Computer Assisted Coding (CAC) – Why isn’t it working??

In this first article, l discuss Process Improvement and Document Improvement as it pertains to Computer Assisted Coding. Follow-up articles will touch on Interfacing, ADT’s, abstractor and encoder considerations, as well as networking and impacts to the EHR.

The past few years I have had the chance to work with numerous health systems, either directly or in advisory capacities. In many we were brought in to build, lead and oversee their large ICD-10 Programs and most include Computer Assisted Coding Programs. I have worked often with both 3M and Optum solutions and think both solutions have their merits and faults. Both have the potential to provide robust value, but, I have yet to see where the product alone, without significant organizational improvements, performed to the estimated productivity standards or met the quality thresholds.

My firm has been called repeatedly by providers to assist with improving the productivity and performance of their CAC systems as well as manage new implementations. They are facing major implementation, budget and timeline challenges they weren’t prepared for.  Most had no idea of the significant impact on interfacing both from the number of systems, the number of interface modifications, encoder-abstractor upgrades and modifications.

Comparatively Speaking, organizations that have one abstractor, encoder, EHR, etc… will find that their CAC System generally performs well. However, organizations with more than 2 abstractors and a disparate environment will experience implementation and performance difficulties to the point of eliminating any productivity gains.

There are things that could be identified early but aren’t. A CAC solution is somewhat new to most. Organizations often don’t know the questions to ask or can identify the behind the scenes challenges when they are in the early phases of their implementations. The vendors do a poor job overall of guiding the providers to an optimal performance state.

Providers are given the impression that they implement the product and the miracle of auto-suggested coding occurs. They see a hefty implementation cost from the vendor and think it should come ready-to-go with vendor direction and a few internal resources. Unfortunately, this couldn’t be further from reality.  Executives don’t realize that to achieve the productivity standards and quality coding they’ve been promised, there needs to be significant effort in the following areas, before you can expect success with CAC:

  1. Process Improvement
  2. Document Mapping & Improvement (Document & Data Quality)
  3. Interfacing
  4. ADT data normalization
  5. Networking (capacity)
  6. EHR Impact

 

CAC IS an Enterprise System

Most healthcare organizations who are implementing CAC are learning that it is not like other departmental-based systems. Computer Assisted Coding is an enterprise system of integrated modules and takes input from numerous upstream systems. It can be a massive resource, network and interface drain and is further complicated with the implementation of Citrix. It is important to recognize that, with the number of foreign system interfaces, document types, formats and other configurable components, the scope of CAC can be compared to that of an HIS (EHR) system and needs similar levels of effort. It impacts clinical, patient access, revenue cycle, ancillary, inpatient and outpatient. Some even incorporate physician billing.

Two primary factors go into a successful CAC solution:

CAC not a quick fixProcess Improvement

Most healthcare organizations have not made significant improvements to their Patient Access, HIM and Revenue Cycle policies and procedures in many years. Add to that the number of mergers and acquisitions, you now have large organizations with extremely disparate environments, systems and teams.

New systems are implemented and their workflows are set on top of old policies and procedures (originally designed for manual or outdated legacy systems or tools) which are wrought with inefficiencies and lack automation. When running a high volume of business with the level of increase in specificity (which is the case with ICD-10), the more manual touch points you have or the points between disparate technology and systems, the higher the probability for breakdowns, bottlenecks and issues.

** NOTE: Large health systems and IDN’s need to carefully consider their disparate nature and understand that for CAC to successfully achieve the goals, especially in an enterprise instance, they will need to expend time and effort to improve their workflows, documents and standardize their procedures, not to mention normalize their ADT’s just to offset the impact from the varying and disparate nature.

Many health systems make efforts to improve but unless you identify at the user level and document these steps with in-depth analysis for duplication, repetitive tasks and improvement opportunities, across all coding specialties, facilities and groups, most opportunities to improve will get missed.

For example; in most organizations the management, including the HIM Directors or their managers, are not fully aware of the amount of non-system time spent to complete work on a specific encounter. Opportunities to improve are impeded by a bias for familiar system flows and procedures versus new concepts, models and tools. In most cases, we can find up to 8 minutes of non-system time doing things such as; communications, approvals, follow-up on missing documents, etc… These lost minutes add up to significant levels of effort when multiplied times the number of encounter types the organization codes. This is just a single example of the type of process modeling and re-engineering needed to improve coding capacity planning. Lowering costs and the number of negative impacts could be fixed relatively easily with special automated reporting, scripting and distribution tools.

A good process improvement solution looks at what the core and other business requirements are and then determines the combination of system, tools and functions for the business unit and/or end-user to achieve these requirements. Every step is standardized and automated wherever possible with contingencies for risk areas. Enterprise standards should be set wherever possible. Ironically, this is a very similar process to PMO development.

Document/Data Quality

The old adage ‘Garbage in equals’ garbage out’ is true here. Imaged or scanned documents are not good options. Although some of these can be processed through the OCR within CAC, there is always inconsistency to the document depending on the image quality. Additionally, there’s a cost with managing the variations and format differences and keeping the system optimal. Quality will constantly be impacted and not achieve the standards you want. The effort, time and document quality impact can take away from the goals you are trying to achieve. You will need to conduct document improvement efforts focused at finding original electronic data and/or documents.

