Successful Adoption and Meaningful Use of EHR Tools and Processes
A non-profit organization was awarded a grant in 2011 to support eligible providers working in the Southwest region meeting Meaningful Use. One facility that deployed the Veterans Health Information Systems and Technology Architecture (VistA) EHR recognized that while they successfully implemented deploying the EHR it tended to magnify certain manual practices that were not optimized prior to EHR go live. As a result Divurgent was asked to provide a solution that would involve a two phased approach. The first phase would be to perform a current-state workflow analysis of the ambulatory departments of Internal Medicine, Family Practice, Pediatrics, Women’s Health, Pharmacy, and Physical Therapy. The second phase was focused on providing support for the successful implementation of the phase one recommendations.
The first phase involved interviewing a broad range of providers and staff from the perspective of the entire processes from registration / scheduling, to clinic patient encounters, then the business office and medical records. The goal was to show differences between each department and to identify areas of potential improved opportunities. These opportunities were than illustrated in each workflow by yellow call outs. These opportunities were validated, prioritized, and further categorized as observations, recommendations, and goals for the organization.
The second phase is to take the recommendations and develop teams to implement each of the recommendations. A tool was developed to assist this process that identified key project components such as goals, objectives, team members, key performance indicators, challenges, and go-live dates. A sample of these goals and objectives were: 1) improve accuracy of clinical and financial patient information throughout the entire patient intake to discharge process by 25%; 2) develop detailed strategy for the elimination of the paper chart by mid – 2013; and 3) perform detailed workflow analysis for optimized performance of clinical and business office staff to optimize revenue recognition and further preparation for ICD-10 roll out.
Brian Fitzgerald has been leading this effort on behalf of Divurgent, traveling to the Southwest region from his home in Greensboro, NC. So not only is it highly interesting work but also an adventure in travel, including roaming animals! Thank you to Brian for all of his hard work in helping ensure a successful adoption and meaningful use of EHR tools and processes!
Facility Transformation Supported by Go-Lives
Divurgent team members provided support to a community based healthcare network provider, in completing a Cerner Clinical & Revenue Cycle system re-implementation and the replacement of their General Financials and Supply Chain with McKesson applications all within a fifteen month time period. As the largest health care provider in the nine-parish area of southern Louisiana, they implemented Cerner and McKesson applications and associated re-defined workflows in five distinctly different environments:
a 353 bed acute care facility, previously on an early version of Cerner and Oracle
a free standing surgical hospital, previously utilizing paper for clinical documentation
a 25 bed Critical Access facility, previously on paper
two affiliated urgent care clinics, previously on paper
Key functionalities and enhancements in technology included:
EMR utilization in five facilities, four previously on paper
full CPOE in all implemented locations
full Barcode Meds Administration
Cerner Surginet implementation in all surgical procedure areas i.e. Operating Room, Cath Lab, Endo
Enhanced device integration
In addition to the clinical objectives the organization completed financial system upgrades and or enhancements achieving:
Conversion to MedAssets for claims editing, clearing house and processing
Transition to and compliance to 5010
Electronic patient address validation
Enhanced EDI transaction set processing including automated ordering of materials and Accounts Payable invoicing
Supply chain automation using handheld devices
With the above initiatives and a planned system upgrade for 2013, the community based healthcare network is well on its way to meeting Meaningful Use Stage 1 and establishing a road map to meet ICD-10 compliancy.
Achieving an Information Technology Organizational Redesign
Our client hired the DIVURGENT Advisory Services team to help them redesign the organizational structure of their Information Technology (IT) Department to align with future initiatives and overall organizational strategy. The IT department was at an interesting crossroad. With their reporting period for stage 1 meaningful use about to begin (with anticipation that they would readily meet the reporting requirements), senior management wanted to take time to conduct a review and ensure the IT organization was structured in an optimal manner to meet business needs. Key questions pursued included:
Is IT leveraging industry best practices?
Is IT organized in a way that is optimal for the organization?
What new skillsets might be required?
What SLA’s (if any) are required?
Does IT have the right demand management model? DIVURGENT utilized a combination of best practices reviews, client interviews, analysis, and development of alternative organizational approaches to develop the best go-forward approach. In the end, DIVURGENT produced a plan that is well-defined, could be endorsed by senior management, and is readily implemented.
DIVURGENT successfully completed our most recent engagement at a multi-site teaching organization comprised of 12 hospitals or hospital partners, two nursing homes/skilled nursing facilities and more than 60 clinics providing care to residents in a 29,000-square-mile service area. The organization employs more than 13,000 employees, 900 physicians and scientists, and is a primary clinical teaching facility to approximately 400 medical residents and fellows in training. In addition, the healthcare organization serves more than 180,000 members within its own healthcare plan.
