Spring 2013  
Return on IT Investment
Over the past 10 years, Healthcare organizations have made significant investments in information technology to improve their abilities to deliver patient care and to enhance their financial performance. Given the rapid rate of changes in our industry, and uncertainty over healthcare reform in particular, Boards are more focused than ever on the Return on Investments in IT. While projecting financial ROI is now common place for IT planning, healthcare organizations need to include clinical quality into their ROI analysis.
For example, understanding baseline quality measures frequently identifies opportunities or requirements for improvement. Implementing new workflows supported by leading edge technologies improves the ability to continually monitor these measures in a real time manner and to better incorporate evidence-based approaches into the patient care model.
An effective methodology for measuring both qualitative and financial benefits should include the following components:
  • Identification of key areas and drivers of change related to the acquisition and implementation process.
  • Analysis of the impact of this investment related to items such as quality, patient safety, process improvements, communication and regulatory compliance.
  • Evaluation of financial performance information pertaining to patient flow, resources, and billing improvements.
  • Roadmap for how to carry the ROI analysis forward to establish quality and financial targets, and to continually monitor and manage an organization's progress towards those goals.
Culbert would like to congratulate Mount Sinai Medical Center on their Davies Award. We were fortunate to have worked with Mount Sinai to develop their ROI analysis as part of their application. While healthcare organizations like Mount Sinai have made substantial investments in information technology, it is always interesting and enjoyable to help organizations understand the value realized by these strategic initiatives.
Preparing for Allscripts v11.4
By Keith St Denis
Spotlight Article
Allscripts Enterprise EHR v11.4 provides clients with an ICD-10 compliant platform as well as significant improvements in the performance of the system for many key functions. Allscripts is not the only vendor that has bundled performance enhancements with their ICD-10 version and it is clear that the feedback from the provider community has been heard and remedies have made their way into many of the vendor offerings. The topic of system performance to improve the provider experience may be worthy of its own article but below we will focus on how you can best prepare for your upgrade to v11.4.
The deadline for ICD-10 compliance remains October 1, 2014 and CMS is suggesting that all practices begin their formal ICD-10 project no later than April 1, 2013, a full 18 months before the deadline. This start date presumes that internal communication is well underway and that all payers and vendors (systems, billing services, clearinghouses, etc.) have been contacted and assurances have been received that they will support ICD-10. As a user of Allscripts, you already have these assurances in hand!
At Culbert we have established the following four phase process to help you prepare for and upgrade to v11.4. These four phases represent classic IT best practices: Planning, Preparation, Execution, Post Go-Live Activities.
Phase 1 Planning
Your upgrade to v11.4 needs to be done in the context of the larger ICD-10 project and begins with scheduling your upgrade date with Allscripts. Allscripts has a specific upgrade methodology for v11.4 and each client will work with them to establish the right mix of client, Allscripts and outside resources needed for a successful project. Key items that need to be addressed in this step include a review of the system environment and identifying and installing any new hardware needed. A review of your Careguides and Notes to identify any customization that will need to be transferred to v11.4 is another important step. But perhaps the most important step in the planning process is the set up and use of Allscripts' Problem Mapping Tool. In planning for your upgrade to v11.4 and the transition to ICD-10 it is important to know that Allscripts recommends installing the PMT (Project Mapping Tool) on your current server in your current live 11.X environment. You can begin mapping and planning now for your upgrade and be ready for ICD-10.
Phase 2 Preparation
Working together with Allscripts and any chosen outside resources, you will confirm that all of the steps in Phase 1 have been completed so that the Execution Phase can be completed as planned. Allscripts will certify that you are ready for the upgrade and that all of your customizations have been taken into account. During this phase the training plan will be completed and further communication to the end user community takes place. A project timeline will be established based on the number of modules installed as well as the overall complexity of your environment including interfaces and downstream processes.
Phase 3 Execution
This phase begins with the installation of the new version into your environment. The timeline established in Phase 2 will be used to drive the project and as with all complex projects, weekly calls with the key project team will take place. Allscripts will provide standard test scripts and you should be prepared to add any site specific testing that is needed to ensure a successful go-live. Complete testing of the installed modules and integrated workflows is critical to your project's success. Training of the end users will take place during this phase and should be done as close to the expected go-live date as the number of users and the calendar will allow. Planning for the go-live is an important step in identifying any last minute issues and lining up the necessary resources. If all of the work has been completed and the resources identified, then the go-live event should be a virtual non-event.
Phase 4 Post Go-Live Activities
If any items were defined as out of scope for the upgrade to v11.4, these will be completed during Phase 4. This phase is also an opportunity to circle back with practices and providers that were identified during the project as needing additional attention and coaching.
