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

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





Healthcare On-Demand: An Experience with Epic MyChart

Today’s consumers live in an “on-demand” world. A benefit coming from this societal shift to self-service is unique in the context of healthcare, where increased patient engagement can correlate with improved patient satisfaction. One way in which we can be more engaged in our healthcare is by enjoying the benefits of mobile applications for smartphones – staying connected and able to act wherever we go.

Many companies are racing to provide the on-demand convenience of scheduling, results review, telemedicine, but for me, Epic has already provided a product that goes above and beyond meeting that need. As a result, my healthcare experience has changed dramatically since Epic MyChart was implemented in my community. Not only does MyChart make communication with my physician readily accessible from my smartphone, it also provides a portal to quickly access my recent medical records and lab results. Additionally, the app is well designed to be user friendly, a bonus when the user base varies in age from millennials to baby boomers.

I recently needed to schedule an urgent doctor’s appointment, something which ordinarily might have required a phone call and lengthy wait time until I could be seen. However, now that my physician’s office offers MyChart, I was able to simply log in via my smartphone and select the next available appointment that was compatible with my schedule. Additionally, when I logged in, I received a notification letting me know that I was soon due for an annual physical, which I was able to conveniently schedule via the app. Without this reminder, I probably wouldn’t have scheduled the physical until far past its due date, if at all. A few days later, when my illness was not responding to medication, it was a relief to be able to simply send a MyChart message to my physician letting her know of some new symptoms, rather than having to call and ask front desk staff to relay the communication. My physician quickly received my message and was able to prescribe the correct antibiotics, helping my symptoms to improve within a few hours, rather than over the course of several days.

This ease of use and increased communication promoted the feeling that my healthcare experience was personalized and attentive to my specific needs as a patient, it was truly “on-demand” healthcare access. It left me eager to engage with the healthcare community in order to promote health and minimize the delay between onset of symptoms and presentation at the clinic. Knowing I have the opportunity to review my records, carry them with me, and interact at a higher level with my healthcare team is incredibly reassuring and reduces the stress of care. I overwhelmingly enjoyed the experience of being an empowered consumer of healthcare, a feeling I am passionate about sharing with my community and my clients.

Non-technical Considerations Before Beginning an Epic Connect Project

An organization’s decision to extend their instance of Epic to outside practices and/or facilities, known as Connect, offers many advantages to patients, providers and organizations. Used appropriately, the functionalities extended enhance the providers’ understanding of a patient’s clinical results, history and charts. In turn, this enhances the patient experience with an overall better, more comprehensive treatment and understanding of that patient’s particular problems.  A goal of ‘one patient, one medical record’ is more attainable and sustainable and should lead to better outcomes.  Additionally, communication and relationships between organizations and their medical community providers is improved.  It is not difficult to understand why an organization may decide to offer a Connect product to their community.

On the surface, the implementation planning sounds easy. After all, the organization offering their EHR has already done the ‘heavy lifting’ of building workflows and determining best practices.  Oftentimes, the overall mindset in these projects initially is to treat an implementation the same way the project team would treat an internal implementation (e.g., a new department or service line).

As with any implementation, there will always be lessons learned. There are some key areas of potential risk to your ‘customers’ overall satisfaction with a Connect implementation. These items can be easily addressed prior to contracting and can ultimately alleviate or bypass future pain points for both your customers and your project team.  Although not comprehensive, below are some recurring challenges that can be experienced in Connect projects.  Organizations should ensure they have a clearly defined and communicated strategy around them.