The organization is implementing GE Centricity Business (GECB) (formerly known as IDXExtend and IDX Flowcast) to replace aging Siemens Signature systems that had been their practice management system for more than 15 years. The organization looks to use GE Centricity Business as their front-end registration system for all ADT activity – including the physician practice scheduling and registration activity and acute care (hospital) ADT activity. Of primary importance, is the ability to derive benefit from standardized processes, reducing variability, and moving data edit resolution to the areas that have the information to resolve the edits in a timely manner. Historically, the data was entered and all corrections are resolved on the “back end” causing billing and collection delays.
In January 2011, DIVURGENT was engaged to provide Testing Manager Services directing all testing activities. These activities were directly related to the GECB implementation and included additional areas with indirect or tangential implications. At the engagement’s commencement, a number of opportunities existed including, but not limited to:
System build decisions and associated workflow development were still underway
System application build activities were still underway
Minimal unit testing and proper documentation had been completed
Partial integration testing had been planned for and conducted with limited results
Simulation testing plan and scheduling required full development
Activation planning, original date of April 2011, re-scheduled
To successfully manage the testing situation and ensure the client was successful we rapidly developed a revised testing approach and plan leveraging existing test scripts and testing conditions. This supplemented the initial integration testing conducted on a partial system build platform. As a result, the first simulation testing focused on objectives related to functional, unit, and partial integrated testing concepts.
Outcomes and results of the initial testing included; allocating additional time and resources to complete the build activities, re-focus and enhancements to the simulation test scripts, and the incorporation of detail level test scripts for organization wide integration across all affected applications.
The final round of Simulation Testing involved more than 100 people, organization wide facilities and departments, and ran for two continuous weeks, including weekends allowing for a more future state simulation. A very deliberate and methodical approach was undertaken – stopping as each on-line transaction was completed to validate interface transactions in all affected downstream systems. Similarly, on a daily basis the team validated each financial transaction and billing activity to verify the expected charge amount or billing activity produced as expected. Any variance identified was followed up with a root cause analysis to ascertain the variance.
The following table is provides a sampling of the final testing scorecard:
% of Correct Charges
Count of Correct UBs
Count of Correct 1500s
% of Clean Transactions from GE to Invision
Account for Variance
% of Clean Transactions from Invision to GE
Account for Variance
% of ADT Transactions from GE to Invision W/O Fatal Error – Demographics
% of ADT Transactions from GE to Invision W/O Fatal Error – Insurance
ADT/Provider Based Case Creation
Account for Variance
Correct Initial Bed Placements
Account for Variance
VM Alerts – % Alerts Triggered Correctly
VM Alerts Worked
ETM Tasks – % Triggered Correctly
ETM Tasks – % Worked
% MSP Form for Medicare Patients
% UB Claims Produced W/I 7 – 10 Days of DOS
% Occurrence Code Correct
% Span Codes Correct
% Condition Codes Correct
% Value Codes Correct
% PoO Correct
% Visit Priority Correct
% Discharge Disposition Correct
% Bill Type Correct
Numerous lessons learned were identified, including:
Managed through the difficulty of obtaining the right testing resources and maintaining the proper level of commitment through the script writing exercise.
Obtaining the right knowledge base from the diverse departments proved challenging and an opportunity to cross silos and share knowledge across the departments
The system build was not complete and system build decisions were fluid throughout the process, creating delays in test script development, processing and mitigation planning
Due to time constraints the testing approach combined components of unit, integration, and workflow testing into a single simulation event. While successful and covering the client’s key business objectives, the process was very intense and was not the breadth a standard simulation testing activity would accomplish.
Due to time constraints, ideal testing cycles, testing detail and mitigation steps were challenging and required creative ways to manage through to solutions.
Engaging Physicians as Implementation Leaders
Sentara Healthcare IT leadership attributes the fact that many EMR projects are not adopted by physicians to a failure to engage physicians at the initiation of the project. Focused on ensuring vested interest, support and adoption of eCare, Sentara Healthcare IT leadership established structured partnerships with physicians and employees from across the organization. The leadership credits the active involvement of physicians in the development and implementation of eCare with its quick and successful adoption. Following implementation, Sentara hospitals achieved nearly 90% computerized physician order management (CPOM) within two weeks. This rapid adoption rate significantly exceeds national rates of 25-50%.
