Image of the White House Lawn

cliexa’s hard work and commitment to improving our country’s healthcare systems has been recognized by the Office of American Innovation (OAI) for our advancements within the industry. The OAI, appointed by President Donald J. Trump, and led by Jared Kushner, has invited cliexa to attend the 2019 White House Blue Button Developers Conference in Washington, D.C. on Tuesday, July 30th at the Eisenhower Executive Office Building. We are humbled and honored to receive this invitation. We are looking forward to connecting and potentially collaborating with policymakers, technologists, and medical experts to advance the sharing of medical information through mobile technology.

We are one of the few technology vendors who have successfully enabled the Center for Medicare and Medicaid’s (CMS) Blue Button 2.0 API into our software platforms. According to CMS’s website, the Blue Button 2.0 API is a “developer-friendly, standards-based API that enables Medicare beneficiaries to connect their claims data to the applications, services and research programs they trust.” This API enables patients to sync their Medicare accounts to our applications and bi-directionally share the information, specifically claims data, to their providers, and care teams.

With this information, there are a variety of potential outcomes from leveraging this data, including streamlined documentation and the secure exchange of patient information which can lead to uncovering new insights about patients’ health status and increasing time for face-to-face interactions between patient and provider.

Image of cliexa-EASE with CMS' Blue Button 2.0 API enabled

Our first use case for this API was in our application, cliexa-EASE, designed for the Department of Health and Human ServicesAgency for Healthcare Research and Quality‘s Step-Up App Challenge. With this build, we were selected as one of the three winners of this challenge. The goal of the challenge was to develop an application that simplifies the process of collecting, interpreting, aggregating and sharing patient-reported outcomes (PRO) data related to physical function outcomes. Using the Blue Button 2.0 API, patients could connect Medicare accounts to our platform and share their claims data directly to the health systems’ electronic medical record system. Other functionalities including the connection and aggregation of data from IoT and wearable devices, electronic medical record systems paired with custom, mobile clinical assessments.

To learn more about the Blue Button 2.0 API, and the Blue Button Developers Conference, visit //bluebutton.cms.gov/

Digital Health Solutions for Compliance and Reimbursement

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

 

Image of the "Best Rheumatoid Arthritis Apps 2019" from Healthline Media
Image of the "Best Rheumatoid Arthritis Apps 2019" from Healthline Media

In a late May article by Healthline, cliexa-RA was named one of the “Best Rheumatoid Arthritis Apps of 2019.” For the second straight year, cliexa-RA has been nominated for this selection, receiving a perfect five stars on the iOS App Store and the highest average score among all apps named. With the extensive features, assessments, accuracy, and patient-physician efficiency included with the application, it is one of the most thorough rheumatoid arthritis apps on the market.

cliexa-RA is a specially designed app for tracking patient progress, medication adherence, and complications from the patient’s smartphone. It includes several medically validated and custom assessments for keeping tabs on patients and providing physicians with accurate and up-to-date information. The app can also use a patient’s medical history and statistical data to more clearly assess patients\’ rheumatoid arthritis progress and therefore help physicians accurately provide treatment plans. The outpatient data helps create efficiency of communication between patient and physician, cutting down on time spent at the clinic and providing more accurate care solutions.

cliexa’s platform implements effective Remote Patient Monitoring to optimize clinical workflow, medical billing compliance, and reimbursements. Accurate outpatient data is essential to the cliexa platform, with cliexa-RA being recognized for its capability to utilize Remote Patient Monitoring effectively.

Read More: The Best Rheumatoid Arthritis Apps of 2019

Previous: The Best Rheumatoid Arthritis Apps of 2018

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

“cliexa’s vision is to be the state-of-the-art patient-reported outcomes and remote patient monitoring platform for comorbidities and real-time data provider for future medicine by increasing patient-provider engagement and compliance,” said Mehmet Kazgan, Founder & CEO of cliexa.

On March 5, 2019, the Agency for Healthcare Research and Quality (AHRQ) announced three winners from Phase 2 of the AHRQ Step Up App Challenge, a competition that was designed to address the need for patient-reported outcomes (PRO) data into clinical care. Out of 10 semifinalists, and over 50+ applicants, cliexa® was selected as the 3rd place winner, and will receive $25,000 in prize money.

cliexa is a HIPAA-compliant cross-communication platform that improves the quality of care, clinical workflow, income generation, and time spent with patients. Patients will play a more significant 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. Payors will be provided with longitudinal data to understand the necessary treatment decisions and patient status better. This will lead to improved communication and greater efficiency in the billing process while expanding the understanding of clinical methods that support patient well-being for future coverage improvements.

cliexa-EASE is a native application developed for Phase II of the AHRQ Step Up App Challenge, designed to track physical function, pain interference and depression using PROMIS measures. The application also has a patient reporting function where the patient can see the recorded scores over time and email this to other care team members, as well as a medication and complication tracking functionality. The application was tested for functionality on 6 patients at an integrated pain center, New Health Services, in Denver, Colorado. The application helps clinics fully leveraging PRO data to integrate validated clinical assessments to patient intake and remote-monitoring processes while collecting clinical metrics and compliance data for quality reporting. The discrete clinical data and PRO data enable providers to improve clinical decision making while reducing liability and billing concerns.

cliexa-EASE White Paper (FB)

We want to thank the Agency for Healthcare Research and Quality for rewarding us this opportunity. It has been a pleasure working with the folks who have dedicated their time and resources to ensure a smooth operation. Congratulations to all other companies who participated in the Step Up App Challenge. We believe programs of this nature foster an environment for technological innovation and provide a great path for advancing the healthcare industry.