Addressing Physician Burnout-It’s Not Just the EHR

Tactics for addressing Physician Burnout

Epic’s Revenue Guardian

Revenue Cycle leaders return home from Epic’s campus this week with a few new tricks in their bags.  One highlight and quickly becoming a hot topic is Epic’s Revenue Guardian.  While Epic has the charge router, front and back-end automation and workqueues abound, the Revenue Guardian is a secondary check of the system to prevent lost revenue, missing charges, and target areas you know your organization needs to keep a close eye on.  (Epic also announced a new Payment Guardian expected soon.)

Simple examples Epic offers are checking contrast orders to ensure there is a contrast charge, missing observation charges, or even missing rev 391 rev codes.  Epic uses the best practice advisory functionality many organizations are familiar with to accomplish these checks.  As of a few weeks ago, there were 25 examples in Epic’s foundation system, though now we have over 100 pre-built examples to take advantage of.  Requirements to implement are to have Epic’s HB module as well as either EpicCare Ambulatory or Epic Inpatient.  Revenue Guardian checks are only for hospital accounts and hospital billing charges at this time.  While you can configure these checks to trigger a DNB, this should be carefully discussed with your revenue integrity lead and team.

Reports, workqueues and other data can be produced from these checks, with the goal of eliminating revenue leakage and improving front and back-end training where missing charges can be automated or corrected by workflow.   Putting the appropriate governance into play to support the check findings is essential to turning the data into action.  Culbert works with organizations from design, build, and revenue integrity optimization with these checks.

Director Epic Practice

MGMA 2017- Presentation : Optimizing Health Information Management

Another outstanding MGMA conference in Anaheim CA.   Proud of our speakers Elizabeth Morgenroth, CPC and Randy Jones, DHA, FACHE,FACMPE who presented:

“The Data Integrity Department: Optimizing Health Information Management”

Looking forward to MGMA 2018 in Boston!

Epic Provider Efficiency Profile (PEP)


As hundreds of organizations return home from a week of Wizardry in Verona, Wisconsin, they bring back new memories, new connections, lists of new features to explore, and a high for the potential of the newly named ‘CHR’ (Comprehensive Medical Record).

In the clinical space, conversations were abuzz around provider satisfaction, efficiency and CHR usability.  The topic was perhaps spurred by Carl Dvorak referencing supposed negative news media about provider adoption and happiness, though tempered by the notion that Epic users are among the happiest.  That said, everyone agreed there is a long road ahead.

The provider efficiency profile was highlighted as a ‘spell’ in the land of Epic wizards to help organizations develop keener insights into their clinical community.  The PEP as it’s called, provides clinician-level data about workload, system usage, specific number of tools adapted, amount of time in certain activities, time spent during specific hours of the day, and much more.  The efficiency can be determined looking in comparison to others, as well as in comparison to specific workflows (example: disposition in the ED).

The PEP must be turned on by the build team, though it can be focused on the providers or clinics you choose.  In one case study, Culbert found identifying opportunities at 5 clinics to improve specific smart tools, improve in basket training and share high efficiency provider notes with others reduced the average time after work completing and closing encounters by 30 minutes per day.  The PEP is a powerful tool for just after go-live and to continue to monitor throughout optimization cycles.


Jaffer Traish- VP Consulting-Culbert Healthcare Solutions





Selecting and Mentoring your Physician Champions for Organizational Change

Healthcare executives know that physician champions are critical to achieve successful change within their organization for many projects. However, merely selecting a physician to function as the champion for an organizational change project, is often insufficient. Things don’t always turn out as envisioned.   The physician may not be effective as hoped due to lack of credibility, inability to obtain buy-in, or inadequate communication skills.    It is not only important to select the right physician champion, but also to provide guidance and mentoring to maximize their effectiveness.

