….and moving to our new location on our website – www.mtuitive.com/blog/

There we’ll have our opinions about the latest from the world of surgery, pathology, evidence-based medicine, structured data, synoptic reporting, and a whole host of other issues. There will be more writers covering more areas of discussion. So please head on over to learn more about us (although it may take a few days for it to stop looking so wonky).

www.mtuitive.com/blog/

I was reading this piece on Dark Daily, entitled “Behavioral Economics Likely to Push Up Utilization of Clinical Pathology Laboratory Tests” which suggests that laboratory usage will increase due to a trend in insurance companies to lower premiums through proactive intervening tests instead of costly reactive procedures. These tests would measure and inform certain healthy/unhealthy behaviors and would influence the price of coverage for individuals.

The piece’s author, Michael McBride, believes that more people will choose for less expensive coverage in exchange for living healthy, which will result in more testing sent to clinical and pathological labs.

While I thought it was interesting – especially as we at mTuitive have a pathology product – I was unsure about the validity of McBride’s assumptions. Luckily, I’m fairly familiar with behavioral economics as my friend Ryan has been studying it for years and is currently in the economics PhD program at Duke University. I asked Ryan if he could clarify for everyone the definition of behavioral economics and provide any examples that either support or contradict McBride’s findings. Here is Ryan’s response:

Behavioral economics is a burgeoning field due to its robust nature in explaining economic decisions. Where many view standard economics as too rigid, relying on assumptions of consistent preferences, full information, and unbounded rationality, behavioral economics use of flexible concepts like social/cultural framing, the status quo, and loss aversion seem to be more representative of the “real” world. Due to its accommodating assumptions and straightforward approach, though, there is a tendency for people to simplify or generalize the predictions of behavioral economics. An example of this trend can be seen in the Dark Daily article, “Behavioral Economics Likely to Push Up Utilization of Clinical Pathology Laboratory Tests.”

The article presents a well thought-out premise; new insurance schemes which incentivize improving health will have large take-up and thus subsequently lead to major increases in clinical lab tests. To motivate this discussion the author states, “given a choice of either unhealthy activities (e.g., smoking, eating badly, not exercising) coupled with an expensive health benefit plan, or an inexpensive, even zero cost, health plan that promotes healthy choices, behavioral economics theory predicts that consumers eventually choose the latter. That choice should lead to improved health while driving down the cost of healthcare.” This statement though is not completely valid. Nothing inherent in “behavioral economics”, or standard neo-classical economics for that matter, makes a costly insurance program with no behavior related stipulations necessarily the preferred choice over a cost-less but regulated alternative.

Predicting how people would react to these different insurance instruments is completely reliant on how one models the preferences of the consumer. If being in the regulated insurance program brings the consumer dis-utility from following the stipulations of the “healthy choices” plan or if current day enjoyment of behaviors (unhealthy choices) trumps long-term happiness derived by the expectation of future health (i.e. if the consumer is impatient enough) standard economics would predict that the costly insurance would continue to dominate the market. Moreover, when the findings of behavioral economics are used to predict the insurance choice, the outcome is increasingly unclear.

One prediction of behavior economics is that the way we contextualize particular decisions matter. Simply being offered two goods can be a very different choice problem depending on the circumstances surrounding the decision. In the case of insurance and health behaviors this context factor may be of great importance.

For example, it has been shown that when one views a decision as a market transaction versus social construct behaviors can vary greatly. Experimentally it has been shown that offering a wage for an activity that had been done freely before, and previously had been thought of as a “social duty”, actually can decrease participation in that activity. According to standard economics this should never happen, but when one is offered money for an action, the activity now becomes framed in terms of the market, and if that wage is not as high as they think they deserve, a previously freely done good deed can be interpreted as a poorly paid “job”. This contextualization issues applies in this insurance decision as well. If making healthy decisions is a choice motivated because it is “the right thing to do” or because it is more “socially acceptable” putting a price on acting unhealthy may legitimize for some the trade-off between paying for health insurance and acting unhealthy (encouraging “moral hazard” behavior). Additionally, behavioral economics is very keen to pursue how people deal with risk and loss. Common themes of this field of study are loss aversion, risk aversion, and ambiguity aversion, and each has its place in the insurance decisions.

