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What to Expect When You are Expecting to Convert Your EHR

In the current world of population health management and value-based reimbursement models, many health systems are embarking on the conversion of their EHR as a major goal in reaching full integration and the ability to analyze clinical and financial performance. An EHR conversion has 2 simultaneous tracks each requiring significant resources:

  1. Legacy system support
  2. Converting and implementing the new EHR

In spite of the best project planning, the preparatory work needed for the overall success of each track is often overlooked, especially in high cost/high revenue departments such as Surgical Services. These highly visible and costly projects must be managed in a way that reflects the focused scrutiny that perioperative and other critical patient care areas should receive.  In a recent survey reported in Healthcare IT News, “87% of financially struggling hospitals now regret changing their EHR systems.”  While there were several reasons cited for this regret, the ease of achieving “buy-in” of physicians and other clinicians and the impact on clinician ability to deliver hands-on care with the same effectiveness is worth noting because of the potential impact on operational efficiency once the conversion is completed.

There are still good reasons for hospitals to proceed with an EHR conversion, or, given the expense, to optimize an existing system. However, keeping the potential regret in mind, it has been our experience, that recognizing the following failure and corresponding solution will serve you well as you undertake your conversion effort.

The “BIG MISTAKE”: Failure to Optimize the “Gap” Period Between the Decision to Convert and Software Vendor Kick-off

Project Managers often assume that the optimization work specific to perioperative services, as well as critical standards and integration decisions, can be done as part of the design and build portion of the conversion work plan often without appropriate multi-disciplinary collaboration (i.e. Anesthesia, IT, Finance, Materials Management, Pharmacy, Radiology, Physician offices, etc.). This can lead to a new EHR that is not optimized and incorporates incomplete or inaccurate data, directly impacting your ability to improve upon your prior system experience and to derive/extract the level of analytic data required. Even worse is the convergence of limited resources and aggressive vendor timelines that often result in the decision to simply move legacy data with the intention of “fixing” it later.

The SOLUTION: Pre-Project Optimization Work & Decisions

By knowing what to expect in advance and allowing the time for key decisions, your pre-project optimization work will allow you to walk into the EHR kick-off meeting prepared to support your existing legacy system while focusing on the new system’s design and build.  The pre-project optimization phase is as critical to your success as the new system implementation phase and helps you stay on time and within budget.

A well facilitated pre-project optimization phase offers the opportunity to:

  • Ask the right questions to avoid common failure points in system conversions; define leading practices and understand the differences between your legacy system and the new EHR; find out what you don’t know.
  • Articulate the strategic, clinical, and financial goals of the EHR conversion.
  • Ensure that interdependencies among other departments, important to the strategic success of the OR, are included in decisions that are made in the early part of the overall conversion project.
  • Take a fresh look at industry standards for core data and practices needed to evaluate and achieve the right level of data granularity. As the significance of analytics continues to increase, standardized data is integral to making the best design decisions about how you will capture and analyze data as well as time to evaluate the impact on various types of staff.
  • Update or rework core data tables consistent with the structure of your new vendor system (is moving legacy data really the best decision?).
  • Understand the entire perioperative workflow from a patient-centric viewpoint and find opportunities to eliminate inefficiencies, redundancies, reduce cost, and improve patient care and the electronic documentation of that care.
  • Prepare for the variety of staff resources needed for the design, training, testing and roll-out of the new system while maintaining the same level of quality patient care; plan for “peak” periods of build activity (i.e. conversion of surgeon preference cards). Set your project team up for success by not underestimating the commitments needed for a project of this size and significance.
  • Prepare for the possible re-assignment of internal resources from maintaining your legacy system to new system activities (how and by whom will the legacy system be managed?); ensure a smooth cut-over from old to new systems.

Pre-Project Optimization and focused decisions on 6 core areas of master data will directly impact the perioperative continuum from accurate scheduling of cases to appropriate patient & room readiness to the effectiveness of supply chain to cost analysis to patient/clinician satisfaction. The level of advance effort and/or the decisions related to each core area may vary but they are equally important. They include:

