Telehealth has been growing in practice for years, with the COVID-19 pandemic and its required social distancing accelerating adoption. There are many benefits to telehealth, but it can present challenges for Health Information Management (HIM) professionals.

These challenges include ensuring integrity and confidentiality are maintained and that a provider’s scope of practice is within the legal statutes set forth by the state where they’re practicing. It’s also important that diverse payer coding guidelines are followed. In addition, organizations must determine who is responsible for documenting patient information and how that information is shared.

Health Information Management professionals should educate providers and staff on the relaxed HIPAA rules including the difference between secure and nonsecure connections.

It’s worth it to tackle these challenges because as we’ve seen during the pandemic, telehealth can be a lifeline in difficult times – and come in handy during brighter days. Telehealth makes it easier for patients to receive a second opinion or be regularly monitored for issues like cardiac health, medication adherence, and behavioral health therapy. Perhaps the top benefit of telehealth is access to care during social distancing and for people who live in underserved areas where there aren’t as many providers. School-based programs are another great use of telehealth – they benefit schools by keeping kids in the classroom, allowing families to stay at work, and decreasing unnecessary emergency room utilization. Meanwhile, children benefit from more class time and better health. Telehealth takes healthcare to where families live, work, play, and learn. 

Time saved is a benefit of telehealth. Patients and even providers don’t have to commute to an appointment, and patients can sometimes see a specialist in a shorter amount of time than if they had to wait for an in-person appointment. Money saved is another benefit. Telehealth can reduce cost efficiencies through shorter hospital stays and better chronic disease management.

Finally, as a Health Information Management (HIM) professional and the president/chair-elect of the American Health Information Management Association (AHIMA), I’m particularly excited that telehealth can lead to improved access to health records and information. If we make more health information available online, we empower people in the management of their health, shifting the paradigm from brick and mortar care to a more consumer-centric care delivery model. In addition, we should promote online discussion groups for both patients and health professionals, because as we have learned during COVID-19, connection is everything – even if it’s virtual.

Telehealth during COVID-19

With stay at home orders impacting many states, it’s not surprising that providers and patients would both seek ways to meet virtually. On March 17, the U.S. Department of Health and Human Services published guidance that relaxes HIPAA rules related to telehealth during the pandemic. The guidance allows providers and patients to meet over commonly used platforms like Apple’s FaceTime, Facebook Messenger, Google Hangouts, and Skype. Two-way conversations are allowed on these channels – what isn’t allowed is speaking on more public-facing platforms like Facebook Live or TikTok. Health Information Management professionals should educate providers and staff on the relaxed HIPAA rules including the difference between secure and nonsecure connections.

The Centers for Medicare and Medicaid Services support of payment for telehealth services has been rapidly adopted by the payer market. However, issues for HIM professionals have emerged because there are differing opinions on which CPT 4 codes should be utilized to classify services delivered. It seems as if the payers are changing their views daily, which burdens HIM professionals. I hope this is sorted out soon.

The Importance of Documentation, Privacy, and Security

Whether a provider and patient are meeting in person or virtually, the importance of accurate clinical documentation remains. HIM professionals should work with medical staff to ensure the organization continues its high standards for documentation. In fact, as regulations remain fluid around telehealth, documentation will be more important than ever. Post-pandemic documentation will be vital for helping organizations ensure that accurate billing, coding, and public health reporting occur.

Of course, HIM professionals, providers, and staff need to remain cognizant of the Health Insurance Portability and Accountability Act, more commonly referred to as HIPAA. AHIMA recommends HIM professionals create a fact sheet for their organization’s staff that reminds them about the importance of confidentiality and access.

HIM professionals should also remain vigilant against cyber scams. The Cybersecurity and Infrastructure Security Agency said cyber actors might send emails with malicious attachments or links to fraudulent websites in an effort to trick victims into revealing sensitive information. All staff should exercise caution in handling any email with a COVID-19-related subject line, attachment, or hyperlink, and be wary of social media pleas, texts, or calls related to COVID-19.

