Fall 2012  
Culbert Healthcare Solutions Continues to Enjoy Strong Growth
by Rob Culbert, President & CEO
Culbert Healthcare Solutions continues to enjoy strong growth, not just in revenues and number of employees but also in the breadth and depth of services we can provide to medical groups, hospitals, integrated delivery networks and academic medical centers. Many of our clients will often times ask about the types of new projects we are working on. In this newsletter, we wanted to devote some attention to this and share examples of the engagements we are completing across the spectrum of our practice areas which include, Strategy & Leadership, Revenue Cycle and Information Technology. Below you will see examples of the engagements.
  • Provided an Interim Department Administrator for a faculty practice plan responsible for oversight and management of of all ambulatory operations, administrative staff, and financial performance as well as serving as a liaison between the department and hospital leadership.
  • Developed new Single Billing Office structure to support both professional and hospital
    revenue cycle operations with the goal of producing a single consolidated patient statement.
  • Centralized inpatient and ambulatory registration and scheduling functions into a new Centralized Patient Access Unit for an integrated delivery network.
  • Provided a Project Manager responsible for all project coordination for enterprise-wide implementation of Epic's patient access, clinical and revenue cycle applications.
  • Performed assessment and optimization of the GE Enterprise Task Manager (ETM) for a large multi-specialty group practice.
  • Served as Interim Director of Revenue Cycle for multi-specialty group responsible for management of all aspects of their Central Billing Office.
  • Led conversion from Allscripts Enterprise EHR v10 Note to v11.2 Note.
  • Completed an assessment and optimization of the Allscripts Enterprise PM application to leverage advanced functionality to automate the work effort which led to improvements in billing efficiencies (costs) and effectiveness (revenues).
  • Led evaluation and selection of a new enterprise-wide clinical application platform for a complex academic medical center.
Allscripts v11.4 ICD-10 Ready Solution
by Paulette DiCesare, RN, Senior Consultant
Just because the new deadline to transition to ICD-10 for medical diagnosis and inpatient procedure coding has been pushed to October 1, 2014, does not mean you should not prepare now! Allscripts Enterprise EHRTM v11.4 is set to be in General Availability in Q4 2012, and will be ICD-10 compliant. The sooner Allscripts clients implement this version once it is released; the better they can proactively prepare for the transition to ICD-10. While most clients know a lack of preparation could result in a halt to reimbursements and a revenue cycle disaster when ICD-10 is required, proper ICD-10 preparation will prevent losses in revenue, provide time to address inefficient operations, and lessen anxiety within the organization. Impact assessments, workflow analysis and documentation evaluations are the types of preparation that should be occurring in the near future. The move to ICD-10 will affect both clinical and billing operations and workflow changes are inevitable. For physicians, changes in clinical documentation requirements may be one of the most significant challenges. ICD-10 requires users to capture additional, new clinical data to meet coding and billing regulations and to qualify for governmental incentive payments. Version 11.4 is ICD-10 ready with the ability to address many of the expected transition challenges by increasing provider and coder efficiency and lessening the risk of costly coding errors.
v11.4 Functionality Highlights
Because ICD-10 codes are more detailed and descriptive, the new functionality improvements of v11.4 support physicians in handling comprehensive documentation. Physicians will use this new functionality to align their clinical documentation at the level they need for ICD-10 because v11.4 has the capability of producing documentation with a high degree of specificity, is user-friendly, intuitive, and functional at the point-of-care.
Problem List Changes
There are extensive changes to the look and feel of the problem list, ranging from the details dialog box, problem viewer, management of the patient's problem lists, and problem search.
A major change in v11.4 is the problem context menus which are now consistent throughout the EHR including: Clinical Desktop, ACI, HMP, QuickChart, Encounter Summary, and v11 Note. Providers can convert a problem to an ICD-10-ready problem from the context menu. A conversion process takes place to cover most instances of problems so that physicians will not have to manually sort through data, nor worry about their coding proficiency. Instead they can focus on the patient.
For system administrators the problem dictionary's content will automatically update approximately 10 times a year. Medcin updates will continue to update Past Surgical History items and Physical Exam Findings. The problem dictionary has been updated with a new classification for viewing and searching for problems as well as allowing administrators to view the associated ICD-10 code, ICD-10 name, ICD-9 code, ICD-9 name and SNOMED-CT codes for the selected problem.
The Charge Diagnosis searching within the Diagnosis tab has been updated to use the same search functionality as from the ACI, unifying the experience when searching for problems. Physicians have the ability to view ICD-9 or ICD-10, individually or together, and billable indicators when viewing and searching for codes in Charge. This functionality is consistent throughout the application.
