Hospitals

Health Management Technology asked select experts the following question: What are the most significant challenges today in picture archiving communications systems (PACS)/radiology information systems (RIS), and how might these challenges best be overcome?

It’s all about integration

By Steven Tolle, senior VP, solutions management, Merge Healthcare

The most significant challenges in the PACS/RIS market center around the competing requirements to unify these applications at the radiologist reading station, while also integrating each one separately with broader imaging and information solutions.  

Ideally, radiologists need all the appropriate information for diagnosis on screen, automatically linked together as easily and quickly as possible in a unified workflow.  Unfortunately, the tyranny of non-integrated workstation applications and desktops forces many radiologists to read with many windows open on multiple PCs. This gets exacerbated in dispersed reading workflows where the radiologists are spread across multiple locations.

At Merge Healthcare, we believe this challenge can be alleviated by integrating the various viewing functions into a single workstation where all of the studies are presented in proper context. This context requires tight PACS/RIS integration that must move beyond relevant priors and dictation system integration to include read state, ED discrepancy workflow, critical results notification workflow, broader patient health information and the display of related documents.

This unification, however, competes with priorities for broader image and information integrations. Hospital users want RIS/EMR integration for consistent information workflow, as well as broader imaging priorities for standard archiving with VNA, and true enterprise image distribution. In the ambulatory market, RIS must bring in EHR capabilities or integrations to provide certified technology for meaningful use, stay current with payers, connect with referrers and engage patients. Enterprise imaging and information competencies built through natively integrated applications are required to achieve these broader integrations.

Proper prioritization of these competing requirements involves a deep understanding of the longer-term vision defined by the various healthcare legislative changes, along with clinical and technical advancements. Having a broader perspective allows for innovation that maximizes image and information workflow both at the point of the read and throughout the healthcare enterprise. Merge believes this is best gained by tapping into a user community that spans all aspects of the workflow, participation in legislative discourse and key relationships with technology vendors that can be leveraged for PACS and RIS innovation.

For more on Merge Healthcare, click here.

PACS should be Web-access enabled

Radiology information systems and picture archiving and communications systems have been adopted by an overwhelming majority in the healthcare community. Information technology is instrumental to increase the ability for radiologists to grow the types and number of services they provide, to include advanced visualization in routine practice and to increase efficiency and quality of reporting and patient care workflow.

Radiology has already embraced new, disruptive architectural paradigms in IT, such as virtualization and cloud-based storage. These technologies are required to address the evolving requirements that come with increasing data volumes generated by imaging modalities, and to enable the use of a range of mobile devices in a secure fashion.

The Office of the National Coordinator for Health IT recently issued a Notice of Proposed Rule Making for Stage 2 Meaningful Use of an Electronic Health Record. These proposed guidelines now include image access and sharing. IT will be essential to enable this functionality across hospitals, IDNs and health information exchanges. Storing all the imaging information in an EHR is not a practical proposal. As such, PACS and RIS will have to be Web-access enabled, and the imaging studies ideally could be archived with private, or hybrid, cloud-based technologies.

This architecture will benefit the total cost of ownership, because a stringent requirement in today’s healthcare paradigm is to increase quality while reducing cost. The recent popularity of cloud-based, PACS-neutral archives is an example of this concept in action.

With “vendor-neutral” archiving (VNA), PACS will truly become an “enterprise” solution. Different front-end viewing applications will be able to share the common back-end archiving cloud. Cardiology, pathology, dermatology, ophthalmology, surgery, oncology and many other disciplines that have needs for imaging informatics applications today could be able to roll out these applications in a cost-effective way by eschewing the need to manage a department-specific archive.

The traditional PACS paradigm is changing. The future of PACS is here.

For more on Siemens Healthcare, click here.

Unified standards are key

One of the most challenging issues in the PACS/RIS world today is the lack of unified standardization and archiving for the storage and retrieval of medical data.  

