March, 2017:

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.

 

Connecting the Dots- The Value of SSOT Crosswalk Documents

Many healthcare organizations adopt a “best of breed” philosophy regarding their information systems. In many cases, they want the best practice management system for professional billing, plus the best EHR for clinical documentation, plus  the best hospital PM/PA system for technical and facility billing, etc.  Sometimes, they would rather implement one system that can do it all but due to financial constraints or contractual agreements, they are obligated to maintain their multi-system/multi-vendor environment.

In such complex integrated environments, it is imperative to maintain Single Source of Truth (SSOT) crosswalk documents to help the organization’s IT, finance, and operations teams connect the applications together. When integrating new practices or departments into the enterprise, it is especially crucial that the implementation teams understand how not to tangle those connections.

In a recent project, an organization attempted to transition newly acquired physician practices from legacy RCM and clinical systems onto their enterprise solution, which consisted of a diverse environment of practice management, clinical, hospital financial, and ancillary systems. Despite those enterprise systems being in place for several years, it was a surprise to learn that the organization had never taken the time to specifically document how all of their departments and locations in the source practice management system mapped to corresponding values in the downstream systems.  The provider entries in the various systems had also not been reconciled, which sometimes caused interface failures.

As the project manager representing the practice management system initiating the visit/encounter process, I offered to create a catalog of master mapping (crosswalk) documents which would be used to design the application builds and connect each department, location, and provider in system A to the corresponding values in system B, system C, etc.

Once the various IT teams agreed upon the exact values that represented the “dots to be connected” in each system, project sponsors endorsed the mapping documents as the Single Source of Truth (SSOT) to be referenced for all implementation activities. The SSOT documents were then utilized by all teams to correlate application build mapping variables between the multiple RCM, EHR, and ancillary systems.

Armed with the knowledge of how the key data elements for each system reconciled to each other, the implementation teams could formulate detailed future state workflows, business requirements, technical cutover plans, and integrated testing scripts. Whenever interfaced transactions failed during integration testing, most issues could be easily traced back to values that were not in sync with the SSOT documents.

Maintaining current and accurate crosswalks and SSOT documents may seem like a no-brainer in an environment with multiple disparate systems that must communicate with each other. However, it can be tedious and time-consuming work and when time and resources are both limited, many organizations overlook its importance.  Many hours of redesign, rebuilding, and re-testing could be avoided if time was spent wisely by first identifying critical integration points and connecting the dots.

 

 

Patient Perception is Everything When it Comes to Patient Satisfaction

In the medical practice, patient satisfaction scores offer valuable insights to the perception of the patient experience. The person having the most significant impact on the organization is the provider. Practice workflows should focus on optimizing access, decreasing wait time between the scheduled request and the date of the appointment, ensuring providers have the tools they need when they enter the room, spending adequate time with the patient and understanding concerns and providing treatment options. Below are some options to pilot in the office:

Templating – Consider the provider’s template. Does it have an adequate number of new, established follow-up and same day appointment slots to support the size of the patient panel?  Is the actual cycle time of these appointments reasonable and easily met? Would the practice benefit from adding advanced practice clinicians (nurse practitioners or physician assistants) to boost and extend the work of the physician?  Does the practice have enough dedicated staff to ensure the patient flow is fluid?

Wait Time – Two critical elements of patient wait time is the time between the appointment request to appointment and wait time the day of the visit. Some patients may perceive it as a long wait, even if it is not.  Studies have suggested that too long of a wait time to the appointment can contribute to an increase in no show rates.  Assess your check-in process.  Do you provide a verbal update to the patient regarding wait time? Do you have a patient access center to smooth the pre-visit process to streamline check-in and billing? Do you have visual management tools for your staff tracking front-end preventable errors? Do you have an automated call reminder in place?  Do you have scripting for your staff to ensure they present the delay in a positive light? Be frank with patients when emergent situations arise and unexpected delays occur.