What is a physician champion? The physician champion functions as an important liaison between project leadership and the physician community.   It is important that they represent the physician’s voice, not just their own, and can “speak” to physician’s interests broadly.   In addition, they are an important communicator back to the physicians.  They need to be able to speak directly to the physicians and focus on the most relevant issues.  Physician champions should help identify important stakeholders, both advocates and naysayers, and communicate effectively with these important groups in order to maximize buy in for successful change.

Selection of physician champions.  Obviously, selecting the best person for the role is critical.  You should not assume that your CMIO or CMO is the right physician champion for every project within your organization.   It certainly makes sense for them to be aware and support change projects, but they may not always be the best person to function as physician champion.  Are they viewed as “a suit” and not clearly a physician voice? Are they stretched too thin for a time-consuming change project?  Do they lack credibility, due to limited clinical or operational experience, to represent physician’s interests on a given project?  The organization may be better suited by a physician more closely aligned with the physicians and/or the project subject matter.

Clinical credibility is often very important when selecting a physician champion.  You may have physicians interested in leadership roles because they are IT gurus, but they aren’t viewed as walking in their colleague’s shoes.   Or you might have physicians who view their role to be the voice of the physicians… “against any change that might ever impact the physicians.”

Supporting the role of the physician leader.   Physicians tend to be independent by nature.   Training has taught us to make and own important life and death decisions.   Although todays medicine often focuses on team care, it doesn’t come easily to physicians nor do the leadership skills required to achieve consensus and deal with conflict.   It is important to not assume that by simply identifying a good physician champion they will be successful   Identify a mentor who can guide them through the core responsibilities of a good physician champion.

Core responsibilities of a physician champion:

  1. Develop an effective process to gather broad based physician input
  2. Effectively represent physician interests in governance and design meetings
  3. Stakeholder management through development of a stakeholder list and action plan
  4. Develop and implement a communication plan
  5. Effective dealing with naysayers, conflict, and setbacks within a project.


Selecting the right physician champion for organizational change project is only one important strategic step.  It is equally as important for the champion to understand the expectations of the role.   Providing the champion with appropriate mentoring and guidance will help assure success.


MACRA MIPS Basics and What You Need to Do Now

By now, your organization, hopefully, is on its way on deciding what level of participation your organization should take on reporting MACRA for 2017. The Medicare Quality Payment Program (QPP), which began in January 1, 2017 applies to physicians, NPs, PA, CRNs, Nurse Anesthetists (not hospitals or facilities) and must participate in either the Merit-Based Incentive Payment System (MIPS) or in an advanced Alternative Payment Model (APM). Because greater than 50% of Clinicians are MIPS-eligible, we will focus on MIPS.

You are not MIPS-eligible if any of the following apply:

  • You are newly enrolled in Medicare
  • You see 100 or fewer Medicare Part B patients per year
  • You have less than or equal to $30,000 allowed Medicare Part B charges annually
  • You are on the participant list on at least one of 3 snapshot dates (3/31, 6/30, or 8/31) for a model that CMS has deemed an Advanced Alternative Payment Model (AAPM) for purposes of QPP participation. See the Centers for Medicare & Medicaid Services (CMS) list of AAPMs


Unless you have an exclusion from MIPS due to any of the reasons mentioned above, you must participate in the program in 2017. Understanding the different requirements in all 3 categories is essential in deciding your level of involvement for 2017. Those categories are:

  • Quality: Report on quality data on clinician-selected measures. This category is a replacement for CMS’ Physician Quality Reporting System (PQRS) and includes nearly 300 possible Quality measures (for example, providing receipt of specialist report or documentation of current medications in the medical record). Additional measures may be available through your specialty society’s Quality Clinical Data Registry (QCDR).
  • Advancing Care Information (ACI): Report on performance on certain Electronic Health Record (EHR) measures. This is the replacement for CMS’ EHR Incentive Program (Meaningful Use) and requires use of Certified Electronic Health Technology (2014-CEHRT).
  • Improvement Activities (IA): Attests to performance on certain CMS-designated improvement activities (for example, annual registration in a Prescription Drug Monitoring Program or improvements to care transition in the 30 days following patient discharge).


