No World Borders Expands Health Care, Process Improvement Practice to Latin America

Newport Beach, CA - No World Borders today announced that it has expanded its health care and process improvement practices to Latin America, with projects under way in Mexico, Puerto Rico, with teams available for new market opportunities in Panama, and Uruguay.

Michael Arrigo, President & CEO of No World Borders said, "The world continues to become more global and borderless in terms of the need to align business and information technology. Latin American companies in the health care insurance business need bilingual English-Spanish speakers who understand process improvement, claims adjudication, electronic health records, claims systems, and the new HIPAA EDI standards X12 5010 and ICD-10. Recently, our partners and customers have turned to us, our team and our relationships to help reduce cost and risk in their business as they seek to become more efficient and paperless."

Renato Escobar, with Latin American services for No World Borders in Miami Florida added, "Our company brings multi-cultural, bilingual skills to emerging markets in health care and other industries. The U.S. has long been a model for health care best practices and process improvement. We are excited about our new offerings in this dynamic, high growth market place, and our innovative approach timed well for new business opportunities there."

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For more about No World Borders go to www.noworldborders.com

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IBM approach to implementing ICD-10, X12 5010 for health care payers

While at the America's Health Insurance Plans (AHIP) health care reform conference held in June 2009 in San Diego Ms. Barbara Archbold, Partner, Payer Industry for IBM Global Business Services is interviewed by Mike Arrigo, CEO of No World Borders.

Ms. Archbold recommends that health insurance payers approach the issue from a business point of view, start planning now for the new medical coding standard ICD-10, that they create a strategy and approach to reduce risk and cost for modernizing legacy systems by "touching these systems only once."

The Health Care Payer Role in HIEs

Health Data Management had an interesting article in the June 2009 issue on the payer role in HIEs. The core philosophy of health information exchanges (HIEs) is to bring together industry stakeholders to facilitate the appropriate sharing of patient data throughout a community, region or state. Several steps need to be taken to create widespread movement by the health plans to support heath information exchange. These include better "as is, to be" process improvement, an open dialogue between payers and providers by skilled facilitators, and a skilled team of subject matter experts at payers who understand ICD-10, X12 5010, and the impact on and modernization of the claims systems and adjudication process.

From Health Data Management, "...But while HIEs have worked for years to get established, a major stakeholder - health insurers - remains absent or a marginal player in many initiatives. Some health plans still are waiting for a viable business model that will justify a major investment in HIE initiatives. Others, particularly national payers, don't have a large market share of covered members in many of the regions that have an HIE. These payers and even regional insurers also often can't get involved in HIEs if their employer clients aren't sold on the idea of data exchange."

A small number of payers, however, are knee-deep into HIE initiatives. Chattanooga-based Shared Health, serving all of Tennessee, launched its HIE using claims data from two major insurers to provide physicians with a basic summary of care. Moreover, Blue Cross and Blue Shield of Massachusetts spent $50 million to wire up physicians with EHRs in three towns and get HIEs established there. "We have answered questions that these systems can scale and how to implement them," says Steven Fox, vice president of provider network management at the Blues plan. "We view it as a worthy investment and successful."

The HIE is a fundamental component of Obama's plan to make health care more efficient and affordable.

HIT Policy and Standards Committees Commence Work on National Health Information Infrastructure HITSP

HIT Policy and Standards Committees Commence Work on National Health Information Infrastructure HITSP (Health Information Technology Standards) updated to the National eHealth Collaborative in early June 2009. Here are a few highlights:

HITSP has moved rapidly to focus on meaningful use and ARRA's 8 priorities:
1. Encourage technology that protects the privacy of health information
2. Nationwide health information technology infrastructure
3. Utilization of a certified electronic record for each person in the US by 2014
4. Technologies that support accounting of disclosures made by a covered entity
5. Electronic records to improve quality
6. Technologies that enable identifiable health information to be rendered unusable/unreadable
7. Demographic data collection : race, ethnicity, primary language, and gender
8. Technologies that address the needs of children and other vulnerable populations

