The Evolution of the Clinician's Role: An EHR Implementation Story

Becker's recently ran a post called "25 quotes that show just how fed up physicians are with EHRs," and the comments section suggested that those 25 were just the tip of the iceberg. The quotes coming out of a 2015 implementation at OhioHealth, one of the top 5 large health systems in the country, take a distinctly different tone.

As one OhioHealth executive remarked to the System VP of Revenue Cycle during the project: "I was rounding at the hospital and nurses are talking about revenue." Remarks like this one demonstrate OhioHealth's unusually successful approach in terms of clinical buy-in. Having returned to pre-live baseline metrics for gross revenue capture within 10 days of go-live at the 7 hospitals involved in the upgrade, the financial motivations for undergoing the transition have also met with success.

How did OhioHealth avoid common implementation pitfalls and gain the trust and dedication of clinical leaders? How did it learn what the system's end-users needed, and ensure that the system met those needs? Part of the answer was a strong, positive relationship between IT, revenue cycle, and clinical operations leadership before the transition. These 6 steps were the rest:

1. "You don't know what you don't know"
With any large-scale organizational change, identifying the unknowns is a humbling but necessary first step. OhioHealth talked to peers across the country years before the go-live, and nearly all of the steps below were influenced by those discussions: some peers had undergone implementations without full political support by administration leaders; others had neglected to include clinical and operational users in the system build and testing phases. Learning that gross revenue could get lost in the shuffle, OhioHealth engaged McKinnis Consulting Services (MCS)  nearly a year before the first go-live to guarantee stability in gross revenue, which was accomplished through months of pre-live planning and testing, including 100% charge testing to ensure accuracy with the new clinical workflows.

2. Get the political infrastructure aligned first
Executive leadership alone is not sufficient for a successful EHR implementation, but it is most certainly necessary. Leaders must understand, and communicate to the entire organization, that the project is mission-critical. At OhioHealth, those leaders established a multi-disciplinary Revenue Integrity Team (RIT) whose sole focus was to ensure that gross revenue capture didn't drop during or after go-live. The RIT met monthly to review project progress, including the timelines and potential risk areas that surfaced during the build and testing phases.  

3. Involve and integrate, from the outset and throughout the process, the financial, clinical, and IT sides of the organization
21st century healthcare organizations must recognize that to be successful they need to break through departmental siloes and integrate operations. One of the main benefits of a next generation EHR is to aid in this integration, both structurally and systematically. There's no longer a buffer between a clinician's action and its financial ramifications, whether the outcome is meeting a performance metric or triggering a charge. It has traditionally been an uphill battle to help clinicians see the utility of accurate and consistent charging as it relates to patient care, especially the link between healthy revenue yielding better resources for providing care. However, when the revenue and clinical sides are enlisted early and engaged genuinely to accomplish such a massive project, with leads from both groups called on to influence its workflow design, testing, system evaluation, and continued success, the project can be a bridge rather that a wedge. To create that bridge, a few tips:

  • Build collaboration into the project structure. Whether it's a cross-functional group coming together to describe current workflows or a new Revenue Integrity Team overseeing revenue reconciliation, collaboration among IT, revenue cycle, and clinical operations should be reiterated at every level of the initiative.
  • Recognize that vendors are crucial to the effort, but the organization itself must deliver the project leadership, staff engagement, and organizational buy-in.
  • Create a paper trail: OhioHealth composed over 200 revenue cycle-related decision documents signed by key stakeholders across the organization to ensure that the right people were making the right decisions.
  • Develop detailed training for clinical areas explaining the "why's" of the new charging and reconciliation expectations, not just the technical buttons to be pushed.
  • Enlist key clinical leadership early and give them real influence and distinct, sizeable responsibilities. At OhioHealth post-go-live, clinical leadership joined in daily revenue integrity meetings until revenue was returned to baseline.

4. Charge testing: test early, test everything, test with everyone
Testing early and extensively is the only way to catch and address system issues before they can do real damage. The participants in this testing are as important as the number or type of tests. It's critical, for instance, that clinical operations are intimately involved in the charge testing because they will be responsible for ensuring accurate charge capture after the transition. Involving clinical operations also introduces and increases buy-in at a much earlier phase of the implementation. Through assisting in the testing, clinicians begin to feel more confident in taking ownership of the system once it is in place.

OhioHealth's clinical operations were instrumental to the system build and its subsequent testing. For months, they met with the revenue cycle team and IT in testing rooms to walk through the post-live clinical workflows that would trigger charges, and then reviewed the resulting charges to ensure they were accurate. This allowed OhioHealth to catch and resolve issues far in advance of taking the system live.

5. Help sustain clinical interest throughout the process
Building infrastructure devoted to problem-solving can be crucial for sustaining clinical interest in revenue through the EHR go-live. OhioHealth's daily, multi-disciplinary meetings post-go-live helped to identify issues clinicians were facing with the new system, and created a forum for sharing solutions and fixes across department lines. These meetings were also used to compare each department's daily go-live revenue performance to its historical revenue performance.

OhioHealth also established a centralized go-live "CommandCenter," where clinical staff could find IT and revenue integrity resources to help them resolve issues with revenue capture and reconciliation as they arose.

6. Understand that the project never ends
Keeping the IT, clinical, and financial people of a healthcare institution communicative, responsive, and respectful of one another's contributions to quality care is one of the biggest quandaries of hospital leaders. It is also one of the keys to sustainability in U.S. health care. OhioHealth's dedication to inclusion and the end-user made its EHR implementation successful, but the trick is making sure that the culture of cooperation is supported after that success.

Building multi-disciplinary teams and empowering them to tackle new problems as they arise is one strategy to keep the momentum going. OhioHealth's Revenue Integrity Team evolved into a sustainable committee that continues to address and even optimize gross revenue capture. That kind of tangible teamwork is crucial to the evolution of the clinician's role in the contemporary healthcare organization.

Margaret Schuler, MBA, is executive director of revenue cycle for OhioHealth in Columbus, Ohio. She directs the operations of the Central Business Office and is responsible for the collections of over $2.5 billion annually for 10 acute care hospitals and more than 350 physician practices. Prior to joining OhioHealth, Margaret was a revenue cycle consultant assisting hospital providers with net revenue initiatives such as reengineering charge capture processes, optimizing third party reimbursement, streamlining accounts receivable management, developing charity care policies and managing the installation of new health information systems. Margaret is currently a Chapter Board Member of the HFMA Central Ohio Chapter.

* McKinnis Consulting Services, LLC (McKinnis) was acquired by Navigant Consulting, Inc. (Navigant), effective December 31, 2015. The results detailed in this case study were derived through an engagement McKinnis conducted with OhioHealth prior to its acquisition by Navigant.

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