Summer 2018  
Alert Fatigue - A Challenge for Both CMO's & CIO's
By Wayne Thompson & Dr. Nancy Gagliano
The title of an article in Health Affairs from 2011 sums up the challenge well. Kesselbaum & Creswell, et al, labeled their article “Clinical Decision Support Systems Could Be Modified to Reduce ‘Alert Fatigue’ While Still Minimizing the Risk of Litigation”1. As ARRA and Meaningful Use incentivized the implementation of EHRs, provider organizations faced a dilemma. They could turn on all of the clinical and quality alerts that those systems provided, or they could turn them off and face possible legal challenges if patient outcomes had the potential or the perception of being impacted. Some systems allowed nuances, such as alerts being tailored to each specialty or provider, but initially, many had a broad on/off switch for key alerts. Pharmacy and lab systems had a longer history of managing alerts compared to the EHR, but they too were not as granular as desired, and were handled by a relatively confined group of knowledgeable users. The EHR placed these alerts in front of Nurses, Physicians, and Physician Extenders, and removed the shielding that paper systems and historic workflows had previously provided. A large number of organizations defaulted to turning off all but the most critical alerts in response to push-back from clinicians. In fact, in 2013, Phansalkar (one of the authors from the previously cited Health Affairs article), Van Der Sijs, et al, published an article in JAMIA advocating for the removal of select alerts that had little value, and should not interrupt clinician workflow2.
In 2018, the situation remains substantially the same. Systems are much better at managing alerts, and deciding which ones should apply when, which should be global inviolate alerts, etc. However, a plethora of new alerts have also emerged inclusive of payer-specific quality programs, patient centered medical home, syndromic surveillance, ICD-10, etc., that perpetuate the original dilemma. Both legal and compliance are now involved in this arena to a greater extent. The issue has risen to the level that according to AHRQ, “Alert fatigue is now recognized as a major unintended consequence of the computerization of health care and a significant patient safety hazard.” This is substantiated by vendor-based research such as Cerner touting 90% alert override rates, and by initiatives to combat alert fatigue within provider organizations such as by UVM3. The CMO, with patient care as a primary focus, and the CIO, charged with providing an efficient and yet compliant system in which to conduct that patient care, often find themselves as unintended combatants in a quest to strike the appropriate balance.
CMO Perspective
In today’s healthcare environment, there are many technologies that now produce some kind of audible or visual warning to clinicians, aimed at preventing unwanted or unsafe situations. Besides those produced by the electronic health record, there are smart pumps and motion alarms, and vital signs monitors. Each alert is well-intentioned, and may have value in isolation. However, the combination leads to an alarming (pun intended) number of warnings from a variety of sources that an individual clinician must absorb and to which they must react. Studies have indicated that 3%-6% of orders placed result in one or more warnings. It is easy to understand how alerts can climb to a level where their very purpose is defeated. There is a level at which alerts become “noise” rather than “signal”.
This is compounded by the fact that many alerts, and many would argue the majority of alerts, are not clinically significant. Many are factually accurate, but should be overridden, and/or silenced because they lack the context or knowledge that is inherent to a clinician. There is also plenty of clinical and analytics literature suggesting that alerts in their current form are not very effective4. The problem is that most of today’s systems lack the ability to configure alerts or to “learn” from clinicians so that they can be tailored to the environment and the specific clinical service. Alert Fatigue is now widely recognized as a patient safety issue, a physician satisfaction/burnout issue, and an unintended consequence of expedited EHR implementations across the country.
The good news, is that improving the situation has a few common addressable components. The AHRQ articulates the following5:
  • Increase alert specificity by reducing or eliminating clinically inconsequential alerts.
  • Tailor alerts to patient characteristics and critical integrated clusters of physiologic indicators. For example, incorporate renal function test results into the alert system so that alerts for nephrotoxic medications are triggered only for patients at high risk.
  • Tier alerts according to severity. Warnings could be presented in different ways, in order to key clinicians to alerts that are more clinically consequential.
  • Make only high-level (severe) alerts interruptive.
  • Apply human factors principles when designing alerts (e.g., format, content, legibility, and color of alerts).
CIO Perspective
Organizations pay a great deal for the best tools that they can afford, and they try to ensure that evidence-based content and best practice are “baked in” to the implementation. Regulatory and accreditation compliance often add more checks and balances. Next, the Quality and Patient Safety realms can often require more stringent alert triggering. Lastly, in today’s environment, Payer Contracts and population health may have even more alerts to add to the fray. The resulting environment is often burdensome, but it is usually the result of the layered collective needs as expressed by the stakeholders.
