Third Next Available (TNA) - A Tool for Patient Scheduling?

Third Next Available, abbreviated as TNA or 3NA, is a calculation commonly used in medical practices to measure patient accessibility, or provider availability. The idea is to determine, at a specific point in time, the third available appointment slot for a specific appointment type. This represents a realistic time patients will have to wait on average to get an appointment with that provider for that specific appointment type (New Patient, Follow-up, Annual Wellness Visits, etc.). The reason to use the third next available and not the first next available is that the first next may have become available a few moments ago due to a cancellation or reschedule, so third next give a reasonable margin of error in calculating provider availability. The concept is to reduce the 3NA value to as low as possible, depending on the specialty, in order to improve patient accessibility to an optimum level.

The concept of appointment availability introduces a possibility of schedulers to think that this is an effective tool to use for scheduling. However, one must not forget that as soon as the first appointment is booked, the 3NA number could change considerably depending upon the new third next available appointment. It is best to use the actual provider schedule within the practice management system for determining the next available appointment. 3NA is a tool to be used for trending by calculating this week after week on the same day/time, and helps only t determine how busy the provider schedule is on an average. Based on this trend, the practice administration can determine if the provider schedule needs to be tweaked, or more resources need to be made available, or add another provider is appropriate. Keep in mind that 3NA makes sense for each appointment type individually, and comparisons between providers of similar specialties provides a better criteria to work off of.

It can, thus, be concluded that 3NA is not an effective tool to be used for patient scheduling, rather it is a measure of provider capacity to see patients in a timely manner or, in other words, patient access to a provider.

Security Considerations for Use of Mobile Devices in Healthcare

It is not uncommon these days to see physicians showing off their iPhone/iPads or Android phones/Tablets and demonstrating how they can access their patients' health records from anywhere. Well, just demonstrating in itself is a violation of Privacy laws under the HIPAA/HITECH Acts, there is also a much larger security concern attached to the use of mobile devices. HIPAA Privacy section deals with three core factors of patients Protected Health Information (PHI) privacy, and these include Confidentiality, Integrity and Availability.  HIPAA Security section deals with the Technical, Administrative and Operation safeguards for PHI. Another term becoming more and more popular recently is Bring Your Own Device or BYOD, and it refers to using a mobile device personally owned by you and using it for work. There certainly are considerations to be aware of for both company maintained/issued and personally owned devices us for remote access to PHI.

Best Practices for Using Mobile Devices to Access PHI:

• Authentication: Make sure to use a password or other authentication process to identify the user of the device. This is achieved by enabling the lock screen for your mobile devices and establishing a strong password, PIN or passcode. These must be masked to prevent people around you from seeing it. Also activate screen locking after a set period of inactivity.
• Install / Enable Encryption: Encryption helps secure local storage and safe transmission/reception of PHI. The mobile device may have built-in capability of encryption, or you may have to procure a 3rd party tool for this purpose.
• Remote Wiping and Locking/disabling: Remote Wiping allows you to erase data from your mobile devices remotely on a lost or stolen device. Remote locking.disabling is more useful when a device is misplaced and not stolen. By remotely locking the device you can unlock it once it is found, as opposed to remote wiping where nothing can be retrieved even if you are to find your device.
•  Disable File Sharing: Most of the mobile device come with a built-in capability of sharing stored data within a local network or over the internet. You can also find application that can be installed for sharing files. The mobile device file sharing capability should be disabled and not file sharing applications should be installed on them.
• Enable Firewall: Firewalls protect against unauthorized connections to your mobile device,  they intercept incoming and outgoing connections and block or permit them based on preset rules.
• Security / Anti-virus / Anti-Malware software: These security software protect against malicious applications/programs, viruses, spyware and malware. Make sure your security software is up to date with latest virus/malware definitions installed. 
• Research new Apps before installing: Before installing a new app or software, make sure you are aware of the permission it has for access to data and functionality of your device. For research use reputable websites and sources. 
• Maintain Physical Control: Mobile devices have the benefit of being portable, smaller in size which are also their biggest disadvantages when it comes to security. They are easily misplaced or stolen and that might lead to unauthorized access to PHI. You must maintain physical security of your device at all times to prevent it getting into an unauthorized person's possession. 
• Using Public Wi-Fi Networks: Public wireless connection pose a huge vulnerability of data interception and access by unauthorized persons. You must only use secure, encrypted connections, and only use public networks if you have the ability and knowledge to secure your communication by using VPN and or encryption technologies. 