CACTruths

Let’s compare process:

Without CAC;

        Let’s say a coder needs 5 pieces of documentation to get to an ICD-10 code for a particular encounter

        The coder has only 3 legible documents.

        The coder has to investigate and search for the 2 illegible documents

        Once located the coder can proceed to code

With CAC;

        CAC receives documents from enterprise

        CAC processes encounter, suggests code

        Coder notices inconsistency and realizes documents missing during validation or CAC can’t process due to insufficient documentation

         Coder has to investigate and search for the 2 illegible documents

          Once located the coder proceeds with completing coding

Unless CAC has a high hit rate for certain well documented (electronic) forms and procedures, this is going to create a negative impact to coding. It actually takes longer due to the lack of sufficient data or documentation requiring a quasi-manual coding effort. This doesn’t mean your CAC system is bad, it just means you need to improve the concentration of documents to clean standardized formats and optimize the coder workflows. Every variation takes away from an optimal CAC state!

Additional areas to focus on are data and terminology normalization, configuration utilities and workflow variance. While internal efforts to improve are helpful, bringing in specialists who have seen this in multiple organizations usually yields better results and improvements. They generally have more experience reviewing and identifying solutions. They also have real examples of improvements and ways to optimize, with the ability to look at the organization ‘outside the box.’

Adept Healthcare is a Knowledge Leadership, Advisory & Solutions based consulting group that specializes in clinical, revenue cycle, supply chain and HIT. We have knowledge & thought leaders who help our clients develop plans and strategies to integrate and improve. We support operational performance, leverage IT investments, improve patient care tools and governance standards and to achieve strategic goals through change management, program and PMO development, operational performance and performance excellence. For more information contact me at EMcGuire@Adept-Healthcare.com

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Healthcare Provider Governance has improved but further evolution is still needed

Project StrategyHaving been in governance and project management for over 20 years and have witnessed the dynamics and landscape change dramatically. The principles of project management have remained the same, however, the requirements and scope have extended dramatically. More and more project, program and portfolio management have become more pervasive with more complex structure and strategies. Healthcare leaders have started to learn that the methodologies and rules governing project management have the discipline, structure and controls needed to successfully recognize better cohesion and improved efficiencies in all areas.

The greatest deficiency in healthcare provider governance strategies today, is a lack of solution development required to have operational success. Providers too often expect ‘out of the box’ success with IT initiatives, relying on the vendor system to answer the problem in stand alone fashion. IT groups are designed as support groups and do not have development capabilities and tools. Modern healthcare operations, requirements and changes require better enterprise approaches. This creates issues as achieving operational integration and utilization require detailed operational requirements, as well as, mechanisms to build, test and deliver true solutions that are integrated in operational processes as much as system functionality.

When I took the PMP certification back in the 90’s, Program and Portfolio management were new concepts just starting to be defined and methodologies created. Now they are robust disciplines of their own with increasing changes and fingers that stretch into all facets of business, providing discipline and control throughout large enterprise organizations. To continue this evolution organizations need to develop strategies which embrace the development of solutions and not just implementations of systems.

clinical-governance

Most healthcare IT PMO’s are designed to use project managers who are more coordinators which handle multiple projects simultaneously. This may be effective at getting more projects implemented but can be self-defeating in providing a robust systems that will deliver the expected ROI and capabilities envisioned. These project managers are ill-equipped to ensure the solution achieves the desired results. Additionally, recognizing the benefit of various methodologies, like Lean and Agile and understanding where they fit and what areas may benefit are significant as they may be better fits for particular initiatives and organization structures.

Activities start in the pre-sales stages. Leadership needs to ensure the operational area is mapped and the initiative is aligned to their strategy. Validating how the technology impacts and ensuring operationally the new functionality is integrated to operational procedures and that workflow is adjusted to accommodate and improve proficiency, as well as a new tool.

As we help organization develop robust PMO, portfolio and program management structures we encourage the development of permanent development platforms which enable organizations to vet out these important criteria and requirements. It also enables full life-cycle testing to ensure integration and interoperability. This requires that all impacted systems are included in this ‘sandbox’ so the entire workstream can be tested. The majority of systems implemented today impact other systems and operational workstreams therefore these systems become vital to smoother implementations and success.

Healthcare providers are just now beginning to understand the benefits of strategies based on these structures and tools. The days of simple project management are quickly going away being replaced by robust governance structures designed to build on these tools as core principles of their business philosophies and ongoing strategies.

IT has always been a huge driver for project management and the rapid adoption by healthcare providers and payers, to achieve Meaningful Use, ICD-10 and other strategic initiatives. This is bringing about a metamorphosis, in larger provider organizations, in their strategies and operations to incorporate these tools, expanding on the traditional philosophies which have guided providers and payers alike. This same approach needs to be adopted by providers of all sizes, types and disciplines.

change-managementChange Management is a critical step in this direction as a true solution involves changes in operations, as well as, tools to achieve them. The primary roadblocks to this transition are governance and executive teams unfamiliar with the benefits, as well as, reluctance to change the ‘tried and true’ models they are familiar with. New methodologies and disciplines help with this as it provides information never before available to these executives and directors enabling them real-time control, if the tools are in place to empower them with this knowledge.