There is also the issue of who should see the alerts, and how “invasive” the alert should be. Should Pharmacy see 100% of the drug alerts in addition to the ordering clinician? Which alerts should require an override reason or a second confirmation? What if it is more of a revenue cycle alert (eg: not covered)? You can readily see how the configuration team (usually heavily populated by IT/Vendor staff) are faced with a dizzying array of variables to try and reconcile, often without clear direction or consensus.
To compound things further, the CIO is almost always working with a tool that is less flexible and granular than he or she would like. The complex logic inherent in clinician thinking and stakeholder requirements, is often difficult or impossible to fully recreate in the EHR, leading to compromises which leave nobody completely satisfied. Testing is often an important step that sometimes fails to achieve the goal of fully engaging all of the stakeholders. This is true whether it is associated with a Go-Live, or just an incremental change as needs evolve. The result is that often, the real impact of the collective requirements is first realized in production. This can lead to a typical reaction from clinicians of “Turn them off until we sort this out!” The CIO then reactively sits between constituencies, if he or she is the perceived owner of the issue, or they turn to clinical leadership for an answer….
An Integrated Approach
An enlightened approach starts with the question of ownership. Who oversees clinical alerts? Med Exec, the CMO, the CMIO, Patient Safety, the P&T Committee, each practice/service? We often hear 3 common answers to this question:
  1. Nobody, or I don’t know
  2. Several conflicting answers
  3. IT
Of course none of these are desirable answers, so step one is to make ownership clear and explicit. The organization in general, and clinicians in particular, need to know where to direct questions and requests for impacting alerts. IT is usually not the right answer. Step two is to break away from the common tendency to have the clinical enterprise define what they want, and then have IT respond. There is often a lot of valuable clinician time expended, and then an iterative process which whittles away at what was desired. Instead, start with an analysis of the alerts that are most intrusive, or which fire most often. Provide the top 10. Have lead clinicians, IT, Pharmacy, Lab, and CMIO agree on this fact-based list, and then address changes in brief work sessions which can rapidly result in changes to the most impactful items. Depending upon the nature of the organization and the changes to the alerts, it is usually helpful to have risk management either at the table, or as a review step. Changes can be quick, and leadership can point to some noticeable improvements for clinicians which further empowers the workgroup.
Alerts in and of themselves are neither good nor evil. The magic is in managing them within the boundaries of your technology platform, and your patient care environment.
If you would like to learn more about an integrated approach to addressing Alerts, contact Culbert Healthcare Solutions at 781-935-1002.
1Kesselbaum, Cresswell, et al. Health Affairs V30 No.12 2011
2Phansalkar, Van Der Sijs, et al. Journal of the Medical Informatics Association V20 No.3 2013
3Healthcare IT News
Case Study - Epic Revenue Cycle Transformation
By Judy Riesen & Michael Cleary
Spotlight Article
One of Culbert’s Integrated Delivery Network clients just completed their “Big Bang” go-live of Epic’s enterprise applications. This organization is comprised of 5 hospitals and over 500 physicians. In parallel with their Epic go-live, Culbert led a comprehensive transformation of patient access and revenue cycle operations to centralize and standardize these functions across the health system.
The patient access and revenue cycle transformation engagement resulted in the creation of a Single Billing Office to support professional billing, hospital billing, self-pay operations and customer service. This was supported by Epic’s SBO module. Professional billing was also insourced as a part of this project. Statement processing was previously outsourced to a statement vendor, was also insourced and supported by a newly designed consolidated statement generated by Epic. Lastly, a new Interactive Voice Response (IVR) solution was implemented to support their customer service operation.
Culbert’s team worked collaboratively with client’s operational leadership utilizing the “two-in-a-box” approach. Director-level client stakeholders (who possessed knowledge of the organization’s operational requirements, patients, payers, and culture) were paired with a Culbert consultant certified in each domain expertise including Grand Central, HB, PB, SBO, and HIM. Each pair worked collaboratively on critical future state operational design decisions, which were translated to the IT team responsible for the Epic build. The two-in-a-box concept delivered the necessary combination of institutional knowledge and experience with Epic best practices, from both operational and application perspectives.
The two-in-a-box team continued to work collaboratively on system validation, integrated testing, and defined role-based training requirements for the training team to develop and deliver a comprehensive training curriculum comprised of user roles, new policies and procedures, new workflows, and Epic system navigation.
The migration to a Single Billing Office involved significant involvement from Human Resources. Standardized job descriptions and salary structures were required to reflect the centralized staffing requirements of the newly formed team. Standard pay grades were of critical importance to ensure equality across professional and hospital billing teams. Insourcing professional billing and statement processing involved the hiring of new staff to support the previously outsourced functions.
