EHR

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.

 

EHR Capture of Outpatient Evaluation and Management Services

Electronic health records (EHRs) have now been implemented in the vast majority of physician practices in the United States. As a certified coder, auditor and physician educator I’ve been actively involved in this process for years.  Healthcare is without question evolutionary.  But the implementation of EHRs is one of healthcare’s greatest revolutions affecting both the clinical and business aspects of medicine.  As an example, let’s take a look at how EHR implementation has affected outpatient Evaluation and Management (E/M) services.

E/M documentation, coding, charge capture, audit and the related follow up education have all been deeply affected by the implementation of EHRs. Healthcare continues to shift away from inpatient to outpatient services and payment methodology continues to shift from fee-for-service to risk and quality of care based reimbursement.  Additionally, physician practices are being incorporated into facilities.  Given these circumstances it is important to appreciate history as we consider the future so that we are poised to address change effectively.

Not so long ago a physician would see a patient, document the encounter by hand-written note or dictation and enter procedure and diagnosis codes onto a hard-copy “superbill”. A qualified (hopefully!) medical coder reviewed documentation and physician coding for each encounter.  Ideally, coders and physicians collaborated to address any documentation and physician coding discrepancies and finally a compliant claim would be generated.

Today most physicians document E/M encounters and assign codes using EHRs. Most EHRs include a billing interface that generates claims automatically based on coding assigned by the physician. At best, a qualified coder spot checks for documentation and code assignment discrepancy, but the expectation is that physicians document comprehensively and assign codes accurately.  Of course, a well-run practice also has an audit schedule in place, with effective follow-up education, as part of its compliance plan.  Ideally coders and physicians work collaboratively toward compliance and revenue maximization but even the most robust audit schedule reviews only of fraction of encounters for which claims are generated.  Clearly, much is expected of physicians.  There is no longer a coder acting as a “filter” through which documentation and coding passed prior to claim submission.  For this reason it is imperative that physicians have a deep understanding of documentation/coding guidelines and the technological knowledge that allows them to use the EHR most effectively.

Most EHRs have tools that prompt physicians to capture E/M key components and their elements. However, E/M compliance and revenue maximization still requires that physicians:

  • Know the E/M guidelines
  • Understand that medical necessity must drive the level of E/M service
  • Know how to appropriately score E/M services and assign procedure codes
  • Know how to use the EHR effectively to document only accurate, applicable and meaningful content

Of course all but the last bullet were important considerations prior EHR implementation.

Another issue emerging related to outpatient E/M services is diagnosis coding. While accuracy is important, historically diagnosis code assignment for E/M services has not been a reimbursement consideration.  However as physician payment models shift from fee-for-service to risk and quality of care reimbursement, it is essential that documentation and coding include more robust information related to illness severity and comorbid conditions.  Of course the adoption of ICD-10 allows for capture of greater diagnostic detail but along with this detail come more complex code assignment guidelines.

Since the implementation of the Diagnosis Related Group (DRG) payment methodology for inpatient services in the 1980s, clinical documentation improvement (CDI) efforts have been established to optimize capture of illness severity and comorbidities.  One of the advantages to facilities incorporating physician practices is that these institutions have clinical documentation optimization experience.  Still, outpatient healthcare has its own unique set of guidelines that must be learned by CDI specialists and then taught to physicians.  It is also important to note that, while physicians are expected acquire documentation skills that optimize inpatient code assignment, they are not required to actually assign the codes.  As the importance of diagnosis code assignment increases for outpatient services it will be interesting to see where responsibility for code assignment falls.

Healthcare is continually evolving. The EHR itself influences some aspects of this evolution while assisting with other aspects of it.  Innovation and flexibility have always been and will remain key to a successful healthcare delivery system.

 

Translating EHR Training Into Improved Revenue Cycle Metrics

Technology continues to drive mankind forward in ways unheard of from when the great millennium occurred in 2000! Who would have thought that we would be tied to our smart phones, performing a myriad of functions that once took precious hours of our time? Now, we do online banking, book air travel, hotels, rental cars, and many other daily tasks regardless of where we are!

These same technological advances have, in so many ways, impacted the healthcare industry too. And, arguably, the largest invention has been the creation of the Electronic Health Record (EHR). So, it stands to reason that most of the healthcare institutions have either implemented, or are in the process of implementing the latest and greatest EHR system for clinicians to record, track and share critical medical record information regarding their patients.

The installation of EHR systems may run into the millions of dollars. Often, they are integrated, or interfaced with Billing Accounts Receivable (BAR) systems to provide the tools needed for submitting claims cleanly, and in a timely fashion, for prompt payment. After all, as the saying goes, it truly is all about the Benjamins; it is about healthcare institutions having the funds necessary to succeed and to carry out their Mission Statements.

So, if State of the Art EHR and Billing systems are in place to optimize patient care and outcomes, and if they are designed to bring in a steady stream of required cash to run the institution, how is it that so many healthcare institutions have less than desirable revenue cycle metrics to show for all of the financial investment in the implementation of an EHR system?

During the many system implementation projects that I have led across the country, the single most neglected component of a complex system implementation is End-User Training. Although institutions will invest millions today to ensure that they have the latest and greatest software available for its end-users, tomorrow (after the system installation) they will attempt to minimize costs with a meager training curriculum. In some cases, training is a minimal consideration at best, offering a series of online tutorials; in other cases, training may be a couple of hour sessions for a given application. Often, trainers are limited in their knowledge of the software, or even worse, have no operational background to marry operational tasks with the new system.