 

Adept Healthcare is a Healthcare Managerial & Solutions Consulting Group that specializes in Clinical, Revenue Cycle, and IT. We have knowledge & thought leaders who help our clients develop plans and strategies to integrate and improve. We support operational performance, leverage IT investments, improve patient care tools and governance standards and to achieve strategic goals through change management, program and PMO development, operational performance and performance excellence.

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ICD-10 – Are you certain you are ready?

How confident are you in having ICD-10 success?

You have done your upgrades, added Computer Assisted Coding (CAC), conducted internal and payer testing, conducted physician and coder training, communicated every step throughout your organization so everyone is aware of the activities and their part, but how do you know that means you are going to have success with ICD-10? Successful completion of each of these areas in and of themselves does not guarantee you will submit clean claims and get paid timely. I liken these activities to building an application, testing that application in the lab but never testing it in real life scenarios.

Like most enterprise efforts in healthcare, ICD-10 success is dependent on life cycle planning, operational strategy integration, as well as, testing and remediation. Benchmarks and results based on overall strategies rather than individual component success is a much truer indication of the likelihood of success, however, that still doesn’t guarantee success.  In our client engagements, Adept works hard to drive process improvement and enhance performance excellence. While these process advancements are substantiated through life cycle testing, we have concluded that numerous uncertainties still remain.

 

Our ICD-10 Program was built to ensure not just achieving success with the critical success factors but also validating these concerns are addressed or have processes in place to address as they are uncovered once ICD-10 does finally arrive. As with anything, it’s best to plan for the unexpected. An ability to react and adjust is just as critical as proactive planning and improvements.

Remediation planning is a core part of the ICD-10 program we have built as it creates mechanisms to make adjustments to the overall ICD-10 life-cycle once you go live with ICD-10.

Here are some questions to ask yourself;

  • Are you certain your CDI efforts deliver patient documentation as needed for the specificity of ICD-10 and is it aligned with ICD-10 approaches?
  • Have you reviewed and adjusted your coding documentation requirements based on specificity requirements to code for ICD-10?
  • What payer variations were not accounted for and how do you handle those?
  • How do you approach CAC inconsistencies or manual coding inconsistencies?
  • What is your strategy to improve denial management impacts that weren’t expected?

ICD-10 is really a comprehensive program, a series of initiatives that touch most major areas of healthcare. It is not just an IT or revenue cycle initiative. There are components critical to the life-cycle process which impact results for other downstream parts. At Adept, we have developed a lean process tool, called 100 Day Waves, which allow us to do fast-track assessments to determine where exactly a client is with the critical path components of ICD-10. It will tell you if you are achieving your expected results or if a particular area is not expected to produce and thus may result in issues or problems in your overall strategy for ICD-10. We recommend every organization do these type of assessment to ensure you are achieving success across the entirety of ICD-10. Some examples may be, how many remediation’s do you have from payer testing? How many quality ICD-10 codes are you generating, from each specialty area and are you meeting quality coding thresholds? What are your productivity standards for coding and how have you validated those?

 

Here are some particular considerations to keep in mind as you evaluate the probability of your ICD-10 success;

Payer Testing
There are two primary parts to payer testing, functional and native coding. Functional testing is about ensuring you can submit a claim to your clearinghouse or directly to the payer and getting a claim back and it processing without issue. The second is where testing becomes critical.

  • Functional – Determines provider and payer can submit electronic claims between each other (835/837 claims). Most providers submit x12 format claims to clearinghouse’s who generate the 837 claim format. Payer responds with 835 claims.
  • Native coding validation – Provider submits high risk and high volume claims which are analyzed by payer so payer can provide feedback on code interpretation. A provider organization should take these and identify process variations and modify their processes to accommodate these variations.

Most organizations use GEMS for crosswalks which is a huge benefit, however, each payer and provider organization then customizes and interprets these differently. This is where native code testing helps to identify these variations. The challenge is that the provider needs to capture these variations and determine a means to communicate with the coders when coding claims for that payer. In some cases remediation’s can be done to the system as they may impact all payers but the bulk of these really are payer specific. This means some vehicle needs to be developed or identified which can alert and notify a coder before coding or at the very least alert and notify during CDI review depending on the nature of the variation.

 

HIM/Coding Objectives
There are 4 major approaches to addressing the ICD-10 coding challenge. Most organizations use a variation of these different approaches;

  • Adopt technology and functionality within systems to define and select appropriate ICD-10 codes
  • Adopt technology and functionality to allow physicians to select and code ICD-10 codes
  • Train physicians to code during patient activities
  • Train coders to natively code in ICD-10

Whether your organization is utilizing technologies to improve proficiencies in coding or heavy training and having physicians and coders bear that burden, the bottom line is the organization needs to have a strategy that is aligned with how HIM and coders plan to operate. Providing a sandbox (test system designed to allow the coders to get familiar with new systems and functionality will help. Dual or double coding sometimes helps mitigate this but it doesn’t allow for adjustments and tweaks as much as most are done in production capacity.

