Joyce Frieden

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than was its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” said Ms. Leon-Chisen. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” whereas ICD-9 codes cannot.

Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters. Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

Medicare officials and others are still wrangling with when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended the following resources for more information on ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than was its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” said Ms. Leon-Chisen. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” whereas ICD-9 codes cannot.

Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters. Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

Medicare officials and others are still wrangling with when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended the following resources for more information on ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than was its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” said Ms. Leon-Chisen. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” whereas ICD-9 codes cannot.

Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters. Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

Medicare officials and others are still wrangling with when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended the following resources for more information on ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

Leaders of several health care and labor organizations met with President Obama at the White House and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “If everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said. “In some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

“We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon. … We are heartened by the sector's growing acceptance of responsibility to engage constructively in a search for solutions, but we believe that those solutions will need to be embodied in law.”

President Barack Obama meets with health care reform stakeholders at the White House May 11, 2009. OFFICIAL WHITE HOUSE PHOTO BY PETE SOUZA

Leaders of several health care and labor organizations met with President Obama at the White House and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “If everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said. “In some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

“We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon. … We are heartened by the sector's growing acceptance of responsibility to engage constructively in a search for solutions, but we believe that those solutions will need to be embodied in law.”

President Barack Obama meets with health care reform stakeholders at the White House May 11, 2009. OFFICIAL WHITE HOUSE PHOTO BY PETE SOUZA

Leaders of several health care and labor organizations met with President Obama at the White House and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “If everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said. “In some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

“We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon. … We are heartened by the sector's growing acceptance of responsibility to engage constructively in a search for solutions, but we believe that those solutions will need to be embodied in law.”

President Barack Obama meets with health care reform stakeholders at the White House May 11, 2009. OFFICIAL WHITE HOUSE PHOTO BY PETE SOUZA

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., explained the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

After the meeting, the Markle Foundation released a consensus document with a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., explained the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

After the meeting, the Markle Foundation released a consensus document with a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., explained the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

After the meeting, the Markle Foundation released a consensus document with a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

WASHINGTON – Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for buying an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

The day after the subcommittee's meeting concluded, the Markle Foundation held a press conference to release a document on the definition.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

The consensus document is available at http://www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

WASHINGTON – Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for buying an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

The day after the subcommittee's meeting concluded, the Markle Foundation held a press conference to release a document on the definition.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

The consensus document is available at http://www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

WASHINGTON – Just what exactly does “meaningful use” mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for buying an electronic health record, the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said. The only way to reduce that overuse is to feed the information back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

The day after the subcommittee's meeting concluded, the Markle Foundation held a press conference to release a document on the definition.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.”

The consensus document is available at http://www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

Leaders of several health care and labor organizations who met with President Obama proposed ideas aimed at reducing the growth in health care costs by as much as $2 trillion over the next decade.

In a letter to the president, the six organizations–the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union–vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said in an interview. “We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

Dr. Rohack said he thought the president heard what the AMA was conveying. “Clearly, the message of defensive medicine costing dollars in the health care system was received, as was the recognition that prior attempts at tort liability by just creating global caps hasn't been successful. We are going to have to work at other creative ways of achieving the goal.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

Reaction to the meeting varied. “If the savings described today occur, this may be one of the most significant developments in promoting meaningful health care reform,” Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. “These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care.”

Others were less impressed. “We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care, a progressive advocacy group. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon.”

Rep. Michael Burgess (R-Texas) said he was glad that the groups were trying to work together, but he criticized the approach. “The announcement by the health industry leaders misses the mark in several areas,” he said in a statement. “It promises no guarantees that Washington bureaucrats won't stand in the way of Americans getting the treatment they need when they need it; no promises that patients will be able to control their health care decisions; and no assurances that Americans will have their choice of doctors or hospitals,” he said. “Until more details are revealed, I would encourage Americans to be circumspect about [the] announcement.”

President Obama called the meeting held to discuss cost savings in health care “a watershed event.” Official White House Photo by Pete Souza

Leaders of several health care and labor organizations who met with President Obama proposed ideas aimed at reducing the growth in health care costs by as much as $2 trillion over the next decade.