Our client developed a comprehensive communication campaign to communicate information to all employees, and to solicit feedback in order to address questions and concerns before they impacted morale. Town hall meetings and PB/HB/SBO staff meetings were held consecutively so everyone was informed at the same time to minimize confusion. This gave all employees a chance to ask questions and reduce anxiety from the changes that were occurring.
Furthermore, the new SBO staff and the legacy customer service staff were located on different floors as their functions were separated in the pre-Epic legacy environment. In preparation for the Epic go-live, all customer service employees were moved to the same area two months prior to go-live, and cross-trained on both legacy systems and Epic. This enabled both teams to understand the differences between hospital and professional patient accounting, enabling the staff to address patient service with a single phone call before the Epic go-live. This incremental cross-training strategy proved to be an effective approach mitigating the overall change management challenges commonly associated with SBO implementations.
From a patient access perspective, scheduling and registration had been largely de-centralized to each practice or service line. The access transformation strategy involved the creation of a centralized scheduling unit. The implementation of this centralized unit involved a phased approach which sequentially consolidated before the Epic go-live. This enabled an incremental training approach involving new roles, scheduling requirements by department or service line, new policies, procedures and workflows, and finally Epic application training prior to go-live.
One month after go-live, this has been viewed as a very successful implementation. As part of every engagement, we work with our clients to understand key project success factors and opportunities for potential improvement. This establishes an inventory of best practices, several of which are highlighted below:
  1. Operational managers should develop a list of organizational specific requirements which must be supported by the implementation. This should be completed early on in the implementation as part of a current state analysis. Simple examples include unique payer billing requirements or employer contracts. Epic adoption sessions (or similar implementation approaches followed by any other vendor), are based upon years of client experience, however that does not mean that every unique client requirement is known to Epic. Identifying these gaps is essential for mitigating revenue risks at go-live.
  2. Operational managers should be included in adoption sessions and build decisions. The integrated nature of Epic’s Master Files requires integrated decision making across application teams. Incorporating operational managers in the design decisions ensures requirements are being addressed. Additionally, these managers will be better prepared to support their staff by translating differences between current and future states.
  3. Decisions made outside of the formal adoption sessions should be documented and communicated to all stakeholders. This documentation is important should there be any staff turnover throughout the project. Clear and consistent documentation is simply a best practice.
  4. It is not uncommon for workflow revisions to be made throughout the adoption session process. All applicable stakeholders should be engaged in this process to prevent unintended consequences given the integrated nature of Epic Master Files and system build.
  5. Engage Human Resources from the beginning of the project. If possible, try to dedicate resource time towards the transformation initiative to prevent delays in the HR related tasks (job descriptions, pay grade evaluation and staffing discussions).
  6. Develop training materials using operations subject matter experts to ensure the content is both thorough and appropriate, and to determine the necessary training time for each user role. Operational leadership should partner with the training team to ensure the content is understood and that the trainers are aware of that organization’s unique requirements. Users should understand that playground time is mandatory, and access and training time should be tracked. Training is paramount to an implementation and is one of the last places to cut should the project budget face constraints as the go-live approaches.
  7. When developing centralized operational units such as an SBO or central access unit, a risk and readiness assessment is essential for scoping the services provided at go-live, and what services can be added after go-live.
  8. Communicate, communicate, communicate. A robust communication strategy cannot be emphasized enough. Whenever there is a big change in an organization, it is important to communicate through all levels of the organization. Employees are afraid of losing their jobs, changing responsibilities, decreasing pay, moving locations and many other factors in an implementation. This is an anxious time for employees and by providing frequent communication, it can reduce fear, gossip and minimize lost productivity.
Single Billing Office Planning & Design
By Brad Boyd
Consolidating professional and hospital revenue cycle functions into a centralized Single Billing Office (“SBO”) structure presents several benefits, the most significant include:
  • Enhanced patient experience through the reduction in statements and simplification of customer service,
  • Reduction in statement costs,
  • Improved self-pay collection performance, and
  • Staffing and operational efficiencies.
The ability to capitalize on these benefits is largely dependent on an organization’s ability to manage risk associated with organizational change. Culbert’s SBO Planning and Design framework involves three separate, but integrated planning activity components.
The first step is for an organization to conduct an SBO Risk and Readiness Assessment. Based on the findings of this analysis, an organization is better prepared to determine the scope of their initial SBO capabilities. This is known as the SBO Design. For many organizations, SBO represents the consolidation of patient statements and the centralization of customer service operations. Professional and hospital billing teams remain separated, with two separate leadership teams, typically reporting up to one revenue cycle executive representing the health system.