Tips to protect and secure PHI on Mobile Devices:

1. Install and enable encryption to protect health information stored or sent by mobile devices.
2. Use a password or other user authentication.
3. Install and activate wiping and/or remote disabling to erase the data on your mobile device if it is lost or stolen.
4. Disable and do not install or use filesharing applications.
5. Install and enable a firewall to block unauthorized access.
6. Install and enable security software to protect against malicious applications, viruses, spyware, and malware-based attacks.
7. Keep your security software up to date. 
8. Research mobile applications (apps) before downloading. 
9. Maintain physical control of your mobile device. Know where it is at all times to limit the risk of unauthorized use. 
10. Use adequate security to send or receive health information over public Wi-Fi networks.
11. Delete all stored health information on your mobile device before discarding it.

We are covered, our EMR is Certified. Really??

When asked, almost any small practice owner would respond that he doesn't have to worry about HIPAA compliance, their EMR (common terminology in vogue for practice management systems) is certified. Most don't even know what HITECH or Omnibus rules are. If you try to explain, they take it as someone trying to eek out a few bucks from their already over-burdened cash flow.

Well, let's go through a list of items that would really make a covered entity compliant with HIPAA and related regulatory obligations. This should give one a fair idea if merely having a certified EMR would suffice to be considered HIPAA compliant. The following list has been updated to reflect implications of the recently modified HIPAA/HITECH rules that became effective March 26, 2013 and all CE's are required to be compliant by September 23, 2013:

• The very first requirement for HIPAA compliance is to have a Risk Assessment/Analysis study conducted to identify security and privacy vulnerabilities in your business environment, which extends beyond your place of business as almost all systems provides remote and mobile access. Any audit or inquiry will begin by asking you to provide a copy of you risk assessment report. The risk analysis is an ongoing process and you need to be proactively monitoring your environment for any new or upgraded risks that you should mitigate.
• The Notice of Privacy Practices (NPP or NOPP) needs to be updated. You probably got a template over from somewhere and have been using that. The terms need to be updated with latest requirements that cam into effect this year (2013). You can get some recently updated NPP samples from the websites of VA, Stanford University Hospitals, etc. and develop yours accordingly/
• Your business associates (BA's) have now become covered entities and you need to update your Business Associate Agreements to cover these requirements. Any agreements signed before the March 23, 2013 effective date can be update within next 18 months, but any new BAA's dated after this deadline need to be updated by September 23, 2013. 
• Update your policies and procedures, and train your work force to be aware or the privacy and security requirements. All staff including the higher management are required to undergo training and tested and documented at least once annually , as well as at the time of initial employment. The key words here are training, testing and documentation.
• Your computer environment must be protected by firewall to prevent unauthorized access, anti-virus protection to avoid theft or loss of protected health information and backup system to recovery within reasonable time from any disaster. 
• Mobile Devices are being utilized more and more to access and update information to EMRs, either locally (on premises) or remotely (off premises). Some protective measures to consider include use of complex passwords to access the devices, enable data encryption (both during transmission and local storage - local cache), file sharing apps should be disabled, use only secured Wi-Fi connection - never use public Wi-Fi hot spots, enable remote locking and wiping of the devices to guard against lost or stolen devices.
• The Omnibus rule (new updates in 2013) dis-allows transmission of information on specific patient procedures/treatment to the health plans if the patient pays out of pocket for that service. Your process for coding and billing should be set up to take care of such cases.
• Physical access to your facilities should be well controlled to protect against unauthorized access to PHI. In addition track the backup copies of your data, hard copy information, thumb/external hard drives, CD's/DVD's, tapes and other portable storage media should be properly accounted for. Remember to wipe computers, devices and even your networked copiers/printers before disposing them off as they may have PHI that can be accessed by unauthorized persons.
•  You should be able to produce logs of who logged into your EMR/EHR, when and where the logged in from, and which data or files did they access. Review these logs periodically and in case of any discrepancies, record and take appropriate actions based on violations.
• Be prepared for Disasters, natural and physical failures, and quick recovery to ensure continuous access to patient data.

