Winter 2011  
Community Connect: How to Avoid Common Obstacles
By Tom Gantzer, Manager of Consulting Services
As the rush to deploy EHR technology to independent community practices begins to hit critical mass, effective approaches for ensuring successful implementations are becoming more evident. Keeping the main beneficiary, the patient, in mind during this flurry of activity is often a challenge; though the improvements in patient care are significant, they are not always obvious at first.
Epic Community Connect initiatives will extend elite workflow tools to independent practices and community hospitals, often at a subsidized cost. These tools improve patient safety, quality and continuity of care, clinical content, mobile solutions and billing tools just to name a few, which provide advantages that will take organizations to the next level in the evolution of the electronic health record and patient care.
Additionally, the advantages to a host organization cannot be ignored. Creating a true shared record through the community will close information gaps to create a more complete patient record, but will also build trust and a stronger relationships with your referral base.
The prevalence of these implementations has brought some of the common obstacles and risks into acute focus. Fortunately, these can be mitigated through proactive planning:
  1. Pricing and subsidy levels: Current federal subsidy guidelines are generous so hosts choosing to subsidize at the maximum rate are able to offer Epic software at an extreme value. A host should be prepared to answer the following questions: Should current build teams be complimented with internal or external resources to expedite the implementation? Will permanent resources for ongoing maintenance, optimization, and post go live support be needed? Is the training team staffed to handle the increased volume?
  2. Strategy and philosophy of your marketing: Setting your pricing and staying competitive is the first step. Deciding on the overall philosophy of how this product will be presented to the community is an equally important factor. Careful wording is needed to prevent a sense of intrusion. Before sending the first email, the host organization needs to seriously consider how to neutralize some of the natural suspicions that providers have. They're often weary of a perceived loss of control associated to signing on with a larger enterprise. The possibility of a competing provider having access to patient and fee schedules to other facilities trying to poach patients and referrals are frequently voiced concerns. These valid concerns can be offset with a brief overview of the way Epic functions. Epic is regularly configured to provide complete privacy when it comes to their patient and fee schedules and trickles down to the more detailed concerns like protecting high profile patients with utilization of break the glass. Addressing privacy concerns and stressing their ongoing independence should play a large role in your presentations and marketing materials and combined with stressing the benefits of a "single shared record" should go a long way in staving off many initial fears.
    While pricing is a priority in most cases, these groups have a plethora low and high tier alternatives to choose from. Even Sam's Club is entering the fray. A host organization offering Epic knows that they're offering a superior product; they can hang their hat on Epic's KLAS and HIMSS Davies awards. They can pass along the fact that it's the consensus choice among the country's leading health care systems. The problem is the average physician with no previous EHR experience may not be aware of this benefit. Well structured and aggressive demonstrations are needed to educated and influence undecided groups. Another vital marketing aspect for hosts is to include existing work on Meaningful Use and the status of the project. Presenting progress on the HITECH portion of the stimulus package can be enough to convince many providers to join.
  3. Identifying the business structure and controlling interests: A private practice's business model can be an unexpected difficulty. Separate corporations often exist, multiple billing vendors, and different philosophies on patient care which can affect nearly every facet of your build. With larger groups, gathering all of these personalities and opinions together into a semblance of a decision making body can be a difficult task. Establishing a single provider or small group that's authorized to make these decisions can expedite the process.
  4. Level of Customization: Determining a general level of customization must be addressed before the initial offering. Making clear and defined boundaries in customization including where there is flexibility, can go a long way in forming budgets, developing the initial scope and helping the community customer form realistic expectations. Labor intensive pieces like the development of outside interfaces and device integration are common stop signs for many hosts due to the cost and the potential time for implementation but the presence or absence of interfacing and device integration can be a deal breaker. Many entities already have a form of EHR in place and this represents a significant and unacceptable loss of functionality for them. For host organizations without diverse interfacing or a robust interface team already in place, an expensive decision must be made that involves absorbed or passed on expenses. Many hosts will take the opportunity to develop new interfaces that are commonly used which improves internal operations as well as their community connect offering.
    Another tool the host organization should clearly communicate to the customer is that content is already developed, vetted and utilized on a daily basis. While most providers and organizations will want personalized touches like letter templates and headers, analysts should be able to draw many parallels with preexisting clinical tools that can save time and money. While much of the existing clinical content may be adequate, your scope should allow for some orders and navigator work to allow for easier integration of existing workflow and billing practices.
