The movement toward Electronic Health Records, and Certified Electronic health Record Technologies (CEHRT), clinicians are forced to review their current technologies and processes. While these changes are being influenced from CMS, it is causing confusion due to the virtual alphabet soup. The following is intended to provide clarity on the topic.
The cost of healthcare globally is anticipated to exceed $10 trillion, with current spend equaling $3.3 trillion today. While an alarming number already, it is anticipated to rise to 80% by the year 2040. In the US, it is also estimated that roughly 30% of the total spend comes in the form of administrative costs, which approaches $1 trillion annually. This number represents roughly 10% of the total spend on healthcare globally. To state this again, the administrative costs of healthcare in the US represents roughly 10% of the healthcare spend of the world.
While the US internal debate of Medicare for all will likely continue for some time, it is clear that the lowest hanging fruit to reduction in healthcare costs may well lie in streamlining of administrative processes, which can be impacted dramatically by technology.
With this recognition, the US passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015. While the concepts of this act will be covered in a different document, the primary purpose has been to incentivize providers to update their IT systems in an effort to unify platforms in the US, but also globally. This unification, or interoperability, of systems can begin to minimize the administrative costs, and shift the focus from processing claims to providing better care – and ultimately reductions in the cost of care. While the Electronic Health Record (EHR) and Electronic Medical Record (EMR) are at the center of the technological approach to improvements, it extends beyond just the health record to include claims, practices, assessment data, determinants of health, real-time vitals, and far more.
Most relevant to the overall exercise, is the ability to speak a common medical language. While simple on concept, this is far from simple in practice. In fact, these “standards” have been developed or in development for decades, and still fall short in many ways. There has however been major progress, and the remainder of this article speaks to the most central components of this progress. Not all items are listed below but understanding the overall landscape can be helpful when assessing future technology investments for healthcare.
As you can see, the sheer number of standards and purposes of each can be rather overwhelming. Supporting all of these is even more of a challenge, as medical practices vary in their implementation of systems that are compatible, and the cost of technology can be somewhat restrictive.
As described at the beginning of this document, however, MACRA was implemented in part to incentivize clinicians to move in this direction. At its heart, MACRA is an initiative that supports the standardization of process and technologies that will improve care, as well as increase interoperability, access to data, and streamline reporting and administration. Ultimately, it is an attempt to lower the significant costs of healthcare administration.
MACRA provides incentives to clinicians through the Quality Payment Program initiative which rewards value and outcome through two programs: MIPS (Merit-based Incentive Payment Systems) and APMs (Advanced Alternative Payment Models). While not intended to be the focus of this article, it is important to understand that a main goal of both programs is to encourage the healthcare industry to modernize technologies and provide improved and additional services. Both programs are better accomplished through the use of an Electronic Health Record (EHR), and more specifically, encourage the use of a Certified EHR system.
While part of the current MIPS program, a certification initiative began a number of years ago referred to as Meaningful Use. Meaningful Use was intended to move medical practices onto an EHR in order to provide a standard process, and to takes steps toward an overall interoperability of systems, including nascent technologies such as telehealth video conferencing, remote patient monitoring and more. While now a component of MIPS, the principles of Meaningful Use still apply as a foundation, and certification continues, although now through the Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program. It is a voluntary certification program specifically for health IT.
While CMS has been driving the industry in a positive direction, it is a slow-moving process. Major strides have been made in achieving the long-term goals, and standards continue to evolve toward this end (for example the ICD-11 standard is being designed to largely match the SNOMED standards of the future to provide parity). While it may not prove to be the magic wand that lowers healthcare costs, it is most definitely a movement in the right direction.
SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) is the most comprehensive and precise, multilingual health terminology in the world. It serves as a common semantic language for medical terms and supports multi-language support with the goal of creating a common set of terms in an international manner. Some items of note:
ICD (International Classification of Disease) serves as a semantic language related to the diagnosis of disease, injury, disorder, infection, and symptoms. ICD is an exercise to numerically codify these diagnoses for easy definition.
Begun as a way to classify the cause of death, the international lists were compiled and shared over time to represent diagnosis of diseases, infections and symptoms, and eventually became known as the International Classification of Disease). Now in its 10th revision, with the ICD-11 standard in development. ICD-10 represents the current standard.
In the US the National Center for Health Statistics is responsible for ICD-10 use, and has developed a modification used only in the United States called ICD-1 0-CM (Clinical Modification). In addition, the Centers for Medicare & Medicaid Services (CMS) developed ICD-10-PCS to define codes designating procedures used on hospitalized patients. Procedures performed on outpatients in the U.S. are coded using CPT codes rather than ICD-10-PCS codes.
CPT (Current Procedural Terminology) is administered by the AMA (American Medical Association). CPT codes are used primarily for the purpose of filing claims for medical services. Tied to CPT codes are HCPCS (Healthcare Common Procedural Coding System). HCPCS was developed to provide a coding system for describing specific services and items. All CPT codes are in fact HCPCS codes, however, level II HCPCS codes are not CPT codes.
CMS oversees both the definition and usage of HCPCS codes. CPT codes can be used to describe medical services provided, but when billing Medicare, HCPCS codes must be used. A third level of HCPCS codes (Level III) are for use in specific jurisdictions and programs, but not nationally recognized.
To provide greater flexibility in documenting, modifiers were added to both CPT and HCPCS coding. Modifiers can provide more detail, or additional information. For example, the modifier RT is used to define a service performed on the right side. Using the proper modifier can be key to efficient payment processing.
HL7 (Health Level 7) and its members provide a set of standards for the transportability of data including the integration, sharing, and retrieval of electronic health information. The standards define how information is to be packaged and communicated from one system to another. HL7 standards support clinical practice and the management, delivery, and evaluation of health services. They are recognized as the most commonly used standards in the world.
HL7 standards are grouped into reference categories ranging from Section 1 (a-h) to Section 4. Each section focuses on a different set of standards ranging from syntax, to domain analysis models, clinical and administrative messaging and document standards, to technical specifications and programming and software standards.
HL7 FHIR (Fast Health Interop Resources) has become the certitfied standard for interoperability and transportability of healthcare data.
LOINC (Logical Observation Identifiers Names and Codes) is a standard used in identifying laboratory observations. It is one standard used by FHIR, bot of note in that it served to standardize the coding standards of differing laboratories and lab observations.
LOINC is endorsed by the American Clinical Laboratory Association and the College of American Pathologists. It has been adopted by some large commercial laboratories for use in HL7 result messages and is used by some US federal agencies with healthcare interests. While initially created specifically for HL7 messaging, its use has expanded to Digital Imaging and Communication in Medicine (DICOM) ultrasound messages and Clinical Data Interchange Standards Consortium (CDISC) pharmaceutical industry messages.
RxNorm serves two purposes, 1) it normalizes naming of generic and branded drugs, and 2) it acts as a tool for supporting semantic interoperation between drug terminologies and the existing myriad pharmacy knowledge base systems.
RxNorm contains the names of prescription and many over-the-counter drugs available in the US, including generic and branded. RxNorm includes individual clinical drugs as well as drug packs (multiple drugs combined in a single pack to be administered in a specific sequence.