You have a choice of three participation tracks in 2017 to avoid a 4% penalty on your 2019 Medicare reimbursement. You should choose your participation track based on how you think you will perform on Quality, ACI, and/or IA performance categories. The tracks are:


  1. Minimum Participation: Avoid any penalty and report performance on either:
  • 1 Quality measure; or
  • 1 IA (Improvement Activity), either high or medium weight (depending on practice size); or
  • 4 or 5 base score ACI (Advancing Care Information) measures (depending on whether you have a 2014 or 2015 certified EHR, respectively)
  1. Partial Participation: Report on as many activities as feasible to be eligible for upside bonus. Keep in mind that because the program is based on a balance budget and virtually no penalties will be distributed, there will be very limited upside bonus available.
  • More than 1 (6) Quality measure; or
  • More than one IA (2-4); or
  • Base score ACI measures plus at least one additional ACI measure (core EHR measures plus up to 50 points in additional reporting)


  1. Full Participation: Excellent performers are eligible to share $500 M across the country but will be competing among organizations that have been focused on quality measurement for years:
  • 6 Quality measures, including one outcome measure; and
  • A combination of high- and medium-weight IAs (exact number will vary based on practice size and rural or non-rural location); and
  • Base score ACI measures plus any additional performance or bonus measures


You do not have to elect a participation pace as CMS will determine your pace based on the data that you submit. Still unsure of the pace or your involvement in 2017? To better understand how you may perform in the MIPS program and tailor your participation in 2017, review your past performance in other Medicare quality programs, such as PQRS, the EHR Incentive Program (Meaningful Use), and the Value Based Modifier (VBM). You can use your September 2016 Quality Resource Use Report (QRUR) or your 2016 PQRS Feedback Report to assess future performance. These reports have drill down tables that feature performance by group and individual, and can help you understand how you’ve done in the past and how you might do in the future.


You might consider minimum participation if you have no PQRS or just implemented your CEHRT. Partial participation might be the path if you have been on a CEHRT and have reported PQRS in the past, but are facing some physician resistance. You can also use 2017 as your trial run to prepare you for 2018.


Regardless of the path you choose to report in 2017, remember that this is a 2-year process. You will be working on your 2018 process before you know your 2017 results. Lastly, remember that you can successfully participate in the Minimum Participation track and avoid the 4% penalty by reporting one Quality measure. However, if you plan to participate in the Full or Partial Participation tracks, CMS requires a minimum 90 day participation period, which means that you must begin participating in those activities no later than October 2, 2017.

Paulette DiCesare -RN

Crossroads Between Physician Productivity & Burnout

Deconstructing the Construction of a New Facility

The success of building a new clinical location is dependent on many factors and people working collaboratively and in sync.  Some tips for a successful outcome include:

Time – One can never start planning too early.  Prior to construction and during construction, take time to understand and document wants vs. needs vs. must haves.  You can narrow and prioritize the list at a later date.  Changes to the design during construction can result in additional costs.

People – Consult the users of the space.  This includes all stakeholders including providers, front desk, billing, clinical staff, ancillary services and your administrative team.  Observe the work in the current space and verify all of the key workflows.  Ensure barriers to productivity are resolved.  As you design the new space, consider opportunities to enhance efficiency, patient and staff and physician satisfaction.

Communication – Consider building “touchdown space” in the clinical area and optimize your flow.  Many designs now have co-located shared space with providers and support staff, which is known to improve communication and teamwork.

Voice of the Patient – The voice of the patient is key when constructing and problem solving; not to mention when creating a patient centered environment.  Interview patients to obtain their input.  Consider surveys, on-site interviews, focus groups and outreach calls to gather information.

