HFMA Roundtable

An electronic health record (EHR) implementation can disrupt many areas of hospital operations, and the effect on the revenue cycle in particular may pose significant financial risks. During this time, organizations often see their days in accounts receivable and denials increase while cash flow slows. However, when hospitals and health systems address risks to the revenue cycle prior to go-live and as part of EHR workflow, they can stay on track and maintain positive financial performance during the transition. With this in mind, participants in this HFMA Executive Roundtable, sponsored by RelayHealth Financial, share insights into how to mitigate financial risk when implementing an EHR.

Has your organization recently implemented or are you planning to implement a new EHR?

Teresa Handy: We started our enterprisewide system implementation in late 2010. At that time, we brought five hospitals online in less than a year, and we also rolled out physician billing with a big bang approach prior to our first hospital go-live.

Margaret Schuler: We have just gone live with seven hospitals, 343 physician practices, eight urgent care centers, several home health and hospice providers, and three large medical complexes that include freestanding emergency departments. We started in June 2014 and finished in November 2015.

Greg Meyers: We are in the midst of implementing a single solution that will replace our inpatient and ambulatory clinical programs, as well as the revenue cycle system that supports the hospital and physician practices. We recently brought up physician billing for 450 physicians and the ambulatory EHR for about a third of those physicians. The remaining physicians and four of our hospitals will go live over the next year. It will be late 2017 before we have completed the transition for all of our facilities.

Was a change in revenue cycle partners part of the process in considering EHR solutions?

Jane Berkebile: We made a strategic commitment to move from a best-of-breed approach to one systemwide solution as much as possible, and that meant replacing both our clinical and financial systems. Even though we had a high-functioning revenue cycle, we had 23 different bolt-on products that enabled the process. As we moved forward with the single vendor, our objective was to eliminate as many of the bolt-ons as we could; however, we fully understood that all of them would not go away. In fact, setting that expectation with organization leadership was critical. At first, we had a few leaders who thought the new system would completely replace all best-of-breed solutions, and we had to stress the need to keep several of the original products. We still have around 13 separate programs that integrate with the EHR, allowing us to continue delivering the expected services and results. Some of the programs that remain pertain to patient statements, eligibility, clearinghouse, clinical edits, and so on.

Meyers: We had a lot of internal discussion about whether we should just replace our clinical system—which was the initial driver for the project—and then interface our legacy revenue cycle solution. However, given our primary goal, which is to move to one integrated patient record, we ultimately decided it made sense to make the change on both the financial and clinical sides through the selection of one single vendor.

Dyke: EHR system vendors may come to the table with “preferred” revenue cycle vendor relationships they want providers to adopt. With this in mind, it’s important to weigh the true cost of changing your revenue cycle-specific technology, especially during an already tumultuous core system change. You need to fully understand what benefits you’re giving up and what revenue cycle processes will be affected by changing technology. For example, there may be capabilities in your current claims management system and processes built around those capabilities that, if eliminated, would negatively impact payment speed and cash posting efficiency. Limitations in legacy patient accounting platforms often restrict what organizations can reasonably accomplish with their revenue cycle technology. New EHR platforms have improved standardized integration and data exchange capabilities, allowing providers to more fully leverage features their existing revenue cycle tools may have long supported. A great example of this is in patient access, where tightly integrated real-time processing through Web services and bidirectional HL7 can deliver considerable value—without requiring a wholesale revenue cycle system replacement.

What did you do to prepare for implementation in terms of the revenue cycle?

Meyers: Almost immediately after Integris made the decision to onboard a new EHR, the revenue cycle department began performing an end-to-end assessment, looking at every revenue cycle segment and validating whether existing workflows were the most efficient and optimal ways of doing business. We tried to make sure this was an honest evaluation of what was working and what needed to be changed. Basically, we were looking to improve operational efficiency and patient satisfaction while at the same time taking cost out of the revenue cycle—with the ultimate goal of reducing our cost to collect.

Schuler: Approximately two years before we launched the EHR, we engaged a consulting group that partnered with us to ready the revenue cycle for the transition. Three key areas in which the group focused were charge testing, mitigation of discharge-not-final-billed (DNFB) spike, and claim testing. Because we had heard a lot of buzz in the industry about losing gross revenue during a system implementation, we were eager to make sure we would not have that experience. Our target was to get back to baseline gross revenue within 14 days of go-live, and we exceeded that at all of our hospitals, getting back to baseline within 10 days. At a couple of our facilities, we were able to get back to baseline within five days. With our extensive DNFB risk-mitigation plan, we spiked at week four post-implementation. Now, less than a year after our first hospital go-live, we are exceeding our baseline performance metrics (i.e., under 5 days).

