Health agency closes gap on verification

Not long ago, when American Indian patients walked in for care at the Albuquerque Indian Hospital, it was a chore to determine what kind of health insurance, if any, they carried.

The hospital is part of the Indian Health Service (IHS), an agency within the U.S. Department of Health and Human Services that serves about 1.6 million American Indians and Alaska Natives. The hospital used IHS' Resource and Patient Management System (RPMS), an integrated set of computer applications that performed a variety of administrative and health functions including eligibility verification.

However, RPMS was updated only monthly and eligibility usually couldn't be verified until 24 hours later, said Michael Weaver, who recently retired as the hospital's pharmacy director. Therefore, a hospital wouldn't know if a patient had insurance until after the visit.

That meant IHS units couldn't bill insurance companies or government programs for services. "We'd kind of lose them," he said, adding that the hospital sees 80 to 180 patients daily.

But for the past year or so, the hospital and several other IHS offices and facilities have been using a free, hosted Web-based verification system developed by two employees from IHS' Shiprock, N.M., unit, that offers instantaneous verification of a patient's insurance coverage.

"It's very simple," Weaver said. "You just click on the icon. Put the information in there, and it comes back and tells you if [patients are] verified or not. We could send them over to our patient benefits coordinator and have them apply for Medicaid" if they have no insurance.

Tom Duran, Shiprock's chief information officer, and Mike Pike, its information technology specialist, developed the E-Verify application in-house, and it is updated weekly as a way to beef up collections from Medicare/Medicaid and private insurance companies as Congress requires.

"We decided that it was important to determine what insurance the patient had so we could bill appropriately," Duran said. Providing adequate health services was becoming a problem in the Shiprock service unit, which serves approximately 50,000 and comprises the 52-bed Northern Navajo Medical Center, two health stations and two health clinics.

E-Verify helped double collection in the first month for Shiprock, Duran said, adding "it's done that every month thereafter." The product also helps save money.

For example, it costs about 30 to 40 cents to look up a patient's eligibility using commercial verification software, he said. With E-Verify, nearly 400,000 checks have been completed to date. If you multiply that by 35 cents per verification, it adds up to more than $140,000 saved, he said, adding that installation costs of up to $30,000 per site are also avoided.

The savings are significant, Pike and Duran said, because budgets are tightening and that could mean layoffs. By automating a facility's administrative functions, savings can be shifted to the clinical side, they said.

Based on E-Verify's success, the two are developing what they call an E-Series — E for excellent — system of other Web-based health administrative applications they've rolled out or are hoping to within the next year.

Currently, about 1,000 people across IHS use the E-Series system to some degree (see box).

"It sounds farfetched, but I want our hospital to be like the Starship Enterprise," Pike said, adding that the applications also can be used on wireless handheld devices without being reformatted.

Duran, a pharmacist by trade, said he envisioned the e-verification application three years ago. He added a $60,000 high-end server two years ago and InterSystems Corp.'s post-relational database called Cache. Then, he budgeted for developmental costs. The actual development of E-Verify — now on its fourth version — took Pike about 12 hours one day early last year. Although they couldn't tally their total developmental expenses, they said purchasing equivalent commercial software — if it existed — would have cost significantly more.

Although IHS has a central technology department, Duran said the Shiprock unit budgeted in-house development to speed up applications from concept to design. That was "needed to overcome what we were projecting at the time, a pretty large deficit," he said, adding that the IHS technology department reviewed the system to ensure it had robust security.

"The reason it took such a short time is because by putting development at the point of care, you can develop the software that's needed right then and right there," Duran said.

Pike said there are three elements underlying the E-Series applications. First, it runs on a Red Hat Inc. Linux operating environment because of its speed, reliability and uptime, he said. Second, he and Duran needed a database fast enough for searches. "Patients are sick so you have to get them through there as quickly as possible," Pike said. They selected Cache "because it currently is the fastest database engine available."

Third, Pike said, they needed a graphical user Web interface on top of Cache and chose InterSystems' WebLink Developer. "And the reason it had to be that way is because with IHS you have a million different platforms, a million different PCs, and we needed something that would run on everything," he said.

In developing the E-Verify application, Duran went to the insurance carriers within the IHS system, including the federal government and three states, to get eligibility information, which was put into a standard database dynamically updated each week. There are about 1.6 million such records so far, he said.

Weaver, the retired pharmacy director, said that Duran and Pike should be rewarded with a larger budget to do more applications. "They're finally moving us into the 21st century," he said.

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E-Series applications

In addition to E-Verify, the E-Series suite of applications includes:

E-ID, a single point of authentication to verify users' credentials and give them authorized access for all or some E-Series applications.

E-Exec, to query and generate management reports.

E-Trax, help desk management.

E-Post and E-Batch, which take remittances or insurance carriers' paid claims and post them automatically to the system's billing records.

E-Code, a coding system that converts physician diagnoses into alphanumeric codes on the bill.

E-Nvision, a prototype for electronic health records.