapies are listed below:

  • Comfort Therapy

It involves companionship, hot or cold compresses, exercises, massages, meditation, drama or music therapy, counseling, and occupational therapy.

Physical and occupational therapy are beneficial and can be implemented through aqua-therapy, desensitization, psychosocial therapy, and strengthening exercises for the muscles that may have lost power and tone due to immobility.

  • Psychosocial Therapy: 

It involves counseling in the form of family, group, or individual counseling. This method helps a patient become more accustomed to their condition and helps teach coping mechanisms.

  • Neuro-stimulation: 

This method involves electrical nerve stimulation, which immediately helps relax tense muscles and improves neural impulses through fatigued muscles, acupressure, and acupuncture.

How does cliexa monitor its patients? 

Remote Monitoring

Clinicians need to have a profound grip on opioid use. The only solution to narrowing down the prevalence of this epidemic is by finding a method to track the intake, risks, and effects on a patient dealing with crippling chronic pain. The way clinicians can do this is by using cliexa to their advantage. The cliexa platform allows patients and their clinicians to seamlessly track the activity and progress of the disease, whether in-clinic or through a remote monitoring program. Their proprietary technology is exceptional and allows for intelligent correlations between the dosage of medicine the patient is ingesting, their frequency of drug use, and whether symptoms have heightened or lessened. Managing chronic pain has become better because the best way to reduce an opioid or drug overuse is by ensuring that drug intake stops once the patient becomes better and shows no reason to continue his drug intake. The system allows their patients to connect to software that will enable them to communicate with their physicians without any interruption. This technology assists the providers through its ability to adequately document changes in any baseline metrics and helps patients get access to timely treatment. This would inevitably result in lesser complications.

The remote monitoring services allow patients to use their phones to send any healthcare data to their providers, and easily covering either a range of diseases and make necessary amendments in their ongoing treatment. This trend is powered by cliexa through its ability to provide clinically validated assessments with an automated disease activity score, all through its ability to gain real-time data through the wearable devices their patients wear. The wearable allows for data collection that could easily go undetected in many patients. This helps to improve the reported outcome vastly and improves patient satisfaction immensely.

Connect to claims data to visualize prior hospitalizations

The data is made available to clinicians through cliexa’s Evaluation and Management services. It’s responsible for medical coding and medical billing. These E/M services integrate history, exam, and medical decisions that are vital for establishing patient visits that are thorough and detailed. Medical compliance is based on proper documentation of medical records that help physicians and extended healthcare professionals evaluate their patients excellently. Treatment options are then made optimal and accessible. Real-time data that is gathered for the patients is used by the physicians to provide the utmost high quality of care when dealing with their patient’s mental health.

Wearable devices for real-time, activity data collection

Among their numerous mobile applications, cliexa-SENSE is routinely implemented in behavioral clinics where patients dealing with depression, alcohol abuse, narcotic abuse, and opioid abuse are treated. cliexa-EASE is a mobile application that is a pain assessment model for monitoring chronic pain. This app helps maximize reimbursements and helps improve chronic care management. cliexa- RA is responsible for reporting rheumatoid arthritis symptoms using patient-reported outcomes using clinically validated assessments. The disease activity scores are reported diligently through this, and quality care is further optimized for patients. cliexa-COPD is tasked with providing preventive and value-based care for people who are afflicted with COPD.

Identifying opiate risk 

cliexa has partnered with Colorado Clinic, New Health Services, and more pain, behavioral health, and mental health facilities to combat the opioid crisis exceptionally. This is their method of improving chronic pain care and management. cliexa has digitized the entire process of the patient’s arrival, consent documentation, and chief complaints. At-risk patients will be monitored in this manner and will have to fill out screener questions that will be based on the Screener and Opioid Assessment for Patients in Pain model. This model is designed in such a manner that it will help self-report and address the extent or appropriateness of therapy in patients suffering from chronic pain. They will receive intelligent treatment options that will be aimed at minimizing the extent of pain. This information will be entered into the EMR system. The scores that will be generated after the patient is screened, and their responses gave the appropriate score, their risk of opioid abuse will be graded as low, medium, or high. This will help clinicians strategize treatment and duration of drug administration accordingly. The health care providers will even have to ensure they use urine drug monitoring as a necessary part of their clinical assessment, as this will help monitor the patients before their drug therapy and following their drug therapy. Random and routine urine analysis can help manage low and high-risk patients fruitfully. It’s even been studied and proven that urine drug monitoring will help drug compliance and prevent misuse of drugs. cliexa’s AI helps software hopes to optimize pain management by continually producing intelligent solutions from patient input. 

Conclusion

Innovative methods to manage patients are continually being used by clinicians and hospitals as they wish to optimize the quality of care that they deliver to their patients. Patient education must be encouraged as this will make patients self-aware of the harm they can inflict upon themselves by poorly complying with drugs. Doctors and patients must work together to reach a solution that aims at reducing the number of medications ingested to manage pain and related mental disorders. This way, drug complications will be narrowed down, and the risk assessment for many patients liable to misuse drugs will decrease.

 

 References

  1. https://www.ncbi.nlm.nih.gov/m/pubmed/28226333/?i=2&from=/29149119/related
  2. https://www.practicalpainmanagement.com/amp/22565
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069064/
  4. https://www.hindawi.com/journals/prm/si/674036/cfp/
  5. https://www.webmd.com/depression/guide/depression-chronic-pain
  6. https://medlineplus.gov/opioidmisuseandaddiction.html
  7. https://www.psycom.net/depression.central.opioid.abuse.html
  8. https://www.cliexa.com/evaluation-management-services/
  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699803/
  10. https://www.cliexa.com/?cat=-1
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