Spring 2012  
Healthcare Business Intelligence: Less Talk About Data and Reports; More Talk About Consultative Analytics
By Jaci Edwards, Consultant
The demand for business intelligence (BI) in healthcare is at an all-time high. How will you demonstrate meaningful use of your EMR? Can you measure the access patients have to care and whether the care is patient centered? What about the quality of that care and clinical outcomes? It's hard to consider a single influence on medical groups or health plans without immediately thinking about the data and reports that will serve as tools, guiding organizations through the changes that are absolutely necessary to survive and grow. The need for information is not new but over time internal and external forces can create BI gaps. If you wonder whether your organization has gaps, ask yourself these questions:
  • Has patient adherence to specific drug therapies improved in the last 12 months?
  • What is promoting or limiting the productivity of my providers and how does their productivity compare regionally or nationally?
  • What is the demographic profile of the member or patient that is the most satisfied or has the strongest loyalty?
  • What are the top opportunities for contract renegotiation?
  • Are patients well "bonded" to their PCP? Are we providing the necessary access to primary care?
  • Which patients have a care gap that can be closed such as a missing mammogram or A1C result?
  • What can be expected to happen to A/R if we switch to a new billing application?
  • Do you have answers? If not, you have a gap in your business intelligence. Many organizations have a reflexive and technology centered approach to close the BI gap. Across the organization, IT teams may form to address questions like whether the platform for the data warehouse should be Oracle, Teradata, SQL Server or something else. They'll also discuss how to integrate data from multiple clinical, financial and operational systems into one unified warehouse. Other considerations include the tool set for extraction, transformation and loading (ETL) of data and the query and reporting tool. Reports are designed with careful planning of the fields to pull from the data warehouse, the manipulation and calculation needed to produce measures, and the formatting needed to make the report consumable.
    These are important considerations, yet none of these decisions will greatly affect whether the quality or cost of the care or insurance delivered tomorrow will be of greater benefit to the patient than it is today. In this era of Accountable Care Organization (ACO), Patient Centered Medical Home (PCMH), Healthcare Effectiveness Data and Information Set (HEDIS) and Meaningful Use (MU) programs, better care at a better cost should be the mission of every clinical, administrative and support resource an organization including the business intelligence unit.
    It's well understood that deciding how to store, query and report on data is just the beginning of the BI effort. Many organizations are less aware that the production and delivery of reports is only an intermediate step. A well-designed dashboard that allows the information consumer to drill through to detailed reports is not the end product. It is a tool used to provide the end service. So, what is the end product and service for a BI team?
    How do you measure their success?
    A BI team is responsible for developing intelligence – a body of knowledge about the organization's patients (or members), care and costs. This body of intelligence is the end product.
    Analyses are derived from the body of intelligence, supporting decision-making at all management levels and yielding new strategies. This consultative analytics is the end service of a BI unit.
    Measures of success for a BI team are indistinguishable from the measures of success for the executive management team. As examples, the BI effort is successful when it results in increases in patient satisfaction and loyalty or improvements in clinical quality measures.
    This concept is so important, it bears repeating. Reports are not the end product. A body of intelligence is the end product and analytic consulting is the end service.
    Keys to developing a strong business intelligence department:
    1. Create the team on the business side or under IT leadership with strong business analysis skills. It is imperative that the BI team understands the business issues and thinks in terms of business processes and consumable, actionable information as opposed to rows and columns of reports.
    2. Integrate report writing, analysis and consulting into one BI unit. These efforts are highly interdependent. Efficiency of the effort demands that these functions reside in one team, one manager.
    3. Raise the floor of the BI skill set. Having a high degree of skill in SQL(query) writing is the minimum qualification for the most junior position on a BI team. The majority of BI team resources need to be subject matter experts in one or more business areas and have a deep understanding of your business model. For the most senior resources, an understanding of the healthcare industry as a whole and the ability to consult are necessary.
    4. Design the team to have multiple "input" streams.
      The team should analyze and consult:
      • In response to strategy proposed from the executive level (Ex. clinic expansion)
      • In response to business questions raised at all management levels (Ex. Is the wait time for new consults appropriate?)
      • As required based on industry changes (Ex. Meaningful Use Stage 2 proposals)
      • On an investigative basis in order to discover trends that suggest new strategies
    An organizations BI effort may be almost non-existent or mature. Either way, the odds are that BI gaps exist. There was a time when using information and developing intelligence was a hallmark of the best healthcare organizations. It is now a condition for survival and growth. It is also far more than data and reports. As we move toward becoming ACOs, pursue accreditations, or simply adapt to new policy or best practices, an organization needs more than new reports. It will need to understand what the reports are saying about the business, why the trends exist and then support what needs to be done. Such decision and strategic support is only possible with consultative analytics and true business intelligence.