In a letter to the president, the six organizations–the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union–vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said in an interview. “We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

Dr. Rohack said he thought the president heard what the AMA was conveying. “Clearly, the message of defensive medicine costing dollars in the health care system was received, as was the recognition that prior attempts at tort liability by just creating global caps hasn't been successful. We are going to have to work at other creative ways of achieving the goal.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

Reaction to the meeting varied. “If the savings described today occur, this may be one of the most significant developments in promoting meaningful health care reform,” Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. “These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care.”

Others were less impressed. “We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care, a progressive advocacy group. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon.”

Rep. Michael Burgess (R-Texas) said he was glad that the groups were trying to work together, but he criticized the approach. “The announcement by the health industry leaders misses the mark in several areas,” he said in a statement. “It promises no guarantees that Washington bureaucrats won't stand in the way of Americans getting the treatment they need when they need it; no promises that patients will be able to control their health care decisions; and no assurances that Americans will have their choice of doctors or hospitals,” he said. “Until more details are revealed, I would encourage Americans to be circumspect about [the] announcement.”

President Obama called the meeting held to discuss cost savings in health care “a watershed event.” Official White House Photo by Pete Souza

Leaders of several health care and labor organizations who met with President Obama proposed ideas aimed at reducing the growth in health care costs by as much as $2 trillion over the next decade.

In a letter to the president, the six organizations–the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union–vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency;

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency;

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively;

▸ Implementing proven prevention strategies; and,

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. “For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure,” AMA president-elect Dr. J. James Rohack said in an interview. “We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline.”

Dr. Rohack said he thought the president heard what the AMA was conveying. “Clearly, the message of defensive medicine costing dollars in the health care system was received, as was the recognition that prior attempts at tort liability by just creating global caps hasn't been successful. We are going to have to work at other creative ways of achieving the goal.”

The president called the White House meeting historic. “[This is] a watershed event in the long and elusive quest for health care reform,” he said after the gathering. “And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings.”

Reaction to the meeting varied. “If the savings described today occur, this may be one of the most significant developments in promoting meaningful health care reform,” Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. “These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care.”

Others were less impressed. “We are very cautious about the particulars of the voluntary effort that groups proposed to the White House,” said a statement from the National Coalition on Health Care, a progressive advocacy group. “Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon.”

Rep. Michael Burgess (R-Texas) said he was glad that the groups were trying to work together, but he criticized the approach. “The announcement by the health industry leaders misses the mark in several areas,” he said in a statement. “It promises no guarantees that Washington bureaucrats won't stand in the way of Americans getting the treatment they need when they need it; no promises that patients will be able to control their health care decisions; and no assurances that Americans will have their choice of doctors or hospitals,” he said. “Until more details are revealed, I would encourage Americans to be circumspect about [the] announcement.”

President Obama called the meeting held to discuss cost savings in health care “a watershed event.” Official White House Photo by Pete Souza

Leaders of several health care and labor organizations met with President Obama at the White House in May and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency.

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency.

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively.

▸ Implementing proven prevention strategies.

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. "For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure," AMA president-elect Dr. J. James Rohack said in an interview. "We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline."

The president called the White House meeting historic. "[This is] a watershed event in the long and elusive quest for health care reform," he said after the gathering. "And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings."

Reaction to the meeting varied.

"If the savings described today truly occur, this may be one of the most significant developments in promoting meaningful health care reform," Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. "These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care."

Others were less impressed. "We are very cautious about the particulars of the voluntary effort that groups proposed to the White House," said a statement from the National Coalition on Health Care, a progressive advocacy group. "Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon."

Leaders of several health care and labor organizations met with President Obama at the White House in May and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency.

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency.

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively.

▸ Implementing proven prevention strategies.

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. "For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure," AMA president-elect Dr. J. James Rohack said in an interview. "We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline."

The president called the White House meeting historic. "[This is] a watershed event in the long and elusive quest for health care reform," he said after the gathering. "And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings."

Reaction to the meeting varied.

"If the savings described today truly occur, this may be one of the most significant developments in promoting meaningful health care reform," Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. "These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care."

Others were less impressed. "We are very cautious about the particulars of the voluntary effort that groups proposed to the White House," said a statement from the National Coalition on Health Care, a progressive advocacy group. "Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon."