System administrators will have the added functionality with a Problem Mapping tool to update and review User Dx Favorites, Exploding Sets, and Groups/Subgroups mapping to ICD-10 ready problems. Also, an updated Charge Admin function will provide new Problem searching capability when creating Diagnosis Favorites, Exploding Sets, Groups/Subgroups, and Situational Data Elements.
Health Management
Based on user preference, physicians and clinical staff will be able to view the patient's HMP with ICD-9, ICD-10, or both codes together. Not only will providers be able to associate all newly added problems to ICD-9 and ICD-10 codes, they will also have the capability to set either code on orders, whether it's via an order interface, or print on the order requisition. This same capability is also available with medication orders when sending via Surescripts.
v11 Note
It will be easier for Physicians to navigate within the Note and manipulate the Problem section as Allscripts has updated the Note Authoring Workspace (NAW) with new problem components to be consistent with the Clinical Desktop. This includes all actions available on the Problem component from the Clinical desktop. The History of Present Illness (HPI) section has also been updated with Problem Note Forms functionality to support linking problems using the new problem search, as well as the display of ICD-10 codes.
Mandatory use of ICD-10 will be required by October 2014 and is one of the largest changes to impact health care providers. Clients can ease the ICD-10 implementation by taking a proactive approach and begin planning their upgrade implementations. This is the first step that is just one piece of a much larger project. Understanding the changes to the problem list, Charge Diagnosis searching, and new Health Management and v11 Note is critical to ensuring cultural acceptance and proficiency. The degree of success a practice will have transitioning to the new ICD-10 code set will largely be determined by how well the ICD-10 project is executed prior to October 2014. Start now!
Collaboration: The Key to Future Success for Independent Practices
By Jeff Wasserman, Vice President of Strategic & Executive Leadership Services
For the last few years, there's been a lot of talk about healthcare's transition to collaborative care. But all that stuff about a "paradigm shift" goes in one ear and out the other if there's no financial incentive to get on board.
If you're part of an independent physician practice, that day has arrived. There are plenty of sound financial reasons for jumping on the collaborative care bandwagon—and a distinct financial downside for not doing so.
In short, small independent practices can't do it alone any more. While Marcus Welby could afford to be a maverick, I believe all practices now need to work closely with other physicians and hospitals to be able to document the quality care that leads to higher reimbursements.
For independent physicians, this requires a completely new mindset: moving from individual episodes of care to a focus on improved outcomes for entire populations. It also requires electronic medical record data to document quality improvements as well as greater teamwork with other area physicians and hospitals.
You have to demonstrate that you're helping improve care for, say, all of your diabetic patients and helping to lower the number of avoidable hospital readmissions. Your practice's financial health will be directly tied to how well you meet these metrics.
Now's the time for small independent practices to begin leveraging data to prove that they can hit the quality and financial benchmarks that will land them a share of the reimbursement pie. Here are four strategies that can help independent practices access the systems that can help them enjoy the financial benefits of quality-based care:
  • Take the EMR plunge. Access to an EMR is critical to future viability as a practice. There are affordable EMRs many practices can implement right now.
  • Get help from a Health Information Exchange (HIE). This strategy works well in some localities like Rochester, New York, where the HIE is already selling information technology services to independent practice associations (IPAs) in the region.
  • Start or join an IPA in your area. This is arguably the best choice because you get more negotiating leverage when you join forces with other independent practices. You can band together to get the best pricing on EMRs, risk contracting, and incentives from commercial payers. Better yet, focus on clinical integration – providing the right care for your patients at the right time.
  • Work closely with your hospital's medical staff. Many forward-looking medical staffs are actively reaching out to independent practices, offering to share strategies and the hospital's formidable IT resources.
In recent years, we've seen countless articles about how cooperation and care coordination are the pathways to a brighter healthcare future. But now those aren't clichés—they're the key to your practice's financial performance. In the state of Massachusetts, for example, there's already been a sea change due to Blue Cross/Blue Shield's Alternative Quality Contract (AQC) program, which provides incentives for large physician groups to meet quality care metrics. Physicians who meet those metrics get a sizeable bonus—up to 20 percent of total reimbursement. Working closely with other physicians and your hospital isn't optional any more. It's the only way to gather the quality data that leads to higher reimbursements.
Epic Community Connect Overview
By Scott Kelly, Senior Principle Management Consultant
What is Epic's Community Connect program?