Many studies have shown that people would prefer to take a less advantageous position in which there is not risk for failure. Not being able to succeed can be very disheartening and thus motivate risk-insulated behavior. In this way sticking to the “status quo” plan and avoiding the insurance in which one’s behavior is evaluated can be the optimal choice. Further, if people fear that failure to achieve levels of healthy behaviors will cause them to be dropped by the insurance plan or can drastically shift their budget, people may prefer the more consistent and non-action dependent plan than one which contains some ambiguity related to evaluations which the consumer fears they can not control (fear of failure to self commit), feel has some amount of chance (risk-aversion), or feels they don’t fully understand (ambiguity aversion).

Predicting economic behavior is of utmost importance to those who wish to create policies that incentivize certain outcomes. While standard economics provides a theoretical framework to do this, its assumptions can feel too constricting to interested parties. The field of Behavioral economics has opened the door to more flexible models of human decision-making and its use is imperative to proper development of policy prescriptions. With its flexibility though comes complexity and in most cases behavior economics, at a baseline level, cannot give strict predictions of outcomes, as with all models, the results will be conditional on the assumptions of the researcher. Thus, when making predictions about the impact of a policy it is important to combine the intuitive modeling of behavioral economics with rigorous empirical investigation and then one can start to make informed market and behavioral analysis of the introduction of a new good.

So what’s the take away? In the end, as William Goldman says, “Nobody knows anything.” Well, that’s a bit too cynical. But it’s too early to tell if, as these behavior and lifestyle dependent insurance programs are rolled out, they will be widely embraced.

Sure, if people know that they will pay less if they follow certain criteria or benchmarks that they should already be hitting, (like smoking cessation, etc.) that may encourage them to adopt the healthier lifestyle and therefore utilize more clinical testing. At least, that makes a certain amount of cognitive, logical sense.

But behavioral economics isn’t the study of logical actions – it’s the study of actual actions. Where people can be swayed by fear, or anxiety, or some form of rationalization that allows them to circumvent the logical. For those who are worried about being dropped from coverage for not making weight, or those who simply look at the extra cost for the “regular” insurance as a “fat tax” – then they have no problem with the current reactive system. Which would then translate to no change to lab tests.

It’s possible that this trend of applying “behavioral economics” could translate into more money for labs. But, by ascribing any probability to it in its infancy, the article’s conclusion is an assumption that is based more on McBride’s (hopeful) bias than on any previously documented behavior.

Be sure to check out the follow up study.

There’s a new opinion piece by Dr. John Mattson in Becker’s Orthopedic & Spine Review. Entitled “3 Reasons Justifying Synoptic Data in Surgical Operative Reports,” the piece examines the inherent problems with dictation and the multiple ways that synoptic reporting improves on this increasingly antiquated system.

Click here to read it!

Orthopedic surgeon Dr. John Mattson, a consultant to mTuitive OpNote, recently gave an interview to Healthcare Informatics about the benefits of mTuitive OpNote and how his experiences with reporting helped inform OpNote’s development.

Click here to read the whole interview!

1) Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them.

Many surgeons are attached to (or at least very comfortable with) their current workflows; they’re used to dictating their reports and it’s hard to envision another way. Especially when you couple in the fact that dictation can be very quick (moreso with the use of dictated templates), it’s a painless easy process that is just accepted as “the way things are done.” That means that when approaching surgeons with a different method, you’re already at a conversational disadvantage. However – that doesn’t mean they are not willing to change. Many surgeons now use various mobile apps to code their procedures to initiate billing and reimbursement faster. Additionally, the mentality of “the way things are done” tends to be a bit of a straw man argument; if you can prove something is more convenient while empowering the user, people tend to go with it. For example – how many people use ATMs versus tellers at a bank? Certainly there are some transactions where the teller is better – but for your most common uses and needs, why not use the ATM?

3) Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

This is an important point that we at OpNote have had to stress with our prospective users. It’s a hard sell when convincing people that an initial time investment will result in tremendous time savings later on. Modern society/culture is not conducive to delayed gratification, but through careful explanation hopefully we can illustrate how much time is actually being saved. One way to do that is to really work on your arguments and shape them as precisely as possible. For example, the time it takes to complete a report isn’t just how long it takes to dictate that report. There’s time to transcribe, time to revise and time to resubmit. The real measure of time is between finishing the surgery and signing out the report – which is generally anywhere between a few hours and a few weeks. By repositioning surgeons so they can see a larger view, hopefully they’ll be able to recognize the validity of our perspective.

• Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.
• Voice recognition with products such as Dragon creates an immediate benefit from savings in dictation costs, enhancing EHR adoption.

Templates are key to promoting adoption of electronic solutions amongst surgeons – but not the way that eClinicalWorks or other EHRs use them. In the comments section of this post, some users have talked about the problem with these canned text/unstructured templates. Which is something we at OpNote agree with – unstructured templates are essentially useless and more cumbersome than helpful. Even for surgeons that use templates, they still have to go through the awkward phrasing of what to change in their template, and then need to make sure that the correct changes were made before signing out. Digital reports should allow for the most common aspects of the procedures to be defaulted in by surgeons, but still be dynamic enough for users to make changes based on the unique aspects of each surgery. When possible, these reports need to be broken up into structured elements with a finite number of responses. For example, anesthesia used, position of patient, blood loss, discharge, etc. are all areas where a specific answer can be culled from a limited list of possibilities. This approach encourages comprehensive and complete reporting and a standardized electronic report will be much easier to integrate into the patient’s (and other facilities’) EHRs.

With templates, division of labor among practice staff, and interoperability, surgical practice EHR implementation can be successful, especially if incentives are aligned so that costs decrease and stimulus dollars flow.

In addition to the compensation from stimulus incentive programs, electronic reports can help increase payment as well, and not in a dubious manner. As Dr. Atul Gawande has discussed in his pieces on “The Checklist Manifesto,” seeing items in a checklist format helps tremendously with the practice of medicine. Even if the item that the physician recalls isn’t on the list, the list helps the physician remember to even mention that item. In fact, a recent study out of the Netherlands reveals how incorporating various checklists throughout the surgical process (pre-, peri- and postoperatively) helps improve patient care and outcomes.

But, more to the point of compensation, seeing the possible answers (or just those that are related) laid out spurs memory and encourages these surgeons to include more information in their reports. And, with the report having a synoptic and clear structure, it’s much easier for those in billing & coding to see what occurred, and how much they should be compensated. Eliminating dictation and transcription, boosting inclusion of more information to be properly coded while capturing valuable pieces of data for various initiatives all result in an a very persuasive financial argument for such adoption.

So much of what is done in these practices and facilities is already electronic; the scheduling programs that book the operating rooms and coordinates with the appropriate staff; the mail merge/carbon copied referral letters that are generated with reports and faxed to the appropriate PCPs; the intake of a new patient. Why not include one of the most important – and information rich – elements of a patient’s care into this workflow? Not only does it make sense for safety reasons, but it also can lead to improved patient care and financial benefits for the surgeons who recognize this and adopt to it.

As physicist William G. Pollard once said, “Without change there is no innovation, creativity, or incentive for improvement. Those who initiate change will have a better opportunity to manage the change that is inevitable.”

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Birmingham, AL, November 15, 2010 – SourceMedical today announced a partnership with mTuitive, Inc. to help ASCs and surgeons improve postoperative reporting and streamline medical coding processes. Built upon mTuitive’s electronic postoperative reporting solution and fully integrated with the AdvantX, Vision and SurgiSource applications, SourcePlus OpNote will provide ASCs and specialty hospitals with immediate access to surgeons’ postoperative reports and coding data leading to more rapid and accurate revenue cycle processes.

“As an orthopedic surgeon who does exclusively outpatient procedures, I see significant value in the integration of mTuitive’s OpNote into SourceMedical’s management software such as improved reporting for participating ASCs,” said Dr. John Mattson, an active user of the OpNote system. “After a short learning curve, surgeons will find that SourcePlus OpNote is faster than dictating and far less onerous for surgeons as the repetition present in 90 percent of operative reports is eliminated. We now produce superior operative reports while generating additional revenue. Integrating this technology with SourceMedical’s ASCs management software is a win for both surgeons and facilities.”