One key is to ensure your approaches to ICD-10 coding fit in real-time. In example; I have noticed many organizations doing heavy coder training for ICD-10 and then rely on them to get familiar through limited dual coding. If your organization uses Epic, this is somewhat self-defeating as the Epic tools are designed for the physician to select the code and the coders to validate the code. The focus needs to be on validating as many 1-1 coding scenarios to streamline validation for those and focusing training on more complex coding scenarios.

 

Computer Assisted Coding (CAC)
CAC systems are an impressive tool and can really be beneficial, especially with automating the 1-1 scenarios we mentioned above. However, many organizations don’t realize these systems are not out of the box solutions. They require significant planning and coordination. As with any system it carries the garbage in, garbage out philosophy. It is not as simple as send documents to the system and you’ll get quality codes and deliver to the productivity standards as defined by the vendor. Document types, formats, source system versus system of record (preliminary versus final) all require careful consideration as they impact the output. CDI alignment is a huge impact as well. These systems are not stand alone systems and should be considered in the life-cycle of coding just as ICD-10 is. Sure you may get 120 Radiology codes per hour but can your CDI reviewers handle that volume? Have the adjustments for payer variations been built into it? Fine tuning and other activities need to be planned as getting quality coding standards consistently doesn’t just happen. So yes, CAC is a great tool but needs to be planned carefully with continued maintenance to ensure overall success.

 

 

 

 

 

 

The bottom line is there are numerous touch points within ICD-10. Any one issues or area not addressed can have a daisy chain affect and impact the entire process and success of ICD-10. All of the testing available can’t account for real world challenges that weren’t identified or undervalued during planning. So ask yourself, before pushing off ICD-10 activities, are you really confident your organization is ready?

I recognize there are different approaches and priorities for any strategic initiative and welcome comments and suggestions to further educate and provide insight to all. Please comment here as well as in the discussions for this post. Thank you, I look forward to hearing your thoughts.

Adept Healthcare is a Healthcare Managerial & Solutions Consulting Group that specializes in Clinical, Revenue Cycle,  and IT. We have knowledge & thought leaders who help our clients develop plans and strategies to integrate and improve. We support operational performance, leverage IT investments, improve patient care tools and governance standards and to achieve strategic goals through change management, program and PMO development, operational performance and performance excellence.

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ICD-10 Provider Initiatives.. Things to consider

As most of us know by now, ICD-10 is a massive effort impacting huge aspects of healthcare and healthcare IT. It requires application upgrades, data normalization, CDIS (Clinical Documentation Improvement Services), conversion of reports, forms, documents and procedures. The scope is from patient intake (clinical) to clean bill (patient billing) and includes Denial Management, Reimbursement Risks, ACO (Accountable Care Organization), alignment with meaningful use and other governance reporting with simplification and automation of the clinical documentation, coding, patient billing and reporting processes. My latest initiative, with a large IDN with multiple abstracting instances, regions and a very disparate environments with multiple HIS instances (McKesson, Cerner, Siemens, Meditech and Epic), so please keep in mind to adjust this to fit your organization. Some activities are weighted due to the regionalized and disparate nature of the organization.

The ICD-10 Program I have developed and manage is ahead of schedule compared to other providers so I have had numerous questions about various activities so I wanted to share some important things to consider and plan for;

Build a strong Program Management Office; As the Program Director for the ICD-10 PMO (program management office), to accomplish the development and management of the program required flexibility and an ability to wear multiple hats. Relationship building was a key in building a strong foundation for the program. We developed a core team of project managers with varying skills and abilities to assist with developing the tools and templates needed to support our project management and operational processes.

Standardization and developing a toolkit of templates, how to’s, simplified process and procedures, defined ‘rules of engagement’ for clear, simple, repeatable processes and activities are part of the approach to achieve the program goals.

The ‘ICD I0 Program Approach’ was developed to guide us during the overall life of the program and a way to segment the work type based on impacted systems and users. This enabled us to create a guide and toolsets to provide a roadmap to improved revenue cycle performance and ICD compliance.

  1. Application upgrades for all systems with procedure and coding impacts, to ICD-10 compliant version.
  2. Assessments of all ICD impacted systems, workflows, regulatory requirements, coding processes and revenue cycle/supply chain touch points and clinical documentation audits
  3. 3M 360 Encompass CAC & CDIS implementations and integration
  4. ICD functionality integration and automation initiatives
  5. Data normalization–  36 hospitals across 7 regions with varying abstracting instances
  6. Complete report/form standardization and ICD remediation
  7. Coding simplification and automation initiative
  8. Comprehensive testing strategy – System to integration to full life cycle testing required so plan for and build a realistic testing approach that will enable full life-cycle testing
  9. Full life-cycle integrated ICD testing –  From patient intake to a clean bill/denial management

    ICD-10

Here is a summary of high level activities for a successful ‘ICD-10 Program;’