  • Everyone is special – Determine your customization thresholds. Just as your organization is different than another in your city or region, your Connect partner is likely different from you. When extending your instance of the EHR, you need to clearly and frequently communicate to your recipients what, if any, customization you will support in their EHR with you. Customization in build is not just limited to clinical workflows but can include interfaces, third party vendor relationships, user security templates, billing/claims workflows and clearinghouses, scheduling templates and reports/reporting, among other items. Any items or areas in which your organization is willing to step away from in an established build and workflow, needs to be clearly defined for all so your Connect partner is aware of what is or isn’t possible and your project team has set parameters. Keep in mind that the more customization of the build you allow (vs. standardization), the more complex and costly your maintenance of that build will be long-term. 
  • No one likes to be ignored – Determine what level of participation your Connect partners will have in your governance and/or clinical content decisions. The quickest way to antagonize your Connect partners is to make them feel ignored. Clinicians, particularly specialty clinicians, will have preferences and suggestions to the clinical content and workflows you have extended to them. Your organization should strongly consider inviting representation of these partners into your governance and/or clinical content infrastructures. Such a strategy not only leverages additional resources to enable better patient care, it also serves to start shifting your organization’s internal culture to include consideration of outside providers and facilities in their deliberations.
  • You may need a culture shift. When you sign on your first Connect partner, your organization is no longer just “your” organization. From that moment forward, everyone from your leadership down needs to be aware that changes to workflows and content in Epic build could now impact your partners, and therefore those entities need to be included in any consideration of such changes. This is particularly important for the Epic team, as they are the ones responsible for your build, as well as any system upgrades and updates. You also may need to incorporate your Connect partners into any communication and/or training protocols you currently use around changes and upgrades in your system.
  • What are your long-term strategies around your Connect partners? How will problems be reported and resolved with your partners? We have seen a variety of solutions to these questions with our clients. Many organizations use their normal help desk operating procedures (call in a ticket, ticket is reviewed & prioritized using organization standards, ticket is assigned and worked by Epic team), but some organizations utilize a dedicated team and phone number for their Connect partners’ requests and problems. Another long-term consideration is new employee on-boarding at your Connect partners since your organization remains subject to your Epic agreement, which includes training requirements prior to access. You should review who/how that training is to be provided and how a partner communicates the need for training. As a corollary, how is your organization to be told of employee terminations for security inactivation?
  • What is the exit strategy? Unfortunately, Connect partnerships do not always work out. This may be due to practice closure or provider dissatisfaction. To protect both your organization and any of your potential Connect partners, it is strongly recommended to ensure you have an off-boarding protocol clearly laid out and communicated prior to contracting. This protocol should include the steps of how a partner initiates off-boarding activities, what the reasonable expectation of deliverables after off-boarding will be (i.e., how does the partner access the patient medical record once they are off-boarded?) and the projected timeline of an off-boarding.

Each of these items is underscored by the underlying theme of communication.  Wherever you land on decision points in your Connect implementations means little if these decisions are not shared clearly and frequently with your partners, your organization and your project team.

Connect projects are exciting opportunities for any organization to better care for patients, both in-house and in the community. Just be sure to look at the entire picture before beginning these partnerships so you can ensure your partners will be  successful using your EHR.


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.



Improving Population Health using Epic’s Healthy Planet

Population Health Management isn’t a concept that is new to the healthcare industry however, efficiently managing high-cost and high-risk patients is becoming a necessity with payment models focusing on reducing cost and improving outcomes. With this, many organizations are instituting an increased focus towards population health management, participating as Accountable Care Organizations (ACOs) in order to more effectively identify, understand, engage, and track patient populations. An ACO delivering high-quality and low cost care will share in the savings that is achieved for the Medicare program.

Many EHR vendors, including Epic, are looking to provide tools to assist organizations in moving toward better and more coordinated care for individuals, greater health and disease prevention, and less healthcare expenditure.  Healthy Planet is Epic’s solution for helping organizations achieve these goals.  It allows clinicians to identify and address gaps in care with patient populations using tools within Epic – EpicCare Ambulatory, MyChart and Cogito – to take action on population health analytics, integrate care management and coordination, and engage the patient in their care.

Many of our clients are part of an Accountable Care Organization (ACO) establishing integrated care teams made up of physicians, nurses and social workers that utilize the tools provided by Healthy Planet such as navigators, dashboards and bulk ordering and communication functions as well as MyChart to help manage the needs of their high-risk patients. Healthy Planet’s ACO functionality has been used to define ACO patient populations, complete patient questionnaires for risk stratification, track patient outreach, provide care management which includes documentation of medication compliance, care plans and goals, as well as interaction through MyChart. Organizations have also begun to create team Longitudinal Plans of Care allowing other clinicians throughout their organization as well as other Epic organizations to see their care efforts in one concise place.

As a result, organizations have already begun to see the benefits of their Population Health Management efforts meeting the goals of:

  • Accurately and efficiently capture data for preventive care and disease management services
  • Monitor the performance of providers on closing care gaps for these services
  • Implement chronic care management workflows for care managers
  • Apply risk stratification models to your patient populations
  • Increase efficiency through bulk ordering and communication
  • Engage patients through MyChart
  • Improve transitions of care and patient engagement with a longitudinal plan of care


Through their care management teams, they have been able to better understand patient needs in areas ranging from transportation to doctor’s appointments and picking up medications to education regarding their clinical care. Reporting shows decreases in Emergency Room visits as a specific example and clients continue to gather data that demonstrates how critical care management is to overall population health.   The successful implementation of tools such as Healthy Planet provide both short term and long term benefits that result in a more educated ACO and an overall improvement in the healthcare experience and general well-being of individual patients.

