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

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

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”

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

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• CPT coding review, chargemaster review• Benchmarking

How Are you going to Integrate all these things????

A few things you need to know 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• CPT coding review, chargemaster review• Benchmarking

And there is another storm on the way

The Perfect Storm of Facility Reimbursement

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.”

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 it’s plan in 2005 . . . .

CMS Proposed Plan – Wound Size

Level One0 cm2 to 25 cm2 Level Three

50.1 cm2 to ∞

Level Two25.1 cm2 to 50.0 cm2

Quarter, 4.44 cm2

Stamps, 22.44 cm2

Approx. Level 2

Playing Card, 56.45 cm2

Approx. Level 3

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.

How big are wounds?Average Wound Size by Type in 5,108 visits

Wound Type

Number of Wounds

Number of Encounter

s

Average Wound

Size

Arterial 22 111 7.15 cm2

Diabetic 66 1198 13.24 cm2

Post Op 98 1147 9.37 cm2

Traumatic 236 1671 16.72 cm2

Pressure 206 1519 5.38 cm2

Venous 237 2632 12.66 cm2

What would have happened if these 5,108 Visits were billed by Wound Size as Proposed by CMS?

-1000

0

1000

2000

3000

4000

5000

1 2 3

Level of Service by Wound Size

Vis

its

(n

= 5

10

8)

Level 1 89.42% 4,589

Level 2 4.42% 226

Level 3 6.16% 310

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)

Billing By Acuity Score

ProsActual measure of work performedYields a normal data distribution Integrates well with an EMRPunishes inefficiency

ConsDifficult to calculate by handNo consensus guidance on relative value of

points

How Would the 5,108 visits have been billed if Acuity had been used?

A Normal Distribution Curve

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100 120 140 160 180 200

Acuity Score

Vis

its

(n

= 5

10

8)

Mean: 95.6

Standard Deviation:30.0

Correlation Coeff.: 0.881

Level 1 0 – 35Level 2 36 – 65Level 3 66 – 125Level 4 126 – 155Level 5 156 – 200

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

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

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!

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. . . .

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)

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?

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

Paying for Quality

• There are over 100 programs involving health plans and medical groups covering 10’s 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?

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

What is the Solution?

• What tool can STANDARDIZE facility DOCUMENTATION?

• What tool can STANDARDIZE physician DOCUMENTATION?

• What tool can automate quality assurance and benchmarking?

All of these Issues Can be Fixed with the SAME Tool

What is it?

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

“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

1. Provides secure, reliable, real-time access to patient health record information.

2. Functions as clinicians’ primary information resource (i.e., it is THE medical record).

3. Assists with delivering evidence-based care (i.e., CPGs).

4. Captures data used for continuous quality improvement, utilization review, & risk management,

5. Captures the information needed for reimbursement.6. Can support clinical research, public health reporting,

and population health initiatives.7. Supports clinical trials and other research.

EHR Attributes andEssential Requirements

If a system cannot do ALL of these things, it is NOT an EMR.

PatientRegistration Patient

Encounter

Web-BasedEMR

RecordsCustodian

ScannerNon-Searchable

FaceSheet

Transcription

PaperChart

Dictation

HandwrittenNotes, Nursing

Orders

HandwrittenNotes, Rx

Labs, Orders

Communication toReferring MD, DME

Home HealthPharmacy

Web Based “EMR”Web Based “EMR”

Web Based “EMR”

Is it the “Clinician’s Primary Resource?” (HIMSS definition)

Where are the legal medical records in a Web based system?

Web-Based“EMR”

Wound Center PaperChart

+ + +

Hospital

Wound Photos

PatientRegistration Patient

Encounter

Web-BasedEMR

RecordsCustodian

ScannerNon-Searchable

FaceSheet

Transcription

PaperChart

Dictation

HandwrittenNotes, Nursing

Orders

HandwrittenNotes, Rx

Labs, Orders

Communication toReferring MD, DME

Home HealthPharmacy

HumanHumanInteractionInteraction

Steps requiring Human InteractionSteps requiring Human Interaction

HH

HH

HHHH

HHHH

HH

HH

HH

HH

HH

?

Web Based EMR?

“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.

Who is this guy?

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.

Surveillance withSurveillance withWeb Based EMRWeb Based EMR

CPGs?

PatientRegistration Patient

Encounter

Web-BasedEMR

RecordsCustodian

ScannerNon-Searchable

FaceSheet

Transcription

PaperChart

Dictation

HandwrittenNotes, Nursing

Orders

HandwrittenNotes, Rx

Labs, Orders Communication toReferring MD, DME

Home HealthPharmacy

90

Standard reports obtained from Vendor quarterly

Where are the CPGs in this system?

Can a “Web-Based” System Qualify as an EMR by the HIMMS Criteria?

1) “Real Time, point-of-care?” No. • Not if the data is not entered IN THE ROOM at the time you are

seeing the patient. 2) “Reliable access?” No.

• The Internet does not meet reliability standards for EMR3) EMR must be the Clinician’s “Primary Resource:” No.

• The medical records are in several places with a Web-Based system,

• Not unless ALL health information is collected.4) “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

5) Automates workflow? No. • There are many manual steps using a Web-Based System.

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.

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.)

Nursing Notes

Document Automation Your Wound Center

Your Wound Center

Physician Communication

BEFORE NOW

Your Wound Center

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

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.

Physician Billing: Intellicure Calculates It

Report Automation

PatientRegistration

Patient EncounterPoint-Of-Service

Documentation

Intellicure EMRIntellicure EMR

HL7 InterfaceIN: Demographics,Labs, AllergiesOUT: Documents

HospitalRegistration

AutomaticPhotoArchiving

CPGs

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.

Intellicure EMR: The $ Dividends

• Facility Billing• Physician Billing• DME orders• iHealthRecord• Quality Assurance• Pay for Performance

(Medicare)• Data Analysis

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

EMR and Wound center functions

Clinical R

esearch

Phy

sici

an d

ocum

enta

tion

Facility billingOutcomes analysis

Management reports

Physician billingB

enchmarking

CPGs/Best practice Nur

sing

doc

umen

tatio

n

Supply ordering

Pro

du

ct Efficacy

Ph

oto

Arch

iving

EMR