Leaders of several health care and labor organizations met with President Obama at the White House in May and proposed ideas to reduce the growth in health care costs by as much as $2 trillion over the next decade.

In a letter sent to the president, the six organizations—the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, America's Health Insurance Plans, and the Service Employees International Union—vowed to work as a group to help achieve the cost reduction. Among their proposals:

▸ Cutting costs by focusing on administrative simplification, standardization, and transparency.

▸ Reducing overuse and underuse of health care by aligning incentives so that physicians, hospitals, and other providers are encouraged to work together toward the highest standards of quality and efficiency.

▸ Encouraging coordinated care and adhering to evidence-based best practices and therapies that reduce hospitalization and manage chronic disease more effectively.

▸ Implementing proven prevention strategies.

▸ Making common-sense improvements in care delivery, health information technology, workforce development, and regulatory reforms.

The American Medical Association told the president that although evidence-based guidelines will be helpful in reducing costs, the reductions could be enhanced if physicians had more liability protection. "For example, if everyone who walks into the emergency room gets an MRI for a headache, it's a costly procedure," AMA president-elect Dr. J. James Rohack said in an interview. "We know that in some areas of the country [that test has] been done because people sued when they didn't get the test. If we create scientifically based guidelines that say not everyone needs to have the MRI for a headache, physicians have got to have liability protection so they don't get sued if they follow that guideline."

The president called the White House meeting historic. "[This is] a watershed event in the long and elusive quest for health care reform," he said after the gathering. "And as these groups take the steps they are outlining, and as we work with Congress on health care reform legislation, my administration will continue working to reduce health care costs to achieve similar savings."

Reaction to the meeting varied.

"If the savings described today truly occur, this may be one of the most significant developments in promoting meaningful health care reform," Ron Pollack, executive director of Families USA, a liberal consumer health organization, said in a statement. "These savings would cut projected health care costs for families and businesses, and they would enable adequate subsidies to be offered so that everyone has access to high-quality, affordable health care."

Others were less impressed. "We are very cautious about the particulars of the voluntary effort that groups proposed to the White House," said a statement from the National Coalition on Health Care, a progressive advocacy group. "Most of the measures that they cited would help to make the health care system more efficient over time, but, as the Congressional Budget Office has indicated, should not be counted on to produce substantial savings soon."

WASHINGTON — Just what exactly does "meaningful use" mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to "meaningful use." Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

"The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system," said Helen Darling, president of the National Business Group on Health. "We have a fiscal crisis, not just a health crisis; we have to act urgently."

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. "Gray area" discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician "and start to have a conversation" about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of "meaningful use" of them differed. "Meaningful use might vary by site of care as well as by type of care," said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was "processes and workflows that facilitate improved quality and increased efficiency."

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups.

The consensus document provides a "simple" definition of meaningful use: "The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs." The document lists slightly different meaningful use requirements for the first 2 years, however; during that time period meaningful use would be when "the provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve medication management and coordination of care."

WASHINGTON — Just what exactly does "meaningful use" mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to "meaningful use." Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

"The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system," said Helen Darling, president of the National Business Group on Health. "We have a fiscal crisis, not just a health crisis; we have to act urgently."

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. "Gray area" discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician "and start to have a conversation" about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of "meaningful use" of them differed. "Meaningful use might vary by site of care as well as by type of care," said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was "processes and workflows that facilitate improved quality and increased efficiency."

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups.

The consensus document provides a "simple" definition of meaningful use: "The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs." The document lists slightly different meaningful use requirements for the first 2 years, however; during that time period meaningful use would be when "the provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve medication management and coordination of care."

WASHINGTON — Just what exactly does "meaningful use" mean?

It sounds like a simple question, but there's a lot of money riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record, the record must be put to "meaningful use." Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an electronic health record (EHR) was so valuable.

"The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system," said Helen Darling, president of the National Business Group on Health. "We have a fiscal crisis, not just a health crisis; we have to act urgently."

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. "Gray area" discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician "and start to have a conversation" about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of "meaningful use" of them differed. "Meaningful use might vary by site of care as well as by type of care," said Dr. David Classen of the Computer Sciences Corporation, whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was "processes and workflows that facilitate improved quality and increased efficiency."

