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EHR Data Interface Issues for the Third Party Biller


Is the Industry Moving Away From Your Billing Model?

An article by Ron Sterling taken from the May/June issue of HBMA Billing.

Third party billers face a variety of business and technical challenges in interfacing with electronic health records (EHR) and other systems. Indeed, some of the initiatives in the healthcare industry will continue to complicate the establishment and maintenance of data interfaces for the foreseeable future.

Business Challenges

If you go back a few years before Meaningful Use, there were over 1,200 practice management system (PMS) vendors and a couple of hundred EHR vendors. During that time, the third party billers and/or practice management system vendors had the access to, and the attention of, physicians who needed to get their claims out of the door and paid. Consequently, it was the EHR vendors that would offer to accommodate interfaces with medical billing systems. Indeed, a variety of PMS vendors touted their systems as a gateway to a variety of EHR options for their physician clients.

Today, newly introduced integrated PMS/EHR products and EHR acquisitions by PMS vendors and vice versa have led to fewer, if any, billing system options for many EHR buyers. From integrated systems (that by design and business model do not interface with other products), to vendors that will not interface with other options, many vendors have established themselves as one stop shops for medical billing, EHR solutions, and, in some cases, RCM services. Indeed, some vendors have exclusive or "preferred" clearinghouse relationships for the handling of standard HIPAA transactions. In essence, more and more vendors want to position themselves as the only source for healthcare software solutions and services.

That is not to say that there are not EHR vendors who are eager to interface with a variety of practice management systems. However, the industry is moving to fewer interfaced solutions and more integrated offerings. Indeed, the majority of "new" solutions are integrated PMS/EHR offerings.

Healthcare Industry Changes

Related to the business challenges, the Meaningful Use initiative will affect interface strategies for all PMS and EHR products. For example, Stage 2 Meaningful Use core (required) measures include secure messaging with patients and providing electronic access to patient medical information. In most cases, this requires the use of a patient portal.

Patient portals can provide both medical billing and clinical interactions with patients. As importantly, most patient portals are designed to interface with one product line of medical billing and EHR products (such as Centricity PMS/EHR or NextGen EPM/EHR). Patient portals are not typically designed to interface with one vendor's practice management software containing billing data and a different vendor's EHR that houses clinical information. If the patient portal is separately interfaced with a PMS from one vendor and an EHR from a different vendor, the patient portal may not "know" how to properly route the message. In practice, however, patients may exchange secured messages with the practice on both billing and clinical issues.

A strategy that may include a separate patient portal for clinical issues and one for medical billing purposes presents a variety of operational challenges, including coordinating patient access and even accurately routing information. As importantly, separate patient portals will undermine support for the Patient Centered Medical Home and Accountable Care Organizations. For example, a patient who accesses the medical billing patient portal may not be reminded about a clinically-driven patient service issue.

Technical Challenges

Most interfaces are based on the Health Level 7 (HL7) structure. However, various aspects of HL7 are open to interpretation by vendors. Indeed, a variety of PMS and EHR vendors do not strictly support the HL7 standard. For example, some vendors use general HL7 messages instead of designated HL7 messages to send information. In other instances, the information in a message is not placed in the expected place but in a comment or supplemental area. Indeed, some vendors do not use the standard code sets, and instead use text fragments. In each case, the effort to establish the interface may require a painstaking evaluation of the vendor's "HL7" implementation.

Even after achieving success, the interface may have to change to address evolving coordination of information requirements between the medical billing and clinical record functions. For example:
  • The Meaningful Use Stage 1 measures require ethnicity and race information that is commonly captured in the PM systems but is needed by the EHR to track provider performance and qualify for the EHR incentive payments from Medicare or Medicaid.
  • Meaningful Use Stage 2 will require sharing of contact information and email addresses.
  • The HIPAA omnibus rules will affect the information needed to track HIPAA Privacy and Disclosure as well as support exchanges with patients. As a practical matter, most medical billing and EHR interfaces do a poor job of coordinating HIPAA privacy and disclosure status for patients.

In light of these increasingly complex business and technical challenges to interfacing medical billing and EHR products, third party billers may need to establish their own preferred relationships with EHR vendors. However, such relationships will be under increasing competitive pressure and user demands to provide a more coordinated approach to patient service and provider relationships.

Right, wrong, or indifferent, the healthcare industry is moving towards comprehensive solutions to meet patient service challenges and optimize provider performance. Consequentially, the PMS/EHR vendors are addressing those needs. A myriad of changes that affect physician relationships with patients and the expectations of patients and payors will complicate the use of interfaces with EHR products and inhibit the efficiencies needed to manage patient care and service. As importantly, interfaced systems may complicate reporting for quality, operational, and management purposes.

Therefore, interfacing between PMS and EHR systems may present a tactical solution to meet physician needs in these relatively early stages of the transition to EHRs, but present a strategic challenge to address evolving healthcare business and patient service models. Third party billing organizations need to recognize these business and service issues in order to provide a clear strategic path for how your services and products will evolve to meet the new demands that your clients are facing.

Ron Sterling (800-967-3028, publishes the popular EHR Blog and authored the HIMSS Book of the Year Award winning Keys to EMR/EHR Success. He is an independent EHR consultant. © Sterling Solutions, 2013.


1. Chapter 3 - Keys to EMR/EHR Success by Ron Sterling

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