Management Consulting

Leveraging Best Practices to Optimize Your Enterprise Reporting Strategy

Data and reporting have become an integral aspect of healthcare operations from both a clinical and non-clinical perspective. With the widespread onset of EHR platforms, clinicians now have access to powerful data sets that serve as catalysts for better clinical decision-making. Hospital operators are also able to take a deeper dive into potential clinical inefficiencies and make better business decisions, which ultimately helps improve the organization’s bottom line. With the plethora of reporting solutions and reporting tools at the stakeholder’s fingertips, how can an organization leverage enterprise reporting best practices to ensure that key personnel have access to the right data at the right time?

 Many EHR platforms offer a set of canned reporting solutions out of the box upon installation; however, these reports may not be as robust as needed leading to new report requests. Leveraging the implementation of a structured report request process will help ensure your stakeholders receive a reporting solution that meets their needs in a timely manner. Often, report requests are received in the form of an email with minimal information provided, thus failing to provide the report developer with adequate information to begin development. Consider creating a user-friendly and fillable .pdf form using questions written in non-technical terms that can be distributed to stakeholders and utilized as a discovery document for your reporting solution.

 Defining roles and responsibilities of your reporting staff can also assist in ensuring that your reporting solution is delivered in a timely manner. For example, a reporting coordinator can triage report requests as they are received and provide useful input so that the request is assigned to a developer with an appropriate skillset. Alternatively, if your organization utilizes a service desk platform, report requests can be assigned to a pool of developers and categorized based on the classification of the request (Eg: Inpatient, Ambulatory, Revenue Cycle). Lastly, leveraging the knowledge of your application analysts to assist in report request triage and initial discovery can prove to be of great assistance to report developers as they move forward with report development. Often, the application analysts are better versed in the specific data sets and can interpret the request with the correct context. The coupling of their expertise with the report developer’s technical knowledge can drastically improve turnaround times while mitigating the likelihood of errant data in a report.

 Creating an organized and user-friendly manner for distributing various reporting solutions is an integral step in the optimization of your enterprise reporting strategy. This process often requires analysis of your current user and security build to ensure that the proper groups of users have access to view and run reports related to their job function. Additionally, leveraging metadata to ensure that reports are properly categorized will provide greater accuracy in search results should stakeholders query your reporting library.

 Lastly, development of curriculum and training on various reporting tools for your stakeholders will tie together several of the critical elements of a successful enterprise reporting strategy. As we move in to the next year, many EHR platforms and organizations are placing a strategic focus on putting the power of the data in the hands of the stakeholder. For this to come to fruition with long-lasting effect, a clearly defined education and training initiative should be considered as you move forward with optimization of your current-state reporting strategy.


Mitigating Revenue Risk During IT Implementation

Mitigating Revenue Risk During IT Implementation

From small practices to large integrated delivery networks, the ability to evaluate and select the appropriate IT applications is increasingly important. A number of drivers are pushing healthcare organizations to look critically at their IT vendor mix, especially their revenue cycle applications, including clinical integration initiatives (and the need to extend clinical and business applications to affiliates), the shift to value-based reimbursement, competitive merger and acquisition activity, and vendor market consolidation.

No matter the reason, developing a strategy to mitigate disruption to cash flow is a crucial component of any billing system or EHR implementation. The potential risk to revenue is no less an issue for private practices than for IDNs, yet, too often organizations devise their plans to protect revenue after the vendor selection has been completed and contracted. A better option is to address your Risk to Revenue Mitigation Strategy as part of the vendor selection and contract negotiation processes.

For example, practices should include both implementation staffing needs and ongoing staffing demands (i.e., for application maintenance and user support) in their “total cost of ownership” analysis. Keep in mind that, although most vendors have pre-defined implementation approaches that include helpful standard workflows and staffing structures, these vendor-defined best practices may not adequately address an individual practice’s unique workflow or business requirements. Organizations with a single billing office, for instance, will have vastly different workflows and training requirements than those with decentralized hospital/professional billing and customer service.

