Filling the bill in emergencies

Gary Arlen

Innovative public-private partnerships are creating new revenue opportunities for both contractors and government agencies ? and new reasons to scrutinize the public values of such arrangements.

In today's cost-cutting environment, collaborative ventures that generate ongoing rewards to the system integrator as well as to the agency ? and maybe even to the taxpayer ? sound very good.

In that light, a new scheme that expedites billing and collections for emergency medical services, which are often run by local government agencies, seems ideal. The arrangement not only keeps track of the costs incurred during these ambulance expeditions, but also monitors medical data, even forwarding it to the hospital emergency room while a patient is in transit.

It appears to be the ideal mix of public service and improved efficiency: faster, more comprehensive health care and assured payments.

For the system integrator, the set-up creates a continuing revenue stream from a commission-like share of the funds generated by the billing-and-collections component.

But alas, such approaches are also strewn with hurdles. At the very least, skeptics raise concerns that the appetite for new revenue ? for municipalities as well as for the IT provider ? comes before public service. Red-light cameras, with their revenue windfalls for both the cities and the technology vendors, come to mind.

Along with the public dismay for such "big-brother" procedures.

Nonetheless, an argument can be made that those cameras do strengthen traffic enforcement ? and save lives.

Hence, the EMS integration plans now being implemented deserve attention as another example of locally deployed technology that can boost municipal income, and also create recurring income for the integrator.

Affiliated Computer Services Inc. (ACS), through its State and Local Solutions Group, has designed a package that encompasses both the medical and financial aspects of EMS.

Unlike most of its competitors, ACS has integrated a customized wireless device, which it calls the "EMTablet," at the heart of its system. The pen-computing terminal, with integrated transmission capability; is also known as "the Hammerhead" by its manufacturer, Walkabout Computers Inc. of West Palm Beach, Fla.

At least a half-dozen IT companies are chasing the ambulance business. Some of them, such as Medibanc, Diversified Ambulance Billing, ADP, AccuMed and Emergisoft, are well entrenched into hospital billing and administration IT systems.

After a couple years of developing its EMTablet and companion software package, ACS has landed contracts for the package in four urban markets: Philadelphia, Houston, Columbus, Ohio, and New Orleans. Various versions have been deployed.

None of ACS's customers has yet implemented the feature that some perceive as the ultimate value: real-time transmission of medical information to the emergency room doctors so they have a complete profile on hand before the patient is wheeled in. But ACS claims that it is ready to provide such capability when a client requests it.

Until such emergency care activity is put in place, of course, the public may suspect that payments ? not urgent medical treatment ? remain the fundamental rationale for this system.

Nonetheless, in the context of medical care and billing, the financial process is being resolved, and a novel financial arrangement is at the core of the plan. ACS's Richard Hamilton, director of emergency medical services, contends that "improved collections, because of better documentation," have helped its clients recover up to 100 percent more in insurance claims.

Among the greatest challenges, especially in the hustle of an ambulance treatment, is the gathering of relevant medical information and assuring that it is tagged in a way that serves both the health care professionals and insurance companies. Communities have different ways to characterize the same ailment or procedure, so the EMTablet and software have to be fine-tuned to match the patterns of each region. "Respiratory distress" here may be called "shortness of breath" or "breathing difficulty" there.

The EMTablet displays these customized "pick lists" or rosters of medical problems. Using a quality assurance database, it generates follow-up questions so that the EMS worker can build a profile of the situation. For example, a respiratory ailment may trigger questions about heat stroke or other pertinent input. The device time stamps every data entry, which is important in documenting treatment for legal/liability issues, Hamilton explains. Eventually such data could be integrated with existing hospital files about the patient.

Building on the human factors involved in current ambulance services, the ACS visual interface is derived from current EMS procedures.

Typically, one technician gathers information from a patient, while a second technician fills out the paperwork. The EMTablet ? fundamentally a wireless replacement for the intake form ? can display an illustration of a human torso as part of a configurable graphic interface. The technician touches menu items to record the patient's condition and simultaneously build the billing manifest.

It takes about four hours of training for EMS personnel to become adept at using the Hammerhead and its software, Hamilton said.

Looking ahead to future EMS requirements, the system is configured to manage mapping/GPS, medical device interfaces and related features that may become part of the ambulance service. The EMTablet can use native database engines including Oracle, dBase, MSSQL and other software.

To attract local governments to its solution, ACS has devised an unusual business model: ACS basically gives the devices and the service to EMS authorities in exchange for an undisclosed share of the billing receipts.

The set-up offers ACS a greater incentive to track and collect the insurance fees. Hamilton says that it cost about $3 million, including the price of the EMTablets, to equip 100 Houston ambulances with its system. City size determines the scale of the investment: for example, Philadelphia has 60 units; Columbus, Ohio, required only 32 devices; and New Orleans now has 17 units.

For now, ACS is running the process under a service bureau arrangement. Data input by the EMS team goes to an AMS aggregation point, and client hospitals have immediate access to the field reports.

Following ACS's initiative, other EMS and hospital billing contractors are exploring integrated offerings. Understandably, Hamilton believes the integrated system is more productive than traditional means. Los Angeles has 40 city-employed clerks handling the billing process, he said.

Equally important, the unusual revenue-sharing system, which involves local agencies as well as private and public insurance providers and a third-party integrator, offers a new approach to local government service delivery. ACS's refusal to disclose its cut of the insurance collection proceeds comes under the mantle of "competitive" protection. Hence, the ultimate value of the arrangement will be demonstrations that the system actually saves more lives and delivers better emergency care.

As well as expediting the billing process and generating new revenue for the integrator.

If it accomplishes both goals ? medical and financial ? the collaboration will indeed underscore the value of creative service by system integrators.

Gary Arlen is president of Arlen Communications Inc., a Bethesda, Md., research firm. His e-mail address is

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