Winter 2016  
Patient Access, Patient-Centered Care, and Population Health – Let’s Connect the Dots…
By Dr. Randy Jones
After four years as a senior operations executive with a large Academic Medical Center, I moved back into healthcare consulting a few months ago. As the firm continues to research patient access solutions for current and prospective clients, there are several facts that I feel we, as an industry, need to reflect upon if we are going to be successful in a rapidly evolving healthcare marketplace. As we begin 2016, here are some interesting facts to consider.
  • Thanks to more than $12 billion in Federal stimulus dollars since 2011, Electronic Health Records (EHRs) are now in wide use by the majority of healthcare providers. Over 430,000 practicing physicians have registered for the CMS Meaningful Use (MU) quality incentive programs (Medicare or Medicaid) and physicians have received 83% of the incentive payments made1. However, it is one thing to install an EHR and it’s another to be an effective and efficient user of the technology. We continue to hear from colleagues and clients that whole groups or classes of specialty physicians “refuse” to use the EHR, insisting that a medical scribe be assigned to the practice, or dictate the majority of the documentation associated with the patient encounters, creating clinical data that is not easily retrievable or reportable. Data published by CMS earlier this month indicated one in five Eligible Professionals will be receiving a Medicare payment adjustments in 2016 for not being meaningful users2. Refusing to use the EHR is a significant problem in the environment we are moving to where data will be critical in managing the health of a defined population. Without data, and especially in those medical specialties where treatment costs are high, we are flying blind (worst case) or making half-baked decisions with incomplete information (best case). Medical scribes may be a reasonable approach in some of these situations, but they add operating costs to group practices as margins continued to be pressured by shifting payor mixes and payor consolidations.
  • Healthcare spending topped $3 trillion in 20143 largely fueled by 12% cost increase in new specialty drugs. Private health insurers spent 33% of this figure, Medicare 20% of this figure, and Medicaid spent 16%. Research by the Kaiser Family Foundation (KFF) is projecting per capita health care expenditures to grow at an average rate of 4.9% between 2016 and 20244.
Additional research by the KFF has shown that single coverage health premiums have increase by 24% since 2010, but single coverage deductibles have risen by 67%5. This cost-shift from employers and insurers has created a problem for one in five working age Americans who have health insurance with the majority citing increasing copays, deductibles, or coinsurance as unaffordable in a recent New York Times survey6. The Affordable Care Act has reduced the number of non-elderly Americans without health coverage (estimated at 10.5% at the end of 2015, down from 18.2% in 2010)7, but coverage does not equal access to care as provider networks narrow in an effort to control costs.
  • The “Big 5” commercial insurers are trying to become the “Big 3” with mergers that are in various stages of approval by shareholders and regulators. It’s widely discussed in the literature that reimbursement by commercial insurers cross-subsidizes the cost to provide care to Medicare and Medicaid/CHIP patients. An October 2014 study by the American Medical Association found that 72% of metro areas in the U.S. had a “significant absence of competition” and that 17 states had one insurer with a market share of 50% or greater8. Fewer insurers provide fewer options to employers and individuals seeking health coverage and less negotiating power to health systems and providers. This will clearly impact future reimbursement rates9.
  • Timely access to primary and secondary healthcare is problematic. A thought-provoking, peer-reviewed study by the Institute of Medicine, Transforming Health Care Scheduling and Access: Getting to Now10 found what most of us in ambulatory operations know – access is variable, supply and demand is mismatched, the scheduling system is often provider-centric (v. patient-centric), standardized measures and benchmarks need work, and leadership engagement is critical. The study shows how operational leaders in large and complex organizations have used a systems approach to improve access to both primary and specialty care. Many of these concepts have been around for years, but the resonating theme is that it takes a strong leadership to execute these plans.
  • Our leaders are concerned. Research published by the American College of Healthcare Executives (ACHE) in 201511 indicate that CEOs remain very concerned by health reform and specifically the need:
    • to reduce operating costs;
    • the shift to value-based reimbursement models;
    • the alignment of incentives between providers and payors;
    • and, the need to align with physicians more closely.
    Andrew Chastain published last month his “16 for 2016: Key strategic questions for healthcare CEOs in Becker’s Hospital Review12 based on his interviews with dozens of senior leaders over the course of 2015. Although all of Chastain’s questions are relevant to the world we are living in, these three really resonate with those of us with a clinical operations background:
    • Are we interfacing with our patients in a retail-oriented, consumer-friendly fashion? What essential and innovative services can we pursue to improve the experience of patients and/or "health consumers"?