To mitigate risk to revenue during revenue cycle or EHR implementations, consider adopting a comprehensive strategy inclusive of these seven elements:

1. Create a business intelligence blueprint prior to go-live. This is the number-one mechanism for mitigating revenue risk, but it’s often overlooked. While most vendors offer robust reporting and BI tools, during the sales process, these same vendors often do not set realistic expectations as to the work effort required to build them before go-live.

2. Don’t skimp on training. In fact, training should be the last place to look for cost savings. In reality, IT implementations always involve changes to workflows, policies and procedures, user roles, application navigation, and personalization tools. Practices must balance vendor recommendations and methodologies against these changes because lost productivity doesn’t just impact financial performance — it also impacts the patient experience. Whenever affiliated practices or hospitals are included in an implementation, the negative PR of a less-than-successful implementation can — and often does — impact future clinical alignment plans and opportunities.

3. “Accelerate” cash flow before go live. As early as eight to 12 months prior to go live, organizations should begin cleaning up their A/R and identifying opportunities to accelerate cash flow. The goal is to create a cash buffer to offset any dips in cash flow caused by declines in clinical productivity or billing performance once billing begins in the new system.

First, design a plan to aggressively work down legacy A/R in the old system before the new system is activated. If internal staff don’t have the bandwidth to shoulder the responsibility, consider outsourced opportunities for an interim period.

Then, decide how to handle the period of time between when some staff must work out two separate systems to work legacy A/R out of the old system and current billing out of the new system. Operating in dual environments — with two different workflows and two different sets of policies and procedures — presents challenges. Old habits are reinforced through use of the old system, just as you’re trying to instill new roles, workflows, policies, and procedures. To overcome these challenges and hasten the learning curve on the new system, many practices outsource A/R from their legacy system after the first two or three months, during which most of the easier-to-collect accounts are resolved.

4. Develop application talent internally. The key is to tap trusted employees who fully understand the practice’s business, values, and culture. Outside assistance is best used to streamline your team’s learning curve on the new system, to advise you on alternative implementation decisions (and their strengths and drawbacks), for peak periods of build, for date conversion or short term technical expertise, for training, and for go-live support and stabilization.

5. Convert clinical activity to cash through focused integration of clinical and revenue cycle functionalities. Don’t make the mistake of replicating legacy workflows; use the implementation as an opportunity for process improvement, such as the consolidation and/or standardization of visit types. Look at your documentation, charge capture, charge triggering, and charge routing for ways to improve physician efficiencies, and to produce thorough, timely, and clean claims. The ability to close encounters in a timely manner is a necessity. In addition, validate vendor recommendations to make sure your organization’s unique operational requirements — not just application best practices — are supported. Conduct integrated testing with real-life scenarios.

6. Automate data conversions. Some vendors advise against the automated conversion of certain patient and scheduling information. This may be due to the extensive amount of in-house technical expertise an organization would need to have on the brand-new application — which is not typically present. However, such data conversions involve a concentrated work effort for only a finite period of time. If qualified resources aren’t available internally, organizations may find it worthwhile to engage with an outside consultant. Automating data conversion offers a major ROI opportunity compared against tens of thousands of hours of manual data entry.

7. Test, test, test. The importance of system testing cannot be overstated. At a minimum, organizations should test their top volume- and top revenue-generating clinical services through a fully integrated clinical and revenue cycle. That means testing that starts with patient access, continues through the clinical encounter (including clinical documentation and charge capture), and continues through the entire billing cycle (including claims production, remittance, denial management, payment variance analysis, and reporting).

As healthcare organizations continue to align with affiliated practices, IT system builds are becoming more complex. Consider, for example, what happens when multiple practices and facilities all share a common billing system, yet their disparate financial information must be kept separate. In all such situations, a vendor’s standard implementation approach and timeline must be vetted and either validated or modified according to practice needs. Training and go-live strategies should always be grounded in reality; it’s better to reset expectations upfront than to put revenue at risk on the back end.