Allscripts has packaged the v11.4 upgrade to meet ICD-10 requirements and to improve the efficiency with which providers can navigate through the system. I hope that this brief overview of the steps necessary to successfully upgrade your environment is timely and provides you with a high level roadmap to success. If you have any questions, I can be reached at
Growing Pains, Epic and Healthcare Cost Reduction
By Tom Gantzer
With Meaningful Use initiatives maturing, Accountable Care Organization pilots underway and Healthcare Exchanges beginning to come more clearly into focus, we've seen increased attention return to the ability of EHRs to not only improve patient care and safety and share data across providers and organizations, but it's potential to reduce costs and its ability to do so. According to a New York Times article and the most recent RAND report, the continued use of EHRs has brought about a trend contrary to what industry experts had expected. One study shows that there has been a 40% increase in the frequency that expensive imaging tests are being ordered and to a slightly lesser extent lab tests, that 40% is when compared against patients whose providers utilize paper charts. While there are many factors and functionality that make the EHR in all its forms both perfect and imperfect at achieving reduced costs, the relative ease that is associated with electronic ordering is the one culprit that should be suspect and one of the more widely speculated. Regardless, the ability to have and review an integrated chart is supposed to reduce redundant ordering of expensive tests which make up a large slice of the pie in US healthcare costs. Another change that we're all aware of that has increased costs to payors is that EHRs have allowed us to take billing to a very granular level. As an example, the level of specificity has resulted in an increase of one billion dollars in Medicare reimbursements for 2010, over what was collected 5 years previous. The RAND report also identifies that it's not all negative. They call out specific successes in this arena and one important one is tied to Epic. Kaiser has effectively shown through their partnership with Epic that the goal can be achieved to improve care and drive down costs. As this relatively young EHR industry continues to evolve, productivity and efficiency potential are sure to be realized as they have at Kaiser who has spent over 10 years getting to that point.
As Epic users, builders, and administrators we need to use the tools that are in our hands. Clarity reporting, Reporting Workbench, Best Practice and Order Composer are just some of the readily available tools available to counteract the current trend that goes against the new value vs. volume paradigm.
Utilizing or bolstering your organization's reporting team is already an absolute must with Meaningful Use stages III, IV, and V and with ever shifting legislation. Organizations at this point should be able to track and trend high-dollar ordering, associate it with a patient's medical history, and bring findings back to quality and physician review boards for action.
Best practice advisories and order settings can warn when ordering tests that have similar recent results. Sometimes prompting a busy physician to check Chart Review for historical information they may not have previously. Organizations can also look at more prominent solutions such as identifying high-dollar tests and requiring the ordering provider to supply justification over and above a diagnosis link.
User education and training cannot be understated. Many organizations have utilized template e-learning as a way to circumvent costly and time-intensive classroom training and paid the price for it. Early user acceptance and informed use of the system are ways to get our users to really utilize the entire tool in front of them instead of taking advantage of only pieces of it that result in some of the issues we're seeing now.
Admission/Registration: Helping to Improve Accounts Receivable
By Lois Kleisinger
One of the most important areas to improve AR is the admissions/registration areas of any healthcare organization.
Many facilities band aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient. It is estimated to cost heathcare facilities between $10 - $15 per visit to track and collect co-payments and deductibles after the fact. For many heathcare organizations, such as physician's offices, this practice could result in a zero net revenue gain. Additionally, it costs heathcare facilities approximately $15 - $25 per visit for billing staff to correct registration errors and approximately $5 - $7 per statement sent to patients for co-pays, deductibles and co-insurance's that could have been collected up front.
So what steps can a healthcare facility take to remove the admissions/registration area band aids and ultimately improve their AR?
Step One: Management open to changes.
Most admission/registration managers have vast experience in their field and want nothing but a well run department. However for many managers the stress of running a high volume department that can potentially be open 24 hours a day does not allow them the luxury of looking outside the box. Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers which identify errors, and some applications do not record who made the error(s) so they cannot be addressed with that individual. For improvement and changes within the admission/registration areas, management must be open to changes, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.
Step Two: Assign an impartial third party.
The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party. This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism. The impartial third party should not only meet with management of these areas, but 75% of the staff covering all shifts.
Step Three: Logging issues.
This is not the time to address or correct issues that are discovered. Although issues presented need to be clear and concise they should not be demonstrated or dissected as this is purely a fact finding process. All issues discussed are to be logged no matter how insufficient they may appear.
Step Four: Organization.
Issues need to be organized into categories such as process, system, staffing, training and education. Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve(such as lack of staff).
Step Five: Resolving issues.
