No wound center is an Island

1
No wound center is an Island

• Part of pharmacy
• Part of medical staff
• Part of materials management
• Part of housekeeping
• Part of Infection control
• Part of risk management
• Part of quality assurance
• Part of business office
• Part of claims processing
• Part of medical records
• Part of patient access/registration

2
Why wound centers fail

• Wound centers fail because of LACK OF INTEGRATION
• Inward within the facility
• Pharmacy
• Physician to physician
• Lack of integration outside of facility
• Local care givers
• Nursing homes
• Social services
• LTACs
• Case managers

3
The Typical Management Company approach

• Sets you up as an outpatient tertiary
  department
• Hopes to reduce hospital in-patient length of
  stay by providing treatment options for
  discharged patients
• Hopes to benefit surgeons by getting patients out
  of global fees

4
How to Create a Doomed Wound Center

• Minimal attempt at integration into the rest of
  hospital in patient and outpatient services and
  the community
• JCAHO does not like islands of care
• Hospital inpatient and outpatient services NEED
  to be integrated across the entire service line

5
A few things you need to open a wound center

• Business Plan development
• Feasibility Study
• Layout and floor plan, Blue prints and specs,
  safety guidelines
• Training, handbooks, library references
• Physician Billing guidelines
• How to set up your clinic charge master
• To do this you must know how the service rendered
  to the patient will be transmitted into a
  computer system which generates charges in
  relation to financial cycles (this is unique to
  every hospital)
• Wound center facility billing guidelines from all
  third party payors
• Economic realities of various wound care products
  and services
• Staffing models
• Staff training in processes and methods
• Policy and Procedures, integrated into your
  hospital setting
• Formulary
• Inventory Development (many unique issues for
  wound care products)
• Housekeeping issues unique to hyperbarics and
  wound center
• Specific Human resources issues
• Staff education
• Marketing plan
• Data management

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How Are you going to Integrate all these
things????
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And there is another storm on the way
The Perfect Storm of Facility Reimbursement
8
Background

• Federal Register, 4/7/2000, Medicare Prospective
  Payment System for Hospital Outpatient
  Departments
• Codes 99201 5 and 99211 5 were to be used by
  non-Emergency Departments.
• . . . . each facility should develop a system
  for mapping the provided services or combination
  of services furnished to the different levels of
  effort represented by the codes.

9
Facility Billing by Time

• Pros
• Simple system to develop.
• Fairly easy to calculate.
• Cons
• Inadequate surrogate as a measure of work.
• Rewards inefficiency.

Then Medicare Announced its plan in 2005 . . .
.
10
CMS Proposed Plan Wound Size
Playing Card, 56.45 cm2 Approx. Level 3
Level Two 25.1 cm2 to 50.0 cm2
Level One 0 cm2 to 25 cm2
Level Three 50.1 cm2 to 8
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Billing by Wound Size

• Pros
• Simple system to develop.
• Fairly easy to calculate.
• Cons
• Inadequate surrogate as a measure of work in non
  ER scenarios.
• Does not relate to actual work involved in
  providing care.

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How big are wounds?Average Wound Size by Type in
5,108 visits
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What would have happened if these 5,108 Visits
were billed by Wound Size as Proposed by CMS?

• Level 1 89.42 4,589
• Level 2 4.42 226
• Level 3 6.16 310

14
Acuity Scoring System Components (all the stuff
you do for which there is no procedure code)

• Method of Arrival (ambulatory/stretcher)
• Additional Resource Utilization (isolation,
  translator)
• Patient Assessment (history, general physical
  exam, risk, etc)
• Patient Process (coordination of care, education)
• Problem Focused Activities
• Wound Care (measuring, dressing application)
• Edema Management
• Ostomy
• Other Focused Interventions
• Diabetes Management
• Nutrition
• General Procedures (injections, cast removal)
• Testing (hand held Doppler, culture, blood draw)
• Departure Instructions
• Departure Disposition (to home, to ER, etc)

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Billing By Acuity Score

• Pros
• Actual measure of work performed
• Yields a normal data distribution
• Integrates well with an EMR
• Punishes inefficiency
• Cons
• Difficult to calculate by hand
• No consensus guidance on relative value of points

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How Would the 5,108 visits have been billed if
Acuity had been used? A Normal Distribution
Curve
Level 1 0 35 Level 2 36 65 Level 3 66
125 Level 4 126 155 Level 5 156 200

• Mean 95.6
• Standard Deviation 30.0
• Correlation Coeff. 0.881

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Data Analysis Summary

• We agree with CMS that time is not a surrogate
  for work
• Data analysis clearly shows that wound size is an
  equally unrepresentative method for measuring
  work and will result in over 85 of wounds being
  billed as Level 1
• An acuity scoring system is a more accurate and
  reproducible method of measuring actual work

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What does that mean for wound centers?