Feasibility – Do you have a good staff training program to help the provider be more efficient? Ensure your medical assistant or nurse can take a full history and prepare the room working to the top of their license. Can staff load pre-visit forms into the EHR?  Can they set up the room/note for the anticipated service (i.e., open the radiology films, push the labs into the note, update the chief complaint and prior history, medications and allergies)? Does your practice use standing orders in the office to allow staff to complete “Point of Care” testing? This allows the provider to have a full discussion about the findings.

Explaining the Options and Follow-up Plan – The next area to review is the patient and physician decision-making component. Do you have a system to ensure medication changes are reviewed and the benefits and risks clearly explained?   Do you have printed content available? Software such as “Up to date” can also provide credit for Meaningful Use to providers.  Do you have scripting on laying out the options? Train the providers to say “Mrs. Jones, based on the testing results we have three options.”  Encourage the provider to state “the first option is… the second option is …..the third and last option is …..Etc.”

Follow-up Plans and Testing Results – Is your process clear in terms of the next steps?  There is nothing more frustrating to a patient than having to call the office to clarify the treatment plan, timeline and/or next steps.  Do you provide a phone number and address for recommended preventative care such as mammography and colonoscopy or specialist?  Do you have a clear process to deliver test results?  Train your staff to avoid saying things such as “if you don’t hear from us everything is fine.”  Best practice is to provide a written summary of the visit which can be reviewed at check-out.

 

Provider and staff engagement in the process is essential to success. Break the steps down into small, distinct units, provide feedback and assess the improvement over time!

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

 

 

 

 

Why I Talk About the Flint Water Crisis on Go-Live Day

Nearly eight years after the passage of the HITECH Act, it is easy for IT professionals and physicians to be burnt out trying to harness the benefits of integrating software into healthcare. However, a humanizing story of those benefits can remind us all to help remain steadfast in our goal of improving healthcare through technological innovation. This particular story is inspiration to keep promoting EHR integration in practices, to use that data to search for truth, and better the patient outcome.

As of early 2017, the city of Flint, Michigan has been struggling to provide its citizens with clean, safe water for nearly three years. Although the city now admits a problem that has been scientifically supported, their claims to the contrary may have continued far longer if not for the quick thinking of local physicians and the reporting functionalities of the EHR used by the local hospital system.

Flint’s water crisis began almost immediately after the city switched the main source for the city water supply from the Detroit system to the Flint River as a cost saving measure. Residents consuming the water quickly raised concerns, mostly related to rashes after contact with the water, as well as the water’s taste, smell and appearance. At this point, an almost 18-month long battle ensued surrounding public safety as the residents raised a multitude of concerns about the water’s quality. The city admitted early on that there were high bacteria levels in the water but reported permissible levels of lead in the water, even as home tests by residents showed levels as high as 397 parts per billion. State officials and a consulting group brought in by the city stated that water quality met state and federal standards even as EPA experts voiced concerns that testers may be underreporting lead levels.

State findings may never have been disputed if not for the efforts of a group of doctors lead by Dr. Hanna-Attisha of Hurley Medical Center. While at a dinner party, Dr. Hanna-Attisha heard rumors about Flint’s lack of corrosion control on pipes carrying municipal water and sprang into action, driven by concerns of lead exposure to children. The hospital routinely ran lead screening tests on young children and Dr. Hanna-Attisha was able to use this data to compare blood lead levels before and after the city switched water supply sources. That report, run out of the hospital’s EHR system, showed undisputable evidence that lead was leaching into the city’s water supply and into the bodies of children. The presentation of this evidence met significant backlash, but eventually made way for the city to begin taking steps towards providing a safe water supply again. Once the findings were validated by state epidemiologists, the city declared a state of emergency and requested federal funding to replace as many pipes as possible. Progress began slowly to alleviate this crisis.