In Conclusion

I’m excited to see how telehealth impacts the future of healthcare. I suspect many patients and providers who took advantage of it during COVID-19 will want to continue in the coming years. HIM professionals stand ready to help their organizations ensure clinical documentation integrity remains in a new and different – but exciting – healthcare ecosystem. A system in which people are empowered in the management of their wellness and receive care where they live, work, play, and learn. 

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In 2017, each American spent $10,739 on healthcare costs. All of us in healthcare look to identify opportunities to increase value before we become disrupted by someone outside the industry. Several medical professional organizations have supported initiatives to reduce low-value care (disclaimer: I’ve been a member of the American College of Physicians and certified by the American Board of Internal Medicine since completing my residency). Unfortunately, the evidence supporting the contention that these educational initiatives reduce low-value care is weak.

Health systems and payers may be more comfortable deploying these patient-centered tactics once a patient develops an acute or chronic condition.

Health insurance companies use prior authorization to ensure high-value healthcare delivery. In some cases, prior authorization reduces inappropriate medication use (e.g., opioid abuse and overdose among Medicaid beneficiaries, antimicrobial stewardship). In other cases, prior authorization increases costs without reducing inappropriate care (e.g., low back pain with increasing costs due to more spinal injections and hospital admissions,) or impairs healthy behavior change (e.g., reducing tobacco use). In January 2018, several organizations, including the American Medical Association, America’s Health Insurance Plans and the American Pharmacists Association, issued a consensus statement suggesting five methods to improve the prior authorization process.

Some groups have tried other approaches to increase high-value healthcare delivery without resorting to prior authorization. National guidelines delivered through real-time decision support can replace traditional prior authorization in ordering chemotherapy and high-cost imaging. One study found a high-deductible health plan linked to value-based pharmacy benefits with free chronic disease medications increased medication adherence rates among patients with initially low levels of adherence and higher socioeconomic status. But these interventions, like prior authorization, do not address the primary drivers of chronic disease (tobacco use, poor diet and physical activity linked to obesity, excessive alcohol consumption, uncontrolled high blood pressure and hyperlipidemia) in America.

If behavior change is the root cause of chronic disease, how might we support patients make behavioral changes to reduce their risk of chronic disease, the ultimate high-value intervention? In 2009, Polly Ryan outlined the Integrated Theory of Health Behavior Change. The behavioral model suggests a patient’s knowledge, beliefs and social facilitation impact self-regulation skill and ability. The self-regulation skill and ability affect engagement in self-management behavior which subsequently impacts health status. Patient engagement precedes changes in health status. Dixon-Fyle et al. outline a multi-level paradigm using technology to support patients change health behavior with peers, caregivers and clinicians. The group suggests cognitive biases, habits, and social norms with a focus on the patient rather than a specific disease.

Even under the most advanced value-based arrangements available today, behavior change seems only tangentially related to commercial healthcare insurance premiums or healthcare system payments. Payors receive higher payments for having more patients with well-controlled chronic diseases rather than preventing patients from developing chronic disease. Employees often switch health insurance plans to meet changing needs in their lives, reducing the incentive for any health insurance company to support behavior change with expected improvements five or 10 years in the future. Of all the different members of the healthcare landscape, Medicare and Medicaid may be the entities most aligned to help patients support behavior change to prevent chronic disease.

Considering Ryan’s theory of health behavior change and Dixon-Pyle’s model that acknowledges our irrational behaviors, what tools might be useful to help patients support behavior change to prevent chronic disease? Assessing patient preferences and current health behaviors would allow patients and other interested parties gauge each individual’s readiness to change and possible interventions to support healthy behavior change. Framing the risks and benefits of medical decisions around disease prevention and health promotion in patient-friendly terms (e.g., overall mortality, missed days of work, quality of life, out-of-pocket costs) instead of disease-centric ones (e.g., disease-specific mortality, blood pressure reduction) could help patients connect specific actions and their corresponding outcomes.

Health systems and payers may be more comfortable deploying these patient-centered tactics once a patient develops an acute or chronic condition. Now that I have a diagnosis of knee pain, eliciting my preferences and functional status can help providers and payers suggest specific interventions to consider (e.g., physical therapy, acupuncture, non-prescription medications, joint injections) rather than force a specific sequence of interventions as suggested by some prior authorization workflows. This paradigm supports the possibility of healthcare mass-customization consistent with what other industries have already done.