  • ICD-10 Conversion & optimization strategy development
    • ICD-10 Assessments
      • Applications
      • Workflow
      • CDIS/coding
      • DRG/MS-DRG integration
      • CAC & CDIS (CDE)
  • ICD-10 operations impacts
    • Coding improvement
      • Physician/coder training
      • Coding optimization
      • Reports/forms conversions
      • Governance impacts
        • Compliance reporting
        • Regulatory auditing
        • Meaningful Use compliance
    • Application/IT impacts
      • Applications upgrades (294)
      • ICD functionality integration initiatives (63)
      • Data modeling/normalization (61 systems)
      • ICD functionality development and initiation
  • Program/portfolio development & management
    • Charter development
    • Budget development and tracking
    • PMO Program process definition & development
      • Technical groups
      • Infrastructure groups
      • Interface teams
      • Database teams
      • Relationship Management
      • Revenue cycle development & optimization (for ICD)
      • Patient Access & HIM
      • Clinical (intake) optimization
      • Formulary/MS-DRG improvements/integration
    • Strategic planning/integration planning
    • Business/clinical  life cycle modeling & management
    • Risk & quality improvement management
    • Communication process development
    • Relationship Management
    • Requirements definition
  • IT project governance/oversight
    • Application update oversight
    • Application upgrade management
    • New HIS implementations
    • Solution development (new system selection, definition, implementation and integrations)
    • Contract ModelingAre you ready?
  • Clinical/Patient Access/ HIM operations
    • Clinical Documentation Improvement
    • Risk reimbursement
    • Case mix management
    • Coding standardization
    • Standardized and developed improved coding model. Migrated to an Enterprise wide coding model.
    • Third party payer relations and testing

The goals of the ‘Program’ should be related to desired performance. I’m careful to correct insinuations of this being a conversion. To convert to ICD-10 does not provide the integration with revenue cycle, determining  risk reimbursements, contract modeling, accounting  for ACO models, nor coding simplification, all of which is essential to overall improvement and success. Complete coding life-cycle testing is essential to identify any issues between system functionality, workflow, human touch points, reporting, third-party (payer and clearinghouse) and governance models.

Keep in mind, this initiative requires that you delve into and validate the majority of your processes, systems and forms, from patient intake through patient billing/denial management. Why wouldn’t you optimize and improve efficiencies and quality assurance?

Please feel free to contact me with any questions or thoughts. I like to provide my knowledge to help others and always value additional input and perspectives. There is never just one path to success, so please share any insight.

Adept Healthcare specializes in strategic healthcare initiatives, including ICD-10. If your organization needs assistance with ICD-10, CAC and CDIS implementations or coding standardizations, we have knowledgeable and available project leaders and analysts who can help. Please don’t hesitate to reach out to me at EMcGuire@Adept-Healthcare.com

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Project Management is now 3D in Healthcare

image

Having been in project management for close to 20 years I've seen the dynamics and landscape change dramatically. The principles of project management have remained the same, however, the requirements and scope have extended dramatically. More and more project, program and portfolio management have creeped out into clinical, finance and supply chain to become the glue that binds business and operations. Business leaders have started to learn that the methodologies and rules governing project management have the discipline, structure and controls needed to successfully recognize better cohesion and improved efficiencies in all areas.

When I took the PMP certification back in the 90's, Program and Portfolio management were new concepts, subsets of the PMBOK, just starting to be defined and methodologies created. Now they are robust disciplines of their own with increasing changes and fingers that stretch into all faucets of business, providing discipline and control throughout large enterprise organizations.

Healthcare providers are just now beginning to understand the benefits of strategies based on these rules and tools. The days of simple project management are quickly going away being replaced by PMO's and project structures designed to build on these tools as core principals of their business philosophies and ongoing strategies.

IT has always been a huge driver for project management and the rapid adoption by healthcare providers and payers, to achieve Meaningful Use. This is bringing about a metamorphosis, in larger provider organizations, in their strategies and operations to incorporate these tools, expanding on the traditional philosophies which have guided providers and payers alike. This same approach needs to be adopted by providers of all sizes, types and disciplines.

Many medium and smaller healthcare organizations are slow to recognize the value in these approaches and to regard their businesses as three dimensional, 3D, and need to incorporate these approaches to achieve not just meaningful outcomes for improved patient care, but true business success and the return on their investments both in systems and human resources.

Change Management is a first step in this direction as the primary roadblocks to this transition are governance and executive teams unfamiliar with the benefits, as well as, reluctance to change the 'tried and true' they are familiar with. New methodologies and disciplines help with this as it provides information never before available to these executives and directors enabling them real time control, if the tools are in place to empower them with this knowledge.

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System Selection: A defining moment in your organization

System Selection is the process of evaluating, identifying and determining which system or combination of systems would be best for the organization. Every organization is unique, although numerous factors will be similar to other organization. Examples of these include community based hospitals, academic organizations, IDN’s, and pediatric organizations, ambulatory, physician practices and many more. What is important to note is that every organization has multiple layers of variables which needs to be evaluated to understand your system and operational requirements.

