EHR ... Have you got what it takes?
Every health care organization in the United States now faces significant Electronic Health Record (EHR) challenges. Some organizations have invested millions of dollars in new systems and have matters in hand; other organizations are dealing with patched together legacy systems and are scrambling to get the funds and plans in order to roll forward. Either way, there is something to be said for understanding what you are getting into; specifically, what has to happen and who should be doing it. The following questions and answers are designed to transfer important knowledge to you. If you have a question we haven’t thought of, please post it in the comments and we’ll do our best to get you the information you need.
What’s the value-add of a solid EHR?
EHR technology is not just an exercise in automating a vital element of patient care and business operations; it’s also about transforming how hospital clinical and financial operations perform. Properly implemented, an EHR system can help a hospital provide higher quality care, improve productivity and efficiency, and strengthen revenue management. Here’s how:
· access to clinical information, shared across the health system or continuum of care at a single point in time, smooths clinician decision-making and prevents duplicate requests for services
· automating clinical documentation and standardizing patient care services allows costs and outcomes to be tracked more easily.
Under the 2009 stimulus package (ne: the American Recovery and Reinvestment Act), health care providers who demonstrate meaningful use of certified electronic health records can qualify for Medicare and Medicaid incentive payments. There is $17.2 billion put on the table to reward healthcare providers that use a certified EHR system in a meaningful way, beginning Oct. 1, 2011.
To get at this money, hospitals will need to have a certified EHR system that meets all 24 core and menu objectives, instead of the 19 objectives that a hospital could use to demonstrate meaningful use. However, there has been a great deal of confusion and pushback from various groups, including the AHA and the American College of Emergency Physicians concerning meaningful metrics for meaningful use. PUBLIC LAW 111–148, otherwise known as the Affordable Care Act, published March 23, 2010, basically punted on this issue, deferring to a forthcoming decision from the Secretary as follows:
INTEGRATION OF PHYSICIAN QUALITY REPORTING AND EHR REPORTING.—Not later than January 1, 2012, the Secretary shall develop a plan to integrate reporting on quality measures under this subsection with reporting requirements under subsection (o) relating to the meaningful use of electronic health records. Such integration shall consist of the following:
‘‘(A) The selection of measures, the reporting of which would both demonstrate—
‘‘(i) meaningful use of an electronic health record for purposes of subsection (o); and
‘‘(ii) quality of care furnished to an individual.
‘‘(B) Such other activities as specified by the Secretary.’’
So there is a great deal of Medicare and Medicaid bonus money at stake on the basis of an evolving concept. Watch it evolve at:
http://questions.cms.hhs.gov/app/answers/detail/a_id/10147
... and read some of the questions raised (there are over 100 at last count) about meaningful use. If a decision from the Secretary ever comes, who knows, but it appears that the content on the above link is emerging as the de facto policy.
So I can use the stimulus money to underwrite a new EHR system?
The EHR incentive payments cover some of the cost of implementing the system, but no where near enough to fund a new EHR. The decision to implement an EHR should be driven by other criteria. See: “What’s the value-add of a solid EHR?” above.
How is EHR different from other types of IT initiatives?
EHR is more of a concept than a single product or technology. Instead, it is a number of software applications and technologies, revised processes and re-trained staff that theoretically will automate the clinical environment to improve patient care and patient safety.
What kind of investment in technology are we talking about?
Implementing a modern, integrated, scalable EHR is a multi-year project that requires funding not only for the preparation and implementation phase, but also for its continuing use for many years to come. In addition, investing in process improvement as well as the training of physicians, other clinicians, and the IT staff who will support the EHR is invaluable. For these reasons, healthcare organizations should invest in an EHR as a multi-year project rather than as a one-time investment. Once an EHR project is budgeted, ongoing funding is critical.
What kind of leadership is necessary?
EHR impacts every patient care process as well as clinicians. Without clinical leadership, achieving the meaningful use criteria for the EHR incentives will be difficult. It is important to find a role for all the key stakeholders, including C-level executives. The CEO, CFO, CIO and COO must work together to advance the overall EHR effort. Because an EHR can have a strong impact on clinical operations, C-level executives – through their advocacy, leadership, sponsorship, and interest – add significant value to the initiative by demonstrating organizational understanding of the EHR's role in patient care delivery. Implementing technology as far-reaching as an EHR will inevitably be disruptive, so C-suite leaders can provide perspective to make the transition easier. Strong communication and an understanding of the impact the EHR will have on clinicians will smooth the way for issues that will require tough executive decision-making to ensure the necessary organizational transformation.
The CFO and the COO also can help develop criteria for measuring progress, changes, and outcomes of the EHR initiative. Putting in place rigorous measurement criteria will allow you to track your EHR efforts and show tangible progress throughout the implementation and after the go-live. This type of information will keep the stakeholders involved, which is necessary to see the implementation through and then going forward.
Does the CFO have a specific role?