Providers have a lot of inefficiencies to contend with as they work to access the patient data that is housed in multiple and siloed sources. These sources include document scans, master patient indexes and other information repositories that exist in disparate products. Often these inefficiencies can be overcome by interfacing. However, developing custom interfaces costs both money and time, and as the healthcare industry continues to see reimbursements cut, the increasing pressures to deliver enhanced patient care more efficiently will only increase.

Additionally, because of the lack of standardization, even creating interfaces is not a total solution as not all of the information can be shared. What this means for providers is that, by default, they are required to use multiple solutions. With a unified standardization, this challenge can be overcome. Novarad, in partnership with Dell, offers the Unified Clinical Archive (UCA), a complete cloud-based storage solution for all medical image data storage and retrieval. Standardizing all patient demographic and clinical history and making it available through a unified archive eliminates wasted time and costs for provides and for patients, removes frustration and delivers an enhanced and consistent level of patient care.

For more on Novarad, click here.

PACS and RIS components should act in unison

By Jim Morgan, vice president, medical informatics, FUJIFILM Medical Systems

The traditional definitions for PACS and RIS no longer apply. Image management, diagnostic reading, image/report distribution and quality-control functions are still needed. To reach the next generation of capability, PACS and RIS must work together as a fine-tuned engine.

Traditional and mobile platforms, referring physician portal, peer review, critical result notifications, business analytics/reporting, communication tools, images embedded in reports and meaningful-use capability are the starting point for functionality required. Patients and referring physicians are the customers requesting relevant information (not data overload) in a timely fashion delivered on the platform of convenience (handheld, tablet, PC, etc.).

Healthcare is moving beyond filmless and paperless. Effective communication across all stakeholders via voice, chat and text is needed. Radiology departments are also being challenged to increase volume of exams, increase equipment utilization, produce more-accurate billing processes and decrease staffing costs. Business analytics are used to refine processes and allocation of resources to produce an optimum result.

PACS and RIS must also have state-of-the-art platforms that utilize virtualization and enterprise-class databases. This lowers operational costs and provides superior, scalable performance.

Having a well-run department will provide the tools and opportunity for radiologists and clinical staff to focus on the most important thing: patients.

For more on FUJIFILM Medical Systems, click here.

By establishing a committed partnership of third-party resources and internal staff, provider organizations can be proactive rather than reactionary.

Meaningful use of electronic health records (EHRs), HIPAA 5010, ICD-10 and federal programs that shift reimbursement models from fee for service to outcomes-based payment are shaking up the healthcare industry. Collectively, these programs will have a massive impact on the revenue and financial viability of hospitals and medical groups. Throw in the Centers for Medicare and Medicaid Services expanding the number of audits to uncover overpayments and fraud, and the potential for financial damage is significant.

To stay ahead of the continual clinical, financial and regulatory challenges they face, healthcare organizations must rethink their approach toward revenue cycle management (RCM) processes and software. With payers increasingly holding providers accountable for the quality of care they provide, the financial health of hospitals and medical groups will hinge on how efficiently they bill and collect the money they are owed while reducing expenses associated with those tasks.

To stay ahead of the continual clinical, financial and regulatory challenges they face, healthcare organizations must rethink their approach toward revenue cycle management (RCM) processes and software.

By establishing a committed partnership of third-party resources and internal staff, provider organizations can be proactive rather than reactionary because reactive moves and Band-Aid technological fixes will put them at a huge competitive disadvantage. The latter approach will create problems that organizations can ill afford to have, particularly in light of the continual and rising stream of legislative and market changes they will face in the foreseeable future.

Analyzing performance
The first step providers must take to ensure fiscal health is to conduct a financial and operational assessment involving an in-depth review of three core areas of RCM: financial performance, technology and workflow.

The financial performance analysis includes gathering and reviewing accounts receivable (AR) reports that will enable providers to quantify a host of metrics tied to billing and collections. These include days in AR, collection rates, aged AR by payer and the percentages of clean and denied claims by payer. Providers also should review denied claims from their top 10 payers to determine why those claims were rejected and identify possible patterns.