Brad Boyd is president of Culbert Healthcare Solutions.

Transforming Access Through Scheduling Redesign

Long wait times can be a symptom of scheduling and access problems. When new providers join a practice, significant time and effort is put forth to “create” the schedule and the scheduling guidelines.  Rarely is any effort spent reviewing the schedule once the on-boarding phase is completed.

Providers may be satisfied from the perspective of their practice when their schedule is full. However, this is not always a win-win if patients are complaining about the schedule. Delays in care can result in unnecessary costs and less revenue.

There are a variety of strategies which can be utilized to improve patient access. Some practices use team medicine such as the pairing of providers with Nurse Practitioners or Physician Assistants. When care is presented as a unit or a team (and in a positive light by the provider), patients are more likely to see an advance practice clinician when a provider is full.  Practices with significant capitated or bundled income may find it helpful to build the access infrastructure by adding non-provider touches to patient care such as dieticians, nurses or health coaches.  Another option is cutting edge methods such as mobile apps, social media, shared medical appointments, outreach through a patient portal, texting or telephone calls, or virtual care visits.

It can be helpful to review triage protocols to be sure they encourage patients to be seen when new acute conditions arise or established chronic conditions are worsen. Often times patients can be managed by a staff member and providers may miss important signs of a problem.  Determine if refill protocols include standards for visit frequency and ongoing surveillance with diagnostic testing such as lab or radiology.

Ensure the practice has optimized the clinical workflow to be efficient. This includes standardizing rooms and staff duties, co-locating providers near staff to enhance communication, adding huddles to the day to discuss potential issues/concerns and decreasing patient wait time for ancillaries which are ordered at the time of service or in advance by primary care physicians prior to referral to the specialists.

Governance can play an important role when it comes to managing access. Jointly develop standards and guidelines between providers, administrators and staff. Requests to change templates should run through the operations team in order to ensure the schedule is not compromised.  Review schedules in a meaningful way once or twice yearly; confirm a provider does in fact have the required number of patient care hours available and the designated number of new patient appointment slots each day.  Ask questions to understand the reason for blocked or appointment slots on hold. Scheduling protocols can erode over time with meetings and non-work responsibilities which can reduce productivity.   Employ use of automation features and ensure they are hard wired to allow for search optimization and same day visit access.

The “third next available appointment “ represents a nationally reported measure against which practices can monitor their performance with a goal of seeing patients when clinically indicated and when they desire to be seen. Offering this type of data to providers, managers and staff can help to engage them in solving the access puzzle together.  Given the complexity of scheduling, it may be necessary to utilize one or more interventions on a regular basis.

Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS divulges CPC+ regions: What you need to know

Managed Healthcare Executive

CMS has announced regions for the Comprehensive Primary Care Plus (CPC+) program for Medicare beneficiaries.

access article here

Nurse Triage Raises the Bar for Centralized Patient Access Centers

Centralized patient access centers are an important investment for medical groups and health systems as they provide an access point for current and prospective patients. As a means to attract and retain patients, a centralized access center that focuses solely on revenue cycle functions (scheduling, registration, insurance verification and payment collection) may not meet the needs of your patient population and may result in missed opportunities to fully improve patient access and appropriately drive care and service delivery.

Why Do Anything?

Despite the implementation of centralized patient access centers, patients continue to have difficulty obtaining access to urgent or acute care services with their providers. Often times this is due to the non-clinical office personnel’s inability to clinically assess the acuity of the patient complaint or concern.  Same day appointments intended to be filled by the more urgent or acutely ill patient are instead filled with patients whose care needs should have been met in an alternate, more appropriate environment.  Add in call demand from patients recently discharged from the hospital or outpatient surgery, those with a newly prescribed medication or care regimen, and of course the chronic consumers of health care services.  These patient access issues have a secondary effect on the centralized patient access center in the form of higher call volumes and prolonged wait or callback times to find available appointments.  As a result there is an overutilization of emergency departments for urgent care and primary care concerns.  Not to mention the negative impact on patient satisfaction!