With SourcePlus OpNote, ASCs are no longer required to spend time and money having surgeons’ postoperative reports transcribed. SourcePlus OpNote makes surgeon reports immediately available via the fully web-based platform to the surgeon and ASC staff. By standardizing documentation and distributing reports simultaneously to all stakeholders immediately after approvals are entered, the entire coding and revenue cycle process is accelerated.

“Increasing scrutiny of medical claims by insurance companies has elevated the importance of consistency in reporting between surgeons and ASCs,” said Ron Pelletier, vice president of market strategy at SourceMedical. “By leveraging structured, standardized data as a component of all reports, users benefit from improved compliance, accuracy and timely completion – not to mention greater surgeon satisfaction.”

“The most exciting aspect of this partnership is that SourceMedical clients also gain access to a powerful tool that will aid them in efforts to meet the forthcoming conversion from ICD-9 to ICD-10 coding,” said John Murphy, CEO of mTuitive, Inc. “We share the belief that the most efficient, intelligent way to transition to the new coding standard is through capturing discrete data at the time of surgery.”

SourcePlus OpNote provides surgeons with a web-based postoperative report generation tool that eliminates dictation and transcription while accelerating the revenue cycle by providing associated procedural and diagnosis coding data, quality indicators and immediate sign-out. Accessible through any web browser, OpNote is a secure and efficient way for surgeons to record their procedures while ensuring completeness of reporting. A more complete report means stronger risk management and improved medical coding and reimbursement.

About SourceMedical

SourceMedical is the largest provider of outpatient information solutions and services for outpatient ambulatory surgery centers, specialty hospitals, and rehabilitation clinics nationwide measured by both experience and size of customer base. With 30 years of real world experience, more than 5,000 satisfied customers, and the confidence of more than 250 consultants and management companies, SourceMedical offers the broadest range of solutions and enhancements available to the industry. The company’s unique end-to-end systems improve operational efficiency and cash flow while enabling healthcare facilities to capture, exchange, and analyze data to deliver a higher standard of patient care. For more information, please visit www.sourcemed.net.

About mTuitive, Inc.

mTuitive, Inc. develops data capture and synoptic reporting software to assist health care professionals in recording clinical findings and maintaining compliance with established protocols and guidelines. mTuitive’s unique method of capturing structured information provides valuable data for surgery, pathology, oncology and cancer staging applications. Established in 2003, mTuitive, Inc. is based in Massachusetts. For more information, please visit www.mtuitive.com.

We’ve got some great material coming up on this blog in the coming weeks:

• One of our consultants wrote an excellent article that should be showing up around the web next week
• I’m currently working on a post about the latest batch of codes – CPT II (I call them the “Squeakquel”) – which are used to track various quality initiatives
• There’s some big news coming next week that is very exciting…

But today, just a light moment of brief hilarity. Enjoy!

Are you at Becker’s ASC Review’s 17th Annual Ambulatory Surgery Center Conference? Or are you just in Chicago and want to check out mTuitive OpNote in person? Want to see if we can rile up Bobby Knight enough to throw a chair at our booth?

If you answered “yes” to one or more of those questions, then come on down to mTuitive’s booth (#62) at Becker’s ASC Review’s conference. Say hello to Chris & Colin! Grab some of our free swag! Watch OpNote in action on iPads.

Come on down!

Patients receiving treatment at a health facility in the US will be assigned ICD-9 codes for their diagnoses.

October 1, 2013

Patients receiving treatment at a health facility in the US will be assigned ICD-10 codes for their diagnoses.

…What a difference a day makes.

As mentioned previously on this site, ICD coding system is an excellent, standardized way of tracking important diagnostic information. The current system in place is ICD-9, which has about 17,000 codes, and is used for symptoms, diagnoses, injuries, diseases and all other disorders facing patients. The new system is ICD-10, and it will have 155,000 codes – covering the same grouping of symptoms, diagnoses and the rest as ICD-9 – but with a lot more specificity.