In particular, clinicians who ought to become experts on EHR software, are often given minimal instructions regarding the many bells and whistles of a system that contains many wonderful tools for precise, complex clinical data gathering. By the time clinicians grasp the basics on how the EHR works, they are, easily, overwhelmed by the new system and have little time or patience to understand that part of the patient’s record keeping entails the ordering or charging for services rendered. This is where the rubber hits the road, or in many cases, the tires skid along and never connect to the road!

Recently, I was asked to evaluate the revenue cycle performance for an institution that had implemented a new hospital billing and EHR system. The billing and EHR System were designed to interface seamlessly with an existing providers’ BAR system. Unfortunately, the implementation team did not perform a thorough assessment of existing tasks that included the charge entry process. Under the old charge entry process, providers would manually complete encounter forms, submit them to a coding unit (where validation and manual entry were performed) before going through the remainder of the revenue cycle process. Under the new system, provider orders (charge entry data) were generated from the new EHR application into charge work-queues for designated end-users to review.

The training offered to the clinicians who generated the orders (charges) was inadequate. It did not take into account that providers were used to having support staff (coders/billers) complete the charge entry process. As a result, providers didn’t understand how to:

  1. Open an encounter, enter supporting clinical documentation and close the encounter for the system to continue the path of sending those encounters into work queues for review
  2. Link critical, required documentation to orders
  3. Complete and send encounters without creating duplicate orders.

At the receiving end, the coders and billers were not adequately trained to work their designated charge router queues. The results:

  1. Aged accounts receivable over 90 days reached a whopping 30% of the total AR. Prior to the implementation, it was closer to 20%.
  2. Days in Accounts Receivable were around 40 days. Prior to the implementation, this metric hovered in the low-to-mid 30s range.

The moral of this story is: The Best Implementation fails without a proper assessment of current workflows in order to design an adequate training curriculum.  All stakeholders should be proactive, performing their due diligence, identifying the knowledge base required for a successful implementation, and developing a comprehensive training program to meet end-users and institutional needs.

Today, clinicians are being asked to perform many tasks that once were delegated to support staff. Let’s make sure we give them a fighting chance!

 

 

 

 

Improving Provider Efficiency and Satisfaction through EHR Optimization

The system has been “live” now for many months or even years, millions of dollars have been invested in the system, and the physicians have attended their training on how to use the system. Yet their struggles continue long past the initial learning curve; charts not getting closed/completed for days, physicians working late hours to deal with notes, letters, follow-up results, phone calls and the list goes on. What is the solution to help your providers?

A system optimization plan may be the answer to help solve these issues and probably many more. Optimization should be a proactive venture as it is not “break-fix” or implementation of features not included with the initial system roll-out.  So, just what is optimization?  Basically, it is the act, process or methodology of making something (i.e. design, system or decisions) as fully perfect, functional or effective as possible.

There are many ways to go about the optimization and multiple tools to assist with the process. An organization should identify a few (approximately 3-4) clinics that would act as a good pilot for the project.  Workflow re-evaluation is an extremely important part of this undertaking.  Have your optimization team member focus on each step of the process from patient check in all the way through check out. Look for unnecessary steps being done.  Are there any bottle necks preventing patients from getting into an exam in a timely manner?  If there is information needed from the patient, send it to the patient thru MyChart and have it completed prior to the visit.   Are there any functions being done by the clinician that could be done by the nursing staff?  Is there anything being printed that can be eliminated?  Are those lab requisitions for the in-house lab really necessary?  Work with the providers to find out what part of the system or visit is slowing them down.  Are they having trouble placing orders, finding lab or imaging results or is the slow-down with the note creation, or is it just that never ending in-basket.

Make use of any and all productivity tools that may be available to you, such as Pulse or PEP – Provider Efficiency Profile. Pulse is the personal dashboard to measure how efficiently the clinicians are using the system.  It will also offer links to targeted training materials to help providers improve in particular areas (i.e. orders or note completion).  Also, the organizations project team can make use of the Pulse scores to pinpoint areas where additional build or training may be needed.

The Provider Efficiency Profile (PEP) offers invaluable information regarding provider usage in the system. You will be able to see how an individual provider compares to others in the same department or specialty in respects to number of number of new patients being seen, how much time spent in the In-Basket, time on notes, letters and orders and much more.  It will also show how much time is spent in the system when not actually seeing scheduled patients, so you can really drill down on the amount of time doing work after hours.

On a recent engagement we used all of the examples mentioned above to evaluate key areas that providers maybe struggling with throughout their day. After thorough evaluation of all information gathered  in person with a provider and a deep dive into the Pulse and PEP information we formed multiple deliverables to assist with provider efficiency among them:

  • Creation of education sessions for providers focusing on in-basket, ordering workflows and note creation
  • Development of tools to assist with workflow processes i.e. smart sets, standardized “speed” buttons for LOS, diagnosis
  • Learning home dashboards created for the providers with tips, short-cuts and how to for certain functions, links to standardized documentation (i.e. sports physical forms) as well as general help topics
  • Roll-out of synopsis for focused problems such as diabetes, hypertension, thyroid diseases and others

While the impact of a few of these have yet to be reported or assessed, there has been a great deal of positive provider feedback on the first several training sessions that were held. Almost all attending felt that the material presented will help with their speed in the office and with patient care and satisfaction.  Additional training sessions and expansion of the optimization initiative is currently being under taken.

If an ambulatory optimization project is in the works for your organization, don’t forget a little PEP will go a long way in helping your providers be more efficient with time in the system and ultimately lead to a more satisfied patient.

 

 

Why a Thin Line Separates EHR Optimization, EHR Replacement

Healthcare providers will have their reasons for choosing EHR replacement or EHR optimization, but a thin line may be all that separates them.

Jerrilyn Ivey-Director of Consulting Services -Culbert Healthcare Solutions shares her perspective with EHRIntelligence.com

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