For many Americans, the last few years have been a crash course in understanding the complex landscape that is our healthcare system. Regardless of your political leanings, it’s hard to deny that the current system is difficult for the average American to navigate.

On a recent Saturday morning, I opened the Austin-American Statesman to a story about the sticker shock of ambulance bills and the likelihood that they will not be paid for by your private insurance.¹ The article profiled the case of a pregnant woman named Sandy Bayne who was in a pharmacy when she experienced what she described as a sudden and profuse nosebleed that wouldn’t stop. Concerned, she called her father, a physician, for guidance and he instructed her to call 9-1-1, which she did. The woman was transported to an emergency department, the nosebleed stopped on its own and she was quickly discharged.

Bayne later received an ambulance bill for $867 and was surprised it was not fully covered by her private insurance—Blue Cross Blue Shield of Texas. Like many Americans, she has a high-deductible plan and, at the time of service, had not satisfied her policy’s $2,500 annual deductible, which left her responsible for the entire bill.

This is a common conundrum for patients, and there is growing interest to be more informed about care quality and cost. One recent study in JAMA Internal Medicine described the imperfections of the current system. Researchers attempted to get the bundled cost for a hip replacement on a patient without insurance. Many of the hospitals contacted could not provide the cost information and the variation between those that could was as much as tenfold.² This problem is not the case in ambulance service, where fee schedules include only a few different prices depending on your level of service plus mileage.

A simplified fee schedule does not, however, mean that ambulance patients are any more informed. It may be against policy for providers to discuss fees with patients, either out of concern that the cost may alter the patient’s transport decision or that it may create a customer service issue. Further, patients do not make good consumers of ambulance service because they do not have advanced opportunity to shop for quality or compare prices. The decision point is in a time of urgency for them and, in many communities, the 9-1-1 ambulance provider is predetermined.³

But what if a patient wants to be informed about their ambulance service coverage? To test this capability, I inquired with my private insurance provider: Blue Cross Blue Shield of Texas, the same provider Bayne had. Let’s take a look at what a patient might encounter:

• March 13: Using the message center within my health plan’s website, I ask for the information on my coverage. Specifically I want to know what is considered a medically necessary ambulance transport and how much of the bill would be covered.

March 14 (+1 day): A customer service representative replies and is unable to answer my questions, but is forwarding my message to “a specialist in the area.”

• April 7 (+25 days): Lindsey T. replies to my inquiry with the following message: “If the call is determined to be a true emergency, then an ambulance claim would be covered. When services are rendered by an in-network ambulance provider, you would have 100% coverage once the $3,500.00 individual deductible has been met.”

I understand what this means, but it does not go far enough to answer my questions. So I replied and asked: “Thank you. Can you please send me the definition of a “true emergency?” Does “in-network provider” automatically mean the ambulance provider serving the 9-1-1 service area you are in? In other words, I’m assuming I’m covered for a 9-1-1 ambulance in the City of Austin, but if I am in a different city, am I still covered?”

• April 9 (+27 days): A customer service representative replies and is unable to answer my questions, but is forwarding my message to “a specialist in the area.”

• April 29 (+47 days): Silvia L. replies: “If services do not meet emergency diagnosis criteria, then services will be considered as outpatient hospital services. An in-network provider is a provider that is contracted with Blue Cross Blue Shield of Texas. These providers may be contracted under only certain plans that we offer to our members. So when determining if the provider is in-network, the provider must be accepting the contracted plan that the member is on.”

Based on this answer, do you think Austin-Travis County EMS is a contracted provider? I doubt it.

When I read Bayne’s story in the newspaper, I was looking through my EMS lens. To be honest, I was a little critical of her use of an ambulance for her event and her surprise at the cost. But as I approached this from a patient’s perspective and attempted to become an informed consumer, I quickly learned that’s easier said than done.

So where does that leave us? It remains important that we don’t let the potential cost of ambulance care and transport persuade a patient who needs help. That said, it might be time to become more transparent with patients about cost and coverage. For example, giving patients a fee information card or displaying fees in the patient compartment. Whatever the answer is, it would require staff training and careful scripting. Ambulance service leaders need to recoginize the changing paradigm of healthcare and support patients who want to understand and navigate a system that is not designed for their benefit.

REFERENCES

1. Roser MA. (2014, April 12). Even with insurance, that EMS bill could cause sticker shock. Austin-American Statesman. Retrieved June 5, 2014 from www.mystatesman.com/news/news/local/even-with-insurance-that-ems-bill-could-cause-stic/nfYZZ/#05256416.3458239.735365.

2. Rosenthal JA, Lu X, & Cram, P. (2013, June). Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure. JAMA Internal Medicine, 173(6): 427-432.

3. Stout JL. (1985, January). 1985: A turning Point. JEMS, 10(1), 105-106, 108.

The post Patient Perspective appeared first on EMS Insider.

Thankfully, innovative economic models are flourishing. This comes as a result of healthcare financing changes within the Affordable Care Act (ACA) that seek to align incentives to help make the entire healthcare delivery system more financially sustainable. We are also seeing implementation of some long-standing, but stagnant finance reforms.

Some of the more recognized finance changes—such as bundled payments, risk-sharing arrangements, enhanced managed Medicare and Medicaid programs and, of course, Accountable Care Organizations (ACO)—are ways the ACA is transforming our healthcare delivery models. However, programs such as 1115 Medicaid waivers, managed Medicare and Medicaid, and traditional fee-for-service models are rapidly recognizing MIH provides a valuable service in which they should be investing.