Practice – Test out the new workflows and create a mock-up of the exam room.  Map out your table, stools, cabinets, sharps boxes, locations for disposable supplies such as gloves, door, curtain, etc. Simulate how the team members and patients will move within the space.  A fun and effective exercise in the initial planning stage is to put together a cross functional team to create the ideal layout using post-its!  This helps to surface workflows but can also point out differences in opinion among the team.

Team Meetings – Consider if you will need space for teaching or team meetings.  With the implementation of value-based care, a shared administrative space may prove to be essential for your PCMH.  Don’t forget about staff meetings or educational programming, which is required by licensure or recommended by leadership.  If you are a teaching program, consider the needs of students, fellows, residents and instructors.

Technology – Consider your current level of technology.  Will the construction include new features of your current software or upgrades or a completely new system?  This is a good time to review your Electronic Health Record (EHR) and Practice Management System (PM) or Radiology PACS, and identify change opportunities to allow time to plan.  For example, my current client is using it as a vehicle to redesign and optimize their clinical capabilities.  Instead of assigning each student a designated workspace (i.e., Exam rooms 1 and 2), they are using the rooms as resources, which will allow for other users to utilize the exam room when the Monday and Wednesday provider is on vacation.  This change will allow a 36% opportunity to increase production.

Construction is exciting, but identifying a lead project manager can be essential to a successful outcome.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS Quality Payment Program – APM Path- part 3 of a 3 part Series on MACRA

What is an Alternative Payment Model (APM)?

In part two of this specific blog series on MACRA, I emphasized the CMS QPP decision tree and covered the MIPS path.  In part three, we will discuss the APM path.

Alternative Payment Models (APMs) are new approaches to paying for care through Medicare that incentivize quality and value.  The CMS Innovation Center develops new payment and service delivery models.  Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants: the Payment Amount threshold or the Patient Count threshold

Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.




  • A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care.
  • Can apply to a specific condition, care episode or population.
  • May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs.


Advanced Alternative Payment Models (AAPMs)

Advanced APMs are a subset of APMs and enable practices to earn more rewards for taking on some risk related to patients’ outcomes and cost of care

Under the Quality Payment Program, clinicians who participate to a sufficient degree in Advanced APMs are excluded from MIPS and earn a 5% lump sum incentive payment based on their Part B professional services for a given year, and also receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs must meet the following three requirements:

  1. At least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other healthcare professionals.
  2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.
  3. Be a Medical Home Model expanded under CMS Innovation Center authority or:
    1. Meet a revenue-based standard of financial risk that averages at least 8% of revenues at-risk for participating APMs
    2. Meet a benchmark-based standard of financial risk in which the maximum possible loss must be at least 3% of the spending target

In 2017, the following models are Advanced APMs:

  • Comprehensive ESRD Care (CEC) – Two-sided Risk Arrangements
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-sided Risk Arrangement

In future performance years, we anticipate that the following models will be Advanced APMs:

  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • New Voluntary Bundled Payment Model
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • ACO Track 1+

Under the AAPM path, clinicians will receive an annual 5% lump-sum bonus between 2019 and 2024, with a 0.75% increase to their Medicare physician fee schedule beginning in 2026.  While the AAPM track does not carry the penalty risks present in the MIPS track, APM entities must have a risk-based payment model for clinicians to qualify for AAPM.

While Advanced APMs have a fixed bonus incentive of 5% through 2024, it is important to understand that the Quality Payment Program does not change the design of any particular APM.  Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

How Do Eligible Clinicians Become a Qualifying APM Participant (QP)?

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants.  CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods:

  1. The Payment Amount threshold and the Patient Count threshold.
  2. Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.

Using the Patient Count Method, APM entities must see a minimum percentage of Medicare patients through the APM each performance year, with the percentage rising through 2022.

  • Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM.
  • CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity.
  • The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.
  • The QP Performance Period for each payment year will be from January 1—August 31 of the calendar year that is two years prior to the payment year.

Beginning in 2021, this threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.









