EHRs, Automating Coding And Advanced Analytics
The move to create a nationwide system of EHRs (electronic health records) comes at a particularly critical time in the history of our healthcare system. Annual per capita costs continue to soar but without a demonstrated increase in improved benefits to patients. The population is aging, leading to a concomitant increase in those suffering from chronic diseases. And fraud is a growth industry.
For these and many other reasons, our healthcare system needs to embrace integrated systems built around an EHR, or face a future of continued cost escalation, unconscionable waste, burgeoning inefficiencies and a growing epidemic of sicknesses and deaths from inappropriate treatment of patients. The trend can be reversed. The healthcare industry needs to think of every medicalrelated encounter as a transaction. How to optimize the transaction throughout the whole continuum of processing? Its not just the doctor; its the clinic, the pharmacy and the payer, as well as transactions arising from ancillary services.
The Rosetta Stone for Integrating Disparate Systems
How can this work? Previously disparate systems need to be integrated to improve patient care, reduce errors, gain insights into trends in clinical care and identify fraud, abuse and errors in claims before they are paid. The Rosetta Stone: intelligent analytics,which can turn terabytes of data into useful, actionable knowledge in nanoseconds.
The American Health Information Management Association issued a white paper in June 2005 to recommend automated coding software to enhance productivity, effectiveness and anti-fraud activities. The paper reports that when combined with the EHR, automated coding could streamline the way that healthcare organizations gather data and bill for services. When integrated and enhanced with intelligent analytics, the system could become a powerful tool for pre-payment and post-payment audits and predicting potential fraud; it could solve multiple problems simultaneously.
Evidence abounds for advancing the EHR and integration. It starts with studies showing that medical personnel dont have the time to fill in all the boxes on claims. Some claims lack detail because they are simply linked to a percentage of payment. As with financial transactions, validity of the information on the bill or claim will be important to payment integrity and the most important long-term goal of our healthcare system: improving patient care.
Examples From the Financial Sector
Establishing integrated, highly efficient systems has been a proven benefit to the financial sector, which has standards for electronic transactions around the world. You can be in Kuala Lumpur and get cash from a bank in California, plus be alerted to potential fraud if the transaction doesnt fit your profile and history. The same approach can work in healthcare with EHRs managing every claim as a detailed, data-rich transaction that fits into a bigger universe of many other transactions just like it, all being constantly analyzed for appropriateness, new trends and aberrations.
Pharmacies are already at the forefront of this evolution because they operate in the closest thing to a credit card-like system. In this environment, analytics can intercede during the rapid authorization process to prevent fraud. Also information captured on the pharmacy side will be a core element in representing the patients condition to any provider, anywhere, when accessing the EHR.
Dire Need for Consistent Information
Connecting for Health, a public-private collaboration that was launched in June 2002, notes that the current system is economically inefficient and clinically dangerous. It says that emerging technologies offer an unprecedented ability to provide accurate and actionable medical information in a secure and private format when and where it is needed whether by patients themselves, or by the clinicians who care for them.
Access to consistent, quality information can also have a positive impact on improved adherence to prescription regimens, another potential area for proactively controlling costs while reducing human suffering. Studies by the Case Management Society of America note that more than half of all Americans fail to follow their prescriptions, which can decrease the quality of their lives and life spans while increasing healthcare costs throughout the system (e.g., the annual cost of a prescription versus the cost of bypass surgery). In fact, nonadherence to prescriptions costs the U.S. healthcare system some $100 billion a year. Studies by the American Heart Association estimate that non-adherence causes more than 125,000 deaths in the U.S. each year among those taking cardiovascular medications.
Avoiding Deaths From Medical Errors
The Institute of Medicine notes that up to 98,000 people die in hospitals each year as the result of medical errors. Elderly U.S. patients are prescribed improper medications in about one out of every 12 physician visits. More than 57,000 Americans die needlessly each year because they do not receive appropriate healthcare (different from medical errors or lack of access) according to a study from the National Committee for Quality Assurance.
Moreover according to the Institute of Medicine, more than 500,000 people are injured annually in the United States due to avoidable adverse drug events. The institute stresses the importance of linking medical records electronically to ensure more prompt and accurate diagnoses, more appropriate treatment decisions and the avoidance of adverse consequences. This will become increasingly important as the population continues to age and patients begin to see multiple providers with more frequency.
Fraud on the Rise
Estimates of annual losses resulting from all types of healthcare fraud are staggering, and range from 3 to 10 percent of national healthcare expenditures. This translates to $54 billion to $179 billion based on 2004 expenditures of $1.79 trillion projected by the Centers for Medicare & Medicaid Services. In 2002, the Office of the Inspector General of the U.S. Department of Health and Human Services identified $12.1 billion in fraudulent claims paid by Medicare. The system will see additional costs after Jan. 1, 2006, when Medicare Part D of the Medicare Modernization Act becomes effective, making voluntary prescription drug benefits available for the first time to more than 40 million Medicare beneficiaries.
The Benefits of Integration and the EHR
If we integrate the clinical side, pharmacy, payment histories, financial models and other forms of relevant data, the richness of the information will provide benefits and positive results on every front: patient treatment and satisfaction, medical reimbursement, transaction accuracy, best practices and reduced fraud.
The Center for Information Technology Leadership estimates that the use of electronic systems for ordering medicines could deliver national savings of $86.8 billion annually after full implementation and would result in significant direct financial benefits for providers and other stakeholders.