Once this step is completed, an organization can use this data to compare itself against industry standards from the Medical Group Management Association (MGMA) or other third-party data source to see how its performance compares against peers and national norms. Through benchmarking, hospitals and medical groups can identify areas they need to address to improve profitability.

Assessing technological capabilities and needs
When it comes to billing software, it is common for providers to make penny-wise, pound-foolish decisions. They invest in systems that allow them to capture demographics and perform basic  processes, but decline to pay for separate modules – such as batch and real-time insurance eligibility, contract management and robust reporting − that can dramatically accelerate payments and more effectively manage their financial operations.

While some organizations select tools that lack critical features or functions, others opt for full-service solutions but fail to fully utilize and manage the functionality of the system. For example, billing systems that have features such as date and time-stamp tracking are a necessity because they allow providers to manage and monitor workflow and revenue in real time. Without enabling this function, providers cannot accurately document when patients schedule an appointment, when they check in, when insurance is verified, when co-payments are collected, when charges are entered, when payers and patients are billed and when payments are received and posted.

One way for organizations to determine if they are using systems correctly or need to replace or upgrade them is to closely assess and document the capabilities of every application and the functions they actually are using within each system. As providers implement or upgrade their EHR systems, they should consider what implications these systems will have on the revenue cycle and look for the most robust and fully integrated solution. For instance, ICD-10 will have a huge impact on coders and physician documentation, meaning organizations will have to educate and train both coders and physicians to ensure accurate and timely billing.

Additionally, providers need to evaluate if it’s in the best interest of their organization to implement other technology solutions to help them streamline front-office and RCM operations. For example, tools – such as patient portals and patient kiosks – enable patients to self-register for appointments, update their insurance and demographic information and pay co-payments/co-insurance online, either prior to the visit or at the point of care.

Studying personnel and workflow
In addition to a review of financial metrics and technology, a comprehensive assessment requires organizations to interview and observe staff to map out the workflow impacting the entire revenue cycle. It is essential that the assessment includes all constituencies touching the revenue cycle – from front office and billing staff, through clinicians, third-party vendors, financial analysts and managers. These interviews, layered with critical on-site observations, will give organizations invaluable insight by identifying and recommending opportunities for improvement. Two areas that are likely in need of addressing are effort duplication and the transition from manual to more automated workflows.

An example of duplication of effort is when both a scheduler and a central business office employee separately verify insurance for the same patient. By assigning the task to a single person and closely managing the results, providers will increase employee productivity and streamline workflow.

As hospitals and medical groups transition away from manual processes and implement more automated workflows, they are looking to identify and reduce the prevalence of repetitive tasks. A prime target for automation is work assignment, which historically has been accomplished verbally or via printed AR reports, and can now be routed electronically to employees through detailed work lists available at the start of their shifts. Organizations can also implement computer-assisted coding (CAC) software to help coders and health information management (HIM) employees meet increased workload demands from ICD-10, which will boost the number of procedure and diagnosis codes from 16,000 to approximately 155,000 codes. CAC software automatically generates codes from electronic physician documentation for coder review and validation, therefore significantly decreasing the time and effort required by the staff when manual processes are in place.

Road map to success
The final stage of the financial and operational assessment involves the development of a road map for action and remediation based on findings. This strategic plan will specify processes, technology systems and job responsibilities of personnel across the revenue cycle. While the road map will vary from hospital to hospital and practice to practice, it should include an educational, communication and outreach plan for employees and physicians.

It is crucial that physicians and registration, billing, coding and HIM employees understand how their roles affect the revenue cycle and, ultimately, contribute to their organization’s financial health.

Hospital and medical group leadership will also need to clearly demonstrate their commitment to the road map. They can do this by having senior executive management and revenue cycle department directors join project managers to help drive meetings, provide regular updates and quickly address concerns from employees.