  • Master Surgical Procedure file: this core file must be clinically discrete and impacts every other area of the department (accurate case scheduling estimates, pre-certification, clinical supply, equipment & instrumentation requirements, case documentation, case charges, payment delay/denial and reporting).
  • Supply Item Master file: this core file of supply item descriptions & associated critical reporting data must be up-to-date, with a standardized format that links the supply to your purchasing system (actual cost) and charge master (revenue). Every supply used in the perioperative department must be available for documentation in the patient’s record for real-time inventory control; maintenance is determined by system integration and/or interfaces.
  • Surgeon Preference Cards: these files (typically in the thousands) must be thoroughly updated for the top performers to reduce inventory, increase surgeon & staff satisfaction and improve patient care during the procedure (have the right items available at the right time with minimal returns because content is specific to a clinically accurate procedure); support ability to move from clinical preference to clinical acceptability through “apples-to-apples” comparison & contribution margin analysis.
  • Clinical Documentation: the need for “good data” is greatest in the capture of clinical patient care information as evidence of value based care. Review of current clinical documentation (surgeon, nursing, resident, and anesthesia) must occur in order to transition to effective design and consistent data collection. This must be achieved to ensure portability and accessibility of one of your organization’s most valuable assets.
  • Perioperative Throughput Efficiency: review of all real-time throughput metrics & introduction of industry standard time capture definitions will ensure that your system captures the right level of detail needed to make the best decisions for process improvements.
  • Critical Operational Reporting: “catalog” needed reports that must be converted on Day 1 of the new EHR to maintain operational management of the department; ensure future ability to produce actionable perioperative statistical, quality, financial and regulatory reports to include surgeon-procedure case costing, resource utilization, data integrity audits, and quality of care.

Changes in reimbursement and associated patient revenue combined with the significant cost outlay related to EHR conversion is dramatically impacting the financial bottom line of hospitals as recently noted in Becker’s Hospital Review. One hospital commented that they knew their “post implementation strategy will focus on clinical productivity and operational efficiencies to return to normalized operations by year end.” Shifting some of this effort upfront during a pre-optimization phase within perioperative services can help to mitigate the burden required to normalize operations after an implementation.

Keeping your staff successful in meeting all of the expectations of a new  EHR should be everyone’s common goal! Understanding the perioperative portion of patient care and the link to other departments and/or applications is a key determinant in achieving the return on investment expected for the new EHR vendor system. Ongoing financial sustainability requires having the data you need to improve the quality of care, patient/clinician satisfaction, and meet the needs of regulatory, cost, and quality reporting.

Part 2 – Communication vs. Collaboration: Creating a Patient Centric Perioperative Supply Chain Culture

In Part 1 of our series on implementing a patient-centric supply chain, we talked about how communication and collaboration are not interchangeable and the differences between the two need to be understood in the transition to a Value Based Purchasing environment. Now, let’s take a deeper look at how to create this shift.

The ability to successfully transition to the value-based reimbursement world depends on departmental strategic business plans that reflect the overall goals of the organization and consolidate the known strengths of your departmental contributions.

In a volume based environment, Supply Chain and Perioperative Services focus on their own goals and utilize linear communication to manage the intersections between the two cultures – Supply Chain concentrates on the organizational mandate to reduce cost and Perioperative Services on providing efficient quality patient care. Although these perspectives are generally aligned globally, the focus on departmental success tends to prioritize short term individual accomplishments instead of long range sustainable financial growth.

A patient-centric culture can be defined as an approach that evaluates all clinical and supporting activities in terms of what is best for the patient and their family/support system. It is a shift from focusing on problems to focusing on the patient.

Adapting and functioning within a patient-centric culture specific to perioperative supply chain begins with minimizing linear communication and management silos and maximizing cross-departmental collaboration. This starts by embracing the uncomfortable realization that the value of each department is no longer measured only by individual accomplishments, but rather to the level a department’s contribution optimizes cost, quality and customer satisfaction for the patient.

The conversion to a patient-centric culture will require a shift in focus from quality processes to measurable quality outcomes. The key is to re-design processes with this new patient-centric end in mind, not just making the existing process cheaper or faster. Key elements pivotal to this effort include:

Value

  • What is value?
  • How do you define it?
  • How do you measure it?
  • Can you improve it?

Performance

  • Only that which can be measured can be improved.
  • How do you measure performance?
  • How do you measure & track the impact of efficiency on quality; is all efficiency automatically good; is there a tradeoff/a point of diminishing return?
  • How do you re-define accountability for ensuring the communication loop is completed consistently?

Process

  • Is this process necessary?
  • What are the key steps in any process?
  • Do we really need to do this step?
  • How does this add or subtract value?
  • How does this add quality to the patient experience?
  • Does the patient and/or clinician perceive this as adding quality and value to his/her experience?

Old way of measuring departmental success: Look inward and improve the process

For decades, Supply Chain departments have measured operational improvement in terms of negotiated savings and the efficiency of core processes. Total savings, lines per purchase order, expense per adjusted patient day & adjusted discharge, inventory turns and other Key Performance Indicators (KPI), have been, and will continue to be, used to justify the organization’s investment in Supply Chain operations.

New way of measuring departmental success: Look outward and improve the system

In today’s VBP environment, these benchmarks become secondary to the overall quality, cost and customer satisfaction of the services provided. Let’s look at these one at a time.

Quality

Most of us weave the assessment of an item’s quality into our daily personal purchasing decisions. Does the name brand item actually taste better, clean more efficiently or last longer than the low cost generic alternative? The relationship between these subjective quality assessments, and our financial resources, fuel the cost/benefit analysis that influence what we buy.

