Protecting Identity in the New Digital Age

Now that HITECH has been able to increase the adoption of electronic medical records (EMRs), the focus is on interoperability. The market has been flooded with various EMR and PM (practice management) systems but how do they communicate? The challenge of interoperability is being addressed aggressively as we go into Meaningful Use Stage 2 and Health Information Exchanges. However, according Jitesh Chawla, MD the piece that might be forgotten is maintaining patient privacy in this new digital age.

As the nation progressively implements electronic healthcare records, stakeholders have uncovered an elephant in the room – how to implement patient identity and integrity solutions. Linking an individual’s electronic health records across disparate systems, many suggest, will more likely than not require a unique patient identifier. Yet from a policy perspective, implementing this identifier has been extremely difficult. Medical banking, or the convergence of banking and heath IT systems, is spawning new ideas that could impact this difficult area. New forms of efficiency in payment processing may yield a technology platform for managing digital identity by banks that could also be used for healthcare.

Click on this link to read the rest of the article.

Then please post comments and join Dr. Jitesh Chawla for an interesting discussion on this topic.

Dr. Jitesh Chawla reviews smoking cessation trials

Dr. Jitesh Chawla's clinical trial research shows that the first anti-nicotine vaccine to enter Phase 3 clinical trial, NicVax, was in it’s the last stage of testing before hitting the market. The product works by inciting the immune system to produce antibodies that bind to nicotine in the bloodstream, much as antibodies would attack an invading microorganism. Once bound, the nicotine cannot cross the blood-brain barrier to enter the brain. It is the neurotransmitters in the brain that cause chemical reactions leading to addictive behavior. The vaccine was therefore expected to diminish the pleasure of smoking and make it easier to quit. Unfortunately, the failure of the vaccine serves as major set-back to harness the immune system’s power to fight additions such as tobacco abuse.

Figure 1.
Trial paper posting by Dr. Chawla

Nevertheless, Micro-electric  current therapy shows a lot of promise. In one trial studied by Dr. Jitesh Chawla, 1,000 cigarette smokers treated between July 2006 and January 2008, 972 (97.2%) lost their craving for cigarettes within 1 to 5 minutes into a 20 minute session of CES. In those who were in the process of quitting and often at the height of their withdrawal symptoms, cravings started to diminish within 2 minutes of initiating CES and usually disappeared within 10 minutes. Several were 2 or 3 weeks into quitting and still experienced craving.

There may be many reasons for the difference between success and failure including the solidity of the product, trial design, lack of capital, tough FDA reviewers but clinical trials. Even after successful trials and FDA approval some smoking cessation products, like the Nicotrol Inhaler, are not adopted well, as the side-effects and limited efficacy with mediocre outcomes serves as a stumbling block. It is time to try something new. Micro-electrical current therapy has a different mechanism of action than any other therapeutic agent for smoking cessation, currently in the market, and is worth a shot. Next time you are searching for a new doctor make sure he or she keeps up with latest research regarding medical treatments for important common problems such as nicotine addition.

Also, keep following this blog for more exciting clinical trial news from Dr. Jitesh Chawla.

Medicaid Expansion Debate

Dr. Jitesh Chawla felt from the outset that the Medicaid Expansion effort part of the Affordable Care Act was going to be an uphill battle.

The 26 states have refused the are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion.Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

Dr. Chawla found out the North Carolina practices who take Medicaid didn’t really even much of an opinion of the expansion in the first place. In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.
“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.
The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.
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Post comments and join Dr. Jitesh Chawla for the discussion on this important topic.

Viewpoints about Doctors' Salaries

Really, how many porsches do you need?" has been a popular motto among proponents of Obamacare in response to objections by physicians at the possible pay cut brought on by the bill. This is a fair statement as most anyone would agree that if you are wanting to become rich, a medical profession is not the best option. However, physicians do have a reason to gripe in this case. After 4 years of med school and the loans that one can accrue over this period and the gigantic liability that a practicing physician faces, one would expect to be compensated at least enough to be able to pay off these fees once their residency is completed.