What’s The Answer?

Balance the revenue cycle centric patient access center with Nurse Triage. A centralized nurse triage service line staffed by registered nurses with various areas of expertise (ER, critical care, surgical, pediatric, obstetrics) that are guided using nationally standardized triage and practice specific protocols provide safe and clinically appropriate care advice and service referrals.  Telephone nurse practice (TNP) or triage nurses are able to provide medical advice encompassing the treatment of fevers, wound care, and emergent conditions such as chest pain. The nurses are trained to triage conditions to the appropriate level of care at home, with a same day physician appointment, at an urgent care center, or at an emergency department.

What Are The Benefits?

  • Already have a centralized patient access center? – the infrastructure is in place just add the clinical components
  • Decreases risk of delayed or inappropriate care advice – eliminate non-clinical office personnel giving clinical advice or that “silent” heart attack patient waiting hours for a callback
  • Improves physician practice efficiency – clinical staff focused on providing face-to-face services
  • Improves after-hour provider utilization – calls to providers require their expertise and level of care
  • Improves appropriate utilization of services – physician same day/next day appointments, urgent care center and emergency room utilization
  • Facilitates care delivery and coordination through collaboration and exchange of information
  • Improves patient satisfaction – patient needs are met in the moment, no wait for callback or extended emergency department wait times


Nurse Triage Comes in Many Shapes and Sizes

When adding Nurse Triage to a centralized patient access center this service line can accommodate more than just symptom based call management. The clinical expertise of a TNP nurse allows for coverage of calls for a variety of reasons: pre-screening for tests and procedures, post-operative/procedure follow-up calls, new medication or treatment compliance calls and calls for complex or chronic case management, to name a few.  Nurse Triage can be provided during business hours, 24-hours a day 7 days a week, or somewhere in the middle.  Nurse Triage services can be “built” or “bought,” brick and mortar based or deployed remotely, managed 100% within your organization or outsourced to regional or national call centers.  Larger medical groups and health systems are likely to use more than one of these approaches to meet the needs of their patient population and providers.

Does Your Centralized Patient Access Center Set The Bar?

Centralized patient access centers that include Nurse Triage allow medical group and hospital based staff to focus on the face-to-face patient interactions. Investing in a service line that ensures patient care needs are being met at the appropriate level of care by the appropriately licensed professional  improve operational efficiencies, decrease risk to the patient and the organization, increase patient satisfaction, and improve patient outcomes.  Does your centralized patient access center provide appropriate and safe clinical advice, prevent unnecessary readmissions, empower patients in self-care, ensure appropriate ED utilization, and initiate referrals to care providers and services within your organization?

Lisa Monteleone

Lisa Monteleone

Enhancing Team and Leadership Performance Through LEAN Principles


I recently finished an assignment with a client whom was fully immersed in developing a LEAN culture. The experience reminded me, how the use of LEAN principles can enhance learning, promote participation and create more value.   The spirit of LEAN emphasizes participation at all levels and works because solutions are generated from staff or “bottom up” rather than from management in a “top down.”  The following are LEAN tools which can be applied to your setting:

Huddles-Huddles are a great medium to obtain updates from the team, inform staff of changes or obtain suggestions. Huddles can utilize discussion prompts and address a wide variety of areas.  Prompts can tie into the departmental metrics or probe further discovery of problems or assess the status of solutions.

Problem Solving– Root cause analysis is an integral step in a LEAN culture. The process begins with identification of the problem or a “Point of Recognition.” During the problem solving phase, it is important to avoid adopting a solution prematurely.  One must observe the problem and ask probing questions.  This is referred to as “Going to the Gemba.”  Once one understands “why” the problem is occurring, the process can move to applying a containment measure, testing a solution and checking the impact of the applied solution.  Problem solving activities may include data collection, creating paredo charts, fishbone diagrams or the ranking of ideas.