It’s easy to take the 10 basic evaluation questions most selection processes review; however, it’s been my experience these just don’t answer enough critical questions to understand which is best. In fact, that wouldn’t even clearly define current state, let alone future criteria. Some organizations simply review it from a clinical perspective and while it’s primary function is as a clinical tool, the days of standalone (functioning) system are gone, modern healthcare information systems (HIS) need to integrate with revenue cycle systems, materials management, pharmacy, ancillary, as well as, back-end operations, service system and modules. Therefore it’s critical for organizations to have strong Strategic Operations and IT plans.

Now, here is where it gets interesting. With the ability to connect and utilize HIE’s and other interfacing and interoperability solutions, we now have to consider future connectivity options for future HIE based services, such as clinical decision support, laboratory and even radiology services. Therefore, your system needs to have flexibility and so does your strategic plans. Historically, we have bought or developed individual interfaces where connectivity was required, unless you happen to be a Best of Breed (BOB) organization then you normally had an interface engine but an expensive option to develop. Now, we will have the ability to exchange this information simply and securely, so expect and increase in services to medical providers.

In my methodologies I use 5 primary areas of focus with more in-depth focus on specific areas within those.

My primary focus areas are;

  • Business Case – It’s imperative to start with a solid, well thought out business case, using KPI’s (Key Performance Indicators) and carefully defined critical success factors.
  • Business/Clinical Process & Workflow Review – Careful identification of all processes and workflows, including current and future areas of concern. We tend to focus our attention on things we know that works, when it’s best to review it based on what currently needs improvement as a priority. This is both system and process improvements.
  • Requirements Definition & Analysis – Carefully analyze and derive key and unique requirements for the system. You will want to analyze  system and process requirements but ensure they don’t limit your future flexibility.
  • Vendor Review – Researching vendor systems needs careful attention. The vendors will naturally provide references and testimonial clients but dig deeper. Do a comparative analysis using health providers similar to you that use that system, independent of the vendor. Prepare a series of questions you will want ‘real’ answers to.  Lastly, require a virtual demo, where the vendor demonstrates not just to you but to your physicians, nurses and all other staff. This will do several things for you; first, it will help pull your clinical staff into the initiative and give them a real perspective on what they could have. Secondly, it requires the vendor to actually demonstrate the things you want will work together the way they say it will. Thirdly, it will let you know what vendors really want your business and are willing to go the extra mile.
  • Contract Negotiations – Negotiations require very special attention and experience. Please make certain to have legal counsel familiar with vendor management and relations. Additionally, make certain the vendor is accountable financially for any delays they cause (code delivery, fixes, etc…), including covering your expense commitments. Put pressure on the vendor to ensure they can and will deliver. Understand the ongoing maintenance requirements and future costs. Be certain to have an exact understanding of what you are getting, what is considered a ‘service’ versus product and therefore ongoing charges and what the vendors goals for the implementation are (trust me, they aren’t the same as yours).

I’ve been through several system selection processes and can say with certainty, the final requirements are usually significantly different from what you expect before going through the process if you do a good review and analysis. Always find an experienced professional to help to assist through the process. Even slight adjustments can have huge effects.

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The future of healthcare can be seen in other industries….

Healthcare is a diverse industry, with every provider having unique needs and facing different challenges. However similar challenges exist in other industries centered on person to person interactions, like primary education. There are lessons healthcare can learn from these other industries pertaining to governance, overall business operations and managing funding and revenue. In both primary education and healthcare, changes and advancements have been slow to impact the services provided, driving costs and creating a need for breakthrough solutions.

Don’t get me wrong, there are many successful, excellent healthcare providers and educators. However, the argument can be made, and many industry experts agree, that both industries trail others in adopting new technologies and models of service.

Healthcare currently struggles with integrating service models across the continuum of care. The increasingly common stratified approach focuses on an individual’s unique characteristics like age, race, background and habits for decision support. Primary educators working to successfully prepare and teach their students must adapt to and deal with similar issues like diversity and other ‘stratified’ qualifiers.

Some cross-examination could trigger new ideas for healthcare, especially as patient education becomes an increasingly important part of care services. The scope of a provider’s education strategy will need to increase as patient portals, access to electronic health records and patient decision support options become more prevalent.

Providers need to embrace this education trend and integrate it into their transition to wellness care. The roles of CIO’s, and in some instances executive education officers, will expand in the future to include this important aspect of patient care. Providing these integrated services will be key to effectively marketing and drawing new patients in the future.

Ironically, the word ‘doctor,’ in latin means ‘teacher.’

Here a few interesting similarities between healthcare and education I noted from my research:

  • Maintaining accountability is very difficult in both
  • There’s a general lack of the best and most current resources available
  • Primary revenues are derived from third parties: government and the public with primary education versus regulatory and insurance contracts for healthcare
  • Business models and operations are historically paper based
  • Don’t fully utilize effective integrated strategies
  • A need for good knowledge transfer/capture and regeneration strategies
  • Both serve as primary social providers for public sector and face diversity everywhere
  • Lack of innovation in models of primary education and care
  • Need to improve financial models to map from service to revenue
  • Changes in ratios, environments, management and strategies force constant adjustments
  • Few proven and complete models to emulate
  • Lack of ingenuity with developing alternate revenue streams
  • Modernization and new technologies create culture and change management issues
  • Governed by strict regulations and rules
  • Faced with increasing competition in the future

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Filed under Change Management, Education, Organizational Performance, Project Management

Could the future of healthcare involve Franchising?