There have been many politically slanted opinions about the effect that Obamacare will have on doctors' salaries. Many in the medical profession are left wondering, "Will I be able to pay off my student loans?...Will I be seeing twice as many patients for half the amount of money and provide a lesser quality of care?" No one an really say for certain what will happen until the bill is fully implemented.

Many people fear that pay cuts will dissuade potential physicians from attending medical school and cause a great shortage of doctors in our nation. I think the best way for us to navigate this topic is to look at what the bill will do in theory to your salaries, without a political slant. First of all, it is important to understand what the goal of Obamacare is. It's goal is to lower costs of the American Healthcare system without lowering the quality of care. It resembles a European style of healthcare, and in this type of system, physicians make less money on average. In an issue of the journal, Health Affairs, the amount that French primary care physician makes was compared to what an American one makes.

PCP's in the United States on average netted around $186,000 while a comparable French doctor made $95,000. How will Obamacare affect the American pay? Well it is widely stated that the bill will cause physicians to be reimbursed at a lower than market rate for Medicaid. In other words, lower than what they are being paid now. This could spell doom for specialists such as general surgeons, who see many Medicaid patients for surgery.

With the lower pay an inevitability many believe that physicians will have to see a larger volume of patients to make the same amount of money that they do now. Many comment that this will cause a large decrease in care as doctors will rush to see as many patients as they can in a shift. We will continue to look at this issue in the coming weeks with more specific examples of how the ACA will affect you.

Health Insurance Exchanges

The Affordable Healthcare Act may have not only changed the United State's  healthcare system forever, it also may have changed the insurance industry  forever.  The implementation of so called health insurance exchanges, or HIX for short, have helped change the industry forever.  The model is a consumer based  approach, where customers will be able to shop for the best insurance plan for  them.  President Obama focused on allowing states to set up the exchanges  instead of a blanket approach that would make one exchange for the whole  country.

Ideally, the concept will allow people with preexisting conditions to be denied  insurance.  Customers will have to satisfy a smaller amount of conditions in order  to receive insurance.  Lawmakers envisioned this change as a system in which citizens will be allowed to have the same type of variety that members of  Congress have in shopping for their health insurance.  At this point you may be saying, "Great, now how in the world will they  implement this and what does this mean for me?" Let's try to answer this  question! The exchanges can cover a whole state or be broken up in to smaller exchanges in one state.  For instance a state like California may have a Southern  California exchange and Northern California exchange.  As long as the exchange covers a certain geographic area they will be allowed to operate.

States can also partner with other bordering states to create an exchange. As for how the exchanges will be run and affect you, the consumer, lets look at the car insurance model. President Obama has repeatedly compared these  exchanges to car insurance purchasing.  People living in an area that has a HIX  will be able to compare plans online and buy which ever one fits them the best.

There will different levels of coverage, given a gold, silver, or bronze designation. Only companies meeting the standards set forth by ACA regulations will be able  to sell their insurance plans.  According to www.obamacarefacts.com, this alone  will lower insurance premiums 7-10 percent. 

Listed below are the criteria to be  an ACA-approved insurance plan.

All plans must include:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and rehabilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

We have yet to see if these will in fact work in the United States.  In theory,  they sound like a great idea and that they will allow for variety in insurance  shopping.  The hope is that more people will be able to become insured in the  long run.

Mobile healthcare

 

            If you have been in a doctor’s office lately you may have noticed your physician grasping an iPad or some other tablet.  What you have seen is a new trend in the medical field in which health care providers are incorporating technology into their practices. Along with electronic medical records, the practice of medicine, much like most things in our world, is going digital.