This is the first of four columns that will focus on the financing and economic models for MIH services that hospitals, Medicare and Medicaid, commercial insurers, integrated delivery systems, ACOs, hospice agencies and even home health agencies are funding and, more importantly, why they are funding them.

The question for this first article: What is motivating hospitals today to work with other agencies to actually reduce the inappropriate use of their in-patient facilities?

Value-based purchasing

One of the efforts to improve quality and reduce healthcare costs in the ACA is an initiative called value-based purchasing (VBP). Under VBP, hospitals are eligible for bonuses or penalties of up to 1.25% of their total Medicare payment based on quality metrics in 2014. That percentage will increase over the next three years to 2%. It’s worth emphasizing that this bonus or penalty is applied to all Medicare payments a hospital receives, not just payment for admissions on which they did not score well. By way of example, for a hospital with annual Medicare payments of $500 million, a 0.5% VBP penalty can amount to $2.5 million. VBP process metrics and clinical guidelines include considerations such as:

• Percent of heart attack patients given medication to avert blood clots within 30 minutes of arrival at the hospital

• Percent of heart attack patients given percutaneous coronary interventions within 90 minutes of arrival

• Percent of heart failure patients given instructions upon discharge about how to take care of themselves

The second domain of evaluation is the much talked about patient satisfaction measures.¹ These are measures such as:

• How well nurses communicated with patients

• How well doctors communicated with patients

• How clean and quiet the hospital room and hall were

The patient’s experience of care comprises 30% of the total VBP calculation. Consequently, hospitals pay very close attention to the patient’s perception of the hospital both during inpatient care and post-discharge (see article in February JEMS² ). This has increased the hospital’s focus on the patient’s transition from the hospital to the home environment, not only to help reduce preventable readmissions, but to enhance the patient’s perception of the hospital’s concern about the patient post-discharge.

The third area evaluated for VBP is mortality rates among Medicare patients admitted for heart attack, heart failure or pneumonia.

Hospitals could also be interested in programs that reduce ED visits for low-acuity patients. These patients often have long wait times in the ED, resulting in an unfavorable experience of care. When those patients receive patient satisfaction surveys, there is potential that the rating will be low, thereby impacting the 30% patient experience score. Further, decongesting the ED may have a positive impact on the experience for other ED patients through potentially reduced wait times, thereby possibly improving satisfaction scores. In the MedStar system, all four hospital systems are jointly funding the 9-1-1 nurse triage system to help navigate low-acuity callers to safe alternative care sources for exactly that reason.

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based safe transition programs to enhance patient perceptions about the transition.

Readmissions

Another quality measure being applied to hospitals is the 30-day readmission rate for three specific diagnosis-related groups (DRGs): congestive heart failure, myocardial infarction and pneumonia. The reason these three were selected is the cost to Medicare for these conditions, as well as the tendency for these DRGs to have high readmission rates. In October 2014, COPD and hip and knee replacements will be added to the list of DRGs. Hospitals are eligible for bonuses or penalties up to 2% of their total Medicare payments based on their 30-day readmission rate. The readmission criteria is currently an “all cause readmission,” meaning that if a CHF patient who is discharged from the hospital readmits for a fall two weeks later, that counts as a readmission.

Two-thirds of the nation’s hospitals are being assessed a readmission penalty.³ For some, the fnancial incentive to reduce high readmission penalties may outweigh the actual payments they receive for the admission. A recent article in Modern Healthcare reported that Michigan-based Henry Ford Health System’s system-wide fnancial penalty for preventable readmissions was estimated at $2.2 million in 2013, and $4.3 million in 2014.⁴ The financial incentives for hospitals to reduce readmission penalties may lead them to be receptive to EMS-based MIH programs to reduce potentially preventable readmissions. This is likely the reason that the Henry Ford Health System is actively working with, and paying for, its ambulance provider Medstar Ambulance’s program to reduce preventable readmissions.

EMS-MIH Opportunity: Hospitals may be willing to invest in EMS-based CHF readmission prevention programs. Examples of such funded programs are MedEx Ambulance and the University of Chicago Medical Center; Christian Hospital EMS in St. Louis and the Christian Hospital System; Green Bay Fire Department and the Bellin Health System; and East Baton Rouge EMS and Lane Regional Health System.

Public reporting

In addition to the fnancial incentives, hospital readmission rates and patient experience ratings are now published by Centers for Medicare & Medicaid Services (CMS) on their Hospital Compare website (www.medicare.gov/hospitalcompare). Hospital administrators working with MedStar have indicated the public reporting of patient satisfaction and subsequent perception of poor clinical care due to high readmission rates is even more of an incentive to improve satisfaction ratings and reduce readmissions than the current financial incentives.

Medicare spending per beneficiary

Looming on the horizon for hospitals in 2015 is a new measure to which CMS will hold hospitals accountable: Medicare spending per beneficiary. ⁵ This measure will be part of the VBP bonus or penalty and will be based on the amount of money Medicare spends for a patient’s care—preadmission, during admission and post-discharge. This may change the economic incentive for hospitals to discharge patients to high-cost services such as long-term acute care (LTAC), skilled nursing facilities (SNF) or even home health. It may also lead them to look to EMS for programs to reduce length of stay for inpatient care.

EMS-MIH Opportunity: Hospitals are looking for more cost-effective post-acute care, not only to reduce readmissions, but also to reduce the overall Medicare spending per beneficiary in the post-acute setting.