What is a Partial Qualifying APM?

Clinicians are considered Partial Qualifying APM participants if their APM entities participate in an Advanced APM, but meet a slightly lower threshold outlined by CMS.

Clinicians participating in the Partial Qualifying APM track will not receive AAPM’s 5% incentive payment, but they can opt into the MIPS path if they can meet its reporting requirements.

In Summary

The shift from the Sustainable Growth Rate formula’s “fee-for-service” payment model to MACRA’s value-based payment model should ultimately help to preserve Medicare funds in the long-term while incentivizing ongoing initiatives that could make a positive impact on population health in the U.S.  The Advanced APM track and the QP status may be desirable for many MIPS eligible providers.  Due to the inherent financial risks involved in any AAPM, an organization should evaluate these programs with care and consideration.


Senior Consultant -Culbert Healthcare Solutions

Admissions/Registration: Helping to Improve Accounts Receivable

One of the most important ways to improve A/R is the admissions/registration areas of any healthcare organization.

Many facilities band-aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient.  It is estimated that it costs healthcare facilities $15 per visit to track and collect co-payments and deductibles after the fact.  For many healthcare organizations, such as physician offices, this practice could result in a zero net revenue gain.  Additionally, it costs healthcare facilities approximately $15 – $25 per visit for billing staff to correct registration errors and approximately $15 per statement sent to patients for co-pays, deductibles and co-insurances that could have been collected upfront.

So what steps can a healthcare facility take to remove the admissions/registration area band -aids and ultimately improve their A/R?

Step 1:  Management should be open to change

Most admission/registration managers have vast experience in their field and want nothing but a well-run department.  However, for many managers the stress of running a high-volume department that can potentially be open 24 hours a day does not allow them the luxury of thinking outside the box.  Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers, and some applications do not record who made the error(s) so they cannot be addressed with that individual.  For improvement and changes within the admission/registration areas, management must be open to change, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.

Step 2:  Assign an impartial third party

The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party.  This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism.  The impartial third party should not only meet with management of these areas, but with 75% of the staff covering all shifts.

 Step Three:  Logging issues

This is not the time to address or correct issues that are discovered.  Although issues presented need to be clear and concise, they should not be demonstrated or dissected as this is purely a fact finding process.  All issues discussed are to be logged no matter how insufficient they may appear.

Step Four:  Organization

Issues need to be organized into categories such as process, system, staffing, training and education.  Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve (such as lack of staff).

Step Five:  Resolving issues

Process issues:  It is imperative that management and staff be open to resolving processing issues.  A process should not be kept in place because it has “always been done this way” but because it enhances the admission/registration process.  An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the workflow and changing what does not work.

System issues:  Are the admission/registration pathways specific to your site or are they generic?  Does the application provide “help” screens or pathways that are easy to maneuver and are they specific to your site?  Are required billing fields designated as “must enter” and won’t allow staff to bypass?  Is your IT staff knowledgeable of your environment and application?  Is your application vendor directly involved with improving your application pathways?  Can your staff search for a patient’s prior admission/visits within the application?

Staffing:  Are the errors the result of under or overstaffing?  Both can be issues for admission/registration areas as too much work per staff member can cause a hurried approach whereas too many staff can cause disruptions in daily work.  When are most of your admissions/registrations?  Can your facility add or deduct staff according to daily needs?  Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient’s visit?

Training:  Has your staff been properly trained in the workflows of the department and admission/registration pathways within the application?  Does staff understand what fields are required and why?  Does your staff update prior admission/registration information or just process the data?

Education:  Correction of errors must be done by the admission staff and not billing.  This is very important because they need to understand what constitutes an error and why.  Some applications only record the last person who worked on the admission/registration versus who made the error.  This limitation should not stop management from requiring error correction.  Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.

Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities.  As registration is made aware of their errors, it is imperative to teach them how to perform registrations and keep them from repeating the same errors over and over.  Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.