            The hope associated with this trend is the fact that medical practices can become more efficient and cost effective in the long run.  The days of paper charting may be a distant memory in the upcoming years.  According to a survey done by Manhattan Research in 2010, 72% of physicians responded saying that they use mobile devices in their practice.  The report also went on to say that the number will only rise in the future. 

In what capacity these physicians are using the devices in their practice is undetermined, but it is safe to say that technology companies have taken note of the possible new market that they can tap.  Companies such as Apple and Dell are currently in the process of developing mobile devices that are equipped with specialized EMR apps.  Many hospitals have already ordered these devices and are hoping that they will someday replace the infamously bulky and awkward computers on wheels. One hospital that has bought in to the technology is The Ottawa Hospital, which services over 1.5 million people in eastern Canada.  The hospital ordered 500 iPads specially tailored for EMR to a portion of its over 1,000 physicians recently.

            EMR is a new trend that has caught in many parts of the country.  Physicians can now chart physical exams and check patient histories and labs virtually instead of logging through stacks of paper. Though paper charting will probably never be extinct, the advantages of getting real time lab results and radiology right at a physician’s fingertips are astounding.

So how exactly will EMR and mobile devices change healthcare? The question is very broad and has many answers.  One answer is that of accessibility. On one iPad a physician can pull up a patient’s labs, radiology, and medical history without leaving the bedside.  This allows for a large cut down on the time it takes for a physician to give a diagnosis on a patient and places the patient’s information in one place.                        

                                              Photo Courtesy of www.macris .com

            From the information we can gather so far, it is safe to say that a majority of clinicians support using some sort of mobile device and EMR in their practice.  However, there are some limitations to relying totally on this technology in a practice.  Tablets are not the best tool for writing long summaries. In terms of sitting down and writing a long history on a patient or physician’s note, the classic PC is hard to beat.  Though there are some limitations to what tablets can help health care providers accomplish in a clinical settings, the pros definitely outweigh the cons.

            With the dawn of these types of technologies, the days when physicians view x-rays on through standard fluorescent light in a darkened dictation room may be few and far between. The prospects on the amount of time that can be saved from using mobile devices and EMR are very large.  As is the trend in the practice of medicine, the science is always evolving to fit the needs of the patients more efficiently and cost effectively.

Role of EMRs in Accountable Care Organizations

As the final rule on ACOs ( Accountable Care Organization) has come out, it is apparent that that the value that EMRs (electronic medical records) bring is unprecedented.  Under the Medicare Shared Savings Program, ACO participants (which may include medical practices, hospitals and payers) are graded and paid based on 4 domains of care quality: 1) patient experience;  2) care coordination and safety;  3) preventative health; 4) at-risk populations.  The program consists of a 3 year performance period in which the performance of the ACO mapped against thresholds set by CMS. To reap financial benefits from this program, providers must report on 23 of 33 quality measures spanning these 4 domains during the second year and 33 out of 33 in the third. Some of the measures, like # 20, which asks for the percentage of providers that have received Meaningful Use money are easy to satisfy if you have a Certified EMR.

ACO participants are incented to work together and efficiently because if they don’t meet the CMS thresholds they must pay money back. Data is key when trying to coordinate care and the exchange of clinical data must be done properly to meet the quality measures set by CMS.

Now it must be apparent to medical providers that if they want to join an ACO it is very important that they are comfortable using an EMR. The good news is that there are certain features of the software that allow providers to capture the necessary data for ACO quality measures easily. For example, in the Preventative Health domain there are measures such as Adult weight screening and follow-up and Tobacco Use Assessment. Both of these are Meaningful Use criteria and any certified EMR has screens and buttons to record this information. 

In another example, the domain of at-risk population contains a diabetes composite measure in which the number of diabetics who BP is less than 140/90 must be recorded. To do this, it may necessary to setup a report in which there are fields to search for a patient’s diabetic status and their blood pressure level concurrently. For instance, in Patagonia Health’s EMR, there is a section called “My Reports” where users can fully customize search criteria for certain disease conditions, procedures and demographic characteristics.

