The Need for InferRx ™

Improving Reimbursement
Every bill for inpatient hospital services must be generated by transforming the information contained in written or electronic text narratives of patient and family history, symptoms, injuries, diseases, diagnoses, treatments and complications found in each hospital record. That clinical information is converted into the appropriate number designations of the thousands of codes that comprise the current version of the World Health Organizations International Classification of Diseases (ICD-9CM). Every code that is utilized for each patient encounter must be based on a specific, verifiable entry in the medical record. Although other products are available to assist the coder in identifying appropriate ICD-9CM codes after the coder has extracted pertinent medical information, those products amount to little more than electronic indexes. The tedious work of reviewing medical records, identifying critical information and applying the most appropriate codes remains largely a costly, labor-intensive manual process.

In addition, the information gathered during the current manual process generally is used solely for billing purposes and is not collected and maintained in sufficient detail to be useful for other purposes. Healthcare facilities throughout the world, particularly acute care inpatient hospitals, are losing billions of dollars not only in unnecessary administrative expense, but also in unrealized research and income opportunities that their clinical data could generate if they could marshal it in useful ways. Until the development of InferRx, the healthcare industry has had no practical and effective process to collect, manage, control, organize and above all, mobilize its information.

Quality of Care, Utilization Review and Research
The dramatic savings hospitals realize will be augmented by equally dramatic improvements in the quality of care they deliver to their patients. The clinical importance of the database InferRx creates for hospitals, payers, and agencies cannot be overstated.

Healthcare is the largest industry in the United States and in the world, but it is uniquely lacking in reliable information. Current collection and analysis of clinical information follows a decentralized model that is restricted by 20th century data entry technology and is severely limited in purpose and scope. Access to clinical data is at best cumbersome and is universally closed to investigation by researchers outside of the hospital or hospital system where the patient was treated. Decentralization of clinical data and the absence of an accessible single source prevent researchers, public agencies, and healthcare providers from gaining access to meaningful information.

The only setting in which all hospital records are comprehensively reviewed is in the billing department. Hospital coders review all inpatient records and provide payers with limited information for reimbursement purposes by identifying and grouping codes for various medical conditions, procedures, and complications for inpatient admissions. All current hospital coding is done manually (an individual coder reading each record) using obsolete nomenclature (ICD-9CM) exclusively for the purpose of defining a Diagnostic Related Group (DRG) for each admission. In most cases, the information that coders identify is limited to ICD-9CM codes that increase reimbursement. Clinically significant information, including many co-morbid conditions and complications, that will not increase reimbursement in a DRG-based reimbursement system is generally ignored. Moreover, virtually no significant clinical information is available to any agency or hospital system until after the patient is discharged, making most hospital data useless for concurrent identification of an emerging epidemic or widespread complications related to specific pathologies, therapies or drugs.

The limited information that coders compile is seldom used by any hospital or hospital system for any purpose other than billing. Very few hospitals have the ability to retrieve and analyze ICD codes that have been utilized within their own patient or physician populations; and even when that information is accessible, it is not available to agencies or researchers outside of each hospital. Government agencies that have responsibility not only for paying a substantial portion of the cost but also for evaluating utilization and the quality of care, identifying and tracking disease, and funding research currently have no ability to compile or analyze significant clinical information from hospitals and other providers.

All of the costly electronic medical record systems that have been developed and deployed over the past several years are restricted by 20th century data collection models and by a paradigm that is designed to restrict access to clinical data. Although a few hospitals have developed the means to conduct limited analyses of their own clinical data, that information is carefully guarded and treated as if it were proprietary, even though the cost of services that created the data was paid largely by the public. No national system exists to compile clinical information or to provide widespread access to the vast clinical data that would be enormously beneficial if captured and made widely available.

Audit Protection

Federal and state governments have increased their audit and enforcement activities dramatically. They have enacted new laws imposing heavy fines on hospitals for erroneous coding. Strict rules that have been promulgated by the Centers for Medicare and Medicaid Services (CMS), create potential criminal penalties for administrators who are convicted of fraud and abuse. Strict compliance with (CMS) regulations is built into the InferRx application. All billing codes are automatically cross-referenced to specific, electronically preserved source text in the permanent medical record.

View Sample "Coding Summary" - click here!