    • Are we educating patients and families enough about change? One example: In many cases patients are being treated by clinical assistants and health professionals other than their physicians. Are we communicating the rationale behind this so that people understand why their care and caregivers are changing, and that it can be for the better?
    • Can information get to the right people though the right technology at the right time? Now that we have implemented Electronic Medical Records and other new business process systems, can they be leveraged to greater benefit? Can we recoup the costs of investments and see dramatic gains in quality and efficiency of care?
Armed with this information, let’s connect the dots.
As an industry, we have made huge strides in the adoption of technology over the last four years. MU (both Stage 1 and Stage 2) have challenged many of our workflows, but they also served as an “opportunity” to improve and leverage change in clinical operations. Many organizations now have years of clinical and administrative data available to examine scheduling variation (i.e., using a systems approach) and realistically consider alternative care models such as virtual visits for established patients for straight-forward clinical problems.
Costs continue to rise and we are naïve to think that one-third of our purchasers, the large private insurers and self-funded employers, are not going to seek value in their healthcare spend over the next couple of years. Population health is real and it’s here to stay. Health systems will need the tools to manage the overall health of a defined population and provide the service and access that the new health care patient / consumer will demand. Economic “steerage” attributable to narrow networks may keep some patients with their historical providers, but when access to care is suboptimal, the new health care patient / consumer will seek other options and this will be especially true when they are responsible for the first $1,000 to $2,000 of their care expenses annually. When these patients leave their historic providers for episodic care, opportunities to address care gaps can be lost. If care is delayed or skipped because of access issues, costs go up when the needed care is eventually received. Generationally, our younger patients are looking for speed, convenience, and quality. A secure online patient portal and social media presence is no longer an option, it’s a necessity.
As health care operations leaders, are we prepared with innovative patient access models (i.e., primary care open access, after-hours urgent care, online scheduling, optimized specialty clinic access, e-consults, advice lines, and virtual visits) to keep our “at risk” patients within our network of hospitals and clinics? Do we have a retail strategy for those patients who need acute, episodic care? Do we have a strategic plan around patient access that has been developed with our clinical leaders, discussed with our patients, and that has executive leadership buy-in?
Health care organizations that have answers to these questions and plan around some or all of these initiatives will thrive as our industry transitions from a quantity-based economic model to a quality and value-based economic model. What’s your plan?
6. NYT Survey, January 5, 2016 from
8. American Medical Association (2014). Competition in health insurance: A comprehensive study of U.S. markets.
9. Dafny, L. (2015). The risks of health insurance company mergers. Harvard Business Review
10. Kaplan, G., Lopez, M., et al. (2015). Transforming health care scheduling and access: Getting to now. Institute of Medicine of the National Academies.
11. American College of Healthcare Executives (2015). CEO Survey: Top Issues Confronting Hospitals 2014. Healthcare Executive, March/April 2015.
12. Becker’s Hospital Review, December 3, 2015
Upcoming Conferences: Come See Us at HIMSS and AMGA
HIMSS - Feb 29 thru March 4th 2016 and AMGA - March 10 thru March 12
HIMSS 2016 – Culbert Presentations
Clinical Transformation: A Change Management Success Story
March 2, 2016 — 02:30PM - 03:30PM PT
Sands Expo Convention Center
Galileo 1004
This roundtable discussion will focus on strategies to effectively manage change during a large scale electronic medical record and practice management technology implementation. It will specifically address clinical and revenue cycle transformation, and how the process led one organization to an elevated level of clinical quality and enhanced financial performance.
Jocelyn Benes-Stickle, RN, MSN
Johanna Epstein, MBA
How to Transform and Optimize a Large Scale Revenue Cycle Operation
March 1, 2016 — 02:30PM - 03:30PM PT
Sands Expo Convention Center
Marcello 4404
Faced with the need to maximize reimbursement while still providing high quality care, healthcare organizations have begun to invest in the “front end” of their revenue cycles. This session will describe how New England Life Care proactively strengthened its revenue cycle through productivity tracking, follow-up processes, denials management, communication and monitoring. Lessons learned, results and ROI will be shared.