The process of overhauling the revenue cycle can be challenging because it often involves dramatic changes in culture and workflow. But organizations that work proactively and methodically to improve revenue cycle operations from top to bottom will be in the position to accelerate cash flow, reallocate FTEs, decrease costs, boost productivity, leverage cutting-edge technology and gain a competitive advantage that will sustain them through the ever-changing dynamics of today’s healthcare industry.

About the author

Nancy Ruff is the director of health advisory services at CTG Health Solutions. For more on CTG Health Solutions, click here.

Practices that are successful technology adopters consistently outperform their peers.

We’re in a time of transition in the healthcare industry; unfortunately, these transitions are going to weigh heavily on providers’ revenue flow. Many of you have likely experienced claims rejections and payment delays as the industry converted to 5010, and the next major transition to the ICD-10 coding system is going to be even more challenging.

It isn’t unusual for a medical practice to report a gross collection rate of 60 percent or less (MGMA’s Physician Billing Process: 12 Potholes to Avoid in the Road to Getting Paid, 2nd Ed.). That means for every dollar billed, the physician receives a return of only 60 cents. This lack of return combined with ICD-10’s predicted hit to cash flow and staff productivity means it’s even more vital to get your revenue cycle in shape.

According to a LarsonAllen study, practices that are successful technology adopters consistently outperform their peers from a cost and revenue perspective and collected more than half of outstanding receivables in 15 days or less, compared to only 9 percent by those who used technology less efficiently.

While there are a number of steps you can take to maintain a healthy revenue cycle (see sidebar), there are a few key areas where you should focus to experience the biggest impact.

Patient responsibility
Patients are now responsible for a larger portion of their payment, and it is important to check patient eligibility and collect patient payment at the time of service.

• Using tools to check patient eligibility prior to the appointment is the most important task you can do to impact revenue. Yet only 79 percent of practices report checking eligibility, and only 24 percent check it every patient visit (LarsonAllen’s Physician Revenue Cycle Gold Standard Study, 2010). Clearinghouses and payer websites can cut down the time it takes to check patient eligibility.
• Collect the patient payment at the time of service. Sending statements costs money and staff time, and practices are much more likely to get paid when the patient is still in the office. High-performing practices are better at collecting co-payments, deductibles and co-insurance from the patient at the time of service because they use technology to calculate patient responsibility (LarsonAllen’s Physician Revenue Cycle Gold Standard Study, 2010).
• Practices should educate patients about their balances and offer alternative financing options, so they are less likely to receive late or incomplete payments.

Eliminating claims errors
Another common cause of incomplete reimbursements is the failure to catch and correct rejections in a timely manner.

• To avoid major payment delays, your practice should correct any claims rejections within 48 hours of submitting the claim. Get proactive: Develop a process to identify and analyze your most common rejections.
• Identify the number one rejection for your practice and focus on how you will eliminate that error by adjusting coding, educating staff on proper coding or changing the billing process. Once you have done this, continue to eliminate rejections in the order that they impact the practice.
• Bill correctly the first time. On average, it costs $40 in staff time to rework a denied claim, a cost that can add up quickly if your staff has to correct many claims each day (Susanne Madden’s Cost to Appeal Denial analysis, The Verden Group).
• Auto-post electronic remittances, which are more accurate and help staff reduce time spent posting payments.

TIPS TO MANAGE REVENUE

About the author:

Dawn Duchek is industry initiatives coordinator, Gateway EDI. For more information on Gateway EDI, click here.

Those paper-based lockbox solutions are a thing of the past.

The costs of managing day-to-day payment collection through a traditional lockbox service can take a significant piece of the practice’s overall revenue. For many practices, it’s understood that these costs are substantial, but there is not very much transparency. Studies indicate the average cost of managing a single payment from a payer is nearly $3 for a paper check and $1.48 for an electronic payment. Processing explanation of benefits (EOBs) and reconciliation can result in costs of $6 to $8 dollars per payer payment, with similar costs coming during the collection of patient-owed balances. Even the smallest practice will likely bill thousands of annual encounters every year, so the payment process can add up very quickly.