Finally, the exchange of health information between providers and entities requires ability for the system to send and receive data securely and in a format that the receiving end would be able to decipher. Exchange of clinical data is a Meaningful Use criterion and is done through CCR (care of continuity record) which generates a summary of the usually about the patient’s medication, laboratory, immunizations, provider names, vital signs, alerts. Providers simply need to press the CCR button and it generates a file. This file can then be sent in encrypted format through email currently (and through Health Information Exchanges later) to the other provider’s EMR.

EMRs have become a powerful tool that has empowered medical providers to collect the necessary data in order to provide medical care with a sense of accountability and level of quality in the form of an ACO. The Meaningful Use Program has further enabled different EMRs to have the standard features important for this data collection.

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Jitesh Chawla MD discusses the HIPPA Rule

Dr. Jitesh Chawla feels that in order to stay away from nasty trial lawyers and draining courtroom or legal cases or criminal charges, all providers should know the basics of the HIPPA (Health Insurance Portability and Accountability Act) rule.

Covered Entities

HIPPA contains the Privacy Rule whose goal is to protect healthcare information, especially in this age of health IT where information is exchanged frequently and easily. The first step in learing about HIPPA is  to understand who HIPPA applies towards –called “covered entities”..

• Health Plans
• Healthcare Providers (this includes both clinicians and organizations)
• Healthcare Clearinghouses (process non-standard health info to standardized versions –common in billing claims)

Business associates are entities or individuals, other than the covered entities, that provide services on their behalf and may have access to protected health information either by use or disclosure. The covered entity will need to use a Business Associate Agreement in this case in order to comply with the Privacy Rule. But the next question is what is protected health information.

PHI (Protected Health Information)

health information that is individually identifiable health information is one, including demographic data, that relates to:

• The provision of health care to the individual
• The individual’s past, present or future physical or mental health or condition,
• The past, present, or future payment for the provision of health care to the individual
• Anything that can be reasonably used to identify the individual

Common examples include full name, address, birth date, Social Security Number. Even photos can be included as such information.

Hypothetical Patient Jitesh Chawla’s Photo (unauthorized sharing of this could be a violation of HIPPA in some circumstances)

Penalties for non-compliance

These are classified into different degrees of offense.

1) Not more than $50,000, imprisoned greater than 1 year, or both;

(2) If done under false pretenses, fine shall not exceed $100,000, imprisoned not more than 5 years, or both

(3) If the intention is to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or to maliciously harm another, cannot be fine more $250,000, imprisoned not more than 10 years, or both.

Tips to stay out of trouble

1) Abstain from talking about patients in hallways, elevators or where others not involved in care are there

2) If using an electronic medical record, log off the software or the operating system when not using

3) Don’t share PHI in emails, on voicemails or jot down on notes/stickies which can be picked up by others

4) If an organization, make sure all new patients are given HIPPA paperwork, employees sign confidentiality agreements while being hired and 3^rd parties you enter with sign Business Associate Agreements.

You can never prevent all bad situations, particulary in Health Care, but with this knowledge and advice Dr. Jitesh Chawla hopes that meeting trial lawyers or courtrooms for violation of the Privacy Rule is nothing but a bad dream for you.

Please check out my new video on Patient Centered Medical Home at:
http://www.youtube.com/watch?v=FqLH7w9efqI

Dr Chawla reviews Insurance Billing: How to Get Paid For It

Getting a claim paid really starts at the front desk. Make sure you get good information. Get copies of insurance cards, driver’s license or ID. Have your staff verify the patient filled out your patient registration form completely. Verify healthcare insurance and coverage.

Entering Demographic Information
I strongly suggest that the front desk NOT enter the demographic information into the computer system.

Why? Distractions are always there. They are so busy answering phones, checking-in /checking-out patients, and helping patients and physicians, that causes mistakes to happen easily. Just have them enter enough demographic info to make an appointment. Accurate information from the onset makes the claim process go smoothly and quickly.