  5. Training and Support: Developing an effective training plan will be integral to user acceptance and set the stage for implementation teams to transition support to confident users. Temporarily augmenting your existing training and support staff will result in an efficient timeline and create an independent customer. One commonly ignored opportunity is identifying and training super users. Identifying one or two resources to receive super user training can reduce the time needed to spend in support after go live. Doing so leaves customers comfortable with an internal resource, creates a native advocate for the software, and cuts down calls to the help desk for the long term.
    Straightforward assessments of the help desk staff and clinic liaisons must be made to ensure timely and adequate issue support and resolution. Most hosts decide to include post go live support into their existing framework; sometimes choosing to add permanent resources in the call centers and/or liaison areas.
  6. Upgrades, Changes, and Optimization: Post go live timeframes are important to communicate to community providers. Liberal amounts of customization in the beginning may stretch your timeline and affect the ability for some in achieving thresholds for Meaningful Use.
    Another important piece of post go live information is to craft your strategy on patient safety alerts, large scale changes/optimizations, and upgrades. Patient safety issues can be addressed by mass email distribution lists with all community connect clients with more direct intervention if necessary. Most organizations schedule quarterly or semiannual forums for community customers to provide feedback, review, and to communicate changes such as large scale optimizations or upgrades. Depending on your area, population, and regional completion a Community Connect project can be a daunting task. The increasing number of Community Connect projects has given the experts an opportunity to uncover the pitfalls so they can be avoided and guide organizations to a timely go live. Understanding pricing, developing the powerful marketing message, expediting the decision process, managing levels of customization and investing in supplemental training support can lead to a successful implementation; one that yields long lasting dividends to all involved.

During the months of October, November and December, Culbert executives and consultants were published in the following publications:
Becker's Orthopedic and Spine Review, HIStalk Practice (monthly column – From the Consultant's Corner), Healthcare Finance News, MGMA Connexion, Part B News, SURGIstrategies, Health Management Technology and Physicians Practice. Continue to keep an eye in the news for us in 2012! Also, be sure to follow us on Twitter! @culberthealth
Clinical Integration: The Right Time, the Right Thing to Do
News from Rob Culbert, President
"Uncertain" doesn't even begin to describe the future of healthcare in the U.S. We all know that the Patient Protection and Affordable Care Act is law, but it's facing public resistance and an upcoming Supreme Court challenge. What's more, there's little doubt that ongoing budget talks in Washington will bring big changes to Medicare and Medicaid. We fully expect that the push toward performance-based reimbursement will only get stronger.
Now, into this already-confusing swirl steps the just-released Accountable Care Organization (ACO) final rule. The rule reflects the comments of thousands of physicians in provider organizations across the country, and is intended to empower them to join the trend toward clinical integration.
Although ACO participation is voluntary now, most clients we speak with are convinced that this kind of system represents the future of medicine—and not just for Medicare patients under Medicare rules. Physicians—whether rural or urban, independent or employed—will likely climb on board with the idea because it's the right thing to do for patient care. Clinical integration across patient-care settings is one of the best ways to enable providers to reach out to patients to offer better, more proactive services.
Integrated, flexible and patient-centered
Under the new ACO rules, clinical integration can be accomplished in a number of different ways. Overall, the goal is to align providers and institutions with mutual, patient-centered objectives.
Though financial integration is one part of the picture, it's definitely subordinate to the achievement of quality care. At their core, the rules require a commitment on both sides to the concept of aligning incentives for quality care—with the understanding that cost reductions will follow improvements in quality. They also require participants to recognize the undeniable role of IT in making it all happen.
Whether they're headed by a physician chief executive officer (CEO) or a lay CEO, and whether they involve employed physicians or independent physician partners, all ACOs should share these four key characteristics:
  • Common mission, vision and values
  • Mutual respect and willingness to share risk
  • Focus on the patient experience
  • Commitment to quality care
Fortunately, some of the historical obstacles that have barred providers from working with large healthcare systems and payers are disappearing. For example, recent regulations released by the Centers for Medicare and Medicaid Services (CMS) significantly relax federal anti-trust laws. Everything is pointing in one direction: Now, more than ever, it is an opportune time for clinical collaboration.
For physicians, relationships with larger organizations make sense. They allow: easier access to the expertise inherent in the clinical programs of larger organizations; greater payer contracting experience; and the ability to leverage economies of scale. And let's not forget information technology (IT) resources, which will play a huge role in the future of population management and coordinated care.
