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Fifth in an ongoing series proposing CMR model based on credit-card industry.
Editor’s note: This article is the fifth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative. Part Four is here.
A Coordinated Medical Record (CMR) system is based on the concept of organizing information in a complex virtual network. In our configuration of a CMR, Service Centers are regional hubs that provide the administrative services that support the system’s network architecture. The software, policies and procedures of these Centers are fully integrated with those of the system’s Point-of-Service and Data Center components.
Each regional Service Center is staffed by 6-8 data entry and data management personnel. Their basic functions are to generate and maintain a number of network-centric administrative databases.
When a contract is made with a group of physicians to establish a Coordinated Medical Record system in their healthcare community, a Service Center is established. The initial task of the staff is to generate individual but interconnected databases that collectively paint an administrative picture of the entire community. It is a picture of the people, places and tools that define the network structure of the community.
The profiles of the contracting physicians contain demographic information, specialty designation, group affiliations, practice locations, hospital affiliations, accepted insurance, patients affiliated with their practice, short lists of diagnoses, procedures and medications, customized templates, and standard and customized quality report requirements.
Profiles of the patients of the contracting physicians include demographic and insurance information, and a list of the healthcare providers that are authorized to access the patient's clinical record.
The community profile includes information about all physicians, hospitals, emergency departments, labs, pharmacies, diagnostic and therapeutic treatment centers, nursing homes, home healthcare agencies and ambulance services in the contracting physicians’ geographic service area. All of these entities are included in the community profile whether they are currently being connected to the system’s network or not. Active or inactive status is simply indicated with a toggle switch. Generating this baseline information at the outset makes it easy to activate care providers and caresites as the system expands locally and regionally.
All caregivers and support staff that have any access to the system are profiled and assigned security level access designations.
Databases are created for all of the insurance carriers and employers in the area, and for all of the clinical code sets that are used in the community, such as CPT, ICD, HCPCS and NDC.
All of the data elements in all of these databases are maintained in an object-oriented format. If an original file, such as a CPT file, is in a comma-delimited format, it is converted to an object-oriented format. This means that every piece of data in the care provider, caresite, personnel, and code set databases can easily be modified, edited or distributed individually.
After all of the initial databases have been generated, the primary function of the Service Center staff turns to maintaining those databases. This is essentially a modify-add-delete function. Because most of the system’s database update functions have been automated, the staff usually needs to manually deal with a relatively small number of modifications at any given time.
For example, every year the Centers for Disease Control and Prevention (CDC) make minor changes to the ICD-10 code database. This year, there were 473 changes, including 279 new, 143 revised, and 51 deactivated codes.
Whenever Service Center personnel receive the details of these changes, they reconfigure each individual code from its comma-delimited format to an “update object format.” This means that each individual code has a tag attached to it that includes information that tells the destination databases whether this particular code change is a modification, an addition or a deletion.
These changes are then broadcast through the Switch in the system’s Data Center to every caresite in the system, thereby automatically updating every point-of-service database within 24 hours of the Service Center receiving the notice of changes. Employing this type of technology, would have made the process of transitioning from 13,000 ICD-9 codes to 68,000 ICD-10 codes a few years ago much more efficient and less stressful than it was for healthcare providers
As the primary function of a Service Center gradually changes from data entry to data management, staffing requirements do not need to significantly increase because the original personnel have the skill sets to handle both functions.
For example, in our pilot project, one Service Center staff member was tasked with generating a database of all of the insurance carriers in the area, and then reverse engineering their code sets to make their internal processing functions transparent. As the carriers made changes to their benefit packages over time, it took only a small amount of that same staff members work-time to make the necessary modify-add-delete revisions to the database and broadcast the updates to all of the system’s affected caresites.
The highly leveraged internal staffing efficiency of a Service Center is magnified by its once-for-all effect on the entire healthcare community. The insurance information that the Service Center personnel capture and organize is the same information that the billing personnel at every caresite in the entire healthcare community are redundantly attempting to capture and utilize every day in their attempts to avoid claims rejections.
One particular piece of information that the Service Center staff watches for very carefully is a new rejection of a previously accepted claim by any insurance carrier. The staff immediately passes that type of information along to all of the providers and caresites in the community that could potentially receive that same rejection, allowing them to proactively take corrective action. This process can eventually lead to 100% clean claims processing in the entire healthcare community.
Currently, billing and insurance related expenses for all of the healthcare providers in the country are reported to be a staggering $282 billion, with the costs for the insurance carriers being an additional $214 billion. By serving as a single-point-of-contact for gathering and organizing the common and critical information that is needed for claims processing at every caresite, and then serving as the once-for-all dispenser of that information, these Service Center functions can significantly decrease billing related expenses across the entire healthcare industry.
With secure access to the records in the Coordinated Medical Record system’s central database, Service Center personnel are able to generate near real-time, comprehensive, clinical and financial statistics and reports that are unique in the healthcare industry.
Because the system’s data elements are in an object-oriented format and the information in every patient record is reconciled within a 24 hour period, the report generators can see all of the diagnoses, procedures, prescriptions and referrals that were made in the entire healthcare community on that very day. They can selectively mix and match the details from any of the day’s healthcare encounters to generate standard and customized statistics and reports.
Currently, physician practices spend about $15 billion and 785 physician work-hours annually to report quality measures. Service Center personnel can produce any of these reports in minimal time and at minimal cost. It is reported that there are over 3,000 competing quality measures across all government and private initiatives. This is an industry problem because having so many competing measures just doesn’t make any sense, but it is not a technical problem that a Coordinated Medical Record system has any trouble dealing with.
The healthcare industry’s obsession with reports being the benchmark by which quality of care is measured is definitely a misdirection. Although a Coordinated Medical Record system can easily generate any report that is needed, that is not where the system’s quality improvement value comes from. It is the ability of the system to put a comprehensive longitudinal patient record in the hands of every healthcare provider at the time of every encounter,
It is this type of record that proactively helps decrease the incidences of misdiagnoses, inappropriate medications, duplicate tests, unnecessary emergency department visits and hospitalizations. And, it is the central database of all Coordinated Records that can spot an epidemic in its infancy, help identify ground zero, and track its spread in real time.
All kinds of reports can document these benefits sometime later, but the good will have already been done.
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