Value Stream Mapping– This step involves the creation of workflows. Workflows should include the use of standardized symbols to illustrate the process from the start to the end. The first one should illustrate the process or the work as it exists before any intervention.  This workflow is referred to as the “current state.”  Include “decision points” which may result in different outcomes.  Once this is clearly mapped out, the team can envision the “future state” or what it would look like with all of the non-value added steps removed and/or the process working efficiently.  The future state can reflect optimization; with changes made to people, process and technology.

Suggestions– Small suggestions can have big results! These can be simple to implement or complex and involve other people/departments or a formal approval process. Encouraging staff members to participate can bring excitement, innovation and can help to transform the work.  Suggestions may fall into several phases- Suggestions Identified, Planning to Do, Doing, and Implemented.  These can be aligned with the traditional Plan-Do-Check-Act Cycle.

SMART GOALS– The old adage, “If you can’t measure it, you can’t manage it” can hold true. Focusing the team on a goal and measuring progress can serve as a motivational tool.  LEAN is built on the use of SMART objectives.  Or Specific (exactly what is to be accomplished), Measureable (concrete criterion, agreed upon (by all stakeholders), Realistic- must be achievable, but better yet; a reach and Time Based (inclusive of a date or timeframe).  These goals are tracked and reviewed at huddles.

Tom Carlyle said “The person without a purpose is like a ship without a rudder.” The use of LEAN principles can offer an environment of learning, participation and team spirit. Consider adding one or more of these concepts to your management tool box.


Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

How to Align Physician Compensation with Value Based Care

From The Consultant’s Corner 5/5/16

How to Align Physician Compensation with Value-Based Care

The move from volume-based to value-based reimbursement models is undeniable. Care quality, clinical outcomes, patient satisfaction, and cost containment all will play increasingly larger roles in reimbursement over the next few years. However, the pace at which this change is occurring varies significantly from payer to payer. Not all payers are moving simultaneously.

CMS has taken the lead with initiatives such as the Physician Quality Reporting System, the Value-based Payment Modifier, and the upcoming Merit-based Incentive Payment System (MIPS). While some commercial payers are following CMS closely, others have committed themselves to evolving their own value-based programs.

In the midst of this flux, practices face the difficult task of retaining some focus on volume to remain financially viable while the industry transitions. What this means from a practical perspective is that practices can no longer use past compensation plans as a model for the future. In fact, they can’t expect to nail down a physician compensation plan today that will last for even the next three years; physician compensation models must progress with the industry.

Flexibility is Key

Compensation plans developed today need to allow for flexibility, so they can accommodate current productivity requirements while supporting a changing culture and incentivizing the behaviors necessary for success over the long term. One way to achieve flexibility involves the periodic evaluation of payer progress toward value-based reimbursement.

The degree to which a practice accelerates its value-based physician payment model should mirror the practice’s payer mix. Over time, the percentage of overall compensation tied to value-based incentives should increase to align with the percentage of overall reimbursement tied to value-based programs.

The task now is to prepare for — or align with — those new reimbursement incentives. Practices must start turning away from their historic focus on independence and production, and toward a new focus on collaboration, communication, and overall outcomes and cost. By setting the right foundation, practices can ensure that their provider compensation packages accurately reflect their emerging quality, outcomes, cost, and patient satisfaction goals. It’s a significant opportunity to create compensation models that support the dramatic culture shift necessary to achieve value-based care.

Set a Value-Based Foundation

Practice and health system governance frameworks range widely, and include any number of different employment or contract agreements. While the governance model will affect how a practice implements its value-based physician compensation plan — for example, its physician engagement, design, timeline, and communication strategies — it shouldn’t affect the compensation plan’s basic structure. No matter the governance model, all value-based physician compensation plans must incentivize care quality, patient outcomes, and the patient experience. The reason is simple: These factors lie at the center of value-based care delivery. Primary care providers are also part of the nucleus.

