Summer 2011  
Clinical Integration: The Key to Improving Healthcare Delivery
By Jeff Wasserman, Vice President, Strategy and Executive Leadership Services
While there remains uncertainty with the pace and final form of healthcare reform, there is broad agreement that the current level and projected growth of healthcare spending is not sustainable. It is equally clear that there must be a renewed effort at all levels in healthcare to measure outcomes and improve the quality of care. There is significant evidence demonstrating that the best route to reducing cost is through improvements in quality.
Much recent attention has focused on the potential of Accountable Care Organizations (ACOs) to accomplish these important goals. While there appears to be a broad consensus that the recent "draft" regulations promulgated by the Centers for Medicare and Medicaid Services (CMS) fall far short of securing immediate
momentum, almost every health care system, hospital and large physician group is aware of the regulations and discussing steps to prepare for payment reform. There is also a renewed focus on improved and coordinated patient care. In addition, billions of dollars continue to be spent on the implementation of electronic medial record systems, "meaningful use" plans, supporting technology and consulting assistance. Even with current skepticism regarding the proposed ACO guidelines, there is a rush to prepare for a future that is very different from the present healthcare system.
At Culbert, we have a bias on what will be required for healthcare providers to succeed in coming years. Regardless of regulatory or legislative efforts to redesign our healthcare system, the future requires that physicians hospitals find new ways to work together through strategic partnerships. Indeed, there are several things providers can do right now to advance the state of healthcare and support high quality and efficiency. One of the most important things is pursuing clinical integration—the coordination of care between physicians and healthcare organizations.
Step One: Getting Physicians to Work with Each Other
The first prerequisite for clinical integration involves physicians working together within established structures to develop clinical protocols, establish standards and identify ways to improve the clinical experience. These structures can improve quality, drive down the costs of healthcare and move organizations toward a more integrated delivery approach.
When embarking on a journey to clinically integrate physicians with each other, several essential activities support the effort:
  • Understand the mission. Physicians need to fully understand what they are trying to accomplish with a clinical integration strategy and agree upon both short-term and medium-term objectives. These objectives cannot be about increasing reimbursement or securing improved payer contracts. Instead they must focus on improving healthcare through better clinical outcomes, enhanced patient satisfaction and improved value for the healthcare dollar. Pursuing these objectives is not only the right thing to do, but can also avoid potential legal and antitrust issues associated with an initial focus on improved financial performance.
  • Determine the structure that best supports the mission. Depending on the goals of the effort and the variables within a market, a clinical integration strategy may take many forms. A viable structure may include a large group of specialists and/or primary care physicians within a geographic area—or perhaps it will encompass only those practitioners meeting certain criteria. As physicians define the structure, it is important to keep in mind that primary care physicians will ultimately play a critical role in clinical integration because of their ability to coordinate patient care. The more involved that primary care providers are in initial planning efforts—and the sooner they become so—the more successful the integration strategy.
  • Identify leadership. There are two types of leaders needed to support a clinical integration endeavor: Physician leaders and executive leaders. Physician leaders must guide the integration strategy and effort to improve day-to-day patient care activities. Executive leaders can define the infrastructure necessary for the effort, including addressing financial requirements, data management needs, operational issues and so on. Selecting the appropriate leaders requires careful consideration. When developing the mission and structure, certain individuals may emerge as potential leaders based on their leadership abilities, role in the market and their commitment to the clinical integration concept. Particular physician practices and practice leaders may lend credibility to an integration strategy and should be involved early in the development process.
Very often, clinical integration will evolve over time, starting with a small focus on a particular disease and expanding to include a more comprehensive delivery approach. Regardless of the ultimate form of the interaction, getting physicians to work together is not always easy because of professional time constraints and competing priorities. To help get a clinical integration endeavor off the ground, a consultant or other outside advisor may be necessary to provide insight, direction and facilitate the discussion among providers with sometimes competing interests.
Step Two: Partnering with a Healthcare Organization
The second element in a successful clinical integration strategy is collaborating with a healthcare organization, such as a hospital or integrated delivery system. These organizations are essential for clinical integration and bring important resources to the table, including clinical capabilities, operational expertise, community support, capital, infrastructure and technology. However, this stage of clinical integration can be challenging because of medical staff politics and cultural differences between physicians and healthcare organizations. Historical issues of trust between physicians and hospitals often need to be overcome.
Although hospitals in some markets lead clinical integration efforts, this is not always optimal depending upon local circumstances. In many instances, the best strategy is for physicians to organize on their own or with outside assistance. Physician and hospital leaders then come together to discuss their mutual interests in serving the community and improving care. To fully integrate, hospitals and physicians must agree on a mission and objectives, establish ground rules for the partnership and identify leaders to drive the collaboration. These activities will mirror those occurring within the physician phase of the integration.
Although challenging, the benefits of a strong partnership between physicians and healthcare organizations should not be underestimated. Together these groups can manage costs in a way that neither party can alone. They can also identify and implement best practices to yield better patient outcomes and ensure consistent care delivery and quality across the partnership. This streamlined and interactive approach to care can result in improved financial performance for both the hospital and the physicians.
