As the rate of EHR adoption by hospitals increases, so does an unpleasant side effect: lost revenue because of disruptions related to system conversions. Avoiding these shortfalls and expediting a smooth transition during an electronic health record system deployment is a major challenge for hospital CFOs and financial officers.

"Setting expectations is very important," said Patrick McDermott, senior vice president for revenue cycle at Sutter Health. "You don't want surprises."

Before joining Sutter in northern California, McDermott served as vice president of revenue services at Illinois-based Presence Health, where he helped oversee a large-scale system conversion at the first six of the health system's 12 hospitals.

During the first 30 days after the transition to its new EHR, Presence revenue declined by 25 percent, McDermott acknowledged. But because senior management had been carefully prepared for that possibility, it wasn't the disaster that it might have been.

Also See: Making the EHR Switch

The EHR conversion currently taking place at OhioHealth is even more ambitious. The Columbus-based 11-hospital health system "is going 'big bang' with our implementation," explained Jane Berkebile, senior vice president for revenue cycle. "We made the decision to cut over all of our facilities and our entire clinical network at the same time."

Anticipating Horror

But Berkebile had heard "horror stories" about the impact such a wholesale transition could have on a health system's revenue and wanted to avoid any missteps, so she led the formation of "dart teams" to drive revenue capture.

These Drive Revenue Recognition Teams (DRRT, or "dart" for short) were used to promote awareness among the health system's clinical groups, which before the system consolidation effort may not have even known what their group's revenue was. But now that all revenue data would be fed into the EHR's centralized database, it was critical that the leadership of these groups take responsibility for capturing and reporting that data. The teams were key elements in Berkebile's campaign "to continually inform and educate top management on the potential impact of the new system on our revenue cycle."

Both McDermott and Berkebile made many of their comments during the recent Annual National Institute of the Healthcare Financial Management Association. They spoke about the challenges that EHR conversions pose to a hospital's bottom line and detailed the ways these challenges can be addressed.

"A large-scale HIS conversion will require continued focus on inherent revenue cycle risks associated with the change over," said Timothy Kinney, who chaired the session and is one of the founders and managing directors of Chicago-based McKinnis Consulting Services. The consultancy worked with both Presence and OhioHealth on their EHR implementations.

"Both Presence and OhioHealth invested significant capital in their EHR system, with the understanding that, over time, a significant return on investment would be realized," Kinney said.

But along with the potential upside, both hospital systems recognized that there was "significant financial risk associated with the revenue cycle implementation."

Inherent Risks 

Hospitals always face inherent revenue cycle risks, Kinney pointed out, but the risks are greater during a large-scale system conversion. To ensure the smoothest possible cutover and maximize revenue capture during the transition, there are several potential trouble spots financial officers need to closely monitor and manage. These include:

* During the changeover, IT executives will need to manage two system environments, increasing operational complexity and the potential for errors.

* Legacy systems may be neglected at this time, when in fact their performance needs to be maximized.

* Reporting metrics may not carry over from one system to the next.

* Deploying a centralized EHR requires a new collaborative mind-set, and there may be cultural barriers to the change.

* The health system's organizational structure may be siloed and interfere with the integrated, organization-wide data capture and reporting an EHR requires.

* Inefficient workflow, instead of being optimized, may simply be recreated during the transition.

* Unless the new system's end users are convinced that the conversion is both necessary and beneficial, they will resist the effort undermining adoption.

Organizational silos, added McDermott, are "the natural enemy" of a centralized conversion, and highly centralized organizations are in a much better position to succeed with an EHR deployment than hospitals operating within a more decentralized environment. To prevent different functions and departments from working at cross-purposes, he agreed with OhioHealth's Berkebile that revenue cycle management "needs to form SWAT teams to promote teamwork and a more collaborative approach."

Motivating these teams, McDermott said, requires different tactics, including a healthy dose of inter-hospital rivalry. The revenue cycle exec amusingly described how, during Presence's conversion, he'd visit the leadership team at Hospital B and tell them all about the revenue capture achievements of Hospital A. Then he'd say, "'But you know, I really think you can beat them.' I'd look them straight in the eye and say, 'You know, you're really my favorite hospital.'"

Berkebile told conference goers how the success of her dart teams brought revenue awareness to clinicians who'd never even considered revenue before. Their success was brought home one day when OhioHealth's CIO called to tell her he'd been pleasantly shocked to overhear some nurses discussing revenue. "The nurses are talking about revenue!" he said excitedly.

And they weren't just talking. "Some of those nurses," Berkebile said, "went into the basement and found legitimate sources of hospital revenue that had never been reported before."

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