Regardless of the specific health behavior target, Ryan and Dixon-Pyle suggest peer support for new behaviors. With various public and private social media networks, patients could be connected with others who have similar challenges or health states to determine what normative behaviors exist in that network. Rather than relying on local friends, a patient could compare their behaviors and health state against others across the country. The next-level of engagement would be linking specific health behaviors with corresponding health states.

Doing more of what we’ve always done to provide higher healthcare value (e.g., education, prior authorization) seems unlikely to meaningfully bend the healthcare cost curve. Engaging patients around their own health states and preferences could support a generalizable model of health behavior change for primary prevention and chronic disease management with opportunities for healthcare to deliver personalized diagnostic or treatment choices. The patient-level information could then be aggregated across similar populations to leverage social networks to nudge different health behaviors. Although this work may require a fundamental redesign of how we interact with patients across health systems and payer entities, the pivot represents an opportunity to simultaneously engage patients and deliver higher-value healthcare as defined by them.

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We live in an era of incredibly mature electronic health systems and decision support. While some technologies, such as block-chain and artificial intelligence have yet to show their full potential, the rest of real-time clinical decision support is a very mature field. In this context, why is it still so to present real-time cost and coverage information at the time of diagnostic test selection? Instead, it seems that we are locked into the clunky, archaic Advanced Beneficiary Notice of NonCoverage, otherwise known as the “ABN”.

Maybe other organizations have come up with an elegant solution that works for physicians and their patients. In most traditional health systems (those who do not have a health insurance arm), the workflows involved seem oriented to meet regulatory requirements of CMS and the Registration and Scheduling staff. More recently, CMS have pushed health systems to publish their standard prices on line. Both tools are important, and yet do not meet the needs of physicians and patients at the point of care.

Why can’t a physician and a patient know, at the time of consultation, if a test is covered, and what the patient will have to pay?

The current limitations I have observed in the current state ABN workflow is that the alert pops up with a form only at the time of signing the order. It typically contains minimal pricing information and no recommendations about alternative studies or diagnoses.

In an ideal world, in-line decision support for physicians regarding non-covered services would contain the following:

1. The ability to match against the patient’s problem list to look for proper diagnoses already charted on the patient.
2. A list of “common indications” that are typically covered, as well as the ability to add in free text.
3. Where appropriate, alternative procedures that would be covered, given the patient’s diagnoses.
4. The ability to do minimum frequency checks against a future, planned date, rather than the date the study is being ordered.
5. The ability to do minimum frequency checks against related studies that exist in records that are available through the Health Information Exchange (a tall order, I’ll admit!).
6. In-line display of estimated cash pricing.
7. The ability to customize to include additional alternatives, such as clinical trials.
8. Two-step decision making and processing such that the finalized decision is passed to other members of the care team to complete the process, including financial counseling, if appropriate.

Appropriate Use Criteria and Pharmacy Benefit engines are probably getting to be the closest in terms of a usable reference to assist physicians and patients steward their healthcare resources, although not incorporating my entire wish list. An ideal solution would allow incorporation of the Choosing Wisely campaign as well. Although Choosing Wisely specifically steps clear of coverage determinations, it overlaps considerably with how physicians recommend for and against diagnostic tests.

Certainly, the infrastructure for real-time eligibility and preauthorization exists. Standardized vocabularies such as SNOMED and LOINC should make interoperability a breeze. The use of FHIR APIs are in place in most large health systems, to facilitate secure data flow.

We often look for big, innovative disruptions to save us from ourselves in healthcare. Here is a classic “last mile” problem waiting to be solved. Why can’t a physician and a patient know, at the time of consultation, if a test is covered, and what the patient will have to pay? Let’s hope there are a few innovators out there considering how to build that mousetrap. I’d sign up!

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As healthcare continues to transform into a consumer-driven marketplace, it’s incumbent on every employee of every provider organization to understand how they can positively impact the patient experience at their facility. We have marketing teams dedicated to attracting patients to the health system. Once they’re here, we have clinicians who take tremendous pride in providing the best health care to improve patients’ lives. So when it comes time for the patient to interact with the revenue cycle, why should it be any different?