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. However, certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice-president for health information technology at the National Quality Forum, which sets goals for performance improvement.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups.

The consensus document provides a "simple" definition of meaningful use: "The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs." The document lists slightly different meaningful use requirements for the first 2 years, however; during that time period meaningful use would be when "the provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve medication management and coordination of care."

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

"ICD-9 badly needs to be replaced," said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. "It's 30 years old, and the terminology and classification of some conditions are obsolete."

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 "will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture," she added, noting that the new code set will allow health officials to be "better able to track and respond to global health threats."

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, "but not from day 1," said Ms. Leon-Chisen. "It will take a little while" for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

P ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

P With ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

P ICD-10 codes can include the use of a placeholder "x," whereas ICD-9 codes cannot.

She also gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, "pressure ulcer, buttock."

Under ICD-10, the same patient would get L89.111, "decubitus ulcer of right buttock limited to breakdown of the skin." A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, "once you work with it, you're struck by the logic of the system," she said. "It's really not that difficult." Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters.

Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

As an example of the difference in procedure codes, she cited the ICD-9 code 17.43 for "percutaneous robotic assisted procedure," versus 8E093CZ, the ICD-10-PCS code for "robotic assisted procedure of head and neck region, percutaneous approach."

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be "frozen"—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

The move to the new code sets was necessary, according to Department of Health and Human Services to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

ICD-9 needs to be replaced. 'It's 30 years old, and the terminology and classification of some conditions are obsolete.' MS. LEON-CHISEN

Recommended ICD-10 Resources

Ms. Bowman recommended the following resources for physicians interested in obtaining more in-depth information about ICD-10:

National Center for Health Statistics/Centers for Disease Control and Prevention: Information about new disease classifications

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Service: ICD-10 Overview

www.cms.hhs.gov/ICD10

The American Hospital Association: ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association: Newsletter sign-up and other information

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

"ICD-9 badly needs to be replaced," said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. "It's 30 years old, and the terminology and classification of some conditions are obsolete."

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 "will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture," she added, noting that the new code set will allow health officials to be "better able to track and respond to global health threats."

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, "but not from day 1," said Ms. Leon-Chisen. "It will take a little while" for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

P ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

P With ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

P ICD-10 codes can include the use of a placeholder "x," whereas ICD-9 codes cannot.

She also gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, "pressure ulcer, buttock."

Under ICD-10, the same patient would get L89.111, "decubitus ulcer of right buttock limited to breakdown of the skin." A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, "once you work with it, you're struck by the logic of the system," she said. "It's really not that difficult." Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters.

Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

As an example of the difference in procedure codes, she cited the ICD-9 code 17.43 for "percutaneous robotic assisted procedure," versus 8E093CZ, the ICD-10-PCS code for "robotic assisted procedure of head and neck region, percutaneous approach."

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be "frozen"—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

The move to the new code sets was necessary, according to Department of Health and Human Services to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

ICD-9 needs to be replaced. 'It's 30 years old, and the terminology and classification of some conditions are obsolete.' MS. LEON-CHISEN

Recommended ICD-10 Resources

Ms. Bowman recommended the following resources for physicians interested in obtaining more in-depth information about ICD-10:

National Center for Health Statistics/Centers for Disease Control and Prevention: Information about new disease classifications

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Service: ICD-10 Overview

www.cms.hhs.gov/ICD10

The American Hospital Association: ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association: Newsletter sign-up and other information

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, according to several speakers at a meeting sponsored by the American Health Information Management Association.

"ICD-9 badly needs to be replaced," said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. "It's 30 years old, and the terminology and classification of some conditions are obsolete."

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 "will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture," she added, noting that the new code set will allow health officials to be "better able to track and respond to global health threats."

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, "but not from day 1," said Ms. Leon-Chisen. "It will take a little while" for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

P ICD-9 codes contain 3–5 characters, whereas ICD-10 contains 3–7 characters.

P With ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

P ICD-10 codes can include the use of a placeholder "x," whereas ICD-9 codes cannot.

She also gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, "pressure ulcer, buttock."

Under ICD-10, the same patient would get L89.111, "decubitus ulcer of right buttock limited to breakdown of the skin." A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, "once you work with it, you're struck by the logic of the system," she said. "It's really not that difficult." Under the ICD-10 code structure, each character has a specific meaning.