A radical concept, I agree but, after numerous conversations at HIMSS and discussions with clients, the concept needs to be discussed because it could play an important role in the future.
The Future
As healthcare providers become lean and more focused in their direct services, increased capabilities will begin with more and more of it being outsourced to vendors and service providers. Tele–health will become intra-health, with cloud computing providing more secure internet video, voice and information.

Imagine you have a house with a 2 inch water pipe feeding into it. Now imagine that pipe at 50 inches. That’s the kind of capacity increase healthcare providers will have. President Obama is pushing for similar increases to residential sectors which enable huge advances in tele-medicine and online visits. Knowing these kinds of capabilities will be here soon, it’s important to consider how it will impact the future of patient care. Already we have seen an upstart in providers working with device manufactures for devices to conduct monitoring and diagnostic care in the home. Is it too far off to think healthcare models will change to incorporate these unique patient care practices?

A colleague at HIMSS asked what I thought the biggest change will be for healthcare in the future. Without hesitation I said “marketing.” Many of the top providers in the country have already begun working on the foundations for such models. Organizations are securing patents and other intellectual properties while moving more and more diagnostic and therapies to the patient home. Many healthcare provider organizations have initiatives in place to increase their footprint with virtual medicine. Organizations that position themselves as the best, most-effective provider will be the big winners when patients have more options for care.

Already we are seeing advertisements from world known provider organizations and this is only going to increase as there are currently multiple ways to provide patient care virtually or to affiliate, partner and yes, even franchise, through other local providers. In the future, how you provide care and your ability to market that is going to determine an organizations position in the market. I can see it now;

 

a commercial for Cleveland Clinics’ world famous cardiac care, at these local participating providers…

 

Obviously this is an example and I do not know of any particular efforts at Cleveland Clinic, but is it hard to envision?

Here are some possible approaches to emerging parts of healthcare models you might see:

Virtual Healthcare/Telemedicine –Advancements in technology will enable high quality virtual video conferencing between patient and providers, putting a 21st century-spin on the traditional “house call.” New multi-function devices designed for the home will cover most basic diagnostic and that information is shared directly with the provider via secure connection. Radiology images, lab results, EKG are shared instantly.

Physician Practice Franchising – In the future, don’t be surprised to see franchises from some of the best providers. As these organizations perfect delivery methods across the continuum of care, watch for these concepts to be patented and offered to local physicians as a ‘franchise’ approach to running a practice.

Acute Care Partnering – We see it to a degree now, but if you’re a community health provider, would it be easier to build your own nuclear medicine program or partner with one of the many specialty imaging providers popping up in urban areas? How about a community cardiac program in partnership with a premier IDN health provider specialist a thousand miles away? These partnerships are already being developed, and they will only become more prevalent and effective in the future. In truth, the cost of healthcare systems rival’s brick and mortar buildings costs and by partnering or subscribing, those can be provided as a service. This can save from expensive software purchases and installs and enable the provider to focus on patient care.

While not an entirely novel idea, the important part for organizations is to realize the broad range of flexible business options and design strategies that can help them adjust and compete as the healthcare industry continues transforming. Alliances and affiliations will increase dramatically as smaller health systems and hospitals join forces to compete in the next new frontier.

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Change Management – Why it’s critical to the future of healthcare providers

With new EHR/EMR implementations rolling out, I recently found myself trying to explain the significance of change management to a group of nurses from a small health system. I explained that it refers to the process of managing the significant changes occurring in the workflows, procedures and business operations due to healthcare reform.

In a widely read Linked In discussion, ‘The Top 10 Reasons Why EHR/EMR Implementations Fail,’ a majority of the reasons listed related directly to change management. Change management includes more than just procedures and integrating systems. It involves changes in culture and philosophies coupled with a strong business model.

These mindset changes are integrated with new system functionality and workflows to identify weaknesses within the entire business process. It takes a unique ability and experience to identify these weaknesses and it starts with the organization’s top-level strategy. Provider organizations need a Project Management Office (PMO) or internal team to plan for how implementations impact other systems and business procedures, to ensure quality and security. PMO’s, through change management, make a new system a true business solution.

Working with clients over the past years, we’ve noticed a troubling trend among providers working feverishly to achieve meaningful use. With so many new requirements introduced in a short period of time, providers are inundated with initiatives. Meaningful use is great for delivering qualified outcomes but does very little to address improving healthcare providers’ business operations.

As a result, too often organizations don’t take an in-depth look at the indirect integration critical to maintaining a good business model. Too many are waiting to complete implementations before addressing meaningful use requirements. Waiting for systems to be implemented before addressing meaningful use usually means the appropriate change management is neglected. Without proper change management, new systems, workflows and operations won’t function as effectively and efficiently as they could.

During a session at the recent HIMSS Conference, representatives from UHHS of Cleveland dove into the dangers of ineffective change management. An enlightening side by side comparison of organizations conducting implementations while working towards meaningful use illustrated the importance of the process. One organization involved change management during their implementations, while the second made no efforts to include it. The results were markedly different.. Not only was the first organization much improved, it demonstrated great success. The other scenario did not meet the success criteria expected. It was implemented, but riddled with problems and never delivered as expected creating more problems than ever realized.