Although the prospect of managing financial risk associated with switching from legacy revenue management systems to a system that incorporates EHR modules may be daunting, it’s vital for CFOs to get involved in any EHR initiative from the start. Too often, CFOs remain on the periphery of EHR projects for too long, not really getting involved until advanced phases when charge capture and other revenue issues inevitably begin to surface. This means:
- becoming personally involved in all strategic conversations and decisions about the organization’s EHR project
- helping the organization understand that EHR systems require a change in the organization’s core clinical system, and its core revenue system
- recognizing early on that implementing EHRs is a significant challenge because all core departments use chargeable supplies, making it necessary to closely monitor changes in the hospital’s new charge-master
- maintaining a log of key issues, decisions, and signatures, including the issues and options that were evaluated during the decision-making process
- modeling revenue based on the new charge-master, with the goal of a revenue-neutral run rate from the start
- monitoring revenue by department in the weeks and months after go-live
- moving quickly to understand any unanticipated or unexplainable changes in revenue—positive or negative
- factoring into the capital budget incremental costs in such “soft” areas as internal staff time and overtime, consulting, training, and incremental staffing (part-time, contract, and full-time), and
- measuring key results of the initiative and sharing the results regularly with leaders and staff.
Obviously, at a 30,000 foot level, the CFO would keep a close eye on any change resulting from the EHR that might negatively impact revenue. But the CFO must swoop down to a much more detailed level to prevent disruptions in current revenue streams. For example, a big piece of any EHR implementation is consolidation of transactional records and data, including consolidation of multiple charge-masters. This means risks of disruption and error are inherent as the organization standardizes and redesigns multiple charge-masters across departments.
Simply identifying the many potential risk areas is challenging as well. Across legacy charge capture and billing processes, large and small charges are automatically and reliably captured and coded. In most departments—particularly pharmacy and laboratory—virtually all charges are automatically captured through the normal physician order process. In surgery, charges for supplies are typically captured by surgery pick lists. Yet when implementing a new EHR system, a hospital starts with a virtual blank slate. Therefore, CFO guidance is critical during implementation when:
- consolidating multiple charge-masters within the system
- ensuring the efficiency and compliance of the resulting billing and payment set-up
- determining the best way to build the consolidated and standardized charge-master.
The EHR project team needs to understand the Medicare program and their state's Medicaid program. The project team should also identify which aspects of the organization’s operation qualify to participate under the program. In addition, the project team needs to understand the current status of their organization’s EHR. Not all EHR systems are certified (thus qualifying for the incentive payments), so the project team should ensure that their organization’s particular version will qualify. More importantly, they should know what the EHR vendor will provide in terms of reporting and upgrades in the future to meet the requirements.
If your organization employs physicians, you’ll need to assess the qualifications of all the physicians (or eligible providers) and determine whether they should participate in EHR incentive payments under Medicare or Medicaid.
Of course, since there is usually new software involved, just like any other IT-type implementation, one of the big challenges is capturing the functionality of the legacy system – including all of the build-ins and build-arounds that accumulated over time – and customizing the features and functionality of the new system. Such customization is important for transactions that have an impact on patient charges and that involve the application of charge-master guidelines, rules and exclusions. In addition, with regard to charge capture, it is easy to under-estimate the amount of time required to switch from a traditional clinical management system to an EHR system. EHRs initially present risks to the seamless interfaces between a hospital’s clinical management and charge capture practices. There is also the potential for disruptions of information flow and even loss of the standard reports on which department and financial managers depend. Prior to activation of an EHR system, controls should be in place to ensure that the formatting and availability of clinical patient information and charge information are intact and available as needed.
In addition to visible leadership and ownership from the CIO, the organization would be well-served by building strong partnerships with outside EHR vendors – system and application providers, change management and training consultants, and finance consultants.
This is much more than an IT implementation; what about the process change side of it?
The incentive payments are based on achieving specific results, not on implementing an EHR. Identifying the key measures in which the organization is not achieving the specific outcomes is the first step in targeting which workflows need to be redesigned.
Evaluating which year of the program the organization wants to qualify in is important when forecasting the resources necessary to achieve the new performance targets. Failure to meet the subsequent criteria will result in a lost year of incentive payments. Finance should determine when and how the incentive payments should be incorporated into the organization's forecast. The incentive program is complex, so having a detailed project plan designed solely around meeting the qualifications of the program is necessary.
Even after you implement a certified EHR, you may not have the information you need to qualify for incentive payments. Obtaining information about current performance on the core measures is more difficult than you would expect. Until you know where you are starting, you can’t predict when you might achieve the desired outcomes.
What about the change management angle? How do you get people to embrace the change?
Start by figuring out who the stakeholders are, and then figure out exactly what their emotional and factual needs are. And then meet them by putting all of this information into the communication plan/schedule. A good way to get the ball rolling is to look closely at each stakeholder and determine:
- Impact of the change on the stakeholder
- Degree/scope of anticipated change
- Timing of anticipated change
- Anticipated stakeholder perceptions of/reactions to the changes
- Potential issues challenging the organization as a result of the impact of change on the group
- The current level of stakeholder knowledge of changes
- The potential levels of influence which the stakeholder can exert on the organization, and the stakeholder’s predisposition to take action
- Sponsors, change leaders or peer opinion leaders who can influence the group’s perception of and reaction to change
What are the key communication components?
- a thorough and accurate assessment of the current state as well as a rational justification for the expected or proposed change
- the messages should be repetitive and presented through redundant channels
- the format of the messages should be both "push" and "pull" in nature
- the messages need to be clear and understandable to disparate stakeholders
- some tailored messages should be included for specific stakeholders as per specific stakeholder needs
- the messages should provide timely updates so as to avoid surprises which only create anxiety and resistance, and
- the plan should avoid stops and starts; that is, it needs to be reliably presented throughout the course of the EHR implementation process.
Proper communication management around an EHR is the same as any other large change initiative. This means it’s just as easy to screw it up as it is to do it right. So don’t take communication management lightly; it generally means the difference between success and failure.
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