Process issues: It is imperative that management and staff be open to resolving processing issues. A process should not be kept in place because it has "always been done this way" but because it enhances the admission/registration process. An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the work flow and changing what does not work. System issues: Are the admission/registration pathways specific to your site or are they generic? Does the application provide "help" screens or pathways that are easy to maneuver and are they specific to your site? Are required billing fields designated as "must enter" and won't allow staff to by-pass? Is your Information Technology (IT) staff knowledgeable of your environment and application? Is your application vendor directly involved with improving your application pathways? Can your staff search for a patient's prior admission/visits within the application?
Staffing: Are the errors the result of under or overstaff? Both can be issues for admission/registration areas as too much work per staff can cause a hurried approach whereas too little staff can cause disruptions in daily work. When are most of your admissions/registrations? Can your facility add or deduct staff according to daily needs? Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient's visit?
Training: Has your staff been properly trained in the work flows of the department and admission/registration pathways within the application? Does staff understand what fields are required and why? Does your staff update prior admission/registration information or just process the data?
Education: Correction of errors must be done by the admission staff and not billing. This is very important because they need to understand what constitutes an error and why. Some applications only record the last person who worked on the admission/registration versus who made the error. This limitation should not stop management from requiring error correction. Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.
Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities – billing. As registration is made aware of their errors it is to teach them how to perform registrations and keeps them from repeating the same errors over and over again. Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.
Schedule Optimization Leveraging Epic Cadence
By Seth Marlow
Our client, an academic group practice, is a research-driven academic medical center, with more than 2500 enrolled residents and fellows, and more than 2000 full-time faculty. The organization's facilities accommodate nearly two million outpatient appointments a year. Patient surveys reported negative patient experiences regarding patient access, including long call times for appointment scheduling and long wait times for specialist appointments. In addition to revealing patient dissatisfaction, these results highlighted a problem of reduced internal specialty referrals due to wait times for in-network providers. Even as patients were referred outside the network, productivity for specialist providers-- as assessed by RVUs-- was dropping below target levels. Some specialists were personally screening patients before approving their appointments, and in some cases were selecting cases of interest to them by way of diagnosis. In addition to impacting patient access, lower productivity was reflected in reduced charge capture. Additionally, the captured E/M code mix, compared to national specialty-specific code mixes, suggested strong potential for lost revenue.
Long scheduling call times reflected specificity of scheduling to provider preferences as well as excessive creation and use of unique visit types. Culbert Healthcare Solutions was engaged to provide a comprehensive assessment related to improving scheduling efficiencies and overall patient access, ensuring optimal use of internal resources and implementing best practices to improve the referring provider and patient appointment scheduling experience. The goals of this assessment were to identify areas for improvement in patient access while maintaining key reporting requirements and appropriately maximizing revenue, and improvement in provider productivity. An additional goal was understanding the business needs associated with the significant number of unique visit types and determining how to have those needs met while minimizing the number of visit types and improving patient access.
Assessment began with interviews of managers, staff, and physicians from the specialty clinics included in the optimization (General Internal Medicine, Mineral Metabolism, Internal Medicine Subspecialty, Cancer Center-Bone Marrow Transplant, Digestive and Liver, Cardiology, Pulmonary, Cancer Center, Infusion Center ), and also included call center managers and advisory physicians. Collected documentation included provider templates from each provider in each clinic, scheduling guidelines for each represented specialty, other documents related to daily schedules, and patient access related reports including the Third Available Appointment report. Interviews and documentation reviews revealed common problems related to visit type and length, slot type and availability, and provider profile.
In some cases, disagreement among the visit length specified in the provider profile, the visit length specified in the visit type, and the length of available slots built into the provider template rendered Epic's auto-search function unusable. Visit type lengths varied not only among clinics, but also among providers within a clinic, requiring both a multitude of visit types and complicated, provider-specific scheduling guidelines. Inconsistencies regarding the "public" availability of time slots stymied centralized schedulers, who complained of seeing open, appropriate time slots but being unable to schedule into them because they had not been made "public." This was one cause of calls from central scheduling to clinics for scheduling guidance.
These template-build related problems supported and compounded issues related to policy and perception. Namely:
  • Mistaken user perception of billing implications associated with standardizing visit types
  • Provider-specific scheduling information maintained and updated in notebooks kept at the central scheduling location and referenced as needed for each provider
  • Majority of internal medicine providers had closed panels and saw relatively few patients per session, limiting the role of internal medicine as an inroad to specialty care and potentially impacting system-wide volumes
  • Policy inconsistencies regarding provider requests for time away from the clinic
  • Inconsistent session volume among providers as a result of partial session use, resulting in long patient wait times; sporadic schedule changes requiring increased template maintenance and patient rescheduling
Policy recommendations related to the above include:
  • To the greatest degree possible, standardize visit type lengths among providers within a specialty in order to maximize productivity and reduce confusion among scheduling staff
  • Limit diagnosis-based scheduling preferences as appropriate and eliminate provider review of records prior to scheduling
  • Increase patient access by developing a health system standard related to Internal Medicine panel size
  • Increase consistency of provider schedules by consolidating clinic sessions and scheduling a required number of full sessions weekly
  • Implement a system-wide policy regarding leave request and standardize the Absence Request Form to reflect that policy.