Achieving value-based care requires someone — predominately primary care providers — to coordinate care among patients, internal staff, hospitalists, and specialists. That takes time, which fee-for-service models have seldom reimbursed. In comparison, value-based financial incentives should encourage providers to spend time on those care coordination activities and preventive measures that result in favorable patient outcomes. Typically, this kind of compensation plan is structured as base salary (often determined by years of experience) plus incentives for factors such as:

  • Care quality —Practices can use HEDIS, PQRS, Meaningful Use, and other existing quality metrics to measure and incentivize physician quality. Care coordination is another essential component of quality.
  • Patient access — Ensuring patients are seen in a timely manner helps improve outcomes and reduce costs. Strong access capabilities may also play a role not only in lowering cost, but in satisfying patients.
  • Patient satisfaction — Patient communication, education, and engagement activities can increase satisfaction, as well as improve care plan compliance. (Plus, better compliance could result in improved outcomes and decreased costs.) Practices can use existing satisfaction surveys to measure and incentivize physicians for their patient engagement efforts.
  • Corporate citizenship — Practices can further incentivize physicians to follow evidence-based clinical protocols.
  • Productivity — Productivity will not entirely disappear as an element of compensation plans, but should take a different shape. For example, practices should ensure that physician panel sizes are appropriate to their care coordination and management responsibilities.

Smooth the Transition

Traditionally, most value-based factors have been difficult to manage and control. However, the adoption of EHRs and CMS quality programs such as PQRS and MU have established a means for data capture, decision support, and reporting. Consequently, practices now have a good foundation on which to build physician compensation plans that align with the core tenets of value-based care. Still, it won’t happen overnight. Over the next few years, those practices with the flexibility to evolve alongside their payers are most likely to experience the smoothest — and most rewarding — transitions.


Brad Boyd is president of Culbert Healthcare Solutions.

Empowering Patients-

One of the many advantages of increasing the use of your patient portal is to empower your patients. When patients feel a part of their care and feel connected to their health care provider they are more likely to be compliant in their treatment plans.

Organizations have implemented a patient portal to serve the purpose of meeting the meaningful use requirement, without implementing all functionality due to time and resource constraints. By doing so there is real value left unrealized.

Director Of Consulting Services

Director Of Consulting Services

Value Missed

There are several areas in which the value of a patient portal could be missed:


  • Increased patient ownership of their healthcare, allowing them the ability to manage their care and data, as well as validate chart information
  • Functionality to expand patient access (online appointment scheduling) and to improve self-pay collections
  • Ability to send communication between patient and provider
  • Publish lab and radiology results
  • Online Rx refill requests improves patient satisfaction and internal resource utilization

Case Study: Real & Soft ROI

  • When we empower our patients with information and access to their health information everyone wins!
  • An additional benefit from this project was an increase in communication between the patient and provider through standard portal functionality. This functionality is now being expanded to enable eVisits and Nurse Triage.
  • Culbert completed a project in June 2015 where a billing interface was developed allowing 28,700 portal patients to post credit card payments to open invoices in a real time manner via the patient portal. Within the first month of go-live, $81,000 payments had been posted via the portal.

Physician Quality Reporting (PQRS)

Jill Berger-Fiffy, MHA, FACMPE, Senior Consultant, Management Consulting Team

Physician Quality Reporting (PQRS)

PQRS was envisioned to be a driver to improve the quality of care provided to Medicare patients and was initially an “incentive program” focused around achieving evidence based goals.  With the “incentive” or pay-for-reporting stage now complete, medical groups and individual providers (defined by CMS as “Eligible Professionals) who have not met the reporting criteria in 2015 are faced with a -2% Medicare reimbursement “penalty”  effective January 1, 2017. Medical groups or Eligible Professionals who reported in 2013 or 2014 and received an incentive payment avoided any penalties in 2015 (-1.5%) or 2016 (-2%).