Shared risk

More hospitals are becoming part of risk-sharing arrangements with payers. The most talked about model is an ACO. In an ACO, the hospital shares in the potential savings in caring for a defined population of patients. In other words, they gain an economic advantage if the cost of caring for the patients in the defined population is less than anticipated. As such, it’s possible that the hospitalization of a patient in this type of program could actually cost them money.

Perhaps it’s for this reason that the Presbyterian Health System, an innovative integrated delivery system in Albuquerque, N.M., launched its “hospital in the home” project. In this program, patients are “admitted” to the hospital, but the care is provided in the patient’s home. Hospital beds, IV pumps, cardiac monitors and all equipment and supplies needed to care for the patient are brought to the home. Doctors and nurses “round” on the patient several times a day, or are continuously at the bedside. Their experience was that the patients had shorter length of stays and higher satisfaction scores with this arrangement. And, the cost of providing the care was reduced.

Another example of a funded program to reduce unnecessary ED visits is the program Mesa Fire Department and Mountain Vista Medical Center are conducting in Mesa, Ariz. Mountain Vista provides a nurse practitioner and Mesa Fire provides a paramedic captain in a transitional response vehicle. This unit responds to low-acuity calls in the system to assess, treat and navigate patients

UNLAWFUL TO COPY WITHOUT THE EXPRESS PERMISSION OF THE to the most appropriate care setting, thereby preventing an unnecessary ED visit. And, as an added bonus, since services provided by a nurse practitioner are a health benefit under Medicare and most commercial insurance programs, Mountain Vista bills for the services provided by their nurse practitioner.

EMS MIH Opportunity: Hospitals are looking for clinically safe, cost-efficient systems to navigate patients to the most appropriate care. This is a perfect fit for an integrated healthcare delivery model that navigates patients to the most appropriate setting for their care or, even better, prevents the need for acute care services.

Summary

There are numerous reasons why hospitals across the U.S. are funding MIH services. The key to success is in an effective relationship built upon collaboration to meet a defined need for the community and the patient, while simultaneously enhancing the economic model for the hospital as a payer.

Become part of the solution!

REFERENCES

1. Rau J. (Nov. 14, 2013) Methodology: how value based purchasing payments are calculated. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/stories/2013/november/14/value-based-purchasingmedicare-methodology.aspx.

2. Hooten D, Zavadsky M. Patient experience revolution. JEMS. 2014;39(2):54–59.

3. Rau J. (August 2, 2013) Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. Kaiser Health News. Retrieved on April 2, 2014, from www.kaiserhealthnews.org/Stories/2013/August/02/readmission-penalties-medicare-hospitalsyear-two.aspx.

4. Greene J. (Dec. 10, 2012) Hospitals face reimbursement penalties over readmission rates. Modern Healthcare. Retrieved on April 2, 2014, from www.modern-healthcare.com/article/20121210/INFO/312109979.

5. QualityNet (n.d.) Medicare spending per beneficiary measure overview. Retrieved on April 2, 2014, from www.qualitynet.org/dcs/ContentServer?c= Page&pagename=QnetPublic%2FPag e%2FQnetTier3&cid=1228772053996.

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It seems the industry is abuzz with talk about healthcare reform and how community paramedicine programs will help to solve the world’s healthcare woes. While I am a passionate believer in what this future holds for our industry, I am also a realist and pragmatist when it comes to the blocking and tackling that has to happen behind the scenes in order for us to make this vision a reality.

While many groups are focused on the clinical, educational and state regulatory issues related to community paramedicine, few are discussing how to pay for it and even fewer are discussing the fundamental building blocks that must be in place before you can even think about pursuing such a course. Many innovative agencies (including my own) are investing their time, energy, effort and dollars into figuring out how to make this all work for the rest of us, but why are these agencies able to do this, while others are not? What secrets do these trailblazing agencies have that others don’t?

Trailblazing secret

It is clear that significant changes are needed in order to bend the cost curve of healthcare and it is also clear that EMS can play a significant role. But if you want to have a seat at this table, you need to have your financial affairs in order. This is the “secret” of those who are blazing the trail. It’s really no secret, but it comes down to the simple fact that these agencies are able to explore this new frontier because they are at a point of organizational development, structure, leadership, maturity and information richness that they can afford to stick their necks out, make lots of mistakes, learn from them and move on.

The keys to a structured and mature agency are in how it is run. While clinical, operations, communications, training, quality and logistics are all important aspects of any successful EMS agency, none of them can happen without having a deep understanding and mastery of both your revenues and your expenses. Believe it or not, this is also true when looking to throw your hat in the ring of community paramedicine. If your organization can’t easily generate financial data about its existing state, then you honestly shouldn’t even be thinking about entering this next evolution in EMS until you attain this goal.

Cost of providing services

A scary reality was recently exposed about this particular issue, and how unprepared many EMS systems are in their ability to produce simple financial data about their costs and revenues. The American Ambulance Association (AAA) recently invested a substantial amount of money and time to assess the EMS industry’s ability to perform cost reporting—a method used by Centers for Medicare & Medicaid Services (CMS) with healthcare providers to determine their costs of providing services, which is then used to help figure out how much to pay for those services. Disclosure: I am on the AAA board.