Without the digital records and the reporting functionalities of the EHR software, Dr. Hanna-Attisha would have faced an insurmountable volume of paper charts to search for blood lead levels. It would have taken resources and time that may have delayed the discovery of the crisis and further endangered the lives of Flint residents. Instead, she was able to easily access and search the data needed, even without the assistance of a software expert. While the crisis continues to this day, it is important to recognize the vital role played by the EHR in identifying the timeline and evidence of the water emergency. To me, this is a story to tell to the physician who is crippled with frustration on go-live day – struggling to understand why he has to document within the confines of a computer instead of scribbling in a chart. It is a reminder that IT professionals are equipping healthcare professionals with the best tools available to us to serve patients and communities.

The Perfect Storm

Operational planning should include a plan for inclement weather. When considering how to handle an upcoming storm, there are only four options.  They are (1) Open as usual (2) Close all day (3) Open Late and (4) Close Early.   Below are some scenarios you might consider when making your decision.

  • Weather predictions- Use a reputable source for reviewing the potential storm threat. Review a national and credible news organization like Weather.com or FEMA or National Weather Service. Consult your favorite local news station to understand the threat level, the time of arrival and the potential path of the storm. Consider wind, ice and the potential weight of the snow and how this may affect your patient and employee safety.
  • If you have multiple locations you need to consider all of them. Think about the snow plowing, shoveling of walkways for patients and staff, ensure your heat/electric/water and oil are working. If the locations are leased, outreach to your landlord to confirm services are lined up for the storm. You may need to consider different plans for different locations.
  • Ensure parking lots are clear and available for staff and patients to park. Decide if you will have the same hours in all locations, will your urgent care be open? Will the hospital based programs and/or the medical group be on the same schedule?
  • If your staff and patients use public transportation to come to your office, verify if these services are available.
  • There are many ways to notify patients regarding the change.        One day prior to the storm, begin to move patients coinciding with the arrival of the storm. Once the storm has passed, you will need to work with your team to “add in” extra visits to ensure your day is not a financial loss. Consider if you will need a print out of the schedule in the event the power is lost and you cannot dial into the computer system.
  • Optimize technology. Utilize your website, outgoing hold messages, call appointment system to cancel appointments and your patient portal to send your message out the patients. Consider having an emergency message line to inform staff of the plan for the day.
  • Notify the answering service of your plans, how calls will be received and who is on call for the duration of the storm. Also alert them to any changes in hours.
  • Consider your supply chain. Will vital supplies be delivered and if in fact you can wait an additional day to receive them? Check the supply of medications and vaccines in the practice. Be sure you have back up power to store these items at the right temperature. If you have multiple locations without back up power, make arrangements for practice managers to drop off these supplies or have your courier pick up the vaccines and medications and bring them to a central location with backup power.
  • Be clear and consistent about the rules in which staff will be paid if the office is closed. Will it be without pay, Paid Time Off or regular pay minus the hours missed?

In the end, make sure you have thought through the various scenarios and made a safe choice, a strong plan and have communicated this clearly to patients and staff!

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

 

 

Engaging in Process Improvement & Organizational Transformation Prior to a Revenue Cycle System Implementation

In today’s healthcare environment, it is no longer as simple as designing, building, testing and going live on a new revenue cycle system (not that that is simple in and of itself), it is assessing and transforming all of the processes and structures impacted by it. Building the old Three-Legged Stool of People, Processes and Technology.

Having led multiple business and process transformations, I have found that the ideal time to begin this journey is a couple of months prior to the vendor implementation kickoff; this is true whether it is internal client resources, an outside consultant or a vendor team performing what amounts to an additional project. This allows time for a multitude of actions to take place and benefits to be reaped.

One, it gives you the opportunity to really understand what the current state of your business is, what is working well currently and where efficiencies can be made.

Second, this deep dive provides a good look at the skills of your resources and where they might be a better fit in a new structure. Much like in sports, putting a person in a position and system that is more suited to their skills as opposed to forcing a square block into a round hole can result in increased productivity and job satisfaction.

Third, without a doubt, during the system selection and SOW processes, specific KPIs and goals surrounding those metrics were identified as key reasons for a new system and areas of needed improvement. Early stage process and business transformation planning provides a more clarifying look into these metrics, what workflows are causing a certain metric to be lagging or shining.  This also provides the opportunity to shape your future state workflows and structure around the new system.