HITSP has embraced a service-oriented architecture, which enables reuse of capabilities instead of requiring new value cases for each novel requirement. Initial services include:
• Issue Ambulatory Prescriptions
• Query for Medication History
• Communication of Structured Documents
• Communication of Unstructured Documents
• Clinical Referral Request
• Retrieval of Medical Knowledge
• Return Laboratory Results Message
• Communication of Laboratory Reports
• Communication of Imaging Information
• Quality Measures for Hospital based Quality Information Collection and Reporting
• Quality Measures for Clinician Quality Information Collection and Reporting
• Immunization Registry Update
• Immunization Registry Query
• Communication of Immunization Documents
• Vaccine and Drug Inventory Reporting
• Public Health Case Reporting
• Emergency Common Alerting
• Send and Receive Relevant BioSurveillance Data
• Communicate Resource Utilization
• Exchange Administrative Benefits/Eligibility Transactions
• Exchange Administrative Referral/Authorization Transactions
• Provider Directory

HITSP is moving to an electronic publication approach for all its implementation guidance.

HITSP has embraced USHIK as a repository for its harmonized standards and code sets

The July 15 deliverables will directly support the needs of the HIT Standards Committee and its workgroups to identify standards, implementation guidance, and certification criteria in support of meaningful use.

Interview with TriZetto's Rob Scavo (AHIP)

While at the America's Health Insurance Plans conference in San Diego (AHIP) we met with Rob Scavo, President of Product Management and Core Administrative Solutions at TriZetto.

We asked Rob to provide TriZetto's view on what the new HIPAA standards, X12 5010 and medical coding standard ICD-10 mean in terms of not only compliance but opportunities to innovate and improve operations for both payors and providers.

Click play below to view the interview.

HCI addresses fraud, other health care cost issues - AHIP

While at the San Diego AHIP conference we interviewed HCI Insight, a company that promises to reduce the cost of health care by addressing fraud. HCI's loss calculators indicate that a health insurance firm with 3,000,000 (3 million) lives insured stands to lose $381 million over a specified period of time, and their solution is designed to address this issue, according to HCI executives.

We'll post our video interview in an update to this blog later today.

Protests outside AHIP Conference, San Diego

Today while entering the AHIP conference we encountered demonstrators who want the health care industry to change. We intereviewed Kathy Rallings, an employe at California Techers Association. The people *inside* the conference were a bit more subdued in their approach, but we believe that both the demonstrators and those exhibiting inside the conference are interested in improving health care. See our blog and twitter enteries (www.twitter.com/marrigo) for a balance of perspectives from both groups.

Click the play button below to view this video.

AHIP Day One - Passion in the Streets

Fresh blog from the floor of AHIP San Diego.  AHIP (America's Health Insurance Plans) is having their annual meeting in San Diego this week.   Here is a recap of June 3, 2009 the first day.

Last year at AHIP, health care reform was discussed, but most political commentators didn't think much would happen: there was interest, but not passion.  This year the passion has spilled onto the streets.

January 2009, the OMB made a statement that has remained at the center of where we are today- we cannot fix the economy unless we fix health care.

Of the significant debt we are now assuming with the new budget- $35 trillion of that debt is Medicare. We can't fix the economy if we don't fix health care.

One vendor’s health care reform includes four components developed sequentially. First is establishing a solid health information technology structure that we don't have today. Second is focusing more intently on comparative effectiveness and evidence-based service delivery, third is coordinating care, and fourth is consumerism. All of these components are being discussed.  Will we have time execute sequentially as opposed to combining these into a parallel path? The group estimated that this would take six to ten years to put the model in place, but do we have the time?