• Facility reimbursement will change
• Will likely be based either on wound SIZE or on
  some as yet to be determined scoring system
• DOCUMENTATION will be more important than ever
• Despite the burdensome documentation, the
  alternative is 89 Level 1 visits!
• The Alliance of Wound Care Stakeholders has
  recommended that CMS adopt the Intellicure Acuity
  Scoring system for Facility Billing and many
  wound centers are using it now, either
  calculating by hand or in the Intellicure EMR

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Would you like to do this by Hand?

• Not only would you have to fill in this sheet on
  every patient, but you would have to have all the
  documentation to support whatever you filled in!
• However, an EMR would automate this so that the
  acuity scoring is built in!

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Documentation Challenges

• Documentation quality varies among wound centers.
  
• Quality of care varies among wound centers
• Dependent on experience of staff
• Delays in implementing HBOT, VAC, etc.
• Suboptimal Revenue Physician and Facility
  revenue is dependent on documentation and quality
  of care.
• Changes in Reimbursement on the horizon. . . .

21
Problems in Delivery of Care (not unique)

• Inconsistent Care
• Quality of care dependent on experience of
  practitioner
• CPGs can have minimal impact because they are not
  immediately available at time of care
• Delays in clinical decision making
• Negatively affects patient outcomes
• Negatively affects revenue (fewer HBOT
  treatments)

22
How can we improve Quality?

• Physicians cannot keep track of everything they
  need to do for every patient.
• We must have a systems approach to help reduce
  errors, improve care, and prevent patients from
  slipping through the cracks.
• We must have data systems to help us.
• We must reduce errors, reduce hassle, reduce
  cost, improve care, and improve efficiency.
• HOW CAN WE ACCOMPLISH ALL THIS?

23
Improving Performance and Quality

• One approach chart review
• VERY labor intensive
• Sort of punitive (punish poor performance)
• Try harder to educate
• Another Approach Quality Improvement
• Works to a point
• Labor intensive
• Limited application can usually only tackle one
  problem at a time

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Paying for Quality

• There are over 100 programs involving health
  plans and medical groups covering 10s of
  millions of patients, all basing reimbursement
  strategies on QUALITY of CARE.
• Medicare is implementing Pay for Performance
  which it calls, The right care for the right
  patient at the right time.
• It is likely that in 10 years, the majority of
  providers will not pay by procedure or encounter,
  but for OUTCOME.
• How can wound centers on this wagon?

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How Do These Programs Work?

• Doctors install Electronic medical Records
  systems in their offices.
• Carriers and physicians decide on parameters to
  follow (e.g. of diabetics who get a HgbA1C).
• Medical information is transmitted to the
  Carriers from the Doctors Office.
• Carriers reward the physicians for providing the
  care that was agreed upon.

CMS
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What is the Solution?

• What tool can STANDARDIZE facility DOCUMENTATION?
• What tool can STANDARDIZE physician
  DOCUMENTATION?
• What tool can automate quality assurance and
  benchmarking?

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All of these Issues Can be Fixed with the SAME
Tool

• What is it?

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EMR, the Emerging Medical Requirement

• EMRs are not a luxury in the 21st Century, they
  are a REQUIREMENT.
• Estimated that in 10 years all medical records
  will be electronic

29

• Healthcare Information and Management Systems
  Society
• Provides leadership for the optimal use of
  healthcare information technology and management
  systems
• Frames healthcare public policy and industry
  practices

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EHR Attributes andEssential Requirements

• Provides secure, reliable, real-time access to
  patient health record information.
• Functions as clinicians primary information
  resource (i.e., it is THE medical record).
• Assists with delivering evidence-based care
  (i.e., CPGs).
• Captures data used for continuous quality
  improvement, utilization review, risk
  management,
• Captures the information needed for
  reimbursement.
• Can support clinical research, public health
  reporting, and population health initiatives.
• Supports clinical trials and other research.

If a system cannot do ALL of these things, it is
NOT an EMR.
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Web Based EMR
PatientEncounter
FaceSheet
Communication to Referring MD, DME Home
Health Pharmacy
E H R
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Web Based EMR

• Is it the Clinicians Primary Resource? (HIMSS
  definition)
• Where are the legal medical records in a Web
  based system?

Hospital



Wound Center Paper Chart
Wound Photos
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Steps requiring Human Interaction
H
H
H
PatientEncounter
FaceSheet
H
H
H
H
?
Communication to Referring MD, DME Home
Health Pharmacy
H
H
H
H
Human Interaction
34
Web Based EMR?
Who is this guy?