Ms. Bowman pointed out some of the differences between procedure codes under the two revisions. For example, ICD-9 procedure codes have 3–4 characters, whereas ICD-10-PCS codes always have 7 characters.

Also, all ICD-9 procedure code characters are numeric, whereas ICD-10-PCS code characters can each be alphabetic or numeric; alphabetic characters are not case sensitive.

As an example of the difference in procedure codes, she cited the ICD-9 code 17.43 for "percutaneous robotic assisted procedure," versus 8E093CZ, the ICD-10-PCS code for "robotic assisted procedure of head and neck region, percutaneous approach."

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be "frozen"—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

The move to the new code sets was necessary, according to Department of Health and Human Services to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

ICD-9 needs to be replaced. 'It's 30 years old, and the terminology and classification of some conditions are obsolete.' MS. LEON-CHISEN

Recommended ICD-10 Resources

Ms. Bowman recommended the following resources for physicians interested in obtaining more in-depth information about ICD-10:

National Center for Health Statistics/Centers for Disease Control and Prevention: Information about new disease classifications

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Service: ICD-10 Overview

www.cms.hhs.gov/ICD10

The American Hospital Association: ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association: Newsletter sign-up and other information

www.ahima.org/icd10

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. Under the trial protocol, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” said Dr. Walters. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors,” she said, because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” said Dr. Walters, adding that “you can look at the entire population of patients … so that you can take care of the health of the population of [for example] the diabetics or congestive heart failure [patients] that you serve.”

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred a partnership between Dartmouth-Hitchcock and CIGNA to develop a pilot medical home project.

Under that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” said Dr. Walters. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program only began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University, Baltimore, showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” said Ms. Rogers. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures that we can all agree on. … That's probably one of our biggest problems.”

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund' over 3 years. DR. WALTERS

WASHINGTON — Offering interventions to improve balance and ensure proper functioning of assistive devices can cut the incidence of falls by half in older people, researchers found. The same study showed that indicators as diverse as difficulty clipping toenails and leg weakness could predict fall risk.

John Parrish, Ph.D., executive director of the Erickson Foundation, and his associates developed a six-page, 29-item questionnaire to predict fall risk. The questionnaire can be self-administered or given by medical personnel or other professionals, Dr. Parrish said at a session on fall prevention at the sixth annual World Health Care Congress.

The researchers administered the questionnaire to 198 people aged 62 years or older and then checked back 6 and 12 months later. A total of 152 patients completed the survey and both follow-ups.

The researchers found that 48% of respondents had experienced one or more falls within the 6 months before the survey, including 0.5% who had as many as six falls. People who had fallen were more likely to report problems cutting their toenails, poor balance, leg weakness, numbness in their feet, use of an assistive device such as a walker, inability to walk one-quarter mile, inadequate exercise, and dizziness when standing up, Dr. Parrish said.

After the survey, patients who had histories of falling were referred for interventions including balance retraining, medication management, and evaluation of their assistive device to make sure it was working properly. About 94% of the patients who reported falls had received at least one intervention by the end of the 6-month follow-up period, Dr. Parrish said.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency, while 9% experienced more falls than they had before completing the questionnaire. At the 12-month follow-up, the researchers found that only 25% of respondents had fallen during the previous 6 months, a statistically significant decline from baseline.

Dr. Matthew Narrett, executive vice president and chief medical officer of Erickson Health, said in the session that his company, which provides health insurance coverage and medical care at 20 retirement communities nationwide, reduced hip fractures in a population of 2,300 seniors from 45 in 2004 to 26 in 2008. Measures taken included:

▸ Patient evaluation. When a patient falls, an e-mail is sent to all relevant parties. A health care worker goes to the patient's apartment the next day and documents the circumstances of the fall, and results are entered into the patient's electronic medical record.

▸ On-site osteoporosis screening. “We cover it in our [health] plan for men as well as women,” since 20% of men over age 80 have osteoporosis, Dr. Narrett said.

▸ Provider education on vitamin D deficiency. “Using the electronic medical record, we demonstrated a fourfold increase in vitamin D screenings among our residents” after providers were given information on vitamin D deficiency in the elderly, he said.