A report performed by the Moran Company, “Final Report: Detailing Hybrid Data Collection Method for the Ambulance Industry,” highlights its blinded, confidential and independent test results from a standardized and well-defined dataset from EMS agencies, in order to understand the costs and revenues that EMS systems encounter. The end goal of this approach is to use the data to perform margin analysis on the industry, which is how CMS would typically assess and adjust the levels of reimbursement for most clinical providers and hospitals.

The report found “major challenges” to a requirement that every EMS agency in the U.S. perform cost reporting, and therefore recommends a hybrid approach that uses statistical sampling of a variety of EMS agency types, sizes and locations to generate a representative sample of the industry’s expense and revenue experience. This sample would then be used by CMS to assess EMS margins and adjust accordingly if the margins were found to be inadequate or below cost.

This hybrid method is used by other provider types with complex operational and regulatory issues, which is what the Moran Company found exists in EMS, and is therefore a viable option for the industry and CMS to strongly consider.

This is different than how EMS is currently reimbursed, as we are treated like a supplier and CMS puts us into the same category as durable medical equipment and home oxygen providers. This makes it difficult for EMS to be taken seriously when sitting at the same table as a recognized provider, as we are looked at as a transportation commodity and not a clinical service. If we want our community paramedic efforts to be taken seriously, one of the fundamental changes that must take place is a shift of EMS from a supplier to a provider in the eyes of CMS and other payers.

Tremendous efforts are being undertaken by the AAA to make this a reality for the EMS industry. In order for EMS to make this shift, the ability to perform cost reporting in some form or fashion will be necessary. The quickest and most effective path to this end is what the Moran Company was asked to find out.

Specifically, the Moran Company report found that “(1) Ambulance operations have evolved in response to requirements of state and local jurisdictions and not in response to payers; (2) ambulance operations across the U.S. are overwhelmingly small at the national provider identifier (NPI) level with very limited administrative resources, which makes it difficult for these organizations to produce accurate and detailed data; (3) even in larger operations, reimbursement data are often maintained in vendor software and not readily accessible for reporting; (4) fire department and hospital-based ambulance operations often have their cost data blended with other data from the parent institution; and (5) some states, counties and municipalities have ambulance services that rely partially or entirely upon volunteers, which would require such resources to be monetized to be comparable to operations with all-paid staff.”

Given these industry challenges, an EMS customized hybrid approach to cost reporting using statistical sampling by agencies capable of reporting such data is the most viable option if the EMS industry wishes to pursue clinical provider status. While this report highlights a viable solution to this complex problem, it also highlights the issues I am raising in this article.

Current financial challenges

All this brings to light the fact that EMS agencies need to pay attention to their finances and accounting practices, their chart of accounts and how they perform their financial reporting. As the Moran report clearly identifies, even large EMS agencies have challenges when it comes to these matters. A substantial portion of this problem lies in the fact that the EMS industry lacks standardized practices when it comes to metrics, whether clinical, operational or financial. While many of us measure certain common denominators such as unit hour utilization, most of us measure our financial performance or variables such as bad debt differently, and herein lies some of our challenges.

Although standardized or consensus financial templates do not yet exist for the industry, this should not impede your organization from getting its financial affairs in order to the point that you can glean the data necessary to complete a cost report, or be able to prepare an accurate pro forma estimate of the costs of performing the services you provide on a daily basis or for a new service such as community paramedicine.

To have a successfully reimbursed community paramedic program (or traditional EMS program for that matter) that breaks even or is in the black (hopefully the latter), you must first understand a few things about your expenses. First and foremost, you must understand your cost to provide the service and whether the service should be fully appreciated or marginally appreciated as you build it out. Full appreciation means you would take into account everything necessary to make the service happen, including overhead costs such as administration, capital depreciation, insurance and other indirect expenses. Marginal appreciation only looks specifically at the expenses of the program itself and would not include overhead, but would include direct expenses such as salaries, benefits, fuel, etc. Choosing which approach to use really depends on variables specific to the organization and how it has looked at these decisions in the past. Obviously, a marginal approach lowers the perceived costs, but does not help to cover overhead expenses. A fully loaded approach covers all expenses, but increases the costs shown to provide the new service.

Once you have a handle on this first consideration, you should then figure out your cost per hour, cost per transport and cost per unit hour so that you can use these figures to see how much it costs you to provide the actual service. For a community paramedic call, I would look at the length of the visit as well as the number of visits. Don’t forget to allocate unproductive time (time when not on a call) into the expense equation so that you fully appreciate your total cost of providing the service (Take total hours deployed for the service divided by the number of visits performed during that same time period, which would give you an accurate hours-per-visit ratio, including unproductive time. Multiply this by your cost per hour and to give you a break-even reimbursement.) Remember, programs need a margin in order to perform a mission, so include an allocation for this in your calculations as well so that you cover future capital and reserves necessary for longterm program sustainability.

Once you have a handle on expenses, you then need to look at revenues and payers. Since you know your expenses and what you need to cover your cost plus a reasonable margin, you can then work to negotiate a rate that minimally meets this number (but hopefully exceeds it). Having a firm grasp of your revenue cycle management process and revenue-based finances, as well as your payer sources are other important factors when negotiating with a payer. For example, it would be important to understand how much a payer is reimbursing you for EMS services for the cohort of patients you are trying to migrate to your community paramedicine program.