At the other end of the centralization spectrum, some organizations fully integrate their billing teams into one cohesive entity responsible for claims submission, denial management, A/R management, revenue integrity, self-pay, and customer service. This involves a greater degree of transformation, the benefits and risks of which need to be fully understood and planned for in the design process. The final step, the SBO Implementation Roadmap, coordinates all implementation tasks into a comprehensive execution plan
The intent of this document is to share our lessons learned and highlight tactics that have assisted organizations to effectively align their SBO initiative with the strategic goals of their institutions. A thorough planning process is necessary to effectively mitigate the various risk in order to enhance both patient satisfaction and financial performance. This document highlights the Culbert’s best practice approach for successful SBO planning and design.
Step 1: SBO Risk & Readiness Assessment
The goal of the SBO Risk and Readiness assessment is to clearly identify and understand the variances, or gaps, between professional and hospital revenue cycle operations. These gaps, or differences must be addressed to diminish disruptive change and decrease risks to ensure a successful transformation effort.
Culbert has identified 4 key risk areas to assess and evaluate:
  1. People: A review of the current state hospital and professional billing team sizes, structure, job descriptions, compensation plans, and competencies to support current operations and future state SBO requirements.
  2. Process: A review of processes, policies and procedures related to hospital and professional billing operations.
  3. Technology: Conduct a high-level review of the system build which supports self-pay management and customer service (i.e., workqueue design, clearinghouse capabilities, real time eligibility, including propensity to pay and payment estimation tools), and any additional third-party solutions supporting the organization’s revenue cycle systems.
  4. Culture: Conduct a cultural assessment to determine the organization’s ability to adapt to change.
The SBO Risk and Readiness Assessment should result in a formal document include the following:
  • Current state assessment of professional and hospital billing operations:
    1. Revenue cycle related policies and procedures (small balance write-offs, payment plans, partial payment allocation methodologies, GL reconciliation etc.)
    2. Job descriptions to include: compensation plans, staff management structure, staffing levels and competency
    3. Self-pay related workflows – particularly as it relates to the POS Collection initiative Examples might include pre-arrival, financial clearance, calculated patient cost sharing obligations prior to patient arrival, notifying patient in advanced patient notifications by front office staff. These activities align with overall revenue cycle operations, they align with new system POS collection policy and the executive vision and goals.
    4. Billing system setup and functionality to support self-pay management including workqueue design, account prioritization algorithm, clearinghouse capabilities, real time eligibility, including propensity to pay and payment estimation tools
    5. Customer service operations (i.e., hours of operation, telephony. 3rd party technologies, etc.)
    6. Banking relationships and lock-box structure
    7. Use of 3rd party collection vendors
    8. Statement design
    9. High level review of other billing and A/R management workflows
  • Gap analysis to evaluate the degree of variance between policies, procedures, workflows, and staffing structures between professional and hospital billing operations.
  • Risk and Readiness Assessment
Step 2: SBO Design
After completing a review of the current state and completing the SBO Risk and Readiness Assessment, the next step is to develop a recommended future state organizational SBO structure.
This will include key design recommendations related to the following areas:
  1. Governance
  2. Scope of services to implement at SBO module go-live
  3. Statement design
  4. Partial payment allocation methodology
  5. Standardized policies and procedures
  6. Workflows
  7. Staff productivity levels
  8. Reporting
Most organizations enter the SBO planning process with one of two principle definitions of SBO:
  • Centralized self-pay management and customer service, or
  • Truly integrated hospital and professional billing operations.
Both approaches provide benefits and risks. Many health systems have taken an incremental approach to SBO consolidation, initially focused around self-pay and customer service centralization. However, the Risk and Readiness Assessment is a valuable process for organizations to make initial SBO design decisions which lay the foundation and provide the flexibility for future consolation and centralization opportunities.
Step 3: SBO Implementation Road Map
The SBO implementation roadmap should include major tasks and milestones, resource requirements, and timeline and will incorporate the following areas:
  1. Internal and external communication strategy
  2. Staffing levels and management structure
  3. Technology configuration (revenue cycle systems, telephony, third party tools)
  4. Integrated test plan
  5. Training strategy and user proficiency requirements
  6. Change management program
Medical Group Considerations
The benefits of a Single Billing Office are real, particularly improvements to the patient experience and self-pay yield. The major concern of medical group leadership and physicians involves partial patient payments, including point of service patient payments collected within a physician practice, being applied to larger hospital balances. An effective SBO design process mitigates these concerns through the establishment of effective governance, and by designing a partial payment allocation methodology that incentivizes the collection of patient balances within physician practices. Typically, the location which collects the cash received full credit for that payment before any funds are allocated to other balances. Not only does this incentivize practices to collect patient responsibility at the time of service, it is also an effective tactic for alleviating the loss of autonomy over an increasingly expanding portion of the overall revenue cycle.
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