By Caroline Znaniec

During an electronic health record (EHR) implementation, a healthcare provider’s current processes will greatly change. If not integrated soundly to the new environment, there can be significant effects on your revenue and reputation.

Revenue integrity activities focus on process improvement and include those most closely involved in the front, middle and back-end revenue cycle processes. The main objectives of the activities are to reduce revenue leakage and potential customer scrutiny; whether by the payer or consumer.

In this article, I share two case studies where an EHR implementation had serious negative effects. After reviewing each case study, I will cover the common mistakes and their impact on revenue.

Case Study One

A northern medical center with more than 650 beds implemented an EHR costing the medical center over $160 million. After go-live, the investment cost even more due to inability to effectively utilize the EHR to capture charges.

The medical center had a $13.5 million operating loss over 6 months. Executives lost their jobs, hiring was frozen and further implementation activity was delayed, costing even more money.

The lack of training of clinical staff in their responsibility to document to capture charges was to blame.

Case Study Two

A midwest community hospital was one month from go-live in a completely new EHR system. Their current system contract was scheduled to be terminated in 3 months. During the final testing of claims, it was identified that ER charges were not flowing to the claim.

Further analysis indicated that more than $60 million annual revenue in chargeable items, services, and procedures were not mapped to the documentation as they should have been. While present in the charge description master (CDM), the charge capture trigger was not indicated. Items, services, and procedures could be documented but a charge would not result.

Implementation of the new system was delayed and the existing system contract was renewed in the short term to maintain operations. Millions of dollars were spent due to the delay as a result of this finding.

Lessons Learned

The rate of hospitals implementing EHR system has increased significantly in recent years, however, we continue to hear, see, and read in the news how some can have devastating circumstances.

In reviewing articles, case studies, and experiences, a common theme often arises. Many cite the lack of dedication towards the revenue cycle process as a key reason for potentially a poor go-live. And it’s not just the implementation of a completely new EHR solution, but can also be an upgrade of an existing system.

Common mistakes in an EHR implementation that can lead to lost revenue include these below.

Lack of training for non-traditional charge entry staff

Many of the EHR systems today automate the charge capture of services to other workflow processes. Such processes can include documentation, timing from procedure logs, change in patient status, and or processing of diagnostic tests. The automation of charging can improve charge capture accuracy and better support charging and compliance through required documentation.

However, the staff involved in the workflow should be aware of how their actions will:

• Result in patient charges
• Populate reports for code abstract
• Trigger hard coded items, procedures or services through the charge description master (CDM).

This often includes clinicians at all levels. Training should not include only how to navigate screens, but how their actions within the EHR can affect and impact the overall revenue cycle. Staff may also have additional responsibilities in the review of their charge activity and reconciliation, as well as working potential issues and errors. If the staff has not traditionally had responsibility for monitoring their charge activity this can be a steep learning curve.

Translating current charge capture methodology to the new system (1:1)

The ability to automate processes in an EHR can make an incredible difference in the efficiencies and productivity of staff, and improve overall charge capture. However, too often current charge capture methodologies are simply copied over from a charge capture template into an electronic version of the same.

The opportunity to improve upon the identification and capture of the item, procedure, or service is not addressed during implementation. And if problems existed prior in these areas, the same will likely result, but just now in an electronic state.

As a part of an EHR implementation, healthcare providers should take the time to assess current charge capture methodologies and improve upon them before implementation.

Not completely testing patient scenarios

Testing the EHR prior to go-live is a standard practice. Example scenarios are selected and to be followed through the patient experience to ensure workflows from physician order to billing are working soundly.

What can occur is an incomplete test. Healthcare providers should test that the orders are present, that they trigger a response, and that services are documented and charges results. But they should also look deeper into the processes and detail.

Is the documentation complete? Are the charges correct (not just “is there a charge?â€), etc.

Better practice is to include with the patient scenario testing a complete review of the linkage between actions and charges. This is often referred to as an order entry mapping audit.

Inability to troubleshoot issues

EHRs provide a lot of data. Sometimes they provide too much data. The ability to monitor and measure can be great, however, it’s knowing what to do with the data and if needed, how to react.

As revenue cycle metrics may change (and they will) it is important to understand potential root causes. Without this understanding, issues may compound and result in even greater losses.

Conclusion

Healthcare is only going to get more electronic and digital. We will not be returning to the world of paper. In light of this, it is critical that we understand what it takes to run a successful EHR implementation both with regards to the systems and the people who operate them. The profit of health providers, or lack thereof, is directly tied to the success of the EHR.