If your medical group or practice is now in the PQRS “penalty box” now time to prepare 2016 reporting. To achieve compliance, a threshold of at least 50% of the eligible instances (referred to as the numerator) of all Medicare patients (referred to as the denominator) must meet the criteria. There are four National Quality Strategy (NQS) domains which are categorized as Effective Clinical Care, Patient Safety, Communication and Care Coordination, and Community Population Health. Compliance must include at least nine measures; inclusive of one cross cutting measure for providers who have face to face encounters with patients.

What Can Practices Do to Prepare?


  • Determine the participants. Review your types of providers, roles and responsibilities. Confirm which EPs are eligible to participate and are billable providers such as primary care physicians, specialists, advanced practice providers, and some allied health providers.
  • Verify the workflows in the practice. Compare the care provided in the practice to the list of 2016 measures and determine which measures overlap with the current workflow and identify other measures which could easily be integrated.
  • Select the measures. Practices may consider reporting up to twelve measures to ensure compliance with the minimum of nine measures. Choose the measures most relevant to the specialty, the patients and the providers.
  • Initiate a discussion. Speak with medical and administrative leadership of the practice to offer recommendations on the suggested approach to comply with the program.
  • Prepare the team. Develop an implementation and training plan for the practice. Determine if the practice will build automated prompts in your electronic medical record or use questionnaires. Confirm which providers will be responsible for inputting this important data. Licensed or registered staff; such as Nurses or Medical Assistants can input some of the information saving time for EPs to attend to tasks at the top of their license.
  • Training. Data integrity is integral to meeting the requirements. Consider the team and determine what methods of training will be most effective. Choose from a variety of training methods such as hands on learning, train the trainer, posters, written reference materials, checklists and screen shots which describe the steps in detail.
  • Documentation. It is understandable that some Medicare patients will not meet the expected criteria. Prepare the team to document exceptions such as those which are medical, patient or system related. Proper documentation will exclude these patients from the denominator and will not affect your overall score. Consider on the spot observation, data extraction and shadowing as helpful methods to train and monitor registered medical assistants or nurses; as well as other billable providers.
  • Differentiate the reporting method. Select which of the three methods (i.e., Group Practice Reporting Option [GPRO], Claims Based, or through Certified Technology) is best suited for the practice. Be aware of the required timelines. For example, between now and June 30th, practices should self-nominate for the GPRO option. Practices will need to identify the reporting method (Registry, EHR Interface or certified survey vendor).

Benefits and Challenges

Practices are incentivized to participate in PQRS now that the penalty stage has begun. This penalty will continue in perpetuity with funds being shifted to practices complying with the program.  This reduction may be additive to other potential reductions in payments for the Meaningful Use (MU) and Value Based Modifier (VBM) programs.  The coupling of these programs can add substantial reimbursement penalties to practices  – potentially a 9% reduction in Medicare fee-for-service payments.

It is essential to understand the reporting capabilities of your Electronic Health Record. PQRS reporting capability provides an automated way to assess the current status and if the practice is meeting/exceeding the measures.  If you do not have a certified EHR product, a web based registry may be an option. These programs are widely available and easy to use.  These involve an upload of the data to the reporting registry.