Michael G. Souza
William O’Brien
Assessing Revenue Cycle: Staff Productivity
By Jill Barton
Spotlight Article
How are you measuring revenue cycle staff’s productivity? Answers given by management range from “yes, daily” to “I don’t have time”. Whatever your answer, measuring staff productivity can greatly benefit your operation by highlighting areas for staff education and operational improvement, as well as potentially increasing revenue.
In order to measure productivity, begin by having something to measure it against. Productivity goals can be internally or externally created, but no matter their origin, the goals should be clearly defined and understood by the staff being held accountable to them because when productivity measurement is first started, there can be resistance from staff and managers alike. A target that everyone can understand can help create buy in. The goals should contain both quantity and accuracy measurements. For example, 2009 Walker, Woodcock, and Larch recommend check in staff that verify registration information only (no cashiering or insurance verification) should be able to check in 100 – 130 appointments per day with 95% accuracy.
Once you have the goals established, you are ready to move on to the measurement itself. Measurements and feedback to staff should be timely, either daily or weekly. Given the previous example for check in staff, it is not necessary to review all 100-130 appointments for any given staff member for the day. A small sample, 10 - 15 appointments, should give an accurate representation of actual performance. If the staff falls below the 95% accuracy/100-130 appointment per day threshold, determine if it is one issue or many. Also determine if the staff had one bad day or if it is an ongoing problem. For ongoing performance issues, identify and address training or resource needs as indicated.
Issues to consider when rolling out productivity measurement:
  • Know your starting point
    • Staying with the registration example of 100 -130 appointments/day, if you look at your current state and staff are at 50 per day, telling them they have to double their output could cause anxiety, but implementing a graduated approach helps create buy in by setting realistic yet challenging goals. For example: Implement a plan where in 2 months, with additional training and resources, the expectation will be 70 appointments per day, in another 2 months: 90 appointments, and 6 months after implementation staff should be at industry best practice of 100-130 per day
  • Define accuracy
    • Accuracy can be measured against any and all of the following:
      • Department policies and procedures, or
      • Training documents for system requirements
      • Published insurance company policies
    • Other items to consider are:
      • Are the above items available for staff to easily reference (i.e. do staff have the appropriate systems security and access to find the internal documentation: Do they have the proper sign ons for external websites as needed?)
      • Have the specific elements been defined for accuracy? Have they been communicated to staff and signed off by staff as understood?
    • Keep an open mind
      • It is possible given current staffing education levels, as well as resource constraints, that achieving industry best practice could take longer than expected. Be open to making adjustments to reflect realistic, achievable, yet challenging goals for staff
Improving accuracy leads to staff touching accounts fewer times and a cleaner accounts receivable with fewer days outstanding, and will also generally lead to higher cash collections and can show improved patient satisfaction with the billing function.
Starting productivity measurement may be time consuming in the beginning, but the potential upside for revenue and operations downstream is well worth beginning and maintaining the process.
How SmartForms Can Improve Clinical Documentation
By Jennifer Furlong
SmartForms are a powerful but somewhat underutilized documentation tool by many Epic clients. There seems to be a perception that the function of a SmartForm can be easily duplicated by a documentation flowsheet, a SmartText, or a SmartPhrase and that the additional design and build that is done for a SmartForm is not warranted in most situations. While SmartForms can perform the same function as a flowsheet or other SmartTools, they have benefits in terms of functionality and use that may make them a more appropriate documentation tool in certain scenarios.
Benefits/Use Cases of SmartForms
  • Improve Documentation Accuracy – Many providers use SmartPhrases, SmartTexts, and other templates or carry forward previous notes as documentation shortcuts. While these can be helpful time savers, there is also the potential for inaccurate information if a provider forgets to change a value or add more specific information. Using the scripting tools in SmartForms can prevent these situations, as a SmartForm can be configured so that contradictory attributes cannot be selected. For example, if the range of motion of a knee is documented in the SmartForm as abnormal, the provider will not be able to check that the physical exam of the knee is normal. The SmartForm scripting can also add questions to the SmartForm when a certain value is selected; if the knee physical exam has been marked as “abnormal,” additional questions can cascade into the SmartForm to provide more detail about the knee.