Contemporary Organizational Models
There are many ways to initiate a clinical integration strategy. Inevitably, some structure will be required for both the physicians and the new partnership with the hospital or health system. There are many models and legal structures available to accomplish the goals of clinical integration. The best model is the one that fits local circumstances, recognizes how physicians are organized in the market, builds trust and momentum between the partners.
Don't Wait, Start Now
While the world of ACOs may be a long way off, the time to start exploring clinical integration possibilities is now. Waiting will only delay your ability to provide the best care for your patients and may cause your organization to miss out on important and valuable partnerships. Allowing enough time for a clinical integration strategy to blossom will ensure that you are prepared to provide the best patient care, no matter what delivery system innovations ultimately take shape.
About the Author:
Jeff Wasserman is Vice President of Strategy and Executive Leadership Services for Culbert Healthcare Solutions, a professional services firm serving healthcare organizations in the areas of operations management, revenue cycle, clinical transformation and information technology.
Experience and Commitment
News from Rob Culbert, President
We continue to grow and build the Culbert team by adding experienced professionals who can do an excellent job of taking care of our clients. Doing this has been an objective of this company from the beginning. The most recent additions to the firm are Kent Rowe and Jeff Wasserman. It's exciting to have the opportunity to have these men become a part of the Culbert team because I know the value of their experience and the positive effect their leadership will have on our employees and our clients.
Jeff Wasserman's career spans a variety of healthcare settings including academic health centers, faculty practice plans, medical groups, health systems and hospitals. His experience lays in assisting organizations to prepare for the realities of healthcare reform and the movement toward Accountable Care Organizations. Jeff has overseen the development of several faculty practice plans and large multi-specialty group practices, the expansion of numerous clinical programs and directed the planning of several ambulatory care centers. He has overseen financial turnaround plans at several medical centers, including operational and revenue cycle improvements and also led a "Workforce Excellence" program to improve customer service and staff morale. Most recently, his work has focused on strategic models for aligning physicians and health systems. Jeff joins Culbert as VP Strategy and Executive Leadership and is responsible for the overall strategic direction of Culbert's Executive Leadership Services Team.
Kent Rowe has spent more than twenty years in healthcare supporting large academic and multi-specialty group practices and hospitals by delivering software and hardware solutions to support patient access, clinical, revenue cycle, managed care, e-commerce and health information exchange. Kent joins Culbert as VP Information Technology Services, responsible for leading our Information Technology Team and service line including meeting the needs of our GE and Allscripts client base. Kent Rowe is well known to GE/IDX clients, having served as the Vice President and General Manager at GE Healthcare and several Vice President' roles at IDX Systems Corporation.
Ken and Jeff's extensive knowledge and experience are a great value to staff and clients. I welcome them and believe you will benefit from their guidance and support to healthcare organizations and provider groups.
Successful Conversion from GE to Epic: Avoid Common Mistakes
By Sue Ascioti, Principal Consultant
A conversion from GE to Epic impacts every aspect of the revenue cycle. It's imperative that proper attention be given to how Epic can improve workflows. Repeatedly we see the mistake of planning a transition between systems with too little focus on how the new system will influence and improve workflows. Prior to determining optimal workflows in Epic, it is important that the practices and hospital have a clear understanding of current workflows and understand the impact the implementation will have to patient and provider satisfaction as well as the impact to revenue. Improved efficiency in processes can be achieved if work is done by all levels of staff at the beginning of the project to determine the work flows impacted by the system. While the tendency is to involve staff at the level of supervisors and higher in work flow meetings, we cannot under estimate the importance of including knowledgeable staff at all levels of the organization. Involve those closest to the processes and procedures; those who can provide the most detailed information. Additionally, we strongly recommend that someone who is not a project stakeholder facilitate the work sessions. A facilitator who is not a project stakeholder is able to be objective and keep the work sessions moving. This individual can be either internal or external to the organization. The most efficient way to document work flows is by using "swim lane" diagrams. A swim lane diagram (sometimes referred to as a "Deployment Process Map" or a "Cross Functional Flowchart") is a graphical representation of a process flow that shows the interaction of different departments and system on the process and how the process progresses naturally through the different phases of a task. During these work sessions paper flow sheets, paper orders, billing sheets, etc. should be collected.
During the initial stages of an Epic implementation, Epic staff will facilitate validation sessions for facility staff. During each session Epic will present proposed customized workflows particular to a specific department or work process. This is the first opportunity for facility staff to both see where there current work flows could be optimized and provide feedback to Epic staff on additional customizations needed. Developing the current state work flows prior to the validation sessions increases the value of the validation sessions. While validation sessions take place over the course of days or weeks, it is imperative that facility staff remain consistently engaged in the process and respond to Epic requests in a timely manner during the build process. The validated workflows become an information source for training.