    Revenue Cycle System Evaluations: Key Components
    News from Rob Culbert, President
    Implementing and optimizing electronic health records has been a major focus in our industry over the past two years as healthcare organizations have moved to capitalize on the financial incentives provided by the ARRA/HITECH Act. A recent HIMSS survey: 2012 HIMSS Leadership Survey: Senior IT Executive Results, February 21, 2012 indicates there is a shift in focus from implementing clinical solutions to the evaluation of replacing revenue cycle systems to align patient access and billing applications with clinical systems. An integrated core vendor to support an organizations registration, scheduling, clinical and billing requirements provides a variety of benefits including workflow efficiencies, reduced operating expenses, and enhanced reporting capabilities.
    Organizations evaluating a potential replacement in their revenue cycle systems should include the following components in their selection process:
    1. Compare the total cost of ownership (TCO) of acquiring, implementing and maintaining a new system with the on-going costs of maintaining the legacy system.
    2. Identify how the potential conversion could enhance the overall patient experience.
    3. Quantify the benefits in revenue cycle improvement including improved charge capture, reduced missing charges, and cash acceleration opportunities.
    4. Evaluate staffing efficiencies that can be achieved by integrating patient access, clinical and billing related workflows.
    5. Understand how vendor options best support the strategic goals of the organization, not just current state. For example, if you are establishing an Accountable Care Organization, how do vendors support bundled payment requirements?
    6. Consider timing implications of the conversion with other priorities, including ICD-10. With the delay in the ICD-10 timeline, should the evaluation and implementation processes be accelerated?
    7. Understand your organization's expanding business intelligence needs and evaluate how vendor options support those requirements.
    8. What are the reporting enhancements achieved once the clinical and billing information is on the same system?
    There is no doubt that fully integrated systems can provide significant benefits, however conversions do not come without risks and an organization needs to evaluate the cost / benefit of any potential change.
    Interim Management: Does It Make Sense in Your Organization?
    By Sue Ascioti, Manager of Consulting Services
    An interim manager or director brings a high level of performance based on experiences in numerous similar organizations and contributes to the engagement as a driving force to success. Frequently, managers departing an organization leave a knowledge gap which can potentially impact both operations and/or cash flow for many months. A highly skilled interim manager can quickly assess what information may have been left and fill the gap. Additionally, when a new permanent manager is hired, that person typically needs time to learn the new organization and his/her new role. The interim manager can be the conduit for the transfer of knowledge during the transition period so that the permanent replacement can quickly begin adding value.
    Additionally, the interim manager can make recommendations and implement organizational changes that will both benefit the organization as a whole and position the new manager for success.
    Another benefit of an interim manager is to assist the current leadership team. This type of engagement is typically focused on a specific initiative or project. The manager uses unique leadership skills to help guide the organization through a change process which ultimately transforms the operational environment.
    As hospitals employ more providers and/or acquire other hospitals and practices, engaging the new providers and managers of the acquired entity is a common challenge. Providers and managers typically feel as though their practice has been running smoothly and question why change is necessary. The questions raised and any decision regarding integrating the newly acquired entity needs focus and careful attention, a time consideration the current management team does not always have.
    The result is often an underperforming entity. Hospitals frequently find that interim management is extremely helpful in integrating acquired hospitals and practices, especially when the practice management system and/or medical record system is changing and the acquired practice needs to learn the new system(s) as well as integrating numerous other changes.
    Case Studies
    The following represents some of Culbert Healthcare Solutions' interim management engagements:
    Performance Improvement: To replace a revenue cycle manager during the transition from GE Centricity to Epic and improve the financial performance of the billing department. Culbert Healthcare Solutions' interim management role was three-fold 1) filling the knowledge gap left by a departing manager; 2) facilitating the turnaround to reestablish cash flow; 3) transitioning and training the new manager in her role.
    Strategic Restructure: The leadership team's objective was for the interim manager to assess the organization's opportunities, along with overseeing day-to-day operations. Once the interim manager had been with the organization for two months this individual was asked to facilitate strategy development. The interim manager was ideally positioned with enough knowledge of the organization to be an effective facilitator and was also able to bring objectivity and "best practice" recommendations.
    Management Coaching: Providing support to staff members placed in leadership positions to help them exceed goals. Culbert Healthcare Solutions' role was to mentor a director's interactions with providers and members of the leadership team. The interim manager partnered with the director for a number of months providing direct training.
    Is interim management right for your organization? Consider these questions.
    1. How long do you anticipate the engagement to be? Is that a reasonable period of time to engage the staff and implement any culture changes needed to meet the objective?