• Systems are 99.9 reliable and available in
  real-time.
• A snapshot of the internet traffic across the
  world shows that much less than 99.9 of data is
  reliably transmitted on the internet.
• At this time, hospital IT department Record
  Custodians will not allow web-based EMRs.

35
Web Based EMR

• 128 Bit Data Encryption Security?
• Lack of adequate security is another reason why
  hospital IT departments will not allow Web based
  EMRs.

36
Surveillance withWeb Based EMR
PatientEncounter
FaceSheet
Communication to Referring MD, DME Home
Health Pharmacy
Standard reports obtained from Vendor quarterly
E H R
Where are the CPGs in this system?
37
Can a Web-Based System Qualify as an EMR by the
HIMMS Criteria?

• Real Time, point-of-care? No.
• Not if the data is not entered IN THE ROOM at the
  time you are seeing the patient.
• Reliable access? No.
• The Internet does not meet reliability standards
  for EMR
• EMR must be the Clinicians Primary Resource
  No.
• The medical records are in several places with a
  Web-Based system,
• Not unless ALL health information is collected.
• Assists with Evidence Based Care No.
• If the system does not provide evidence based
  help with management at the time the doctor sees
  the patient, it is not an EMR
• Automates workflow? No.
• There are many manual steps using a Web-Based
  System.

38
Is there a Wound Care Specific Program Which DOES
Qualify as an EMR?

• Yes.
• There is a wound care specific software program
  which meets ALL the HIMMS criteria for an
  Electronic Medical Record.
• That is why it is NOT Web-based.
• You control your own data, which can be accessed
  any time from servers in the clinics, and ALL
  medical information is collected.

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How Does Intellicure the EMR Work?

• Data collected at point of service, during
  patient encounter
• All clinical information is entered (physician
  and nurse)
• Not retrospective (like programs where selected
  information is entered later)
• Paper charts are not necessary (can print out the
  documents if desired). The actual medical record
  is ELECTRONIC.
• This electronic record then generates ALL other
  clinical documents (nursing orders, physician
  letters, etc.)

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Nursing Notes
41
Document Automation
Your Wound Center
Your Wound Center
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Physician Communication

• NOW

• BEFORE

Your Wound Center
43
Intellicure and Facility Billing

• Intellicure designed the Acuity Scoring System
  Adopted by the Alliance of Wound Care
  Stakeholders
• The Alliance proposed that CMS adopt this method
  for facility reimbursement
• The Intellicure EMR automatically calculates the
  Acuity Score during the visit
• Should CMS adopt a similar system, calculating
  this by hand will be very burdensome
• Only Intellicure is prepared now for a change in
  Medicare policy.

Capturing charges by hand, for all you really do
for a patient, will be burdensome
44
Medicare andPhysician Billing

• Payment for Evaluation and Management Codes (E/M)
  determined by complexity of care
• Complexity based on key components (History,
  Physical Examination, Medical Decision Making)
• 1997 Rules in 42 page document published by CMS
• 6,144 possible combinations for a visit
  
• EMR becoming the method of choice for most
  doctors because the decision making is so
  complex.
• Intellicure calculates the Physician level of
  service during a wound care visit.

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Physician Billing Intellicure Calculates It
46
Report Automation
47
Intellicure EMR
Patient Encounter Point-Of-Service Documentation
CPGs
HL7 Interface IN Demographics, Labs,
Allergies OUT Documents
Hospital Registration
48
Performance Improvement Analyze That (i.e.,
anything)
Goal 1 Improve the accuracy of patient
identification. Goal 2 Improve the
effectiveness of communication among caregivers.
Goal 3 Improve the safety of using medications.
Goal 8 Accurately and completely reconcile
medications across the continuum of care.
49
Intellicure EMR The Dividends

• Facility Billing
• Physician Billing
• DME orders
• iHealthRecord
• Quality Assurance
• Pay for Performance (Medicare)
• Data Analysis

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EMR is THE ANSWER

• The Answer to QUALITY of documentation
  (completeness, legibility, consistency)
• The Answer to quality of MEDICAL CARE (CPGs
  integrated in to EMR means consistent care)
• The Answer for SURVEILLENCE of care (automated,
  real time)
• The Answer for tracking and improving OPERATONAL
  EFFICIENCY
• The Answer for DATA ANALYSIS (research and
  marketing)
• The Answer for securing REIMBURSEMENT

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EMR and Wound center functions
Nursing documentation
Product Efficacy
Supply ordering
CPGs/Best practice
Clinical Research
EMR
Facility billing
Physician billing
Outcomes analysis
Management reports
Benchmarking
Physician documentation
Photo Archiving