At a completely different end of the spectrum, there are also protests being organized, to show the angst developing in the industry.   Nurses from the  California Nurses Association and allies from groups like Physicians for a National Health Program and Progressive Democrats of America will be there to greet health plan executives.  Their tone is extremely hostile in some cases, calling the insurance industry some surprisingly caustic names.

Our view: HIPAA standards promise to improve health care, but we cannot wait.  Embracing the standard, technology, people and process must proceed briskly.  This is a challenge as member premiums have declined with unemployment ranks rising.   Click here four our recent update: mentoring health payers and providers on how to embrace HIPAA standards and improve process.

The exhibit hall is smaller this year given budget constraints.  However, we will spend more time there on day two.

Healthcare Business Models: Mayo Model Losing to McAllen?

An article in the New Yorker asks: Why does the border town of McAllen, Texas, spend more er person—an average Medicare enrollee there costs $15,000 per year—on health care than any U.S. city besides Miami? The author blames "across-the-board overuse of medicine," which stems from the fact that our health care system "pay[s] doctors for quantity, not quality." This overuse isn't just expensive—it's less effective. "In an odd way, this news is reassuring," the author notes: Providing better health care will also save money. 

This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

Business Process Management Helps Companies Work Smart and Fast

BALTIMORE – The economic decline is continuing to pummel hospitals in the form of reduction of reimbursements, rise of uninsured patients and decrease in number of elective procedures for insured patients.

In this environment of balancing shrinking budgets, staff reductions and patient safety, hospitals are more open to generating efficiencies using IT. Process improvement is a good investment in times when companies need to improve efficiency.

According to an article in Heath Care IT News, "Streamlining administrative processes while continuing to invest in patient care is not mutually exclusive. Business process management, or BPM, can provide a clear view of processes across all systems, including billing, accounting and other legacy systems. "The end goal is to improve business processes running on software, doing things in the smartest and fastest ways, which automates processes, reduces resources and increases accuracy.

An additional benefit of implementing BPM is being able to document and track data in real time, which improves the process for compliance certification and audits."

By using IT to help their businesses fix process issues, C-level hospital executives can "step up and be the champions," especially in this economic environment.

No World Borders' team of BPM experts have cross-industry and cross-technology experience to help your company improve operating efficiencies, reduce cost, and improve process.

http://tinyurl.com/ceehq7

Electronic Health Records and Patient Privacy, Medical Identity

Yesterday, an important message titled “Don’t Rush eHRs Without Addressing Medical ID Theft” was posted on ModernHealthcare.com by Martin Ethridgehill, formerly a provider training specialist with Blue Cross and Blue Shield of New Mexico.

Mr. Ethridgehill points out that if a patient’s electronic medical identity is stolen by someone for health insurance benefits, critical information about the patient can be imperceptibly altered, leading to accidental death in an emergency room for any number of reasons. Furthermore, he points out that even if the real patient is aware that his or her record is tainted by a false patient’s data, it is very difficult to get the comingled record cleared up.

I have also read elsewhere that HIPAA actually impedes resolution of the nightmare because the Rule also protects the privacy of the false patient - prohibiting the real patient from examining his or her own health record.

Reasons to Go Slow

Ethridgehill is particularly critical of the EHR industry which lately has downplayed the importance of patient privacy in order to sell dangerous products. He gives these reasons for the need to slow down in the rush for interoperability:

• “Adding safety and records mitigation protocols ensures patient safety as an ongoing concept and practice.”
• “No industry would be allowed to operate, where the officials in charge of it stated that the market or other bodies would be responsible for creating safety procedures. Can you imagine if the auto industry stated, “We make cars, let the market figure out how to regulate safety”? I doubt that Congress or any other body would consider these people as remotely credible, yet I hear time and time again these statements being made in public and private forums by executives, lobbyists, and even so-called healthcare leaders.”
• “For the public and providers to embrace a product that has no regulation, no built-in safeguards and obviously no importance to safety from the makers of these products, why would Congress expect the American public or healthcare providers to embrace a product or concept that involves the unregulated risk of injury, death, or staggering liability opportunities, let alone without any hope of remedy or proper relief?”