Clearly, the pressure is on for providers and other healthcare stakeholders to align their mutual interests in order to cut the waste from our fragmented healthcare delivery system. With everyone on the same team, we can redefine the current ineffective, poorly coordinated and unnecessarily costly healthcare system.
ACOs—together with other similar initiatives like patient centered medical homes, bundled payments and outcomes-based reimbursement—will become the foundation for delivering high-quality, cost-effective patient care for everyone. The concept of clinically integrated accountable care is here to stay. So it's up to providers to take the lead, developing clinically integrated organizations motivated by a common goal to improve access to quality, lower-cost care for all patients.
ICD-10's Impact on Your Organization: Why Assessments are Critical
By Mary Ellen Roberts, Senior Consultant
A lot has been written about the steps required to implement ICD-10 by October 1, 2013. By now, your organization should have established a steering committee and begun the executive-level education necessary to convince everyone of the importance of this initiative. But most of the education at the executive level is very broad and steering committee members have no idea how it will actually impact their cash flow, budgets and operations. There may even be a tendency to over-simplify this as a systems and coding project. While it is true that these are key components of the implementation, taking this approach will not provide the focused implementation that will mitigate the greatest risks to your organization. Only an impact assessment of your actual environment can optimize the effort and expense that you will invest in the ICD-10 conversion. An effective ICD-10 strategy takes an enterprise approach to assessing and mitigating risk across the organization. During the impact assessment, the business environment all functional areas, systems, and job roles are evaluated to determine what will be affected by ICD-10. The results are aggregated into a report for the steering committee. From this report, the executive oversight group can evaluate various risk mitigation strategies before the organization decides how to implement the project. The result is a focused implementation plan, project budget, training strategy and a financial contingency plan. The ICD-10 project can improve efficiencies and develop a future healthcare environment that is rewarded for quality. This can make the difference between a profitable organization or bankruptcy.
Assessing Your Business Environment:
The payer mix will be a key driver of exposure to risk on October 1, 2013. Payers are struggling with how to meet this federal mandate and some will respond with a cross-walk back to the ICD-9 code, while others will refine their medical policies, benefit structure and claim adjudication systems. Understanding what strategy major payers will be taking is necessary so system rules and workflows can be modified wherever necessary. It is also advisable to take a baseline of key performance indicators now, in order to identify existing vulnerabilities and to provide a basis to monitor changes after ICD-10 is in production.
Assessing Your Systems
Many organizations are already well on their way toward completing their system assessment. Identifying the systems that need to be upgraded is the first step. How have EHR templates been designed to capture diagnosis and procedure coding? What is the impact to interfaces? Where is ICD-9 data being passed between systems? What decisions are being made based on your custom data extracts that contain ICD-9 information today? What reports are people running that include ICD-9? Both clinical research and financial analysis can rely on ICD-9 codes for different purposes. Understanding where Access databases, excel spreadsheets and other departmental systems are using ICD-9 as the basis for clinical or financial analyses will be important. A thorough system assessment will identify the people that need basic ICD-10 training and it may be more than originally estimated. It's important to evaluate the approach that primary system vendors are going to take for their upgrade. How complex will the upgrade be? If there are new technologies or major changes to functionality, the risk increases. Some systems will provide a better structure for meeting ICD-10 requirements than others. Will you need new technologies to manage the risk of decreasing productivity and cash flow? Weighing all the considerations involved in technology changed should be considered and provided in an aggregated report to the steering committee.
Assessing Your Workflows
Workflows are the core of the ICD-10 impact assessment. Procedures that were developed years ago to meet other organizational needs frequently morph over time so that nobody really understands what is being done on a day-to-day basis. Assessing and documenting clinical and administrative functions as they really are will identify vulnerabilities and opportunities with ICD-10.
One of the greatest areas of risk for loss of productivity is providers' clinical documentation and the coder's interpretation and assignment of codes. Do you know how well your providers are documenting now? If they are already doing a good job documenting, then ICD-10 training can focus on the specialty areas that have the greatest changes. How are coders organizing their work now? Are their workflows efficient? It may not be enough to just train coders on the new ICD-10 codes if their workflows also need to change. Only an assessment can uncover these opportunities for risk mitigation.