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Filed under Change Management, Healthcare Reform, Implementations, Meaningful Use, Organizational Performance, Project Management

Things to consider in lieu of ‘Meaningful Use’

In understanding use of the ARRA by the Office of the National Coordinator and Certification Commission for Health Information Technology to fuel healthcare reform, it’s clear the goal is to build a foundation for future advancements in the tools and knowledge available to providers that will allow for improvements in healthcare and clinical efficiency. What’s not clear is exactly what mechanisms will be used, for future enhancements, to further the reform and what incentives might be used to encourage it. While this is fairly well understood in the medical community, the opportunity to also dramatically improve the business of healthcare is often missed. It’s important to realize that not all these types of changes are required for meaningful use and therefore does not have to be implemented immediately, they should be planned for to prevent re-development at a later time.

Clinical vs Business Outcomes – Currently the focus of incentives is to encourage providers to demonstrate they use their EHR according to requirements commonly known as “Meaningful Use” in clinical outcomes; but what about providers’ business outcomes? Incentives are directly tied to being able to define, track, monitor and report clinical outcomes. The incentives don’t include or recommend certain business requirements necessary for a sustainable business model, without which any number of possible breakdowns could severely hinder the organizations operations. “Operational Integration” is a necessary and critical evil that shouldn’t be avoided. While it was never the mandate of the CCHIT or the ONC to deliver “Best Practices” or business incentives – the main focus has been achieving meaningful use in clinical areas—but should it have been?

Health Care Strategies – In order to deliver the most effective and efficient services, healthcare providers will need to have an integrated business strategy. What does this mean? To be honest, the answers are relative to the type, size and makeup of each provider organization. For example, in local community based hospitals, there is not the skill level and operational capacity for a lot of advanced ‘Best Practices,’ as with Academic organization, so their solutions will need to fit what they are capable of accomplishing. When does it make sense to plan for and incorporate an ERP solution and how does that impact initial development? When is it important to look at the makeup and resources in the organization to determine what system and business processes would be most effective?

Understand who you are – As a healthcare provider, it can be tempting to look at systems implemented by other organizations and model your own based on their successes. However, I’ve found during my 17 years in the healthcare industry that success for an organization is based on the set of uncommon denominators they’re working with. While borrowing good ideas from other organizations can be helpful, it’s important to understand it takes careful planning and a strong understanding of your organization and culture, to successfully implement a healthcare delivery system. Every system is unique and should be treated accordingly.

Paper is paper, electronic is not – Moving to Electronic Health Records (EHR/EMR) is just one aspect of improving healthcare. By incorporating the new standards and being able to achieve outcomes, as defined in “Meaningful Use,” we are providing a foundation to improve the delivery of care. Providers need to look ahead and plan how these newly available tools can impact their diagnostic and remediation therapies, as well as their care plans. Examining the effectiveness of diagnostic practices, comparing outcomes with other organizations and implementing business operation and process changes will all allow you to improve care while staying flexible for future trends and tools in the market.

Security is no longer a wall – In the not too distant past, security was thought of as a wall similar to those surrounding the castles of medieval times. With cloud computing, the concept of a closed environment is gone and as a result, security has become a multi-dimensional issue, as HIPPA requirements, third-party integration concerns, new Healthcare Information Exchanges and affiliated practices all create a range of requirements that must be addressed. Security concerns will be furthered as new functionalities and interoperability of delivery systems come on-line. Security, to be effective, needs to be developed and integrated at the corporate level. The importance of security and privacy need to be recognized at the corporate level, just as the role of information has been acknowledged through the rise of the CIO. While many organizations will lump security into their IT practice, it deserves to be treated as a separate entity with governance over all security concerns, including information systems, medical records and registration. In effect, it should be a stakeholder in any Project Management Office (PMO) initiatives.

Enterprise Change Management – Healthcare providers should be encouraged to become lean in business, in addition to diagnostic and therapeutic services. If you or your organization consider’s EHR’s and system implementations as an IT project, your chance of success is dramatically diminished. Success defined as sustainable business model, as well as, achieving ‘Meaningful Use’ and improving clinical outcomes. Providers need to be certain to tie every service, process and product to the appropriate charge. To manage these resources appropriately, it’s important the right tools are in place. Studies have shown that access to better tools, experience and knowledge help providers become more efficient.
Meaningful Use Timeline
While the stimulus program is encouraging and paving the way for providers to become electronic and to attain minimal (electronically documented) requirements, future incentives may also come from competitive motives. All providers should know the future of healthcare will be different. Competition from growing provider practices and health systems will contract to fewer, larger systems that can disperse efficient and effective diagnostic and therapeutic medical services at lower costs. This precedent is fueled by natural market growth tendencies, as well as declining economic factors, which if anything has changed society to be cost conscience in everything, especially medical care. The days of the ‘local’ doctor are coming to an end, the future will be full of choices, options and hopefully, better informed decisions by everyone.

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Filed under Healthcare Reform, Meaningful Use, Organizational Performance