The consultant also helped with claims testing. We wanted to check as many claims as possible and even performed parallel testing, where we pulled 5,000 claims from our legacy system and ran them through the new EHR to make sure the results were the same. During this exercise, we took the opportunity to build edits up front within the EHR rather than having everything run through the claims management system. This drove up our clean claim rate significantly. With our legacy tool, the clean claim rate hovered around 85 percent. With our new system, we hit 98 percent nine weeks after go-live.

How did you ensure that the revenue cycle was part of EHR workflow?

Handy: At Legacy, we started working on implementation 18 months before cutover, and immediately the revenue cycle vice president and patient financial services (PFS) director were in the same room with key leaders from information systems and our EHR vendor determining how the project would unfold. This group discussed the timeline, project management, what the different phases would look like, how long we would allocate for testing and training, and when go-live would be. Throughout the life of the project, this group and our clinical leaders were virtually connected at the hip. It was because of this close, collaborative relationship that the initiative was such a success.

Meyers: We created a system-wide steering committee structure that constantly reviews the activity of three advisory committees. There is a physician advisory committee that focuses on issues like documentation. There is also a clinical advisory committee made up of nursing and ancillary providers and a revenue cycle advisory committee consisting of representatives from every constituency that the revenue cycle touches. From day one, each of these groups has delved in to what we need to do to ensure a successful go-live and to understand the interdependencies of each group. For the past year and a half, the advisory committees have met monthly to review policy, workflow, and IT decisions. During this process, we have reviewed and validated several thousand clinical and financial workflows.

Schuler: We had a similar structure that included a number of multidisciplinary work teams comprised of internal IT, vendor representatives, and subject matter experts from operations. Plus, we had a project manager assigned to each one of the teams, including front-end registration, HIM coding, and, on the back end, a hospital business office team and a physician business office team. These groups met—and continue to meet—weekly. Within that infrastructure, we felt it was important to document our decisions. Throughout our implementation, we documented more than 200 decisions and had both clinical and financial stakeholders sign the documents to show their agreement. These have served us well, supporting the decisions we made and allowing us to go back and revisit our logic. Sometimes you make the best decision at the time, but the conditions change or you learn more, and then you realize that a different decision is warranted.

What were your biggest revenue cycle challenges during this time? How did these impact the organization financially?

Handy: One thing we noticed was the software vendor focused almost exclusively on showing our staff how the system worked, but there was no emphasis on the processes behind the technology. As such, we created procedural training so our staff could learn about the workflow and why we approach the revenue cycle the way we do. During the design phase, we set aside dedicated project time and brought in our superusers and key staff to review the platform as a whole to make sure everyone understood the reasons behind the system functionality and design. We also engaged in staff huddles and had supervisors available one-on-one to answer questions. In addition, we asked employees for feedback on how the training was working and what they were we missing.

Berkebile: We also felt that the revenue cycle staff needed more than just system training. Our goal was to incorporate some theory in our staff education, addressing the who, what, where, and how of revenue cycle processes. For example, we provided the staff with visuals and crosswalks, and we were also able to give real-world scenarios through a test environment. In retrospect, the education may have been a little more effective if system and theory training were combined. Going forward, as new people enter the organization, we are trying to marry the two types of training to give people more comprehensive education in one sitting.

Schuler: One of the other challenges that continues to plague us is late charges. Because we took a “big bang” approach to implementation, the clinical areas are still going through a learning curve and getting used to their new workflows. So, although we are dropping our claims within five days, we are still seeing a fair number of late charges. With our new system, a late charge is not merely a back-end fix; it’s a labor-intensive effort that goes back through the entire edit process. The revenue cycle department is working diligently to bring awareness around the negative effects of late charges. We review regular reports by location and share that information with leadership. The clinical departments are also working to make their processes more efficient.

What key performance indicators (KPIs) did you monitor before, during, and after the transition to identify and respond to problems?

Meyers: We’ve spent quite a bit of time creating dashboards that cover a wide range of metrics, from average registration times to days in A/R to missing charges, and the list goes on and on. We have been tracking these metrics on a monthly basis for more than a year, so we’ll have a solid baseline of historical performance in each area when we go live. As a result, we’ll quickly be able to identify variances. We plan on having daily revenue cycle meetings with key leaders first thing in the morning to review the dashboards. If we see any significant changes, we’ll be able to rapidly implement action plans to identify problems, drill down to the root causes, and resolve issues.

Dyke: There are four strong indicators of performance to watch closely during a disruptive change. First, you want to look at service to payment velocity—how fast you are getting paid. A/R days is the standard industry metric for this measure. Rising A/R days usually indicate a process improvement opportunity. To start responding to the issue, you need a bird’s-eye view of how much time each part of your claims cycle takes. With this perspective, you can see if the slowdown is on your side (how fast you are getting claims out) versus delays with your payers. Finding root causes and having easy-to-interpret data to share with stakeholders in “problem” areas are critical to making timely process adjustments and improvements to keep cash moving.