    2. How supportive is senior management regarding the initiatives the interim manager is responsible for? Staff must be made aware that the objective will stay consistent even after the interim manager leaves to avoid resistance.
    3. Will the interim manager be focused on a specific project, day-to-day management of a department or both? What are the specific deliverables? To ensure the organization receives rewards for the investment in an interim manager, it is important that the scope of work and deliverables are clearly outlined and obtainable within the specified time period.
    Projects with a specific focus take a minimum of 3-4 months. Engagements for clients with more significant issues, or need assistance in multiple departments can last up to three years.
    Assessing the financial outlay is one way to determine the value of interim management. But also consider assessing the financial outlay associated with an interim manager versus a permanent one. Consider the tangible and intangible aspects, for example, the impact of missing a project delivery date, missing revenue due to a system conversion and/or patient dissatisfaction. Also, consider the possibility of staff turnover due to the uncertainty associated with an entity acquisition.
    Patient Access & Revenue Cycle System Replacement:
    Key Things to Consider

    By Randy Shulkin, Principal Consultant
    5010, ICD10, ARRA: Many medical groups today need to consider replacing their revenue cycle systems to be compliant with new regulations or to improve their operations. Whatever the motivation, the need to change systems is an excellent opportunity to gain advantages from new technology to improve workflow and streamline the revenue cycle management process.
    With the major focus on electronic health records (EHR), many practices will not focus on the revenue cycle systems during their evaluation process. Providers focus on the EHR because it's the component that will be in their hands, impacting their daily life. The billing system happens behind the scenes, the clinical staff doesn't deal with it directly, but because of the potential impact to finances it should not be overlooked. Clients need systems that can be flexible and quickly address changing regulations. When evaluating a new registration, scheduling and billing system, know that some vendors offer applications which are fully integrated with the EHR with no price differential. Others have a revenue cycle systems as separate modules from an EHR allowing the practice to select the best of breed option vs. an integrated approach or keep a legacy system. We outline some key considerations in replacing patient access and revenue cycle systems.
    System Functionality
    Registration and scheduling systems are the gateway application for medical groups and hospitals. Before you can document the patient's visit in the EHR, you need to have the patient registered in your system. The basic functionality of revenue cycle applications includes:
    • Patient Demographics
    • Appointment Scheduling
    • Billing
    • Reporting
    Additionally, these applications may provide functionality that can improve workflow in patient flow and revenue cycle maintenance, including:
    • Automated insurance eligibility verification
    • Automated edits to improve registration, charge posting and/or account processing.
    Steps for System Selection
    The process of selecting a new system is an opportunity to evaluate an organization's current position and future potential. The revenue cycle applications are a core tool to accomplish the goals and objectives of the physicians and the organization.
    1. Establish an evaluation team
      Include representatives from all areas of the practice operations, front desk, scheduling, clinical as well as billing, IT and administration. All areas that are impacted and/or interface with the system should be included in the evaluation process.
    2. Evaluate the current state workflow
      Document the current state of patient flow and revenue cycle management within the practice/hospital. Are there unique demands on the organization because of services provided, insurance and/or employer contracts participating in? What automation currently exists within the revenue cycle process?
    3. Core functionality and features
      • Identify core requirements in scheduling, revenue cycle management, patient communications, etc.
      • Identify new functionality desired (electronic remits, automated eligibility, automated appointment reminders, PQRI and Meaningful Use data capture, etc.)
      • Evaluate current reports and reports unavailable with current system including those required to satisfy Meaningful Use.
      • Minimum requirements (integration vs. interfaced with EHR; cost, host internally vs. outsource)
      • Vendor. Vendor capability, market position, experience (local and national), etc.
    4. Timeline
      Does the practice/hospital have internal or external forces dictating a specific timeline for implementation (regulatory compliance, etc.)
    5. Process
      Develop and document a process of evaluation, selection and implementation. Create an RFP to provide an objective means to compare the vendors. Taking time to evaluate vendor options during the EHR selection process and identifying the best revenue cycle applications to meet the short-term and long-term goals of the organization will help to ensure that financial concerns do not develop.
    Sharing Charge Data from the EpicCare EHR
    to GE Centricity Business System

    Jason Drusak, Consultant and Scott Kelly, Senior Consultant
    When a client is implementing the EpicCare EHR, they have to decide if they will use their existing billing software or make a change. There are many reasons a client makes the decision to keep their existing billing system when implementing the EpicCare. The most common reason is to minimize the amount of process change and the amount of new workflows and software applications staff has to learn. With a legacy billing system in which the staff have been using the system for years; they know it inside and out and are comfortable with the system. With all the changes coming via a new EHR, clients do not want to completely change their world and risk creating billing issues.