Hiring a training manager is another important task during the initial stages of an Epic implementation. Prior to beginning training this person should become familiar with current and future state work flows as well as have a working knowledge of GE as well as Epic. This will allow this individual to address specific operational and technical questions rather than provide "broad brush" training. We have experienced "one size fits all" as well as customized Epic training and in our experience the time and effort needed for customized training will result in significant, long-term benefits. This could be someone in house or a consultant.
Validated current and future state workflows as well as preparations for training are key areas to improve the revenue cycle during a GE to Epic conversion. Below are some additional recommendations to ensure a successful system conversion to Epic:
  • Understand Epic's Reporting functionality including Clarity and Reporting Workbench early in the process. While there are a number of ways to obtain reports from Epic, Reporting Workbench is the "end user friendly" tool provided by the vendor. Understanding this tool will provide you with insight on how to set up your master files to best meet the needs of the facility.
  • Assess all Visit Types utilized in GE. Epic provides comprehensive rules-based scheduling and can accommodate schedules for clinicians, rooms and equipment. While the tendency is to allow individualized scheduling, this can have a negative impact when schedules become too restrictive. We recommend minimizing the number of visit types and avoid restricting specific visit types to specific times.
  • Ensure that your claims and payment processing partner meets your organization's needs and that you have staff trained and dedicated to being subject matter experts on this tool.
  • Understanding the various types of work queues in Epic and how they function is imperative to developing a work queue strategy that maximizes the revenue cycle. Pitfalls we have seen are the creation of too many work queues, incorrect or missing work queue rules and either assigning too many work queues to one person or not assigning specific work queues to anyone.
ICD-10: Roadmap to a Successful Transition
By Brad Boyd, Vice President
The transition from ICD-9 to ICD-10 codes is a massive undertaking for all healthcare organizations. It's a matter of sheer magnitude, of course: diagnosis codes are critical to nearly all patient care and revenue cycle activities. Add to that the additional burden facilities face implementing ICD-10 Procedure Coding System. With any project this large, success requires carefully mapping out each phase of the journey. In the case of ICD-10, I suggest a five-phased approach: 1) program development; 2) impact assessment; 3) project and implementation planning; 4) implementation; and 5) stabilization and optimization. Here's a look at the key elements in each phase:
Phase 1: Program Development
The very first step is to establish a governance team responsible for oversight of the ICD-10 conversion. It should include representatives from: revenue cycle (hospital and professional, if your organization has both); coding/HIM; clinical informatics and clinical documentation; IT (patient access, clinical and revenue cycle applications); training; and compliance.
You may have one person wearing many of these representative hats in some organizations. That's OK. Just make sure each of these functional areas is considered in your ICD-10 planning. Your project plan should include a timeline and resource requirements by functional area.
Phase 2: Impact Assessment
Your assessment should focus on understanding the training needed to bring everyone up to speed on ICD-10 requirements. Again, make sure to conduct your assessment by functional area: systems, billing and reporting requirements, and training requirements. Once you've assessed each area separately, though, it's critical that you then aggregate them to create an enterprise-wide view of overall impact. You should end up with a documented inventory of all IT applications.
Phase 3: Project and Implementation Planning
After impact assessment, carry out a separate vendor readiness assessment. The goal is to identify all vendors and interfaces affected by the ICD-10 conversion, then contact the vendors to see if upgrades or other changes are necessary to meet ICD-10 requirements. Any associated costs must be documented, and vendors should be asked to provide you with their ICD-10 test plans.
Phase 4: Implementation
With an implementation that includes as many "moving parts" as ICD-10, it's important to clearly identify expectations and measure your progress toward them. Among the implementation tasks you'll need to monitor are:
  • System updates (e.g., templates, electronic and paper claims/remits, and reports) and upgrades
  • Physician documentation training
  • HIM/coding training
  • Revenue cycle staff training
  • Interface modifications
  • Unit testing
  • Integrated testing
  • Development of new reports
Expect a pretty complex testing plan. In addition to internal testing, you'll need to test with external parties including payers, clearinghouses, and other EDI partners. And unless you use a home-grown IT solution, you'll depend on vendors for ICD-10 updates. Don't underestimate the time and effort vendor coordination and testing will take! Develop a testing schedule that ensures each type of EDI transaction you use processes correctly before the Oct. 1, 2013 compliance date.
Documentation and coding training should be performed in the months prior to implementation, and will be important for reducing coding errors and claims denials after go-live. Once you've converted to ICD-10, it'll be essential to conduct real-time monitoring of clinical documentation, HIM and coding productivity, interface error logs, claim edits, claim denials, remittances, physician productivity, patient visit/encounter volumes, and more.
Phase 5: Stabilization and Optimization
For a successful transition to ICD-10, metrics will be key. Tracking performance metrics throughout implementation is the only way you'll be able to spot and fix any potential difficulties.
Perhaps the best part of the whole ICD-10 implementation is the opportunity for improvement that it brings you. Think about it: You've already created a representative governance team. You've already developed a dialog with your vendors and payers. You've already started identifying and tracking vital performance metrics. You've already done the legwork. Now, combine your metrics with your avenues of communication to do more than just implement ICD-10. Use them to develop and optimize future goals through additional training, workflow redesign and system modifications.
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