David Levin, MD, Sentara Healthcare Chief Medical Information Officer, and Colin B. Konschak, MBA, FACHE, Managing Partner, DIVURGENT, summarized the eCare physician implementation structure in their white paper “Electronic Medical Records: What If We Build It and They Don’t Come?”
BayCare Health System – Clearwater, FL
Revenue Management During a Clinical System Implementation
DIVURGENT was engaged by BayCare Health System (BayCare), a large healthcare integrated delivery system, to support the Revenue Management and Charge Services teams during Phase II of a three phase clinical transformation project using Cerner Millennium® as the electronic medical record (EMR).
BayCare is comprised of 11 not-for-profit hospitals in Hillsborough, Pasco and Pinellas counties. With 17,000 employees and a wide array of healthcare services, BayCare is the largest community-based healthcare system in the Tampa Bay region.
Phase II of the project replaced Siemen’s Invision® clinical applications with Cerner PowerChart®. All hospital clinical personnel, including nurses, patient care technicians and ancillary support, documented patient care in the EMR. The paper chart was virtually eliminated. Charges are no longer entered directly into a system or batched for data entry; they are a by-product of clinical documentation and virtually invisible to the clinical provider. As a result, there was a need for monitoring tools that had not been used previously by BayCare to ensure minimal impact on the revenue stream during activation and beyond.
DIVURGENT was responsible for developing reports and monitoring mechanisms to be used to identify potential revenue issues that included:
A report for nurse managers and department directors to run at the end of each shift that identifies incomplete or unsigned charts that drive charging in the background.
A report of incomplete tasks that have built-in charges on discharged patients to identify potential late charges.
Daily detailed interfaced charge reports to help nurse managers and department directors balance patient load against charges.
Charges that did not qualify for the financial system interface (suspended) to identify issues with unprocessed charges or revenue mapping by department.
The following metrics were used during clinical systems activation to monitor revenue and identify issues:
Gross inpatient revenue per patient day compared to budget and similar day of the week revenue from the previous month.
Gross outpatient revenue per encounter compared to budget and similar day of the week revenue from the previous month.
Number of unsigned clinical documents per day.
Number of overdue clinical tasks per day.
% of total charges that were suspended.
400-bed academic acute-care hospital client located in the Northeast
Three years ago, this organization decided to take advantage of cost savings and the open source benefits offered by Medsphere, a company that created an EMR product from the VA’s VISTA code. DIVURGENT began working with this client in June 2009 in a process redesign role. Today, DIVURGENT team members hold key roles in leading overall clinical transformation initiatives, including:
Project Manager: Responsible for coordination of the project plan and working closely with the client’s ancillary areas (i.e., Radiology, Pharmacy, HIM, and Nutrition) to prepare for the replacement of legacy systems.
Clinical Transformation Lead: Responsible for working closely with nursing and ancillary clinical leadership, is addressing the process redesign and system adoption needs.
Project Executive: Responsible for overall project reporting to the client’s Executive Committee, order set validation, communication planning, change management, and physician adoption.
This three-phase implementation will begin with CPOE and basic clinical documentation implementation. Phase 2 will address bedside bar-code medication administration. The third, and final, phase will result in a nearly paperless environment with the implementation of clinical documentation for all clinicians and physicians. Metrics for Success in Phase 3 will include compliance with the ARRA meaningful use requirements.
New business development strategy
Our team led the development of a business strategy for a large integrated delivery network interested in commercializing intellectual property developed in the areas of technology implementation, clinician integration, project management and vendor selection.
Total Cost of Ownership
Our consultant led the development of a Cerner Total Cost of Ownership (TCO) model for a nine hospital IDN in the Southeast. DIVURGENT partnered with all major client and vendor stakeholders in order to outline a six year total cost of ownership for a suite of applications to be implemented throughout the IDN.
DIVURGENT was engaged to develop a project culture that was built on PMI principles that would improve project outcomes, provide timely project information and the necessary guidance, support that would frame projects to be completed within scope, on time and within budget. In this engagement, our client recognized that a disciplined change agent was required to carry their Information Technology initiatives forward.
DIVURGENT provided various roles in the organization including: Senior Project Manager, Project Managers and the Project Management Office Director. During the engagement DIVURGENT guidance to the organization in the following areas:
pro-actively follow-up with vendors or other stakeholders to resolve outstanding issues.
escalate issues at the appropriate time to maintain project momentum.
successfully communicate and consult with all key stakeholders.
sufficiently track all project issues, ensuring that critical issues do not slip through the cracks.
manage deadlines and budget effectively.