Evidence-based logic and quality assurance (QA) are critical ingredients in ensuring a compliant and defensible medical necessity review program. At Executive Health Resources (EHR), we believe that our consistent review process, our Physician Advisor team organization, and our technology all play an important role in a best practice program. What sets EHR apart in a class by itself, providing the only real-time proven Medicare medical necessity compliance program in the market, is our proprietary evidence-based content, our library of more than 9 million medical necessity reviews, our training/testing/certification methodology, and our QA process. The combination of these program components are the foundation for EHR Logic.
Step 1: Classifying Cases
EHR's Clinical Groups (ECGs), a unique and proprietary classification system, targets hospital admission cases that consistently fail to meet traditional first-level nurse screening criteria or have no criteria that apply. EHR bases all of its evidence-based research on the 100+ ECGs that have been identified, thus far, and codifies every case review by ECG.
Step 2: Content Development
Each ECG was thoroughly researched, with hundreds of articles reviewed, extracted, and analyzed, so that every medical necessity determination is based upon multiple literature citations and a solid evidence-based framework. For each ECG, we created comprehensive documentation to provide our Physician Advisors with detailed examinations of the data, discussion of clinical significance, important statement and conclusions from each peer reviewed publication, and access to our library of articles, should further research be required.
Step 3: Training & Testing
EHR developed training modules based on our comprehensive documentation for each ECG. These modules distill down the key learnings and conclusions from our review and documentation of the medical literature. We utilize an online computer-based training and testing tool that allows us to educate our entire physician and nurse staff on new ECGs and to provide refresher courses and updates to existing logic, based on our ongoing research.
Step 4: Operations
At EHR, we apply our evidence-based logic to every case. To accomplish this, a distillation of the training module is linked into the EHRic (EHR Information Center), EHR's proprietary technology platform that our Physician Advisors leverage every day while completing case reviews. This provides a real-time evaluation every time a case is entered into EHRic and classified into an ECG, a requirement for every case.
Step 5: Quality Assurance
EHR utilizes both real-time and retrospective QA practices to ensure consistent use of our logic by all of our clinicians. Senior Physician Advisors conduct real-time QA assessments and EHR's Quality Committee conducts retrospective QA assessments regularly, so hospitals can depend upon our decisions as compliant, consistent, and supportable.
Contact EHR to learn more about EHR Logic.