In order to improve the quality and efficiency of care delivery, Epic offers Community Connect as a means for their clients to extend their licensed Epic software to community based practices and hospitals serving their geographical area. The application offering can vary, but could include patient access, clinical and revenue cycle applications. Community Connect facilitates the exchange of clinical information throughout the continuum of care in a cost effective manner.
What are the advantages to a community practice or hospital of joining onto an Epic platform offered by affiliated healthcare organizations?
The Community Connect model provides several advantages as opposed to acquiring, implementing and supporting stand-alone software applications. The most recognized benefit is the seamless exchange of clinical patient information. This improves the quality of patient care while reducing the costs associated with the delivery of that care. Secondly, community practices and/or hospitals benefit by leveraging best practice workflows and clinical content. Many Epic clients extending a Community Connect Program leverage the relaxation of Stark Laws to subsidize the acquisition and implementation expenses.
When an organization informs the practice it is implementing Epic's "model" system, what does that mean?
Epic's "Model System" is an implementation approach that leverages pre-configured workflows, clinical content and system build to streamline the implementation process by leveraging proven best practices.
What benefits can I expect for my patients and my practice?
  • Access to comprehensive medical record information throughout the Epic system,, ensuring timely and affordable access to the information needed to make the best possible care decisions.
  • Seamless integration of registration, scheduling, clinical documentation and billing information improves charge capture, reduces missing charges, and enhances the reporting of clinical and financial information.
  • Real time interfacing of results from ancillary systems filed to the patient's record.
  • Functionality allows your practice's physicians to meet the federal government's "meaningful use" requirements including a patient portal.
  • E-prescribing increases efficiency and qualifies for CMS e-prescribing incentives.
  • Charges are triggered by documenting clinical care, reducing manual charge entry.
  • Features that improve claim accuracy and speed up payments while reducing manual entry.
  • Enhanced ability to participate in the quality improvement initiatives.
Where is the Epic patient data stored?
Data is usually centrally stored in the master Epic database and secured within the health care organization managing the community health program. Organizations also commonly store information on off-site locations for safety and disaster recovery.
Do I have to share patient and practice financial data?
Clinical information is shared throughout the entire Epic system, however Epic setup contains functionality to limit access to financial information.
What options do we have when purchasing Epic through an affiliated healthcare organization?
There are many variations, however these are ultimately based on whatever the health care organization wants to provide and why. Offerings may include a blend of registration, scheduling and billing functionality so it is important to make sure private practices and groups understand the arrangements and offerings BEFORE signing on the dotted line. Some options can involve:
  • Option 1 – electronic medical record, registration, scheduling and billing.
  • Option 2 – electronic medical record, registration and scheduling (no billing).
  • Option 3 – electronic medical record, registration, scheduling and an interface to another billing system.
A variety of other services and technologies are available for additional fees. For additional information on Culbert's Community Connect services, please call 781-935-1002 ext 113.
ICD-10 "Not" Business as Usual
By Evelyn Bishop, Consultant
As the United States intensifies its move towards ICD-10 implementation, one thing is certain, how your entity charts its course during the assessment and planning phases will impact your post-implementation outcomes. Today we are seeing ICD-10 projects with increased awareness and leadership support as strategic models take shape to provide industry-focused solutions that include the entities long-term objectives, creation of subject matter experts and a cultural shift to a new way of doing business.
We no longer can look at the project outcomes as an "apple-to-apple" concept. Top project task lists today are quite different than the roadmaps constructed five years ago. In this healthcare environment we've learned the architecture design for long-lasting business improvements requires a focus on the relationship of business operations and planning, and less on IT. Much of this is due to the impact of government initiatives to help drive down the cost of healthcare. ICD-10 transformation is a critical companion in achieving many of the other healthcare projects goals, and no longer is it taking a back seat to Meaningful Use, value-based purchasing, ACOs, and global payment initiatives.
ICD-10 steering committees are providing increased awareness. IT Vendor, payor, and financial readiness assessment tools have expanded up to 50 questions, compared to only 10-15 questions 2 years ago. Communication plans include external collaborative support forums to streamline functionalities and transparency as we accelerate ICD-10 migration, neutrality, and mitigate risk.
National indicators shout for the increased need to recognize the challenges for physician training in coding and medical record documentation to reflect a standard process with clinical importance, in order to stabilize data within the entity and across its partners. Coders and clinical documentation improvement specialist are challenged by the modernization of medical terminology, increased specificity, discrepancies in "GEMs cross-walks", dual coding and in DRG revisions.