The second crucial metric is discharge-not-final-billed (or “candidates for bill”), a subset of service to payment velocity, which is probably the best indicator for your organization’s ability to work through internal revenue cycle mechanics. Additionally, charge trends are also valuable to monitor. An EHR implementation profoundly disrupts your clinical departments. It’s important to understand pre- and post-implementation performance to quickly identify delays—and celebrate acceleration—in charge assembly and submission. Finally, an organization should keep an eye on its denial rate. Identifying root causes of denials as quickly as possible can help reestablish processes that may be knocked out of alignment during a system change. You’ll want to set up alerts for timely filing thresholds. During a big change like an EHR initiative, your team could get distracted for various reasons and innocently miss filing deadlines. That is typically an avoidable mistake if you have a way to keep deadlines top of mind.

What are some key strategies you would recommend for realizing positive financial performance during an EHR transition?

Handy: First off, prior to cutover, do all you can to reduce any backlogs, such as coding, billing, denied accounts, and so on. Second, ensure you have cross-representation on the implementation team, especially your front-line staff and key decision-makers, or folks who can make things happen to minimize financial risk, such as representatives from the technology vendor, revenue cycle leaders, IT professionals, and finance (i.e., accounting). Also, at go-live, have dedicated IT staff who can make real-time system changes in the same room or nearby your billing team. Third, you must monitor essential A/R metrics before and after implementation, looking at them daily where you can—even if you typically monitor them weekly or monthly. Never take your eyes off your metrics. And, finally, take time to celebrate your team. Not only do your employees deserve this, but satisfied employees and a happy team are critical to success in general, and it’s even more vital during challenging system conversions.

Dyke: It is imperative for your revenue cycle vendors to have a strong working relationship with one another, as well as the EHR vendor. It’s a good idea to ask your vendors for integration best practices. A credible revenue cycle company will have experience with most EHRs and be able to guide you through the process of blending systems with minimal cash flow disruption.

Handy: Many organizations see a spike in A/R days soon after go-live; however, at Legacy, we didn’t experience that situation. I firmly believe collaboration, integrated testing, and real-time problem solving post-cutover were essential to our success. One integrated test we performed followed the “life of a claim.” We took a full day’s worth of claims and tested them from beginning to end. Although some organization leaders may not agree with this idea or plan, it is vital. It’s the only way to truly know whether your new system is going to work as expected—or properly. Prior to our implementation, we reached out to other organizations that had similar conversions, and integrated testing was a lesson that they shared with us. As a result, we pay it forward and recommend it to organizations just starting their system implementation journey.

Meyers: We are also spending time looking at the revenue cycle from a patient experience perspective. We’re taking this project as an opportunity to redo all our workflows and internal policies and procedures, asking whether they add value to the patient experience or detract from it. Our revenue cycle advisory committee has worked with the hospital’s performance-improvement team to create a value stream map that starts with the first time the patient has contact with our pre-services center and continues through to when the patient receives his or her bill. The group is examining the various touchpoints along the continuum and considering ways to enhance them to make them more patient-centric.

Berkebile: I can’t stress enough how important it is to involve your revenue cycle people in this process. Some of our colleagues in other organizations chose to rely on the advice of their EHR vendor instead of bringing in their revenue cycle stakeholders and getting their input on what functionalities the system needed and how it should be structured. These organizations struggled greatly. By having revenue cycle involved in every step along the way, we were able to anticipate issues and resolve them when they were easier to fix. It needs to be a true partnership between IT, clinical, and operations. If revenue cycle does not own their part of the implementation, the organization will fall short in realizing the optimal experience.

Participants in this HFMA Executive Roundtable

Jane Berkebile is system vice president, revenue cycle management for OhioHealth in Columbus, Ohio.

David Dyke is vice president of product management for RelayHealth Financial in Alpharetta, Ga.

Terrie Handy is vice president of revenue cycle operations for Legacy Health in Portland, Ore.

Greg Meyers is system vice president, revenue integrity for Integris Health in Oklahoma City, Okla.

Margaret Schuler is vice president of revenue cycle for OhioHealth in Columbus, Ohio.

About RelayHealth Financial

RelayHealth Financial provides revenue cycle management solutions to help providers accelerate cash, make informed decisions, streamline operations, and deepen patient engagement—at all points of service. More than 2,400 hospitals, 630,000 providers, and 2,200 health plans rely on RelayHealth Financial to process 3.3 billion transactions worth $1.8 trillion annually. Interoperability experience, award-winning service, and expert implementation staff and processes complement the solutions to help ensure healthy revenue and a healthy future for our customers.

Publication Date: Monday, February 01, 2016