Traditional lockbox services utilize a post office box for payment receipt, which is then deposited into an account owned by the provider. These services might scan some documents, but many of them send along the paper originals to the provider so they can be manually filed. In either case, the provider still needs to post payments and perform the line-by-line reconciliation. Such services are a decent step toward a fully electronic system, but they do not provide enough efficiency gains for the practice.

There exist significant opportunities to improve upon lockbox services that introduce real automation into the process, so providers no longer face the costs of manually posting and reconciling payments. For payment processing, what are the key ingredients of a “next-generation” solution? It begins with an accurate conversion engine that turns paper-based EOBs into an X12 835 format that is easily accepted by the provider’s practice-management and hospital information systems. Then comes the transmission, where the converted file is sent via a clearinghouse to the provider electronically, followed by file importation into the same system and automatic posting of deposits. Reconciliation in a next-gen environment occurs automatically and provides one of the greatest sources of time savings compared to traditional paper solutions.

Electronic-based data does not hold value unless there is a reporting feature. Next-gen solutions should feature an online dashboard that provides real-time analysis to keep providers informed of any trends. Alerts should also be incorporated that flag over- or under-payment issues. Scanning in such a solution should not be relegated to just claims. Payer correspondence, notes and various inquiries should also be scanned, and all of these images should be batched together and electronically sent to the provider. Top-tier payment-management solutions will index all payments and correspondence for future reference. This capability allows the practice to complete many tasks. For example, they can quickly locate a past primary claim if a secondary claim is received. If patients call into the office inquiring why more of their service was not covered, the staff can easily pull up the past EOB to provide answers. For management, indexing allows historical analysis of payer trends to encourage more refinement of processes and to spot any outliers.

Conversion of EOBs and other documentation to an X12 835 format is important because it provides the practice with a truly digital workflow where there are no longer disconnects in the data. In most instances, paper-based EOBs are still being mailed, because payers are not yet producing these transactions in the X12 835 format. With traditional paper EOBs, the payment-processing entity must gather them from the payer and then sort through the EOBs in order to reconcile the payment and manually process the check. This process is a line-by-line ordeal that introduces a massive risk for error and simply requires too much time. With paper EOBs, there is no chance for analysis of the practice as a whole because the data is not electronic, and therefore can’t be aggregated into a larger piece of sortable information.

After careful review of next-gen solution providers and implementation, one should be selected that will present several core benefits to the practice. A substantial reduction in staff should be quickly realized, as mail handling and the posting and reconciliation of deposits will all be automated.

After careful review of next-gen solution providers and implementation, one should be selected that will present several core benefits to the practice. A substantial reduction in staff should be quickly realized, as mail handling and the posting and reconciliation of deposits will all be automated. Various overhead costs will decrease, including physical space to archive EOBs and other correspondence, office supplies and, of course, the salaries and benefits cost savings of fewer employees. More efficient processes will positively change the practice’s entire revenue cycle, with faster and more accurate reconciliations. A savings of $2 to $3 per check is reasonable. For a smaller practice with 500 payer checks a month, this translates into upwards of $18,000 per year in direct savings.

There are some caveats for practices that are looking to integrate a next-generation lockbox solution. It’s vital to do a thorough review of the software vendor to be sure the system will be a real step forward for the practice and that it actually produces the desired results. Some solution providers have stated they can easily convert paper EOBs and other documentation to electronic versions, but they are buggy and might not offer all of the required functionalities. It’s vital to review the solution provider’s technology that converts paper to electronic EOBs and how they relate those remittances back to the claims and bank deposits. This needs to be a seamless loop in order for the practice to realize the maximum gains from a next-gen payment collection solution that improves efficiency and boosts the revenue cycle.

About the author

Jim Lacy is CFO and counsel for ZirMed. For more on ZirMed, click here.