At Cooper University Health Care, our focus is creating a best-in-class patient experience by leveraging technology in a way that allows our employees to focus more on the patient and less on the trivial headaches that historically come with revenue cycle work. Over the past twenty-odd years, technology in the revenue cycle has transformed a notoriously labor-intensive line of business into one that is much more automated. Perhaps the changes are moving too fast for many of us to keep a handle on. If you have ever been through a revenue cycle system conversion or implementation, you know that automating age-old manual processes creates challenges that make you question whether you know your own name at times.

As an industry, we’ve come a long way. We can now automate insurance eligibility. Patients can schedule their own appointments and pay their bills online. Medical records can be shared across multiple health systems to avoid mistakes and delays in care. We can code simple visits with computers alone. We can predict denied claims before they ever get adjudicated. The vast majority of our transactions with payers are now electronic. We can receive massive electronic remits, reconcile, and post them without even the click of a button. All of this has put our industry in a position to transform the way we think about the revenue cycle and its role in patient satisfaction.

At Cooper University Health Care, we implemented a new revenue cycle platform to integrate with our EHR in 2016. Over the past three years, we’ve experienced all of the benefits (and stress) that come with implementing these technological advances. Three years later, we have a stronger cash position, cleaner claims, and a more efficient business processing system. Through the pursuit of operational excellence in our business practices, we have been able to turn our attention where it should be: the Patient.

Not surprisingly, patient complaints to our billing office have reduced nearly 50% year-over-year.

As leaders in any healthcare organization, I believe it is our top priority to make our employees’ work as efficient, effective, and enjoyable as we can. By pursuing technology that will enhance employee engagement and satisfaction, we believe that it ultimately leads to a better experience for our patients. By engaging our employees in the design process of technology, you can mitigate their fear in what efficiency and automation will mean to them. Employees get to see what having more time allows them to do, and how it impacts the lives of real people each and every day. We take great pride in finding ways to impact patient satisfaction in each area of our Revenue Cycle.

Here are some of the ways that technological advances will allow us to focus on customer service:

In Healthcare Access, streamlining eligibility allows our team to spend less time on the payer portals and allows them more time the phone with our patients. Triangulating this data with contract management and CPT-driven orders will allow us to automate patient estimates. Our Financial Navigation Team is working to contact every patient before their scheduled procedure and explain their out-of-pocket cost and answer any questions they may have about their benefits or payment options.  This allows patients to make informed decisions and to avoid the “sticker shock” bills after they receive their care. Not surprisingly, patient complaints to our billing office have reduced nearly 50% year-over-year.

In Transitional Care Navigation (Social Work/Case Mgmt.), our teams have worked with our IT partners to implement real-time avoidable day tracking within the EHR. This allows our Transitional Care professionals to strategically drive improvements in length-of-stay, resulting in more efficient patient throughput and reduced delays in discharge.

In Health Information Management (HIM), we are implementing A.I. technology that will help us to prioritize charts for Clinical Documentation Improvement, Coding Quality, and Accuracy. This will ensure that the patient’s care is captured and documented completely with the patient’s insurance company, ultimately avoiding unnecessary denials. Many times, disagreements in coding can lead to denials or unexpected claim adjudication behavior which can affect the patient’s bill.

In our Business Office, our systems are working to identify incorrect patient balances, incorrect denials, and comply with regulatory requirements much more seamlessly than ever before. When processing over a million claims each year, being able to highlight the exceptions and work them timely has allowed us to actively handle what would have been a dissatisfying situation for our patients.

Seems simple, right? Well-deployed technology creates happy employees, which results in satisfied patients. It is simple, until the technology or the names on the badges change. If you want to deliver a consistent patient experience, you must deliver consistent training and education to your team.  That is why, at Cooper, we have created a Revenue Cycle Training and Education department.  This group is focused on hard-wiring the progress we’ve made operationally so that our teams can continue to focus on service to our patients. With the ever-changing landscape of payer rules, government regulations, and system upgrades, training and education is the grease that keeps the wheel turning.

Pursue operational excellence, install technology smartly to let your people shine, and hardwire the process with training and education. Your patients will see the difference. After all, isn’t that why we’re all here in the first place?

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