Also, understanding the downstream impacts of what you do under EMS versus what will happen under community paramedicine to that same cohort, and comparing and contrasting these so the payer can value the benefit, is another important variable you will need to understand if you are to get paid for these services. Knowing downstream payer costs in the continuum of care can be a challenge, however more and more healthcare organizations are shifting to transparent pricing in which they may publish their charges for particular services. While this may not represent what the payer may actually reimburse the agency for on a particular procedure (due to contracted rates and discounts), it is a start. Also, there are lots of sources on the Internet that provide federal and state reimbursement rates that are quickly becoming the standards that commercial payers use to set reimbursement rates for healthcare providers, so this too can be used to help quantify the downstream effects your community paramedic program will have on a particular patient population’s cost to the payer.

Conclusion

As you can see, understanding and mastering your EMS finances is just as important as the services you provide. Having a firm grasp of expenses, revenues and downstream financial impacts will enable you to negotiate with a commercial payer to an end that doesn’t put you out of business just for the sake of having a community paramedic program to brag about.

I truly believe EMS is at a crossroads where it can finally stand up with the ranks of other providers in the eyes of CMS and others. Which path we take will depend on our willingness, ability and agility to adapt to new clinical and operational models, while simultaneously mastering our business acumen so that we don’t bankrupt our services along the way as we transition. Get to know your finances well and you too will be able to successfully transition into the next generation of EMS services.

Lastly (I’m going to jump on my soapbox for a minute), the work that the AAA does financially benefits every single EMS provider in the U.S. (thank you, AAA, for my 2014 CMS rate extensions), yet only a small portion of EMS providers join our efforts. I would ask for each and every agency in the U.S. to join our ranks and collectively work to change and reform legislation so that our patients and communities can benefit from all EMS has to offer as an integral piece of the evolving U.S. healthcare system. Without our collective voice, our ability to go down the path many of us desire with community paramedicine may not be possible. Please consider joining our association and supporting its causes. Thank you.

The post Healthcare Reform & Community Paramedicine appeared first on EMS Insider.

The Quality Improvement Committee of the National Association of EMS Physicians (NAEMSP), which I chair, is leading a new project to develop a set of nationally standardized EMS performance measures that may be used by communities and payers to assess the overall performance of their EMS systems.

The need for standardized performance measures is being catalyzed by anticipated changes in rules for payment to EMS provider organizations (EMSPOs) by the Centers for Medicare and Medicaid Services (CMS) and the establishment of contracts between EMSPOs and accountable care organizations (ACOs).

CMS has stated its intent to extend the core measures program to all sectors of healthcare that receive CMS reimbursement for services—including EMSPOs. The core measures program now includes review of acute care hospital, mental health and home health services. When the CMS core measures program is brought to EMS, it is likely to follow the same rules that have been applied to other sectors of healthcare. This means that failure of EMSPOs to report their core measures to CMS will likely result in reductions in CMS payments. Increases in CMS payments are likely to be provided to EMSPOs that are top performers in their core measures.

The establishment of contracts between ACOs and EMSPOs will also create a need for performance measures by which ACOs can potentially hold EMSPOs accountable and make adjustments in payments similar to what has taken place with CMS.

The purpose of the core measures program at the CMS and ACO levels is straightforward: to catalyze improvements in the quality of care by encouraging and supporting healthcare provider organizations to continuously monitor and improve the performance of key healthcare processes.

Hospital core measures are also used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to continuously assess the performance of accredited hospitals. As stated on jointcommission.org:

“Performance measurement is used internally by healthcare organizations to support performance improvement and externally, to demonstrate accountability to the public and other interested stakeholders. Performance measurement benefits the healthcare organization by providing statistically valid, data-driven mechanisms that generate a continuous stream of performance information. This enables a healthcare organization to understand how well their organization is doing over time and have continuous access to objective data to support claims of quality. The organization can verify the effectiveness of corrective actions; identify areas of excellence within the organization; and compare their performance with that of peer organizations using the same measures. Similarly, performance data can be used by external stakeholders to make value-based decisions on where to seek quality healthcare.”

NQF template

Given the significant clinical and financial implications that the core measures program has, CMS and JCAHO have spent significant time and funds with stakeholders and leading performance measurement experts from across the county to create a template for submission, review and approval of healthcare performance measures. The template and review process is managed by the National Quality Forum (NQF). The NQF template and review process is worthwhile for the EMS community to use for several reasons:

• Their methodology has the benefit of input and refinement from a host of technical experts, complemented by refinements through the collective experience of thousands of hospitals and millions of patient episodes of care.

• Benchmarking their methodology could significantly reduce the research and development costs for developing performance measures for EMS from scratch.

• Development of like systems and processes for performance measurement in EMS can help facilitate data system interoperability and exchange across the continuum of care and possibly lead to some alleviation in the difficulties that EMS providers have in linking their data to other healthcare provider organizations.

Core metric criteria

NAEMSP and the collaborating organizations are conducting this project in hopes that when CMS begins to develop core measures metrics for EMSPOs, the performance metrics we develop will have EMS community consensus support and be technically suitable for adoption by CMS.

The following list shows the criteria that should be met by a proposed performance metric in order to be considered for inclusion as a core measure.

• Targets improvement in the health of populations: Measures should address areas where performance improvement is likely to have a significant, positive impact on the health of specified populations.

• Precisely defined & specified: Measures should be standardized with explicit pre-defined requirements for data collection and for calculation of the measure value or score.

• Reliable: Measures should consistently identify the events they were designed to identify across multiple participating healthcare organizations over time.

• Valid: Measures should capture what they were intended to measure.

