By Bernie Kuhn and Warren Jacobson
With the last decade seeing dramatic growth in EMR adoption, it makes sense not only to pause and look what happened overall, but where urgent care ended up given all of this technology investment. Thanks to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the government has essentially pushed the healthcare industry into electronic patient workflow and recordkeeping. The following graph highlights enterprise-level electronic chart deployments over the past decade (data circa May 2016). The impact of putting in the infrastructure to automate the business of healthcare cannot be understated. This is a wholesale market shift for how “work gets done” in about a decade, not to mention the potential for improved outcomes resulting from real-world data availability. We have seen similar cycles with the automation of banking, manufacturing, logistics, retail and other sectors, where the electronic format replaced the paper format, dramatically reducing transaction costs then and setting in motion sector transformation.
Given this proliferation of technology, our article this month focuses on the opportunities for health systems to improve operations by more precisely tuning their EMR investments. This is not an endorsement or indictment of any vendor, and frankly the performance of any system comes down to how well the technology is configured. Rarely is the software itself the fundamental issue.
We present this from the perspective of an integrated health system using an enterprise shared EMR platform. These systems were originally built to handle complex in-patient care as compared to physician office-oriented EMRs that generally grew from a practice management footprint into a chart system. A completely separate EMR segment for occupational health technology forms the basis of another lengthy analysis, but that will be left for a future topic.
Our bottom-line view is that urgent care operators have to be vigilant to ensure quick and accurate patient throughput. But speed and accuracy are easier said than done. Most enterprise EMRs serve a broad spectrum of specialties or service lines and generally are not out of the box built for the urgent care patient or provider. Like turning a minivan into a Corvette, with the right expertise and investment, turning an enterprise EMR into a high-performing urgent care platform can be accomplished. It requires a high degree of customization, but operators with more than one unit should be thinking about controlling these customization top-down instead of each site and provider being uniquely configured. Endless customization to everyone’s whims is not conducive to a consistent, high performance customer experience and seldom helps with financial results.
Some typical observations from clients range from, “Why aren’t we using standardized templates for charting;” to “Why are the hundreds of security settings for the same job titles different;” to “Why does it take 15 minutes to register a patient’” and various other obvious items influencing overall operating performance.
Why This Matters Financially
There are several top-level things to keep in mind on the use of an enterprise EMR in urgent care. Let’s assume you have eight centers with a combined 100,000 visits annually. To frame it up further, say net revenue per patient visit is $140, so this is roughly a $14 million per year urgent care operation. We are being fairly optimistic in the following, and not oriented to any particular platform:
- Front desk productivity. For each patient visit, a non-optimized “current state” configuration typically requires that the process takes an extra five minutes. Five minutes times 100,000 visits translates into more than 8,000 labor hours per year, or about four full-time employees (FTEs), or about a half FTE per site. Optimistically, the extra staff are mostly front desk people, so let’s call it $150,000-$200,000 ($20/hour loaded) in labor, plus additional overhead for training, resources and turnover. It presumes there might be a queue of patients waiting. Because of the sub-optimal process, there is likely high turnover and the rest of the team doesn’t feel equipped to help. This is an even bigger challenge for teams that run lean.
- Clinician productivity. This is a surprising opportunity area given the users are typically the most educated and capable people in the organization. If the average consult is around 15 minutes, and charting takes more than five minutes, either the center is seeing far more complex patients than expected or there is something inefficient here. We’ll assume the default EMR requires around 10 minutes to chart and prepare discharge notes. So another five minutes times 100,000 patients is 8,333 hours per year. But with five times the labor cost you would use a higher blended provider compensation rate of $100. That’s more than $800,000. Wow!
- This isn’t an exact science on the business case, but it is no wonder that some centers seeing 30-40 patients per day go an hour or two past closing time to complete charts before going home. Or worse, they have charts completed days later (with negative downstream safety and financial effects). Remember that the range of most urgent care CPT codes is highly concentrated around 25 codes, so this should be a relatively quick process compared to primary care.
- A separate discussion around coding and charge capture is beyond the scope of this article, so for now we’ll assume different EMRs result in the same claim set.
- Direct technology expense for EMR. The first question is do you rent or buy? The purchase of the enterprise EMR is a typically handled as a capital expense, and the IT investment is depreciated over some period of years, plus annual licensing costs and on-going support. By contrast, many office-based EMRs have a rental model, i.e. cost per-patient, with limited up-front capital investment. In either scenario, integrating effectively, executing with scale, and top-level control is critical. This expense analysis should include timing to migrate data, deploy, train, and integrate. Some EMR vendors also have “a la carte” revenue cycle outsourcing options. Each urgent care operator should have a clear “apples-to-apples” comparison of what their IT platform truly costs them. We see the IT expenses come in somewhere around 3-7% of net revenues, on average. To build the Corvette-type capabilities for the EMR not designed for urgent care, there is going to be added cost which can vary greatly and is hard to predict.
- Billing efficiency. This one is challenging to do a true “apples–to-apples” comparison, as it becomes difficult to bucket-ize the costs here. Some health systems break up the billing process (post-chart completion) into various discrete buckets: managed care items, admin and clinical error work, coding, billing, customer service, posting, denials and re-work, medical records, and so on. Efficiency depends heavily on meeting upfront requirements, such as collecting co-pays, having credit cards on file, capturing correct billing information like scanned ID cards and driver’s licenses, etc.) Depending on how and where the actual coding and claim submission takes place, efficiency also is driven by how many “touches” are involved to get a claim adjudicated correctly and posted and the degree of dedicated versus non-dedicated resources. . Let’s assume this ranges in the 5 to 10 percent of net revenue range, not including credit card fees, clearinghouse costs or bad debt. In our $14 million net revenue example, let’s assume the enterprise EMR revenue cycle is at 8 percent. That translates into $280,000 per year.