    In an environment where EpicCare is being installed at a site with a legacy GE Centricity Business (Flowcast) billing system, clients will define the process of how to get charges out of Epic and into GE. The most common starting point is for the clinical team to first determine how charges will be generated in Epic. There are two approaches for generating charges in Epic: orders based charging vs. integrated charge capture. Orders based charging is a form of generating charges directly from orders placed. This setup can be build intensive but is the most efficient charge process. In this process, an orderable record is built and chargeable records are attached to the order. For example if a clinician orders a test that has a professional billing piece and a hospital billing piece two chargeable records would be linked to the orderable record. This allows the clinician to place the order and both charges drop no additional work needs to be done by the clinician other than selecting the level of service. This approach requires careful collaboration between the clinical team and the billing teams. The second way to generate charges in Epic is through charge capture functions. Charge capture is a section placed on the clinical navigator which users use to navigate through their workflow. A preference list is built for each department using charge capture. It is comprised of groups of like charges, making it easy for the end users to select their charges. The result is the end user sees a list in their charge capture navigator section listing charges to select and submit.
    The charge capture navigator section looks like an electronic version of a client's paper charge sheets. A benefit of this method is that it does not require a complete collaborative effort between the clinical and billing teams. The codes can be configured, the preference lists built and configured to display in the charge capture screen. This method is the quicker and simpler of the two methods from a design and build standpoint, but it does require the clinicians to place their orders and charges in two separate steps – resulting in some extra clicks in the process.
    After the method of charging is decided the next big step is deciding how the charges will be sent from Epic to BAR. There are two methods for doing this: an outbound HL7 feed or a flat file report. Using an outbound HL7 feed is the standard process and Epic will help configure the interface. Field requirements need to be determined and the interface will need to be configured. A downside to this approach is there is a fee for every interface with Epic so initial and long term maintenance costs are a consideration. GE will also charge for an HL7 interface, unless GE can use an existing HL7 interface.
    The second method of getting charges from Epic to GE is via a flat file report pulled daily from Epic and transmitted to GE. This usually is sent in a delimited format, most commonly tab delimited, but there are other variations as well. This report can be pulled out of Epic's Clarity database. It is usually run by searching for charges generated for the previous day for a various charge source or group of charge sources. A charge source in Epic is simply where the charge came from, e.g. emergency, inpatient, EpicCare, etc. Sometimes multiple files are used to separate charge sources. For example, inpatient and emergency charges may be grouped together while another file is run only to capture charges from the ambulatory source. A charge destination must also be used when pulling these charges. This is used to separate professional charges from hospital charges. Here is an example of logic for an ambulatory professional report: Pull charges with a creation date of t-1 with a source of EpicCare (the ambulatory source in Epic is labeled EpicCare) and a destination of "professional". Once the number of reports and logic is decided, the next decision is to identify which fields to send in the file. This aspect offers the greatest flexibility of this option. A good clarity report writer is needed but there are a vast number of fields that can be added to this file to meet the needs of the billing system. After the file is written a secure transfer process must be put in place. Once the file is received a utility is usually ran on the file to convert it into HL7 for loading it into GE. The most common reason sites use this method is to gain more flexibility on the fields they get and to advert some of the costs associated with Epic interfaces.
    The next step after deciding how the charges will be transmitted is configuring the charge router. The Epic charge router controls where charges go. It also includes charge review work queues where charges can be held and reviewed before being sent out. While these queues do not have the flexibility of the queues in Epic's Resolute module, they still allow for some modifications. The setup involves writing rules to get the charge to a destination. This is where destinations are created, e.g. interface, professional billing or hospital billing. If using the interface method, the rules are not as complex because the interface allows for splitting of the charges. If using the flat file method, data needs to be in the chargeable record to determine if the charge is hospital or professional. It comes unused on chargeable records and can be set to hospital or professional. Then a destination needs to be created for professional and or hospital. These destinations do not need code behind them like typical Epic destinations. They can be blank records. Their sole purpose is to give the report something to search for. Then a rule can be written like this: All charges with hospital claim type equal to professional send to professional billing. This keeps the logic simple and allows for easier long term maintenance.
    A final consideration is the reporting workbench reports for charge reconciliation. These are recommended no matter which charge? delivery method is used. Staff will use these reports to verify what the interface sent or what was received via the flat file. If the flat file is used an exact copy of it with the same fields cans be created which allows for easy verification. Additional reports are built and designed based on the needs of an individual site. In summary, sending charges from EpicCare to GE for billing is possible and the client can chose from a couple different ways to configure Epic to make this happen. The decisions around these are site specific and can depend on the financial and staff resources of the client. Once the decisions are made and a plan put in place it is feasible to use an EpicCare and GE for billing.
    800 West Cummings Park, Suite 6000, Woburn MA 01801 Tel 781.935.1002