Additionally, have a good financial agreement for the patient to sign. Most agreements I have seen are only a couple of sentences and are quite inadequate. Include in your agreement collection fees, interest, attorney and court cost. This way if you have to go after the patient for payment they are responsible for the additional costs of collecting what they owe. You may also want to include that they agree to pay for after-hours telephone advice, no-show fees, form fees, prescription refills, and walk-in fees, returned check fees and a billing fee if a patient does not pay their copay at time of service. A good financial agreement gives you the tools you need to collect patient balances.

Charge Posting of Encounter Forms
Along with your front desk not entering demographics and insurance info, they should also not post charges for the same reason, distractions. Charge entry should be done in a quiet location. A claim with the smallest amount of inaccurate data will hold up your payment. Also your nurses or medical assistants provide logs of labwork, sonograms, EKGs or other procedures so that your poster can cross reference the logs to the fee tickets to insure nothing is missed. With EMRs and advance of Health IT, this tracking should become much easier.

Teach your staff good practices from day one. The front staff is essentially in receiving the clinical and financial information that needs to be passed onto billing staff. If a certain protocol is established with best practices is established it will save you a lot of hassle in the long run. The next series of articles will focus on how to train/advise your clinical staff so that your claims get accepted and billing to insurance becomes a bit easier.

The unique EMR needs of Public Health

With the passage of the HITECH Act there is been an ever increasing push towards the use of electronic medical records (EMR). However, public health agencies have generally been slower to adopt for a variety of reasons. Also, their Health IT systems are often more outdated then the ones in the private, non-public sector. However, certain meaningful use rules, such as conducting syndromic surveillance and reporting to immunization registries, ask providers to communicate with public health agencies. Consequently, public health departments are under pressure to re-structure their technology platforms.

Public health has unique workflows which can have major implications for EMR vendors. To understand this it is important to explore how public health is different from medical care in doctors' offices or in hospitals.

1)      There is greater emphasis on population screening and treatment, resulting in separate clinics focusing on specific aspects of care provision – providing immunizations, conducting STD screenings, etc. Also, there may be many more staff involved, some of which play roles that are not present in outpatient practice.

2)      As part of their mission these organizations normally perform a community assessment at regular intervals. This helps to identify the rates of certain diseases in the community and can guide the deployment of conditions that are more prevalent. As a result the type of visits and demographic make-up of the patient panels can vary greatly over time.

3)      The type of data that needs to be tracked is such that epidemiological studies can be readily done on it (ie. incidence, prevalence, etc.).  

4)      There are certain forms that mandatory to use. One example is the use of Healthy Futures Pediatrics for pediatric physicals.

5)      There are unique situations where patients are seen in settings that are not typical for a doctor’s office. For example, a patient that has tuberculosis will be placed on home quarantine. The nurse will go there and obtain sputum samples and treat the patient with none of the interaction taking place in the clinic.

6)      Finally, there are specific reporting requirements by the State and Federal Government. This has implications on the type of and amount of data that needs to be collected. Also, there

As a result, the EMR vendor has to:

1)      Understand various different workflows, each specific to a particular clinic.

2)      Be able to work with a large number of users, some of which play unorthodox roles

3)      Incorporate data fields and a format to capture information that can be used for population reporting. The databases that are used should be able to store a large number of data points.

4)      Provide access to the EMR through a variety of mobile portals – phones, tablets, etc.

5)      Incorporation of or access to certain specific forms.

6)      Design reporting engines that can produce reports in a pre-defined format acceptable to the State and Federal Government requirements

7)      Ensure their product is highly interoperable and can regularly pass data back and forth from providers and to State Registries and between other organizations.

The EMRs that can successfully support public health needs have an architecture that allows need new programming code to be inserted readily without having to create a new. New features can be added through widgets that make it easier for the user to locate and utilize them.