I urge you to go over the above recommendations once more to really understand what's involved in being HIPAA/HITECH compliant and realize that merely having a Certified EMR/EHR does not make you compliant. Remember, OCR (Office of Civil Rights), OIG (Office of Inspector General) and various federal and state agencies are becoming ever more proactive in enforcing the rules, and larger penalties and sanctions are resulting from these actions. 

You can either invest your time to do it yourself or invest in a good consultant to take care of this for you. Either way, it is a necessary investment that is a part of running your healthcare business as required by the law.

PHI - What does it mean?

PHI stands for Protected Health Information. It can be formally defined as:

"Any information about health status, provision of healthcare, or payment for healthcare that can be linked to a specific individual."

Informally, it includes any part of a patient's medical record or payment history.

Under the US Health Insurance Portability and Accountability Act (HIPAA), PHI that is linked based on the following list of 18 identifiers, must be treated with special care:

1.Names

2.All geographical identifiers smaller than a state, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census: the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and [t]he initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000

3.Dates (other than year) directly related to an individual

4.Phone numbers

5.Fax numbers

6.Email addresses

7.Social Security numbers

8.Medical record numbers

9.Health insurance beneficiary numbers

10.Account numbers

11.Certificate/license numbers

12.Vehicle identifiers and serial numbers, including license plate numbers;

13.Device identifiers and serial numbers;

14.Web Uniform Resource Locators (URLs)

15.Internet Protocol (IP) address numbers

16.Biometric identifiers, including finger, retinal and voice prints

17.Full face photographic images and any comparable images

18.Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data

By removing certain pieces of information *based on the above listed 18 items), health information can be de-identified and, hence, can be used and shared publically , but still governed by the Common Rule, which is specifically applicable to biomedical and behavioral research involving human subjects in SUA. Removing these 18 elements is also known as the "Safe Harbor Method".

HIPAA Privacy Rule covers PHI in any medium, while HIPAA Security rule covers Electronic PHI or ePHI.

De-Identifying PHI:

The de-identification standard is covered under HIPAA Privacy Rule [45 CFR 164.514]. Some basic information regarding this rule is stated below:

(a) Standard:  de-identification of protected health information.  Health information [defined above] that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.

(b) Implementation specifications:  requirements for de-identification of protected health information.  A covered entity may determine that health information is not individually identifiable health information only if:

(1) A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable:

(i)   Applying such principles and methods, determines that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is subject of the information; and

(ii) Documents the methods and results of the analysis that justify such determination; or

(2)

(i) The following identifiers of the individual or of relatives, employers, or household members of the individual, are removed:

(A) Names;

(B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Censue:

(1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and

(2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.

(C) All elements of dates (except year) for dates directly related to an individual, including birth date, admission date,, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;

(D) Telephone numbers;

(E) Fax numbers;

(F) Electronic mail addresses;

(G) Social security numbers;

(H) Medical record numbers;

(I) Health plan beneficiary numbers;

(J) Account numbers;

(K) Certificate/license numbers;

(L) Vehicle identifiers and serial numbers, including license plate numbers;

(M) Device identifiers and serial numbers;

(N) Web Universal Resource Locators (URLs);

(O) Internet Protocol (IP) address numbers;

(P) Biometric identifiers, including finger and voice prints;

(Q) Full face photographic images and any comparable images; and

(R) Any other unique identifying number, characteristic, or code, except as permitted by paragraph (c) of this section; and

(ii) The covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.