In the world of healthcare, when financial resources were abundant and the reimbursement was a “cost plus” model, this analysis was an exercise that allowed a greater emphasis on preference (including paying list price and/or acquiring the latest technology) as we may have been willing to pay more for an item that we considered to be of higher quality. When financial resources are restricted, the need for collaboration between the “forces” of cost vs. perceived quality are essential.

In the VBP world, the assessment of quality must shift from clinical preference to clinical acceptability. Each organization must define these terms within a framework that includes patient safety and clinical outcomes. This framework will shift the conversation from subjective preference to the objective selection of items based on cost, defined risk and measurable patient outcomes.

In this environment purchasing decisions are made based on: documented utilization, clinical outcomes, total cost, service, vendor support, vendor reputation, market share, etc. This requires collaboration between, Physicians, Clinicians, Finance, Administration, IT, Risk Management, Audit, Supply Chain and other key stakeholders.

Cost

Most Value Analysis programs have expanded the traditional analysis of unit cost to include total cost and life-cycle cost.

Key elements of this expanded analysis include:

  • Purchase price
  • Terms
  • Shipping costs
  • Inventory costs
  • Distribution costs
  • Rebates
  • Tiered volume incentives
  • Procurement/Receiving Costs
  • Opportunity costs associated with spending financial resources vs. potential interest revenue

Customer Satisfaction

In their book: “Advanced Lean in Healthcare”, Craig T. Albanese MD, MBA; Darin R. Aaby MS; and Terry S. Platchek MD suggest the perception of insurmountable complexity in healthcare is due to the wide scale adoption of “Healthcare Exceptionalism”. “Healthcare Exceptionalism is the belief that healthcare provision is so unique, complicated, challenging, and regulated that any lessons to be learned from other industries are largely irrelevant.”

Variations of Total Quality Improvement, (and similar programs), have been around in healthcare for decades, and although improvements have been made, there can still be resistance to adopting Lean methods in the healthcare environment.

Healthcare organizations experiencing the transition to value based reimbursement recognize customer satisfaction as one of the keys to financial viability, as it is in any business. We are still learning how to apply the techniques implemented by our industrial/business counterparts to redesign processes that align with customer expectations. This requires knowing all your customers and the keys to their satisfaction.

Keys to Patient Satisfaction:

Empathy: understand the experience from the patient’s point of view

Patient is the customer & treated holistically, not just as a body needing repair

Involve everyone wisely & efficiently: as we illustrated in our previous blog post, the patient is the epicenter of everything everyone does but they can be frustrated by duplication.

Keys to Clinical Practitioner Satisfaction:

The practitioner (Nurse, MD, etc.) at the bedside has the greatest impact on the patient experience

Resources needed to provide care are available and appropriate

Technology used contributes to workflow efficiency and productivity

Data used in all information systems is standardized, meaningful, and reportable to meet the needs of all departments that use the information

Supply Chain’s role in optimizing patient & practitioner satisfaction:

The struggle to define a department’s role in the patient’s continuum of care can be simplified by accepting the premise: “In a patient centric culture, if you do not provide care to the patient at the bedside, then you work for someone who does”. From a Supply Chain perspective this means implementing processes that enable the clinician to spend more time with the patient and less time in core Materials Management functions while achieving the organization’s goals of cost savings and operational efficiency.

Key elements included in this effort:

Clinicians and Supply Chain leadership & staff must understand:

  • How their respective information systems impact each department?
  • How standardized data elements impact optimizing quality, cost and customer satisfaction. For example:
    • Standardizing data enables the implementation of Item Synchronization Interfaces reducing the manual effort associated with maintaining disparate clinical and Materials Management item masters.
    • Standardizing descriptions streamlines communication between clinical and Supply Chain personnel.
    • Standardizing UOM improves the accuracy of intraoperative documentation and corresponding usage statistics.
    • Standardizing Unit Cost improves the accuracy of case cost reporting.
  • How to optimize the financial and operational tradeoffs of using clinical personnel to manage core Materials Management functions.
  • The impact of organizing inventory to optimize cost, efficiency, quality and customer satisfaction.
  • The impact of accurate documentation.
  • How to ensure information stored in their respective information systems is capable of providing reliable, timely & accurate utilization and case cost reporting.
  • How to ensure all processes produce measurable data as needed to support ongoing cost reduction initiatives and produce accurate case costing reports?
  • How to prioritize and support the development of a clinical informatics infrastructure to guide and direct collaborative initiatives.

Collaboration means more than scheduling more meetings, fine-tuning meeting agendas and minutes, inviting more people to the meetings or listening more carefully. Even though cost, quality, outcomes and efficiency will continue to dominate the healthcare landscape, they no longer represent the end of the journey. Collaboration channels these interconnected forces to a new focal point at the center of the continuum of care: the patient.

 J2 will be presenting this information during a presentation at the Surgical Services Summit in Las Vegas in December, 2016. We hope to see you there.