Epic Clinical Documentation Improvement-Webinar -Friday February 27th 12:30 est

Culbert Healthcare Solutions invites you to join Jaffer Traish, Epic Practice Director, for a FREE webinar on Friday, February 27th at 12:30 pm Eastern for an insightful look into leveraging CDI initiatives as part of broader clinical and financial improvement programs.


This webinar will discuss and demonstrate the following:

•             The scope and prioritization of CDI initiatives

•             Key approaches and methods for success

•             Important observations and lessons learned


Register today:



Director Epic Practice

Director Epic Practice


Data Sharing in 2015: Still a Hot Potato-

At a healthcare panel last week in Austin, TX, attendees heard from the former E-MDs CEO, an ACO CEO and a legislative HIT coordinator here in Texas.  While the 110M medicaid fraud FBI investigation has stolen the spotlight in town, most of the dialogue circled around data sharing, privacy and patient engagement.

All of the panelists held, to some degree, two core opinions: 1) Patients don’t own the data in our current healthcare model and 2) Organizations continue to lack incentives to drive data sharing.

Let’s examine the first – for many of you who have tried to collect your medical history, there is no ‘download’ button as we have with our financial history.  We’ve got to make phone calls, sometimes faxes, and often multiple requests to the same organization but to different departments.  We’ve no idea how the material will return to us – sometimes by CD, paper copies, or if lucky, an emailed PDF.  Don’t forget, there is usually a charge associated with the data collection and disbursement, in addition to signed waivers or paperwork.

But isn’t this the patient’s information? Do we own it? Should we have exclusive access and a right to determine to whom and where it is shared?  This debate is far from mature.   We can take a lesson from social media – our ‘likes’, personal profiles, behavior, purchasing decisions and much more are all on the open market – for a nice price.  We sign those permissions away in crafted fine print for fun tools of daily life.

The stakes may be higher with health data interoperability.  Lives can be saved if a medication history is readily available thousands of miles away from a patient’s home in a medical emergency.  The pharma and insurance industries also have much to gain – by learning your outcomes, behavior and medical history, their business model will evolve, too (pharmacogenetics and personalized insurance plans…) – to become more efficient, though also more profitable.

This leads us to the second – if data sharing is ultimately good for the patient and industry, why are we still waiting for a responsible, comprehensive solution?  The panelists called out several rationales:

  1. Open data means stiffer competition.  If the neighbor can analyze our weaknesses, we could be incentivized to improve, but we can also fail.  CMS demonstrations are forcing transparency, though not without exemptions.
  2. Information exchange requires billions of ‘information transactions’ – this is costly.  Should providers be paying? Organizations? The patient?  Everyone could benefit, including the payers – but no single entity wants to bare the cost today.  We’re seeing more Care Collaboration organizations being created to pool resources.
  3. Vendors want to help their own, first.  Some vendors have aligned to create a corporate entity to pay for sharing, while other Vendors are large enough to build a network among their own.

Carl Dvorak (President of Epic), in 2014 government testimony shared the following impediments to faster adoption of interoperability:

  • point of care authorizations
  • Phone book containing all exchange ready participants
  • Single trust authority
  • Governance where patient data is ONLY used for treatment
  • Stronger ONC support for eHealth Exchange which supports unplanned transitions of care

CMS required a 10% transition of care exchange rate to comply with MU Stage 2.  This may become 50% for care transitions to include a summary or care record with 10% electronically in Stage 3.  Even the ONC has a 10 year plan, with the patient at the center – able to orchestrate where and when personal information is shared.

The panelists agreed, it is unlikely to see significant legislation driving any renewed independent HIE effort.  Instead, the interim may find continued pressure on organizations to adopt more forms of sharing at their own expense – too great a risk not to keep the reimbursement coming in.  

Interoperable health information is on the way, though we’ll need to find more competent data experts, a louder community voice and market incentives that share the benefits and costs across all.


Director Epic Practice

Director Epic Practice

Epic 2014 Revenue Cycle Updates

In Epic’s 2012 version and even more in the 2014 version, Epic has focused on improving the Revenue Cycle making processes more efficient to keep the health of the Revenue Cycle intact. Below are a few items that clients are finding beneficial as they have or are in process of upgrading.