• Can be interpreted: Measures should have rationale and results that are easily understood by users of the data including accreditors, providers and consumers.

• Risk-adjusted or stratified: Measures should incorporate the influences of factors that differ among the groups being compared that can be controlled or taken into account.

• Data collection effort is assessed: Measures should use information that is available and accessible. There is practicality in the effort and cost of abstracting and collecting data.

• Useful in the accreditation process: Measures should supplement or enhance the current accreditation processes and support healthcare organization quality improvement efforts.

• Under provider control: Measures should be within the ability of providers to influence the processes and/or outcomes being measured.

• Public access: The constructs and calculation algorithms used for the measures should be publicly accessible.

It is important to note that NAEMSP plans to seek the input and collaboration of other national EMS organizations on this project.

The technical formats required by the NQF for healthcare performance measures are quite detailed. More information can be found at http://www.qualityforum.org/Measuring_Performance/Submitting_Standards.aspx. The general strategy will be to start with a review of some of the existing EMS performance measures. They will be evaluated against the criteria listed above. Those that fare well in review will be used to help get the team started on putting them into the detailed NQF format.

A project timeline has not yet been established, but the NAEMSP QI Committee is hoping to have a small set of measures fully developed and ready to submit to the NQF by the end of the year.

The post The EMS Core Measures Project appeared first on EMS Insider.

The Institute for Healthcare Improvement (IHI) Breakthrough Collaborative Series Model is a method used to bring organizations together to learn and collaborate to make significant improvements in a specific topic area.¹ This process was used in ambulance service in Massachusetts from 2009–2013 to improve prehospital stroke care.² A key element of the method is to begin with existing evidence that helps guide developing aims, measures and change ideas.

A core tenet of improvement, research and established professions is to start somewhere—preferably to begin with what’s known and stand on the shoulders of others. In research, we’re asked to present a review of the literature; in business it’s part of the market analysis of the business plan. This ensures your approach is based on the best-known evidence, and your local learning (if published and shared) may help further collective efforts to enhance ambulance service.

Evidence Base of Ambulance Service

In ambulance service, the evidence base is light. This is simultaneously part of the problem, a key to our challenge and a driver for change. In 2001, the National EMS Research Agenda stated it bluntly: “There is not enough high quality EMS-related research to drive improvements in patient outcome, and vast amounts of money are being spent for patient care with little rigorous evaluation of the effectiveness of that care. Methodologically sound research must be incorporated into all facets of the EMS system.”³ For many EMS leaders, the absence of definitive evidence leads them to either pick and choose procedures to implement or, worse, ignore the evidence all together. This does not move EMS forward.

Alternatively, the Institute of Medicine’s (IOM) 2006 report on EMS challenged that “EMS professionals and policy makers at all levels should work to establish a culture of science-based decision making …” and “… scientific evidence should be used to support system level decisions …” including clinical and operational practices.⁴ In order for the EMS profession to meet the demands of the transforming healthcare environment and the constraints of local communities, we have to stretch to understand existing evidence and continually apply it to our practice.

Where Do I Find this Evidence Base?

A good place to begin your team’s journey is with free industry reports and papers that are publicly available. These include reports and projects from the National Highway Traffic Safety Administration (NHTSA), National EMS Advisory Council (NEMSAC), and the websites of associations such as the National Association of EMS Physicians (NAEMSP) and National Association of State EMS Officials (NASEMSO), which also publish papers and position statements. These documents are frequently rooted in existing evidence and compiled by committees of EMS stakeholders.

Peer-reviewed EMS research appears in a number of journals. One worthy of a subscription is Prehospital Emergency Care (PEC), which is dedicated to ambulance service and is the official journal of the NAEMSP, NASEMO, the National Association of EMS Educators (NAEMSE) and National Association of EMTs (NAEMT). A subscription provides you access to the full online archive going back to 1997.

Another way to access peer-reviewed research is by searching the database at www.pubmed.gov. Access is limited to abstracts, but that can be enough to help you find out what’s out there. Note: It’s always advisable to read the actual paper and not just an abstract, so if you find an abstract of interest, please obtain the original paper.Google remains a powerful resource as well. I often find myself researching a topic online and then following the references authors include in presentations and articles online. Trade journals such as JEMS and EMS World can also be helpful, but be aware that these articles are not held to the rigor of peer-reviewed journals when it comes to referencing ideas and presenting data.

These resources will start you at the front of the pack of EMS leaders and put you on good footing to ignite a culture of science-based decision making in your organization.

Science-Based Decision Making

Developing a culture of science-based decision making in your system is not instantaneous. If there was a known approach that worked out of the box, we’d all be doing it. Here are some thoughts for how you can start:

1. At the initiation of any effort to change, clarify with your team what you are trying to accomplish. The more specific you are, the easier it is to design and execute.

2. Begin with some prep work. This may include searching PubMed and Google for position papers, reports and peer-reviewed papers on the topic. Also, take the time to learn about what you are currently doing. What are the existing processes and policies? What is the organizational history of how you got there? What data do you track or can you pull about the current state? Compile what you’ve found and share it with your team to review and digest before meeting.

3. When you do meet, discuss what you’ve all discovered from the prep work. Is there a gap between what the evidence says and what your current practice is? Are there any missing areas in the existing evidence available to help you? What questions do you have?

4. Make a list of changes to help you close the gap between existing evidence and current practice. What changes can you make that you believe will result in improvement? How will you measure that improvement?