Due to ICD-10 nomenclature some carriers are developing unique ICD code-centric logic hybrid reimbursement systems. This is escalating the need for revenue cycle workgroups to create complex dashboards for quick notifications of policy changes and/or increased number of reimbursement mappings and/or structures that will impact high volume services, high risk, and quality measures. Compliance teams bring oversight to the table with needs relating to ICD-10 contracts, contingencies, policy changes, training initiatives and anticipated increased activity with recovery audits during the transition period. Let us not forget all the intensive end-to-end testing of all the supporting IT applications and infrastructure; oh my…did anyone mention something about a Plan "B"?
We are fortunate to have available new technologies that provide opportunities to improve the efficiencies and productivity concerns as earmarked for resolution to many of the operational workflow processes. As we continue to move forward colleagues are in agreement… ICD-10 is "NOT" business as usual.
ETM Best Practices: Use of Views
By Jan Bargmann, Consultant
Setup and Use of ETM Views
The use of roles can help reduce execution time when pulling tasks into a view. Considerations when using
roles are:
1. How do you want to distribute the tasks?
The skills used to work follow-up tasks are related to payer rules and specific billing areas. For example, a highly specialized billing practice such as cardiology requires knowledge of procedures and documentation required for billing. That knowledge, combined with the payer specific rules makes follow-up more efficient and effective. Roles created using the payer and billing area combination allow tasks to be routed to ETM views assigned to patient account representatives (PAR) with those specific skills.
2. How many roles will be combined in one view?
Performance when executing the SQL to create or refresh an ETM view can range from seconds to several minutes depending on the logic and sequence of the statements in the SQL. More than three roles in a SQL statement can cause lengthy execution times, so it is important when architecting roles to take this into consideration. Another factor to consider is the timing of when to present a task. One simple rule is: if a task does not require an action, do not present it in a view. Tasks are created at various stages in the claims submission process. If using ETM for TES and a charge does not pass the TES edits, a task is created so that the edit can be worked. If the charge passes TES edits a task is created when an invoice is generated and it is given a status of New. If a New task status does not update to show that a claim was submitted, it is important to have it appear in a view after 2-3 days, so the PAR can review and release the invoice. If the task does not pass the claim form edits, a claim edit task is created and would appear in the claim edit view so the edit can be resolved. Since claim form edits are at the line item level, you can have several claim edits for one claim. At nightly edit evaluation, the claim form will process again and, if the edits are resolved, the claim will create an invoice and an insurance follow-up task.
With the advent of electronic claims processing, the average days to pay has been reduced and follow-up time should be adjusted accordingly. Dictionary 19 (FSC dictionary) contains the ETM settings by payer that determines the timeframe for electronic or paper claims to appear in the follow-up views. Previously, 30-45 days was the standard for electronic claims follow-up, but the "new" standard is closer to 20-25 days depending on payer. Reports can be run to determine the average days to pay for each organization which will then drive the changes in dictionary 19. Paper claims will require a longer timeframe for processing so the number of days until follow-up is needed will range from 45-60 days.
Rejection views can be used for follow-up when appeal timeframes require shorter turnaround times. Rejection codes are posted and the task stage is updated to rejection processing. Best practice would be to show the task in a rejection view the day following posting to insure timely response to the rejection and refilling or appealing the invoice.
Alert views can be used by management to determine when a claim or rejection is reaching the timely filing limit. Timely filing limits differ for each payer and are managed through settings in dictionary 19. Management can then direct resources to work the inventory in those views. Alert views can also be used to monitor service level agreements if your organization has tasks that require a specified turnaround time. For example, if tasks are used to communicate requests and responses, service level agreements may require a 5-day turnaround time. Using the start date and the current date, elapsed time can be calculated and monitored by management in an alert view.
ETM is a very effective workflow tool, but is dependent on solid processes, efficient SQL coding and management direction and oversight.
Task – the unit of work in ETM. Work is differentiated in the ETM modules through the creation of tasks with different task names.
Task name – defines the type of task. For example, task names exist for insurance follow-up, claim edits, TES edits, eligibility and self-pay follow-up. User-defined task names can also be created.
Views – realtime work queues used to distribute tasks so they can be worked.
Stage – describes where a task is in the workflow process. Stages can be related to payers or processing phases.
Status – describes actions taken on the task. Status is user-defined and can reflect actions such as payments posted or new invoices. Either alone or combined with stages, the status can be instrumental in driving workflow. The system-defined status of Done is used to reflect whether a task has been completed.
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