The Journal of the American Medical Informatics Association estimated that the use of electronic systems for ordering medicines has already reduced the incidence of serious medication errors by 86 percent. Intelligent analytics, with pharmacy data, can help monitor the regimen to ensure its appropriate. It can also detect suspicious activity and billing and policy errors in pharmacy claims at the point of sale, prior to payment or immediately after payment.
The benefits will even translate to favorably impacting one of the more frustrating aspects of visiting a provider: having to fill out a detailed patient history on a fifth-generation photocopy of a typed form with each new visit while having to retell your story to multiple people as you work your way through the doctors office or hospital.
The Bigger Fraud, Abuse and Errors Issue
The EHR and integrated systems will enable the analysis of millions of interactions in a fraction of a second, using both incoming and historical data. Neural networks can then create a multidimensional picture of the healthcare and pharmacy delivery system. Users can quickly identify fraudulent activity, including fraud types that previously could not be detected, new and unknown fraud patterns as well as subtle and complex trends by looking at each claim in relation to deep contextual information, such as the patients and providers histories. For example:
- Wrong tests (e.g., pediatrician giving an allergy test; OB/GYN running a prostate-specific antigen test);
- Double dipping (two bills for the same patient on the same day or consecutive days);
- Upcoding (an expensive procedure not indicated by the patient history);
- Nonstandard procedures (hemorrhoidectomy by a dermatologist); and
- A prescription that doesnt tie into the diagnosis and patient history.
The History of Advanced Decisioning Systems
Advanced analytics has been used in a number of industries for decades. One of the more successful applications today is the detection of fraud in the financial services industry.
Credit card fraud is perceived as a huge problem, yet the use of advanced analytics has reduced annual losses to $788 million, which is dwarfed by healthcare fraud, totaling an estimated $54 billion to $179 billion a year. The technology leaders in healthcare, including payers, understand the potential return on investment and have started using an adaptation of the software that proved so valuable in spotting and stopping credit card fraud. Since this decisioning technology is highly evolved, success is coming quickly; case studies are emerging that demonstrate positive results in detecting fraud in the more complicated and intricate world of healthcare reimbursement.
Saving Money Throughout the Claims Process
Fraud, abuse and errors occur in every aspect of the healthcare system: hospitals, doctors offices, laboratories, dental facilities and pharmacies. A doctor may get away with billing twice for the same surgery on the same patient in the same day, for example, or a dentist may abuse the system by filling cavities on perfectly healthy teeth or dentures. But with adoption of an EHR standard, organizations armed with the latest intelligent software can combat such deviance with dramatic, cost-saving results.
Healthcare payers using advanced decisioning applications find themselves a step ahead of the game. Once data analysis is performed by the system, claim outcomes appear in the form of scores, each coming with explanations to justify the score. Claims adjusters, fraud investigators, case managers and other personnel are able to focus their review on claims with the highest likelihood of fraud, abuse or error. Scoring criteria and thresholds can be used to automatically determine the priority given to individual claims. This allows healthcare payers to operate more efficiently from a personnel standpoint in addition to reducing costs lost to fraud, abuse and errors.
Advanced decisioning systems really flex their muscles through profiling technology. The profiling technology compresses terabytes of claims and claims-related data into essential informational packets, allowing predictive models to perform detailed analyses of such information in a matter of seconds. And since the profiling technology is dynamic, the system is able to detect fraud with increasingly greater accuracy over time and with additional aggregate data, giving organizations a greater opportunity to catch fraud, abuse and erroneous claims before the checks are cut. As a result, the most advanced payers employ both prepayment and postpayment analytics and watch the benefits flow to the bottom line.
Prospective and Retrospective Detection
Systems should be both prospective and retrospective to ensure the reduction of healthcare fraud, abuse and erroneous payments in all stages of the claims process. Used in a number of cutting-edge business applications, such as airline security and infectious disease control, predictive models are able to discover patterns and discern otherwise cryptic relationships among complex data.
Once claims are already paid, the time, the effort and expense needed to attempt to recoup losses from fraud rise exponentially. So its in the best interest of healthcare payers to detect such claims before theyre paid, whenever possible. And with advanced decisioning systems, claims that are most at risk for fraud, abuse or error can be quickly detected with very high accuracy.
Advanced analyses enable healthcare payers to reap extraordinary benefits after payment as well. The intelligent processes of these analyses enable organizations to successfully review suspicious providers without expending laborious hours chasing red herrings. And when payers utilize post-payment analysis, they are able to detect fraud thats only apparent over time, and not necessarily detected in smaller data sets.
Industry-Specific Detection
Advanced decisioning systems can expertly analyze claims for fraud or error from every part of the healthcare sector, including medical, pharmacy and dental. Predictive models then allow organizations to detect unusual medical practices and charges that are inconsistent within a given peer group, so orthopedic surgeons are compared to and against one another, oncologists to other oncologists, chiropractors with other chiropractors. A sophisticated blend of predictive models and expert decision logic are used to understand a providers practice patterns to determine the appropriate peer group for comparison. In one case, advanced analytics discovered a psychiatrist seeing 112 patients in a single day for 75-minute procedures and a total of 140 billable hours in one day.
Benefiting the System
As validated by an increasing body of evidence, every positive step taken to adopt the EHR and integrate it into other elements of the data universe of our healthcare system will generate positive outcomes at every link in the transaction chain. Payers will succeed in cracking down on fraud. The system will run more smoothly and efficiently. The cost savings to payers will enable more affordable coverage plans and reduce costs to employers while improving quality of care.While advanced information technology programs and analytic tools have been used successfully for years in other industries, now is the perfect time for organizations throughout the healthcare continuum to agree on their own IT standards, starting with the EHR, automated coding and advanced analytics.