Whether or not these measures do in fact improve care, remains to be seen. Some worry that the PQRS initiative is onerous and detracts from the work at hand which is diagnosing and treating health conditions.  Compliance with the measures may require additional data entry, staff, and may have little or no relevance to outcomes.   Providers may need to focus on other metrics due state and local health plan requirements. Research published in Health Affairs in March 2016 found that Medical Group Management Association (MGMA) practices spent 785 hours per physician and more than $15.4 billion on quality measure reporting programs. The study found that majority of time spent on quality reporting consists of “entering information into the medical record ONLY for the purpose of reporting for quality measures from external entities,” and nearly three-quarters of practices stated that their group was being evaluated on quality measures that are not clinically relevant.[1]

National outcry from the MGMA and various medical societies has been strong. As a result, there is an effort underway to combine Meaningful Use (MU) and PQRS in 2017.  These will evolve into the Merit Based Incentive System (MIPS).  The standards; not yet available, proclaim to measure quality, resource use, clinical practice improvement and meaningful use of Electronic Medical Record Technology.

In the interim, much preparation and planning are needed to avert payment reductions. Begin planning today. Time is of the essence!



Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant


resource found here

The Value and Challenge of Patient Generated Health Data (PGHD)

Way back in 2009 I found myself at the Chicago HIMSS conference watching the Google presentation of their PHR, Google Health. As a fan of Google products in general I was interested in what the presenter had to say.  His message was that we, as consumers, could be responsible for our own health data and that Google Health was a repository for that data.

[Their] “goal was to create a service that would give people access to their personal health and wellness information. [They] wanted to translate their successful consumer-centered approach from other domains to healthcare and have a real impact on the day-to-day health experiences of millions of our users.” -Google Blog June 24, 2011

What really got me curious about their PHR was, just weeks prior, I was at an Endocrinology specialty go-live, where at one point I was asked into an office to assist a provider. The provider presented a thumb drive and asked “what do I do with this?” The thumb drive being the data that the patient had collected from his glucometer. At the time there really weren’t any tools were we could capture that data directly into the EHR without manually entering those results. This was frustrating for patients and providers alike. Patients having collected that data and providers who would like to see that data trended in a flowsheet to make decisions on patient care.

I was curious at the time if a PHR could be the solution. I wondered if a patient would take the time to enter in their data and if so would that data be available to their providers. A few short years later Google announced the retirement of Google Health stating:

“We’ve observed that Google Health is not having the broad impact that we hoped it would. There has been adoption among certain groups of users like tech-savvy patients and their caregivers, and more recently fitness and wellness enthusiasts. But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people.”  -Google Blog June 24, 2011

But now there is a shift. Patients and providers alike are looking at Patient Generated Health Data [PGHD] in a new light. What we are seeing is that patients are now at the center of their care. I spoke to a friend and colleague working on this topic, and she put it to me this way:

“If I am nervous at the doctor’s office and my blood pressure is elevated, well then it is hard to trend that information with only one or two points of data during the visit and the provider may prescribe treatment for hypertension. However, if I am keeping a record of my BP and know that I have a history of low blood pressure then, I may choose not to take the prescribed medication.”

I myself have been wearing a Fitbit to track my steps and heart rate for a better understanding of my own wellbeing. Doing this inspired me to start capturing my food intake. I’ve got an app where I log every meal. The amount of data I can collect about myself is greater than the data my doctor will ever collect on me. Even if you’re going to your doctor every month, you still have the ability to gather significantly more information yourself at home.

Interoperability still remains an issue. Increasingly we have apps and devices to capture our data and, there’s a lot of us that would like to have all my data sent to one repository. I may want to change my apps or I may update my devices in time and if all my data’s in one place, it’s not that big of a deal to change my apps.

“There are a lot of people out there today with activity monitors and consumer medical devices, but that data is not currently being used in the clinical context,” “Why is that? That’s because there is no structured reporting of that data. Physicians don’t want to take a lot of data in without using it properly.”

PGHD on its own can be a valuable source of information, but ideally it should be combined with EMR data. When this is done providers have a more complete, of the overall picture of the patient.  We are still struggling on how to capture and use of PGHD. Some of the struggle, may be due to a lack of standardized data and best practices for implementing PGHD into the clinical workflow. Ideally we need a system in place where patients can monitor their vitals and transmit that data through their phone and securely transmit that data to their electronic medical record. That kind of mechanism is very valuable.