5. Use rapid, small-scale tests of change (e.g., the Plan, Do, Study, Act tool) that follow the scientific method and display your data over time in run charts to learn deeply and efficiently. You can even annotate the changes you are testing.

6. Regularly meet as a team to share learning, exchange ideas and plan for further improvement.

When it’s all said and done, I encourage you to share your learning and results (even failures). Peer-reviewed abstracts and papers are preferred to add to the evidence, but other avenues are helpful too.

Starting with the published evidence to date, building on and testing those ideas using the rigor of the scientific method, and sharing our results will go a long way toward meeting the aims of the National EMS Research Agenda and the IOM report. It will also help us accelerate the enhancement of ambulance service and engage our peers in the healthcare environment. Don’t feel you have to be a pro on your first try. The best way to learn and improve is through action. So, what’s your next action?

References

1. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement [white paper]. Institute for Healthcare Improvement: Boston, 2003.

2. Daudelin D, Kulick E, D’Amore K, et. Al. The Massachusetts emergency medical service stroke quality improvement collaborative, 2009–2012. Preventing Chronic Disease. 2013;10(9).

3. National EMS Research Agenda [white paper]. National Highway Traffic Safety Administration: Washington, D.C., 2001.

4. Emergency Medical Services at the Crossroads [white paper]. Institute of Medicine: Washington, D.C., 2006.

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Much has been written about the healthcare reforms contained in the Affordable Care Act, and the ways in which EMS and mobile integrated healthcare can incorporate those changes into their delivery systems. But one thing which has not been discussed much in the EMS and mobile integrated healthcare field is the role and requirements of information technology in the global vision of healthcare reform.

The ultimate goal of healthcare reform is to create a seamless, universal, interoperable electronic record system. This means that if a patient from one place has a medical emergency in another location, the healthcare providers at that location will be able to access the patient’s full medical record—in real time—and thus, treat them more appropriately and effectively. Not surprisingly, there are many obstacles to achieving this goal, including privacy and security, interoperability, differing data dictionaries, intellectual property concerns, consumer acceptance and cost.

By now, most EMS providers are moving in the direction of electronic patient care records (ePCRs), but few are aware of the real reasons behind this move and the greater implications for healthcare reform compliance. Most agencies see ePCRs as a way to collect and compile data, and there has been much discussion about using data to prove your agency’s worth to payers and other third parties. So what are the benefits of this new technology, and what considerations do you need to take into account when adding, changing, upgrading or replacing health information technology?

Meaningful use

In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments to clinicians and hospitals through Medicare and Medicaid for using electronic health records (EHRs) to achieve specified improvements in patient care. The incentive payments total up to $27 billion over 10 years, with the ultimate goal of creating a nationwide system of EHRs.

However, HITECH’s goal is not just the adoption of EHRs, but “meaningful use” to achieve significant improvements in caregivers’ decisions and patient outcomes. The regulation spells out what healthcare providers must do with EHRs to be considered meaningful users, including the entry of basic data such as vital signs and demographics, active medications and allergies, up-to-date diagnoses, smoking status and adult weight screening. There are also requirements for the use of clinical decision-making software applications designed to help caregivers make better clinical decisions and avoid preventable errors. Finally, the meaningful use requirements also include providing patients with electronic versions of their health information following treatment and office visits. In short, meaningful use is designed to be a universal minimum set of required data points to measure value and quality, and the rule is part of a larger set of regulations designed to move the health system in a positive direction toward improved quality and effectiveness in healthcare.¹

Unfortunately, since some of the meaningful use data points are not things EMS providers have traditionally asked of or provided for patients, some of the care requirements are not even on the collective EMS radar (let alone built into ePCR systems). But as our nation’s healthcare system moves from a fee-for-service to a fee-for-value model, meaningful use standards and rules will have significant implications for EMS and mobile integrated healthcare providers, especially in light of healthcare reform initiatives such as community paramedicine.

As EMS evolves and expands its role in the healthcare system, meeting meaningful use standards may very well become a requirement. For example, accountable care organizations (ACOs), health systems and other payers will probably require compliance with meaningful use standards as part of payment contracting terms. Community paramedics will likely be required to ask additional questions of patients related to smoking cessation and weight gain/loss during each visit with the patient. For example, community para-medicine programs that are able to bill their state’s Medicaid program will have to record the answers to these types of questions in patient care records, since they will be eligible for receiving reimbursement based upon the quality of care and value they provide, which is measured by the meaningful use standards. It is also foreseeable—as ridiculous as it might seem—that an ACO or payer may require an EMS service to ask the same questions of trauma patients with severe injuries, simply because that is the standard the payer requires from their contracted entities.

Furthermore, if your EMS system is hospital-based, you will almost certainly have to ask meaningful use questions, especially in the case of refusals/treat-and-release situations, and be prepared to provide information, such as discharge and follow-up instructions, to patients out in the field. Remember that under the Emergency Medical Treatment and Active Labor Act (EMTALA), the patient “has come to the emergency department” when they set foot inside your ambulance because the hospital-based EMS unit is deemed an extension of the emergency department. If a patient is refusing transport—or is being treated and released on scene—as an extension of that emergency department, EMS personnel must comply with the same meaningful use standards that the hospital would if the patient were actually transported.

Interoperability

As discussed above, one of the ultimate goals of healthcare reform is to create a nationwide system of EHRs based on the idea that global access to a patient’s medical records will result in better quality, better outcomes, better value and lower costs. To achieve this vision, there must be interoperability.