I’ve been of the opinion that this transition wouldn’t be too painful. In fact, with the intelligent structure of the ICD-10 codes, where each character represents a specific quality of that code (such as location in the body, severity, etiology, etc.), I thought it could be a real boon to medical professionals. Sure, it would be a hard adjustment, but it’s one that’s about 15 years overdue. As I continue to read about ICD-10 and its impending implementation, I was curious about the plan for phasing it in to the current workflow. Based on everything I’ve read so far – I have a confession to make:

I was wrong – this is going to be a disaster.

Okay, perhaps I am being a bit dramatic. But there is legitimate cause for concern.

According to the AMA, AHIMA, CMS and other organizations in the know – ICD-10 codes will not be accepted until October 1, 2013. That means that while you can test the codes and your system for publishing or selecting your codes – you cannot use ICD-10-CM in a live environment until October 1, 2013.

Why is this a cause for concern?

Imagine if everyone’s area codes, nationwide, changed overnight with every zone having a new area code the next day. How would that work out? There would be some information printed up and resources online in a campaign to ensure that people will use the right numbers. But those numbers won’t be available until that initial, national day. And on that day of implementation? There’d be a lot of confusion, mistakes, calls not getting through and additional time spent having to re-check and learn which codes go for which location. Make no mistake – the new area codes could make a lot more sense geographically and be easy to figure out the logical succession of numbers; but assuming that an entire nation of users will be able to transfer over to this new way without any large mishaps is a recipe for an overnight success.

In other words, the exact opposite of this album cover...

I understand the theory of having a 1 day deadline – it ensures adherence to standards and protocols. I rail on about structured data because I think that when it comes to documentation and reporting, it’s important to have these standards in place. And no matter how ICD-10 is rolled out, there has to be one day when it is the only form of diagnostic coding accepted. It’s the timeline and schedule leading up to that crucial first day that is in question in this post.

The AMA has published its 3 year timeline for facilities to follow when transitioning to ICD-10. It includes interacting with vendors, training the pertinent personnel and testing the internal system. It makes sense and is a good, albeit vague, road map for health facilities to follow as they prepare their workflow for this change. The only problem is that it needs the facilities to already be working on implementing ICD-10: they already need to be aware of the changes, in conversations with vendors and getting pricing on the programs needed to make the change. As a vendor who deals in medical codes, I can tell you: those codes aren’t even ready yet. There is a rough draft of the unfinished codes available at Centers for Medicare & Medicaid Services (CMS) – but there will continue to be additions and alterations even after ICD-10-CM is officially adopted and in use. But it’s very hard to find it in any form that can be used by software developers (or else it’s being sparingly doled out and controlled by a small number of coding companies).

Right now, we (the health IT community) do not have as much access to this information as we need in order to help you (the health professional community) make informed decisions on what programs or what costs will be associated with any of these changes.

I really like ICD-10-CM. I think its layout makes a lot of sense. I think its precision and logical internal structure will end up being a huge help for researchers and to make certain that health professionals are paid correctly. I don’t think adapting to ICD-10 from ICD-9 will be that big of a hassle – but that doesn’t mean it should happen on a national scale at the stroke of midnight. This is coding that affects billing, health treatment and, eventually, people’s lives – not some dubious mystical deadline from Cinderella.

What I am proposing is a more phased implementation. I don’t pretend to know how it would be organized – by location, by types of diagnoses, specialty, or whatever. But I do know that people are used to hybrid solutions. Take, for example, the move from paper, analog medical records and electronic health records – that is not going to be a flip of a switch to change it. It is a process of phasing out certain techniques and processes while converting them into a new format. It requires hiring new personnel, training current personnel and a revision of workflows and information infrastructures. Hospitals are making the transition from paper to electronic in waves – a careful and methodical approach that reveals any problems that might arise from a new way of doing things. If the change to electronic records was handled the same way, there would be a computer crash and absolute halt of medical services across the nation.

ICD-10-CM won’t be that big of a change – if handled properly. If coders are allowed to submit the codes earlier and become more familiar with them over a period of years. If vendors are able to get better access to the data to use in their development sooner rather than later. If everything is approached in a calm and intelligent manner, the transition will still require adjustments and cause some stressing. But if it’s done in a phased implementation, then the differences won’t be night and day.