  • Teaching Tool – For some specialties, a SmartForm can serve as a teaching tool for medical students and residents. An orthopedics attending once noted that using SmartForms for the physical exam was an excellent method for teaching the exam to students and served as a checklist for residents to ensure that they were documenting all of the appropriate elements of the exam. Creating SmartForms for physical exams, histories, or other assessments can promote consistency in teaching clinics for both attendings and students.
  • Standardization – The structured nature of a SmartForm means that providers can be steered to document a certain set of data in a consistent manner. In any given practice, there is a range of documentation styles, from five paragraph essay notes to brief bullets as a note. Using a SmartForm does not prevent a provider from writing a progress note, but it can provide a structure to document a basic set of information, ensuring consistency in documentation.
  • Special Situations – SmartForms can be utilized to capture data outside of the typical SOAP note structure. Some examples where SmartForms were implemented to meet documentation challenges are:
    • Pediatric Psychiatry – standardized treatment plans
    • Orthopedics – spinal cord injury scoring assessment
    • Advanced Directives – patient treatment preferences form
    • Social Services – eligibility for state funded programs assessment form SmartForms were effective in these cases because they were able to accommodate large amounts of information, provide numeric scores from values entered, and print data to a PDF. While other tools could have performed these of functions, SmartForms were able to do them in a simple, user friendly interface with more customizable printed reports. In most cases, SmartForms were able to replace the paper forms being used to capture data, eliminating the need to scan additional documents into the chart.
Can you think of physicians or specialties in your organization that could benefit from an improvement in documentation accuracy, standardization or addressing the needs of special situations? Regardless of how large or small the need, Culbert’s team of knowledgeable Epic consultants can assist in assessing appropriate use cases and areas for opportunity with the ability to provide support through implementation.
The Necessity for Ongoing Clinical Workflow Improvements
By Huong Tran
When the decision and commitment are made to switch over to an electronic health records system, an exciting journey begins in reaping the benefits of improving patient care while becoming more efficient and reducing costs. It can be an all-encompassing process which includes planning of resources, configuration, testing, training and then going live with the new EHR system. After an organization is live with the new system, often the myth is that the journey has been completed. However, in order to continuously improve patient care and increase revenue, it is recommended to establish and commit to a post- implementation optimization plan amidst all other competing priorities that organizations face in today’s healthcare landscape.
While there are a number of aspects that are involved in a strong optimization program, there are 3 key components to consider when developing or reviewing your strategy to realize success and continued efficiencies in your EHR post implementation.
  1. Revisiting EHR Workflows and Operational Processes
    EHR Workflows and operational processes should be revisited after a period of 3 to 6 months post-implementation and then at least yearly after. Initially after go live, 3 to 6 months post implementation is often when end users are comfortable with the basic usability of the EHR. This is a good opportunity to engage in both observation and elbow-to-elbow support to see which areas are successful, where there are areas for improvements and surveying users in regards to open issues. If an organization is 3 to 6 months or 10 years post-live, the strategy is the same – engage with end users to understand successes and challenges. Time and time again workflow and system issues aren’t reported or habits developed from workarounds are still in place preventing your practice from being efficient and increasing patient volume.
  2. Continuing Education
    With a sophisticated system, there may be features that are not being used to their full potential or with system upgrades, there may be new and improved functionality. This is a great opportunity to revisit these areas to ensure the best user experience. Most users often find themselves overwhelmed during the initial implementation phase and do not engage in personalization of the system to maximize the use of tools available. By incorporating and optimizing personalization tools we have seen reductions in time spent charting with more accurate and complete data. The best approach in providing continuing education whether for system upgrades, personalization tools or other areas is the understanding that each user approaches the system with their own style. Offering a variety of educational techniques such as classroom sessions, drop in labs, computer based training, tip sheets, one-to-one sessions, etc. allows the end users to engage via methods that are most effective for the individual.
  3. Maintain Support Structure
    Maintaining an ongoing support structure with a variety of resources is essential for success in post implementation and continuous improvement. There should be operational champions identified to be involved in ongoing optimization planning, identifying gaps and difficulties while encouraging and supporting new functionalities throughout the health system. There should also be resources and documentation accessible to assist with first time issue resolution when new functionalities and processes are introduced during every optimization effort – large or small.
Regular post implementation review is critical to long-term success of the EHR. Engaging users in a continuous effort to optimize their use of the system and improve processes will alleviate high volume requests to project team members, improve user experience and contribute to an overall goal of improving patient care and safety.
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