(c) Implementation specifications:  re-identification.  A covered entity may assign a code or other means of record identification to allow information de-identified under this section to be re-identified by the covered entity, provided that:

(1) Derivation.  The code or other means of record identification is not derived from or related to information about the individual and is not otherwise capable of being translated so as to identify the individual; and

(2) Security.  The covered entity does not use or disclose the code or other means of record identification for any other purpose, and does not disclose the mechanism for re-identification.”

© 2012 Health Compliance Consultants

HIPAA /HITECH Acts - New Final Rule 2013 - What changed?

DISCLAIMER: This article should not be taken as legal advice, instead it is a basic introduction to some changes that have been promulgated to the HIPAA/HITECH Acts final rules.

A Significant modification to the existing HIPAA/HITECH Rules was made which came into effect on March 26, 2013. The Covered Entities have until September 23, 2013 to become compliant with the revised rules. Let's start with some changes that are going to make the heaviest impact:

Business Associates are now considered Covered Entities and full force of HIPAA/HITECH Act have been enforced on them as well. This requires the Business Associates Agreements to be updated to reflect this change. The BAA's that had been implemented prior to this final rule became effective can be revised within the next 18 months as opposed to all new BAAs have to be in place for new Business Associates after the effective date to be updated within 6 months (the Sept. 23, 2013 cut off date).

Breach Notification standards have been revised. The Harm Standard, as it was commonly known, has been redefined with a new name or title "adverse to the individual". Each potential breach needs to be evaluated or assessed based on four factors: 1. what information was breached? 2.to whom the information was released? 3. was it actually accessed, used, or disclosed, and 4. what mitigating steps were taken on the incidence. This standard does not only provide some guidance regarding if a breach is reportable, but also enforces CEs to establish a process to establish a risk for every potential breach. The law does require proper assessment for each breach incident and does not allow the process to be automatic.

Patients Right to Access Their PHI has been modified as well. The patients have the same rights as before but they can ask their PHI (Protected Health Information) to be transmitted to them in an unsecured way, and the CE after informing the individual of the risk of privacy breach can transmit it based on the individuals demand. CE's do need to document this discussion for future reference and for their defense in case of an audit or litigation. The important point to note here is that this applies to individual whose PHI is being transmitted and not to professional exchange of PHI, in which case it should be properly encrypted.

We will continue posting further updates to this article to highlight more significant and not so significant modifications to the HIPAA/HITECH laws.

© 2012 Health Compliance Consultants

Whats Wrong With America's Healthcare System?

The US Healthcare industry sits at number 2 just below the Defense in the worldwide industry rankings. It also belongs to a select group of three or four industries that are considered recession proof, again defense being one of them. The cost of healthcare for a common person has escalated exponentially over the last decade and any number of reasons may be quoted for this increase, and primarily depends on who is asked the question. The provider will almost always point to the liability factor, which results in not only them ask for higher reimbursements, but also them practicing what may be termed as defensive treatments. If insurance companies are asked the same question, they would blame it on the providers who charge too much and who also do not manage  their patients properly thereby incurring extra costs in the long run. Patients simply make it look like the physicians bilking them out of their skins to maintain their luxurious lifestyles. Outsiders would blame lobbyists and pharmaceutical companies. Hence, there is no clear cut explanation and as a result no definite solution can be generated. Lets try and gather as many views fro as many diverse audience as possible and try to narrow down the issue at hand. Having spent almost a decade in this field and with significant experience on all fronts, i.e. provider, health plan, and patient, I have my own unique perspective, but will hold back for a while so as not to start a debate in support or against what I perceive as the problems in this industry. Lets try to be very objective in our analysis, and avoid negating or supporting views of others and instead present our own independent views.

HIPAA, HITECH, EMR -- half cooked soup..

With the recent push by Obama administration to incentivise adoption of EMR, a whole new cottage industry has blossomed. Everybody is jumping onto the bandwagon, with physicians focusing primarily on the incentives, the EMR vendors focusing on pushing their products and a whole slew of middlemen figuring out how to get their share from all this. Healthcare in general has been a slow adapter of technology, although you may find an occasional example of an individual provider taking the lead and being at the forefront of technology frontier.