Charge Reconciliation Process

New reports released in 2012 and enhanced in 2014 are crucial to help the operational owners efficiently review the revenue stream and ensure issues are identified and resolved quickly. Some examples include:

  • Inpatient department managers can now be sure that all charges balance, similar to functionality outpatient department managers have used for quite a while. Clients are reporting the benefits of this being available natively in Epic versus a custom report generated for manager’s review. The report is the Enterprise Encounter Charge Reconciliation report and gives more detail than is available in other reports that customers have been using.
  • A new Reporting Workbench Report for Inpatient Note Charge Reconciliation is another example. This report shows physician notes that are missing corresponding charges. This assists in identification of specific users, departments or overarching trends that should be addressed. Because this report is run via Reporting Workbench, it can be available from a user’s Radar Dashboard for quick access.
  • A new Coding Quality Report identifies charges that can be removed from manual review by coders, allowing more time for the most important charge review.


Dashboards have a continued focus across all applications in the 2014 version. As more clients use Epic’s reporting tools, they are constantly pushing for increased functionality and efficiency, especially in this area. Dashboards make monitoring the revenue cycle more efficient and visual, giving users the ability to drill down right to the details.

  • Self-Pay becomes a focus across both Professional and Hospital Billing this release with new components and a dashboard for use in each application. The self-pay enhancements allow clients to manage the metrics with drilldown support to obtain additional detail.
  • Additional sorting capabilities for dashboards have proven helpful for many clients within three of the end of day dashboards HB staff use. The increased flexibility and options for grouping has been beneficial for clients with non-traditional grouping of their revenue cycle staff.
  • The ability for Office Managers to focus staff in the most needed areas has also become more efficient in 2014. The Pending AR component gives insight into all areas of the Revenue Cycle visually, indicating areas that are higher than expected.

Billing and Insurance

  • Many organizations are looking to MyChart for many clinical and regulatory reasons (Meaningful Use requirements, Risk Management, etc.), however, several organizations are also implementing revenue cycle features if those have not been part of their roadmap previously. So clients are simply continuing to implement enhancements available with each version. Many organizations have found success with integration of patient statements, paperless payment options as well as transparency with self-pay amounts and pricing estimates included via MyChart. As patients continue to be technologically savvy, they are requiring their healthcare providers to offer the same type of services other industries offer via the Internet. What we have seen – organizations are responding!

While the items above are highlights for the Revenue Cycle in 2014, there are several other enhancements that clients are taking advantage of based on organizational initiatives for 2014 and 2015.

Epic ROI

Culbert was engaged by a large academic medical center to assess the current state of their Epic system in relation to pending ICD-10 requirements and peripherally perform an assessment centered around base functionality. Culbert evaluated clinical documentation and ordering tools such as SmartTexts, SmartSets and Preference Lists in addition to content such as the existence of specialty navigators, diagnosis groupers and decision support. By comparing and contrasting overall findings with utilization statistics and documentation deficiencies, Culbert was able to provide a clear picture and plan to prioritize and address gaps in build beneficial to both ICD-10 compliance, physician efficiency, and enhanced user acceptance.  The action on this plan involved an individual assessment of departments to educate physician leadership on the scope and reason for the project, review Culbert findings, and identify necessary build to both enhance ICD-10 compliance and physician efficiency. In the early stages of this project, two immediate beneficial findings were found and are described below:


  1. During one specialty assessment and build process,  significant content beneficial to both ICD-10 and physician efficiency was identified and delivered. With the creation of multiple highly relevant and intuitive SmartTools,  physician leadership estimated that individual providers would be able to add an additional 1-2 patients per day. This was a result of reducing the time taken to identify orders and complete documentation. Utilizing a conservative estimate increasing 1 patient per day over 40 weeks and frequency of visits leading to surgery, the specialty calculated that the department would realize a ROI of approximately $1.3mm spread over their 8 providers in the first year alone. Extrapolating to 5 and 10 year outlooks shows an ROI of $6.4mm and $12.8mm respectively.


  1. Another benefit was taken as a very quick win. In educating a physician on Epic’s potential and illustrating the flexibility of the system, a Culbert analyst was able to demonstrate UserPhrases to a physician that frequently authored notes in a free-text manner due to a lack of documentation tools that met her approval. With the creation of a custom UserPhrase integrating existing SmartLists with her most frequently used verbiage, the provider was able to trim nearly 2.5 minutes off per visit. With this provider seeing an average of 12 patients per day, that translated into an average of 30 minutes saved per day or one additional patient. This also provided sharable content for other physicians within the specialty to review, personalize and use.