Fourth, you will engage all of the affected organizational entities and provide them a good understanding, or reinforcement, of why the change is taking place and what to expect during the implementation. It opens an avenue of communication that allows for shared goals to be made, demonstrate how it will bring value to not only their individual roles but to the organization’s overall goals and mission, this cultivates trust and project buy in to occur.

Fifth, it lays out a roadmap of recommendations to the future state of your processes and organizational structure and actions that need to occur throughout the system implementation; as well as a more immediate foundation for the revenue cycle system design about to take place.

Altogether, getting started with process and organizational transformation ahead of the system implementation alleviates having to perform this separate project concurrent to the system implementation. This will reduce stress and additional potential unknowns to pop up.  The implementation team of resources will be under an immense amount of pressure to design, build, test and go live with a new revenue cycle system.  Although the roadmap has been set prior to the implementation kickoff, implementing these decisions still must happen throughout project, but again, you are not gathering documentation and making decisions at the same time.

One other major benefit that is often overlooked is the cutover and post go-live need for a large amount of optimization. Upon cutover, you will see a smoother transition with less impact to metrics (A/R, cash, denials, etc.). Instead of reacting to the change in systems, you have anticipated them and put effective changes in place ahead of time.  No doubt you will need to perform health checks which will result in system and structure tweaks.  What getting your transformation started early and completed with the implementation accomplishes, is to exponentially decrease the post go live optimization needs.  Smaller adjustments as opposed to brand new committees, additional resource time, project ramp up, stress and of course dollars spent.

A couple of final thoughts that will be keys to making a process and business office transformation successful. Draw upon your well of knowledge and experience and relay specific examples of where you have seen this work; as importantly, really attempt to make a personal connection to the individual or groups you are communicating with.  Trust is a very big deal, change is difficult and for many people, scary.  Have a plan going in and execute it, work hard, take what you are doing seriously but don’t take yourself too seriously.

Patient Access Throughput: The Strategy to Success

In today’s healthcare world, health systems experience constant change and at times, a state of the unknown. Patient care is the business of the hospital and when processes are inefficient, business is inefficient.  Medical groups and hospital systems are focused on reducing costs and consequences to patients, staff and the organization as a whole.  However, the overall goal is to improve the ability to optimize how efficiently the processes and operations are managed.

Opportunities for Improvement

  1. Lengthy admissions/outpatient wait times continue to be a major area for improvement
    1. Cross-training scheduling staff to create accounts, schedule, and begin the pre-certification process will reduce the number of calls to the patient prior to the date of service (DOS)
    2. Assign verifiers to “physician teams”
    3. Manage block schedules
    4. Provide the benefit of obtaining co-pay, deductibles, and (out-of-pocket) OOP during the pre-registration process to minimize intake process at the time of arrival
  2. Engagement
    1. Minimize patient complaints through service recovery methods
    2. Open communication with physicians/departmental leaders (i.e., office visits/monthly meetings)
    3. Educate and engage employees to increase customer service
  3. QA, QA, QA! – Accountability is KEY!
    1. “On Your Mark” accountability will minimize errors, denials, rebills, wait times, and patient complaints

Solution

As organizations strive to exceed the patient’s expectations, they must continue to explore new ways of streamlining the patient access processes to improve the patient experience. Today’s consumer is a savvy, educated consumer and they anticipate exceptional service.  The following patient access initiatives can benefit organizations in serving their patients:

  • Pre-registration – Online access, patient portals, etc.
  • Patient access advisors
  • Customer service training
  • Discovering strengths by utilizing the Lean Process, Six Sigma, Eagle Wings, etc.
  • Leadership development (placing the patient’s needs first)

Ongoing Initiatives

Health systems have an interesting road ahead of them, but one thing is certain – the patients come first. Staying abreast of updates on the national and local level is essential to implementation of any strategic initiatives moving forward.  Organizations must continue to make their experience the best, and exceed the goals of stakeholders while doing so.  Communication, education, exploring options and listening to the “customers” will help healthcare providers reach those successful practices.