How about the revenue cycle workflows? Will the primary system vendors provide functionality that will allow rules to be written that guide those workflows? The Business environment and system assessments help inform the workflow assessment, so that the right questions can be formulated and methodically answered as the project progresses. Changing workflows can often be the most challenging part of any project. There is a natural resistance to change, especially when the key stakeholders are not involved in the decision. Assessing workflows early will identify the areas of greatest change up front and allow time to engage the leadership of those areas. Subsequently, leaders can structure project teams to involve staff from their areas to be involved in the design, build and training of the new workflows. The ideal state for the ICD-10 project would be to optimally design workflows with systems that support critical clinical and business decisions.
Assessing Training and Education
Throughout the assessments, job roles will be identified that will use ICD-10 codes either directly or indirectly. Some areas, such as Health Information Management and Coding will need in-depth training on ICD-10 concepts and the code construction. Other areas will need to understand how they relate to charging and revenue. Other areas may only need to know one specialty area. Training needs will differ by job role and the initial assessment will identify what jobs those are and what kind of training they will need. Since multiple systems will be upgraded during the course of the project, the end users will also need training on the system and workflow changes. Wherever possible, the ICD-10 training should be incorporated into that training so staff has concrete visual aids, rather than abstract concepts. ICD-10 education must be delivered throughout the project, starting with a high-level overview for the entire project team and progressing into more specific and focused training materials over the course of the project. The training team must be involved in all aspects of the project, so that they can understand the audience and help manage the change that many areas will face. Developing and delivering training will take time and resources, so it is important to identify a training strategy that will best suit the organization.
A thorough impact assessment of these four key areas will lead the organization to focus on their greatest risks. Not all organizations will have the same risks or to the same degree. It is important to be aware of the many workflows, processes, systems and people that will be affected by ICD-10. Especially since the organization is likely to have numerous other strategic initiatives occurring at the same time. Ultimately it is necessary to invest time and resources to prepare for ICD-10 so it is important to focus efforts on the areas that will make the organization the most successful.
Case Study: Clinical Integration
Culbert's Strategic Services Helps Client Build The Reading
Hospital Medical Group

When Scott Griffin, the Chief Executive Officer of The Reading Hospital Medical Group (TRHMG), was faced with the task of building a medical group from the ground up, he turned to Culbert Healthcare Solutions for interim management, financial, technical, and operations assistance. Griffin needed the right team of consultants because the new group was an integral component of The Reading Hospital's strategy to align with its community physicians.
TRHMG needed to be built quickly and offer physicians a range of revenue cycle, administrative and technology services. Strategic and operational decisions required flawless execution. The organization set forth an aggressive timeline for the opening of their new clinical facility. Integrating the newly acquired practices into the Medical Group posed numerous human resources challenges – and the strategy had to be accomplished without negatively impacting the Medical Group's revenue cycle performance.
Culbert's Role
Culbert was engaged to provide interim management as well as financial, technical, and operations support that would create the Medical Group's infrastructure. Our goal was to execute the strategic plan and develop the concept into a fully operational enterprise. Tasks included physician practice acquisition and transition activities, construction design and build-out, Central Billing Office (CBO) development, revenue cycle management, hiring and training of new employees, merging the practices into a single tax-id and implementing a practice management system which supported the newly acquired practices.
Culbert consultants worked in partnership with Griffin and hospital leadership to ensure that the plan was properly executed and that all project milestones were achieved on time and within budget.
The Results: Services and Value Provided by Culbert
The collaborative approach between Culbert and TRHMG was integral to the success of engagement. The first phase of the endeavor brought together 44 physicians and their staffs, which were previously scattered across 17 locations. As a result of the leadership and infrastructure provided by Culbert, TRHMG has continued to increase in size and now includes over 150 primary care and specialty physicians. Culbert resources served in four specific capacities to execute a wide range of tasks.
About the Client
The Reading Hospital Medical Group is a network of more than 100 physicians and other healthcare providers delivering primary care services to the community. Specialists include Internal Medicine, Family Medicine, Geriatric Medicine, Gynecology and Obstetrics, and Pediatrics.
The Medical Group has physician offices located throughout Berks County, Pennsylvania and the surrounding areas.
Reading Professional Services (RPS) – a wholly-owned subsidiary of The Medical Group – is comprised of over 100 physicians with expertise in various subspecialties and surgical areas of medicine.
The Reading Hospital Medical Group is a non-profit affiliate of The Reading Hospital, governed by its own Board of Directors.
800 West Cummings Park, Suite 6000, Woburn MA 01801 Tel 781.935.1002