Preventing falls has an economic benefit as well, since 25% of patients who sustain hip fractures will end up being admitted to long-term care facilities, he noted.

Bonita Lynn Beattie, vice president of injury prevention at the National Council on Aging, said in her presentation that 35%–40% of adults aged 65 or older fall each year, and if they fall once, they're two to three times more likely to fall again. Of those who sustain hip fractures, 20% die within a year.

“We think many falls are preventable,” she said. “If a person has a history of falls, they really need a clinical assessment to see if there's appropriate intervention.”

All adults need to work on balance and strength, ensure that their meds are managed appropriately, and adhere to their medication regimen, Ms. Beattie said. Vision problems also are an important component that needs to be addressed.

Home hazards also need to be reduced, she said. “Putting grab bars in the bathroom … where people will use them and teaching people how to use them can make a significant difference,” she said.

The panel was sponsored by Erickson Health. The Milton H. Erickson Foundation is a private research and philanthropic foundation.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency. DR. PARRISH

Resources for Fall Prevention

Dr. Parrish recommended the following Web sites for fall-prevention information:

▸

www.stopfalls.org

▸

www.ncoa.org

▸

www.jefferson.edu/jchp/carah

WASHINGTON — Offering interventions to improve balance and ensure proper functioning of assistive devices can cut the incidence of falls by half in older people, researchers found. The same study showed that indicators as diverse as difficulty clipping toenails and leg weakness could predict fall risk.

John Parrish, Ph.D., executive director of the Erickson Foundation, and his associates developed a six-page, 29-item questionnaire to predict fall risk. The questionnaire can be self-administered or given by medical personnel or other professionals, Dr. Parrish said at a session on fall prevention at the sixth annual World Health Care Congress.

The researchers administered the questionnaire to 198 people aged 62 years or older and then checked back 6 and 12 months later. A total of 152 patients completed the survey and both follow-ups.

The researchers found that 48% of respondents had experienced one or more falls within the 6 months before the survey, including 0.5% who had as many as six falls. People who had fallen were more likely to report problems cutting their toenails, poor balance, leg weakness, numbness in their feet, use of an assistive device such as a walker, inability to walk one-quarter mile, inadequate exercise, and dizziness when standing up, Dr. Parrish said.

After the survey, patients who had histories of falling were referred for interventions including balance retraining, medication management, and evaluation of their assistive device to make sure it was working properly. About 94% of the patients who reported falls had received at least one intervention by the end of the 6-month follow-up period, Dr. Parrish said.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency, while 9% experienced more falls than they had before completing the questionnaire. At the 12-month follow-up, the researchers found that only 25% of respondents had fallen during the previous 6 months, a statistically significant decline from baseline.

Dr. Matthew Narrett, executive vice president and chief medical officer of Erickson Health, said in the session that his company, which provides health insurance coverage and medical care at 20 retirement communities nationwide, reduced hip fractures in a population of 2,300 seniors from 45 in 2004 to 26 in 2008. Measures taken included:

▸ Patient evaluation. When a patient falls, an e-mail is sent to all relevant parties. A health care worker goes to the patient's apartment the next day and documents the circumstances of the fall, and results are entered into the patient's electronic medical record.

▸ On-site osteoporosis screening. “We cover it in our [health] plan for men as well as women,” since 20% of men over age 80 have osteoporosis, Dr. Narrett said.

▸ Provider education on vitamin D deficiency. “Using the electronic medical record, we demonstrated a fourfold increase in vitamin D screenings among our residents” after providers were given information on vitamin D deficiency in the elderly, he said.

Preventing falls has an economic benefit as well, since 25% of patients who sustain hip fractures will end up being admitted to long-term care facilities, he noted.

Bonita Lynn Beattie, vice president of injury prevention at the National Council on Aging, said in her presentation that 35%–40% of adults aged 65 or older fall each year, and if they fall once, they're two to three times more likely to fall again. Of those who sustain hip fractures, 20% die within a year.

“We think many falls are preventable,” she said. “If a person has a history of falls, they really need a clinical assessment to see if there's appropriate intervention.”