The revolutionizing of Public Health IT infrastructure is a long-awaited milestone that is soon to pass and will improve the management of population health.   Dr. Chawla feels that this a trial period for these organizations.The Meaningful Use initiative has really started the ball rolling. The key is to use the right electronic medical record.

The Use of Electronic Medical Records for Clinical Trial Recruitment

By Jitesh Chawla, MD.

About EMRs

With the advent of  the HITECH Act and Meaningful Use, EMRs (electronic medical records) have become very popular among practicing clinicians. The technology enables medical providers to chart patient data into structured fields. This allows information to be easily retrieved for analysis and reporting. Another major advantage of the EMR is the ability to provide clinical decision support  (CDS). Rules can be set to alert or inform about patient clinical information that would affect treatment at the point of care. Rule parameters are configured on a settings screen and the rule is run on patient data captured in those structured fields. One example of CDS in action is an OB/GYN clinic that set for an alert to come up for every woman that was overdue on her PAP smear based on age, prior history of PAP abnormalities and family history of cervical cancer. EMRs and CDS can play a vital role in clinical trials.

Clinical Trial Enrollment

Clinical trials are divided into the following phases: 1) using healthy subjects to test for drug safety 2) using a larger group healthly subjects tested for drug efficacy 3) treatment and control groups involved in a randomized control trial 4) post marketing surveillance.  The enrollment requirements significantly increase in each phase (see table below).

Table 1. Typical Enrollment Estimates of Clinical Trials¹

Phase	Subjects Needed
1	20-100
2	100-300
3	300-3000

  Since clinical trials can account for at least 50% drug development costs, which may run up to 1 billion dollars per product, delay or cancellation of a trial due to inadequate or late enrollment is very costly². Once source cites a company lose from $600,000 to 8 million per each day a trial is delay³. Furthermore, with increased government regulations of the pharmaceutical industries and fierce competition, many drug companies cannot afford any major delays or a cancellation.

Challenges and Possible EMR Solutions for Trial Recruitment

Some reasons why recruitment and retention of subjects for clinical trials presents a challenge include:

1)Finding patients that meet the criteria and finding them quickly. The study design specifies very clearly who does and does not quality for trial participation. Also, requirements change based on the phase of study. These inclusion and exclusion criteria are very strict and need several levels of approval (ie. IRB, sponsor, investigator) before any exceptions  are made.

2)   Patient interest. Many patients may not elect to be part of a trial when they otherwise had there been better explanation about the drug being tested or condition being treated. Furthermore, some patients are just too scared to be part of an “experiment” and are not convinced by all the precautionary measures that trial staff explains they have taken.

The beauty of the CDS feature in the EMR is that each inclusion/exclusion criteria can be put as a separate rule. Furthermore, the patient reminders feature can cause a pop-up window to appear every time that rule is satisfied. Secondly, there is no better person than the patient’s provider to convince them that trying an experimental treatment might be the best option and that the benefits outweigh the risks. The relationship between provider and his or her patient is a unique one and cannot be replaced by any clinical trial staff member. EMRs have a patient education button that contains information about disease conditions and can be customized such that details about the clinical trial can be included.  Providers can go through the education sheet with their patients.

Conclusion

It is true that not all patients are suited for participating in clinical trials. Also, despite all the information and intelligence available at the point of care, some providers may choose not to use the EMR to help with trial recruitment. Nevertheless, the fact remains that clinical trial enrollment is a big issue and the EMR with its CDS and other features can help in this endeavor.

In the next article, I will go through an example of how a rule is set up in the CDS module of a typical EMR and give some real-life case study examples of organizations that have leveraged this technology to help them successfully recruit for their clinical trials.

References:

1) wikepedia

2) http://www.promodel.com/solutions/pharma/clinicaltrials.asp

3)  http://www.pdpipeline.org/2011/clinicaltrials/recruitretention.htm

What medical providers need to know about switch to ICD-10

Jitesh Chawla, MD. would be the first one to say this is a major "trial period" for fellow medical colleagues due to the ever increasing requirements from the governement.

