June, 2014:

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.




Executive Equilibrium


Medical Practice Management: Automation

Tips to Enhance Productivity for Non-Clinical Staff

Do your front and back office staff a favor:  Set defaults in TouchWorks PM

In preparation for an EHR implementation, organizations typically customize notes and templates for the clinical staff as this is the normal course of EHR build and development prior to implementation.  The purpose of these customizations is to minimize the number of keystrokes and clicks necessary to complete any given task during the patient visit.  Invariably when we roll out an EHR, we also implement a new practice management (PM) system as well and go through a similar build and development phase prior to actual go live.

During this PM development phase, we build and customize back end master tables so they represent the organization in terms of departmental units, locations, providers, resources, procedures, schedules, diagnoses and claims data.  While these master tables are the backbone of the PM system and we can automate much in this area, there are additional opportunities for automation to eliminate keystrokes for the front and back office staff alike, just as we do for our clinicians in the EHR.

Save keystrokes during the build process

During the initial build of the PM, the Master tables are developed based on the specific organization’s needs.  Much thought must go into building these tables so that any negative downstream effects are understood and hopefully, avoided.  However, when building the Master tables, serious consideration should be given to each opportunity to set as many organizational defaults as possible.  A prime example is the Master table, Practice Options.  Within this one Master table are over 30 global defaults that can be set in the areas of:

  • General Options
  • Registration
  • Scheduling
  • Charge Entry
  • Payment Entry

While Master tables can be used to set many global defaults, there is even more opportunity to automate functions for front and back office staff within each module.  Unlike the global defaults that are set in Master tables, these defaults are user specific.

While automation and customization is critical to increasing usability for providers in the EHR, we cannot stop there.  We must remember to give that same thought and attention to our PM system so that we can increase usability for our non-clinical staff as well.  Talk to and question staff.

Inquire whether they know about these time-saving defaults.  If they do not know about them, show them, and explore additional time savers as a team.  We all understand that as end users and supporter of the PM system, there is much we cannot control.  However, automating and simplifying everyday processes setting a few, simple defaults can produce positive effects in terms of both productivity and staff satisfaction.

Community Connect-The Financial Challenges of Implementation

Organizations and private physician offices undertaking the implementation of Epic’s Community Connect project frequently find the proposition mutually beneficial for all involved. Private physician offices that ordinarily would not have access to Epic find that they now have an affordable, fully functional and integrated EHR that includes Population Management, Quality Measurement and Reporting, Cost Management. Additionally, access to industry standards such as improved medication prescribing and tools for enhanced patient engagement along with the luxury regular updates maintained by the host organization cannot be understated. Often overlooked, but realized after a successful implementation is increase efficiencies now that the practice is working with just one system versus multiple disparate systems to accomplish the same tasks – scheduling, billing and patient charting.

The host organization benefits as it is able to enhance its relationship to providers and institutions in the community by providing an industry leading solution and allowing for full integration across these organizations that want to share patient information and make full use of the Epic population management tools.

Ultimately, the patient wins in that they can now be more engaged in their own care, their information is now shared with their primary physician as well as the specialist, knowing that a test/procedure is coming due (HMA), ability to request an appointment on-line and even have a visit with the physician on-line.

But, as with most things there are challenges with this process.  The greatest challenge that we have seen with a system rollout to a private practice not currently utilizing EpicCare has to do with money.   Approximately 2/3 of non-EHR physician see capital expenditure as a major barrier to the implementation of an EMR in their practice and 50% were concerned about the return on investment[1].  Recent estimates can place the initial outlay for office capital purchases (PCs, printers, scanners, etc.) at  $15,000 and up.  In addition, there are the costs associated with getting the office “wired”, finding an IT resource that is familiar with Epic installations is a key win for the practice.  Besides the cost of office networking, the practice is also at the mercy of this resources schedule for implementation and support.  There may also be costs associated with office reconstruction to accommodate this new hardware, improve workflow and the patient experience.

Another factor is the cost associated with practice downtime during the implementation process.  There are weekly meetings throughout this process that need to be attended by at least some of the staff to ensure that information is disseminated to the project team, the  implementation is on schedule and deliverables are being met.  These meetings most commonly occur during business hours, but can be done after hours or during a “working lunch”.  Physician and staff will have to attend some training sessions on the new software prior to deployment.  Depending on the number and the role of the staff member determines how much training is needed.  This may require the office shutting down for a day or so or having multiple days with a reduced patient load.

Another revenue decreasing aspect of the install occurs during the Go-Live period.  Normally, for at least the first 2 weeks after the Go-Live date, it is strongly recommended that the physician reduce the scheduled patient load by approximately 50% for this time frame.  This needs to be done to help the practice adjust to the new workflows, and charting tools.  Physicians who do not reduce schedules as recommended can experience higher frustration rate with this new process as they may get behind in chart completion right out of the gate.  This frustration can then lead to charting that is just enough to get the chart closed and demonstrate meaningful use and may even lead to reverting back to pre-EMR functionality.

So, how can an EMR benefit the private practice economically?  Use of the new EHR over time can show economic benefits to the practice that can include higher physician efficiency, allowing a greater patient load and also the ability to reduce staff costs by increasing office productivities.  Transcription costs can be greatly reduced or eliminated with the adoption of documentation tools within Epic as well as the utilization of voice recognition. Paper costs are also an area where savings are realized.  Physician can see increases by use of an improved billing processes and more thorough documentation thus leading to higher coding for reimbursement

[1]Electronic Health Records in Ambulatory Care — A National Survey of Physicians Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P. N Engl J Med 2008; 359:50-60