All adults need to work on balance and strength, ensure that their meds are managed appropriately, and adhere to their medication regimen, Ms. Beattie said. Vision problems also are an important component that needs to be addressed.

Home hazards also need to be reduced, she said. “Putting grab bars in the bathroom … where people will use them and teaching people how to use them can make a significant difference,” she said.

The panel was sponsored by Erickson Health. The Milton H. Erickson Foundation is a private research and philanthropic foundation.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency. DR. PARRISH

Resources for Fall Prevention

Dr. Parrish recommended the following Web sites for fall-prevention information:

▸

www.stopfalls.org

▸

www.ncoa.org

▸

www.jefferson.edu/jchp/carah

WASHINGTON — Offering interventions to improve balance and ensure proper functioning of assistive devices can cut the incidence of falls by half in older people, researchers found. The same study showed that indicators as diverse as difficulty clipping toenails and leg weakness could predict fall risk.

John Parrish, Ph.D., executive director of the Erickson Foundation, and his associates developed a six-page, 29-item questionnaire to predict fall risk. The questionnaire can be self-administered or given by medical personnel or other professionals, Dr. Parrish said at a session on fall prevention at the sixth annual World Health Care Congress.

The researchers administered the questionnaire to 198 people aged 62 years or older and then checked back 6 and 12 months later. A total of 152 patients completed the survey and both follow-ups.

The researchers found that 48% of respondents had experienced one or more falls within the 6 months before the survey, including 0.5% who had as many as six falls. People who had fallen were more likely to report problems cutting their toenails, poor balance, leg weakness, numbness in their feet, use of an assistive device such as a walker, inability to walk one-quarter mile, inadequate exercise, and dizziness when standing up, Dr. Parrish said.

After the survey, patients who had histories of falling were referred for interventions including balance retraining, medication management, and evaluation of their assistive device to make sure it was working properly. About 94% of the patients who reported falls had received at least one intervention by the end of the 6-month follow-up period, Dr. Parrish said.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency, while 9% experienced more falls than they had before completing the questionnaire. At the 12-month follow-up, the researchers found that only 25% of respondents had fallen during the previous 6 months, a statistically significant decline from baseline.

Dr. Matthew Narrett, executive vice president and chief medical officer of Erickson Health, said in the session that his company, which provides health insurance coverage and medical care at 20 retirement communities nationwide, reduced hip fractures in a population of 2,300 seniors from 45 in 2004 to 26 in 2008. Measures taken included:

▸ Patient evaluation. When a patient falls, an e-mail is sent to all relevant parties. A health care worker goes to the patient's apartment the next day and documents the circumstances of the fall, and results are entered into the patient's electronic medical record.

▸ On-site osteoporosis screening. “We cover it in our [health] plan for men as well as women,” since 20% of men over age 80 have osteoporosis, Dr. Narrett said.

▸ Provider education on vitamin D deficiency. “Using the electronic medical record, we demonstrated a fourfold increase in vitamin D screenings among our residents” after providers were given information on vitamin D deficiency in the elderly, he said.

Preventing falls has an economic benefit as well, since 25% of patients who sustain hip fractures will end up being admitted to long-term care facilities, he noted.

Bonita Lynn Beattie, vice president of injury prevention at the National Council on Aging, said in her presentation that 35%–40% of adults aged 65 or older fall each year, and if they fall once, they're two to three times more likely to fall again. Of those who sustain hip fractures, 20% die within a year.

“We think many falls are preventable,” she said. “If a person has a history of falls, they really need a clinical assessment to see if there's appropriate intervention.”

All adults need to work on balance and strength, ensure that their meds are managed appropriately, and adhere to their medication regimen, Ms. Beattie said. Vision problems also are an important component that needs to be addressed.

Home hazards also need to be reduced, she said. “Putting grab bars in the bathroom … where people will use them and teaching people how to use them can make a significant difference,” she said.

The panel was sponsored by Erickson Health. The Milton H. Erickson Foundation is a private research and philanthropic foundation.

Of those who pursued an intervention, 91% either stabilized or decreased their fall frequency. DR. PARRISH

Resources for Fall Prevention

Dr. Parrish recommended the following Web sites for fall-prevention information:

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www.stopfalls.org

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www.ncoa.org

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www.jefferson.edu/jchp/carah