Most providers of small practices don’t have the time or resource to fully understand how ICD-10 will impact them. In this article, I will explore this very important topic and provide suggestions for providers of how to prepare for ICD-10 compliance.

The intention behind ICD-10 is to provide a tool that would provide a more detailed, accurate code to match the actual diagnosis. As disease diagnosis has become more specific, ICD-9 codes appear to be obsolete and often don't describe the condition accurately.

The law states for all organizations covered under the 5010 electronic transactions version instead of the older 4010/4010A versions. If you are not familiar with this terminology, please check with your billing manger or practice management software vendor.

ICD-10 is divided into 2 areas: clinical modification (CM) and inpatient procedure coding system (PCS). Inpatient procedure codes are not affected. Outpatient codes are still represented under the current system. ICD-10 is more specific on anatomical location, specificity of diagnosis, etc. To put this into perspective, take for example, if a patient was had a furuncle (boil) on the face and went to the dermatologist. The same patient then returned a few weeks later and had a carbuncle. In ICD-9, the same code would be used which is 680.0. In ICD-10 (specificity of the condition) would be recorded. The furuncle would be L02.92 and carbuncle would be L02.93. Furthermore, ICD-10 would enable you to record which encounter (initial versus subsequent).

The basic structure of the ICD-10 code is:

Characters 1-3: the category, 4-6: cause of problem, body part affected, severity of illness, 7: Place for extension of the code

Some EMR systems have a connection with live database and so a switch to ICD-10 will not affect the users when picking a diagnosis for their note. However, with EMRs that don’t have this link to the live database, the issue is how to migrate the codes into the system. A strategy would be to use transition tables which provide the ICD-10 equivalent to the ICD-9 code since there is no way to convert the codes. ICD 10 Code Translator . Just plug in the ICD-9 code and it will convert it to the equivalent ICD-10 code. This provides enough relevant background for most people about ICD-10 and the issues surrounding it. Please be sure to examine the table below that compares ICD-9 and ICD-10 codes. For providers, health care staff

Bringing Wellness into the Doctor's Office

Wellness initiatives are generally administered by company physicians, wellness companies or disease management organizations.  However, one offshoot of the Accountable Care Act is the requirement of Medicare providers to devise a Personalized Prevention Plan for Part B Beneficiaries.  This is apparently in line with the law’s intent to foster greater preventative services for the population.  Prevention is a major theme in wellness.

The visit is coined as Annual Wellness Visit (AWV). Among the benefits include the fact that the provider will administer a HRA health risk assessment  which can uncover various risk factors that if addressed early enough can prevent disease.  

Sample HRA (link -www.prochange.com)

A second major benefit is that he or she will devise a 5 year schedule outlining which screenings and immunizations a patient needs. It can replace the Welcome to Medicare Visit as a requirement for Part B patients but you are not eligible for this until after 12 months of becoming a Part B beneficiary or within 12 months of IPPE (Initial Preventative Physical Exam). It appears that CMS has this because they want the first year to be a trial (Dr. Chawla's opinion). The only drawback is that the AWV doesn’t cover any physical exams.

This represents another step in empowering the provider to become the primary furnisher of preventative services and not someone who treats sicknesses.

The physician is in the optimum place to administer powerful tools such as the HRA, which when used with follow-up counseling, has been shown in studies to help providers pinpoint risk factors that are not found during routine visits.  Furthermore, prevention planning has been shown for years to help health departments and agencies such as the CDC improve outcomes for population. Government regulations or the lure of higher reimbursement from payers is often what it takes to start such transformation. In the next several years as health reform completely rolls out we will watching to see how “sick care” changes to “well care”

YouTube videos by Dr. Chawla site links -OpeEMR Scheduling and OpenEMR SOAP Note