There is no denying the usefulness of adopting technology to increase availability, efficiency, and manageability. However, the "incentive" and deadlines have forced provider to jump in relying on peer references, and pharmaceutical products like marketing tactics, which more often than not ends up as a sour pill which is stuck in the esophagus, that can neither be spit out or swallowed in. This whole scenario is being repeated all over the country, alongside another major "initiative" being forced by the administration, aka the ECO model. I don't doubt the intentions behind either of the two major initiatives, i.e. EMRs and ECOs, as the the objective is to make this industry more efficient in terms of performance, availability and cost-effectiveness. The problems emanate from a lack of industry-wide standard for the business models, work-flows and long-term incentives (remember the incentives on offer are much less the cost of implementing either of these two initiatives).

Let's take a closer look at the history of EMRs, in order to understand my point above. A 1000 ft. view of a doctors office operations 20 years ago would show a paper appointment book maintained by a front office administrator, patient walking in at appointed time, registering, waiting, a nurse preparing the patient for the doctor, filling out basic information and recording some basic health information, doctor walking in, going over the available information, checking the patient and diagnosing the problem and recommending/ordering remedial actions including  medications, tests, referring to a specialist, etc. Everything gets recorded in the patients medical record, filed in a colorfully coded folder and onto the medical record storage shelve. if a specialist or hospital needed the medical records, they would ask the patient to have these faxed over to them by the doctor's (primary care) office. Now, all this seems standard across any doctor's practice, however, every office, while utilizing similar forms/tools, had slightly modified version of this workflow. The modifications resulted from the personalities involved in the process, office layouts, patients/doctor's/staff demographics sometime forced certain deviations or creative processes being introduced. Once an office starts following a certain process, it becomes hard to make them change old habits. Whatever the flow, any person even with a basic technical knowledge, would consider this model a prime candidate for "computerization" or "automation". And that's exactly what happened. Either the providers hired programmers to develop systems (ancestors of present day EMRs) which after a while evolved in to Practice Management Systems, OR enterprising programmers decided to develop systems themselves and sell them to providers. The most prominent factor here which differentiates this industry (Practice/Medical Records automation) was the direct interaction between the end user and developer. End user defined what was required, and the developer produced exactly that. Even, when there was a pre-built program, it was modified to match the practice workflow as much as possible.Even if it wasn't a customized program, the market penetration was so low that an industry wide standard work flow wasn't developed or it never evolved. This is not unique to healthcare industry, as many other industries have so many disparate systems within different companies within them. But, the case here is that in Healthcare, the administration is forcing (with timelines/penalties) to implement a solution which might suit one practice and may result in complete disarray in another for a variety of factors that include personnel training (not comfortable working on computers, especially the old trusted front office administrator), management motivation (older gen vs. younger gen or gen x) etc. Come to think of a situation where every automaker in the country is asked to adopt a similar workflow management system. This will never happen, companies have their own systems, cultures, management styles, preferences and so on. The only thing that can be mandated in our auto-maker example would be to ask for certain standard reports, with the ability to authenticate when required. If similar mandates (reporting) are enforced ( we already have these), in healthcare industry, then all one has to do is to have the system vendor to make sure relevant information is captured and reports generated as per the administration requirements. Having spoken to a few physicians and working in this industry for almost 10 years, focusing on the technology and information systems, I can see a clash of three cultures here, the administration, the providers, and the techies. Each one of them feels they know what needs to be done and the others should conform to these. Taking everybody on board is also not possible. Every regulation goes through an extensive process of development, debate with concerned/effected parties, and final approvals. In our case the real issue is the involvement of silent majority who do not participate in the regulations development process for various reasons, but are the most important factor in successful implementation. Majority of providers or physicians are entrepreneurs and manage their own shops who are too busy to focus on anything other than looking after their core business.  The sheer number of healthcare providers/businesses make it impossible to "please everyone", but at the same time their represntation have been unable to provide adequate remedies to the core issues.

(TO BE CONTINUED...)