One of the keys to improving life for payors as well as providers and patients will be process innovation. This is accomplished by clearly documenting the existing or "as is" process as well as the "to be" of the desired process. That can only be accomplished with combined disciplines of technicians who know business process modeling (BPM), facilitators who are professionals that can interact with all levels of stakeholders in the health care service chain, and "content" experts who understand legal, medical, and workflow implications of making changes to major functions such as provider management or claims adjudication.

No World Borders has been consulting with several health care payors on process improvement, and preparation of the conversion of systems for electronic health records.

Business Process Engineering for Health Care Payers

The Model for Improvement,* developed by Associates in Process Improvement, is a simple yet powerful tool for accelerating improvement. The model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement. This model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes.

The model has two parts:

• Three fundamental questions, which can be addressed in any order.
• The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement.

Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs.
Forming the Team

 

 

Integrated Healthcare Creates Efficiencies

Barak Obama's administration is expected to spend $50 billion to modernize the health care system, focusing in part on upgrading information technology for "EHR" for electronic health record, and "PHR" for personal [electronic] health record.  

Business process engineering will be a critical component.  Before IT can change, a clear understanding of existing or "As Is" process modeling and a new "To Be" or future state vision must be determined.  As you can imagine, if health care claims are currently being processed via paper, and in the future you expect to process them electronically, the workflow of health insurance company staff, as well as health providers and patients will have to change.  The ability to facilitate meetings with key stakeholders and produce Process Models that enable simulation and what if scenarios are key competencies to help health insurers meet this challenge.

Emergence of a Retail Market in Healthcare

A retail market is rapidly emerging in healthcare as consumers pay a greater share of total costs.

Per-person health spending in the United States has reached $7,110 in 2006 and is expected to climb to $12,320 in 2015.  More than 46 million Americans are uninsured and growing numbers of employers are dropping coverage or thinning benefits.

With healthcare spending rapidly approaching 20 percent of the U.S. Gross National Product, healthcare has reached a crossroads. Either free-market forces will solve the current affordability crisis or the federal government may impose a solution. If the industry hopes to solve the affordability crisis, healthcare payer organizations will have to rethink their roles and fundamentally change the way they provide value in the supply chain. To sustain their role at the center of the healthcare supply chain, payers must lead the industry’s transformation by deploying solutions that enhance their revenue growth and improve the customer experience.

The Need for Innovation in Health Care

The emergence of a retail market necessitates that companies currently offering healthcare solutions undertake innovative integration with new entrants to the value chain (such as financial institutions and payment processors) in order to offer viable, enabling solutions. If payers fail to keep pace with the changing market, they risk losing business to market leaders. Or worse, as healthcare and financial services converge, payers eventually could find themselves replaced. If payers do remain at the center of the supply chain, they can ensure that all stakeholders work in an efficient, streamlined fashion to not only administer claims, but also to facilitate transactions, reduce costs, pay providers and ultimately enhance the health of plan members. 

Integrated Healthcare Management (see IHA) is the systematic application of processes and shared information to optimize the coordination of benefits and care for the healthcare consumer.  No World Borders applies our talent and process knowledge to help improve the flow of information from doctors to payers and funds from payers to doctors, in partnership with leading health care solutions firms.

U.S. healthcare includes significant variability in how healthcare is delivered and in the results it achieves, largely due to divisions among the constituents in the healthcare supply chain: the consumers who use the system, the providers who give care, the employers and consumers who purchase healthcare, and the health plans that pay for services.

Integrated Healthcare Management is a framework that connects all of the healthcare supply chain constituents so that they can collaborate on and coordinate benefits and care.  No World Borders is partnering with companies to provide its consulting services to  give payers the software, services, and blueprint required to power Integrated Healthcare Management, and lead the transformation of healthcare.