Interoperability is the concept of diverse software systems, platforms and computer languages all being able to share data. Eventually, all of a patient’s healthcare providers will be able to access the patient’s medical records, regardless of where, when or with what software those records were created.

Aside from the complex technological issues of developing interoperable health information technology, there are other practical obstacles to overcome. For example, a number of EMS agencies have already encountered resistance from hospitals and health systems in their area when they have asked for permission to upload their ePCRs into the hospital’s EHR system or have their quality assurance (QA) manager be granted access to patient charts for follow-up, research and feedback. The hospitals have expressed concern about security and privacy issues, which is understandable; an outside third party over which the hospital has little to no control accessing protected health information (PHI) contained in the system is a scary proposition. As a result, many hospitals do not allow outside healthcare providers to access or upload directly to their software systems.

In addition, the EHR systems used by most hospital systems were not designed with EMS in mind. Likewise, the ePCR systems in use by many EMS agencies were not designed with hospitals and physician practices in mind. As discussed in the December 2012

EMS Insider article, “The Changing Face of Medical Reimbursement: A Difficult Road Ahead for EMS?” EMS agencies and ePCR vendors need to take the lead on this issue; otherwise hospitals may end up dictating which software healthcare providers in their network can use and the results could be extremely costly for EMS agencies. The good news is that a number of the larger ePCR vendors are already developing interoperability tools, but EMS agencies need to get to the table and control the conversation with the hospitals and health systems in their area so they are not forced to switch to an EHR system that was not designed for the EMS environment.

Privacy & security

As discussed above, one of the problems with interoperability is concerns regarding privacy and security of PHI contained in EHR and ePCR systems. Much has been written and will continue to be written about the privacy, security and breach notification requirements contained in HIPAA, so we won’t belabor the point here. However, EMS and mobile integrated healthcare agencies are well advised to think long and hard about the process and procedures for implementing new technologies and maintaining legacy data and information within their own systems; securing and auditing electronic devices such as laptops, tablets and medical equipment that contain patient information to prevent theft, loss or hacking; and developing strong device policies regarding the prohibition or use of personal electronic devices for job-related functions.

Other considerations

If all of this sounds like just another headache to add to the already overwhelming list of healthcare reform changes, here are some recommendations to make things run more smoothly for your agency:

• Think big, start small, move fast.² It’s easy to fall into the trap of focusing on one particular piece of technology without thinking about how it will serve the agency in the long term. Whether it’s a new cardiac monitor, a new pulse oximeter or glucometer, or new ePCR software, it’s important to think strategically and approach each new implementation with an eye toward the “big picture.” In other words, how will this technology grow with us over time? What are its larger capabilities beyond what we plan to use it for right now? Will it be something that needs to or is able to interface with other electronic systems or software and, if so, what are the limitations, obstacles and benefits?

• Don’t be overwhelmed by the idea that you have to have every system or piece of software in place today. Implementation takes time, and begins one piece at a time.

• Don’t jump into new technology without doing proper research and due diligence. On the other hand, don’t get bogged down spending so much time analyzing and researching one item that you fail to move forward.

• Set realistic goals and timelines, do your homework, then move forward. Remember, technology is already outdated as soon as it hits the market, so taking too long to make decisions may mean that you have to start over again if you take too long.

• Have solid policies and compliance and audit systems in place before you add, change, or upgrade anything.

• Protect legacy data and be mindful of vendors who may go out of business or stop supporting current technology. The cost of migrating data from old to new systems is high and the process is time-consuming. Patients (or their lawyers) may request records in “native format” or at an inconvenient time for your organization (for example, while you are in the midst of lengthy data migration), yet you still have an obligation to provide the information upon request and in the form requested (provided the request is reasonable). Before doing anything that requires a data migration, talk with your vendor and come up with a plan that will allow you to meet all obligations seamlessly.

• Read up on HITECH and be prepared for meaningful use to come up in your discussions with ACOs and health systems. At a minimum, they will probably ask about your system capabilities for compliance and information gathering, and it is highly possible they will require compliance with their technology and meaningful use standards as part of a contract for services and/or reimbursement.

• If you are designing a home-grown database for your community para-medicine initiatives, incorporate as many of the meaningful use data points as possible at the outset. For software vendors, as you design and build interoperable ePCR/EHR software, plan to incorporate the meaningful use data points.

• As you implement new technologies designed to interface with and even upload data into your charts, be sure to create a data map of where information is coming from, where it is going to, where it is stored, who or what other device(s) has access to it and the security protocols or features in place. Also, have policies in place that identify those same items and state how long the data created will be retained for, and how you plan to handle upgrades or changes in devices so that legacy data is either preserved in its original form, or migrated to the new system or software.

“It’s easy to get pulled into complex healthcare information projects that can eat up your time and money,” says Todd Stout, president of FirstWatch, a healthcare information technology company. “So it’s important to try to participate in ways and phases that your organization can handle. Also, some of these projects are ‘pilot’ projects, and implementation processes and standards that are not yet proven. Even great approaches can fail due to no fault of the EMS agency, but they can be left with systems, software or hardware that isn’t supported anymore due to a project failure.”

This article scratches only the surface. Be sure to consult with an attorney and a health information technology consultant to review your organization’s specific needs and obtain appropriate advice on these and related issues.

References

1. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501–504.

2. Credit for this phrase goes to Dave Page from FISDAP.

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