  • Require all Absence Request Forms to be processed by a manager who has the authority to require physicians to comply with the leave request policy
  • Standardize policy on overbooking among providers and clinics
  • Hold common meetings in each clinic area to convey new policy information and ensure all staff members are updates on new policies
Changes to template build and related components support and complement the policy recommendations. These changes include:
  • Reduce the overall number of visit types available
  • Synchronize values for visit type length among provider profiles, visit type profiles, and template slots
  • Identify appointment slots as "new" or "established;" program slots to convert from "new" to "established" if they are empty 3-5 days prior to the appointment date
  • Similarly, program slots to become "public" once they are open to established patients allows appointments for such patients to be scheduled at the central scheduling facility
  • Implement use of provider subgroups and other software-based restrictions to reduce dependence on analog sources of provider scheduling preferences
  • Use security restrictions to limit access to template build and maintenance activities
New workflows related to template build and visit type changes were presented to schedulers in training and documented for their future reference.
  • Reduced the number of visit types from 150 to roughly 20
  • Improved E&M coding through provider education
  • Aligned registration and scheduling templates to ensure provider RVU's are met
  • Instituted patient access best practices to avoid losing clients to competing healthcare facilities due inability to see specialist
These efforts resulted in the client seeing a 14% growth rate in its ambulatory practice, increased patient appointment slots by 25% overall and required health system standards for provider sessions. This optimization effort is now being expanded to other departments throughout the group practice.
Self Pay Management: Taking the Next Steps Toward Revenue
Cycle Optimization

By Jim Akimchuk
As practices face shrinking reimbursements and increasing costs, there has been a lot of discussion about the need for efficiency in the revenue cycle. Frequently offered ideas include automating key business processes, tightening physician documentation and enhancing payer relationships. Although these are all valuable suggestions, there are a few lesser known strategies for revenue cycle optimization that practices should consider.
Get Control over Self Pay
While practices are focused on growing payer reimbursement by seeing more patients, many overlook the patient portion of the healthcare bill, waiting until the insurance company sends its payment before reaching out to the patient about his or her responsibility. This approach increases the workload of internal collections staff—the area of your practice that receives all unresolved accounts. These individuals are typically overwhelmed working a variety of issues and getting a self-pay account addressed quickly may not happen. Additionally, patients aren't as motivated to pay their bill if the service has already been rendered. If the bill is sent to an external collections agency, the cost to collect goes up further, as practices can pay between 12-30 percent on any collected dollars.
Requesting self-pay payments at the point of care lessens the costs associated with obtaining them. Using an automated tool that estimates the patient portion of a healthcare bill can help practices move patient payment upfront. Historically practices were hesitant to use software that estimates patient allowables due to inherent inaccuracies. More recently however, these programs have become easier to set up and the accuracy has increased significantly. Such software programs look at allowables and reimbursement amounts based on a practice's contracts and generate a realistic estimate of what the patient will owe. With the insurance information in hand, information can be entered into the program in advance of this visit, making the patient responsibility readily available when the patient arrives.
Circle Back and Update the Claims Scrubber
A common recommendation for boosting performance is to use a claims scrubber to identify missing data or inappropriate codes and missing modifiers before a claim is sent to the payer. This allows a practice to fix common issues prior to claim submission, sometimes resulting in cash back within 14-28 days.
While many practices have implemented claim scrubber and correct claim edits one-by-one. They do not, however, look for trends in both claim scrubber edits and denials which, if corrected at the root cause, would save the work associated with working claim scrubber edits and denials. An additional benefit is increased cash flow and payments being received sooner. This is more cost effective than waiting until the claim gets denied to address the issue. It can cost a practice as much as 3-5 times more to resolve a denied claim as it does to get the claim clean up front. Being proactive is especially important for large volume practices where eliminating multiple denials by shifting corrections earlier can translate into significant savings.
Get Creative
The ideas outlined here go beyond the typical revenue cycle improvement strategies and they can help practices take that next step toward optimization. It's important to think outside the box when considering ways to streamline revenue cycle operations. By keeping your work flow as nimble and cost effective as possible, you can widen narrowing margins and lay the groundwork for future growth.
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