- Other considerations. Some EMRs “out of the box” are good at forcing up-front collections, verifying eligibility, posting at time of service, providing and cost of care estimates to patients. Some are also good at forcing down error rates not only at the front end, but during the encounter through discharge. A clearinghouse transaction that is $1 per claim, or 3 percent in credit card fees, or bad debt north of the industry at 4 percent: ... these all add up to a material impact, usually tied back to technology
When we conduct diagnostic projects on existing urgent care groups, these factors consistently contribute to bottom line operating performance challenges. Add them all up and there is a major financial impact.
Best Practices Checklist
Here are a few best practices from top performing health systems around the U.S. that run urgent care groups with scale and efficiency:
Smartphone-Based Queuing and Check-in. Finance should be demanding this for your urgent care groups. This is a necessary function going forward and a competitive qualifier. It forces front-end discipline on wait times and volume management, and can act as a proxy for how efficient centers actually are. It also fits with how consumers are using technology to access care, often without regard to health plan or health system. Some EMRs have these features built-in; some do not. It can be a bolt-on and is money well spent.
Registration. EMRs can collect vast amounts of data. Many health systems do not pare down that data to essential elements needed for an urgent care visit. This results in many screens, clicking around, and looking at information that isn’t needed. Good design equals “information that is needed,” not the “kitchen sink.” Ideally, that minimum data set should be included in a single screen. Toggling to new screens looking for required data fields is time consuming and can result in human error.
There is a lot of talk but not much investment by health systems regarding interoperability. We see executives tout this as a key requirement, but then not fund the vision. The underlying use case is also missed: registration should be set to capture any registration data used in the health system rather than having to redo any information. Once core elements have been determined, registration should able to be done on a mobile device or tablet. Customers should be able to capture insurance information and IDs via smartphone scanner.
Credit Cards on File. National credit card networks such as American Express, MasterCard and Visa are ending credit card signature requirements in the immediate future. Get ready to be rid of those printers and processes. You want to keep the signature pads to sign paperwork electronically, of course. Going to zero paper in the clinic, beyond discharge instructions (patients actually need and use these), can be a 2019 objective. American Express will eliminate the signature requirement globally. MasterCard is only dropping the U.S. and Canada, according to the report. Visa will be optional in U.S. and Canada where customers can use chip cards. This cuts out an expense item and productivity hit for most urgent care operators. Think about the time to print, wait for signature, provide copies, scan or store the copy.
Eligibility. Eligibility verification largely takes place upon arrival, and needs to be configured for on-the-fly translation to the system. Clear and easily understood plans help with throughput. This is not usually the case, but providers have to communicate the challenges back to the plans with specific remediation. Many health plans still struggle to include an urgent care co-pay, or the benefit detail is buried under “U” on the long list of options. The plans want this to work, but they often don’t know the walk-in industry. Eligibility verification should be configured for urgent care settings only, and should pre-populate the EMR.
Clinical Encounter. Once the patient is called back to a room and initial biometrics are gathered by a nurse or medical assistant, the workflow should be organized to take out manual tasks and incorporate the data collected. Pick lists should be configured for practice needs, such as being tailored to a pediatric patient. Limit short lists of CPT codes for approved procedures per the medical director. Diagnoses should open to “top 25” for the urgent care center, not long ICD10 lists.
Practice-centric note templates should be created for the most used CPT codes. Limit provider expository writing to necessary elements. Update the templates as new codes/procedures are available. Acknowledgement/credit for Medicare programs help with separate plan directives. Clinical leaders should encourage diagnoses periphery to the visit, such as a patient presenting with a laceration that needs stitches but also has diabetes. Appropriate conversation about how diabetes will affect the healing process should follow with inserting ICD-10 codes at end of the claim. That could have the add-on benefit of meeting Medicare’s population health management goals.
For those looking at this from a payer perspective, or true vertical integration, this miss is also weakening your Star ratings performance. Not having a standardized mechanism in the chart to ensure appropriate multiple diagnosis and clinical notation can significantly impact Medicare Advantage risk adjustment measures and reimbursement.
Discharge. In the urgent care center, an encounter should be closed by the end of the day. Having to complete charts at home or rely on a health system-wide three-day rule is a red flag. Setting up templates (see clinical encounter section above) can assist with that requirement/protocol.
Non-Conforming Challenges for Labs and Radiology
Labs are only charged upon result in many health systems. This may delay the closing of the encounter if the EMR is not set to streamline revenue cycle. Where possible, lab tests should be a separate encounter, automatically generated by the clinical encounter and pull the diagnoses from clinical encounter.
Radiology Results. Similar to labs, radiology services are only charged upon result in most health systems. This may delay the closing of the encounter if the EMR is not set to streamline revenue cycle. Over reads should process automatically and be charged as a service to the urgent care center. Radiology services should be set such that registration data flows automatically to the radiology system and not require a separate radiology registration.
Revenue Cycle Considerations
Segregation of accounts receivable (“A/R”). Urgent care centers should have a method to capture billing and collections separate from other health system service lines. This helps keep these small dollar transactions consumer friendly. Patients with accounts in other health system service lines may end up being asked to pay a past-due bill or be denied urgent care service. This is a sure way to drive customers to your competition.
Pre A/R. Until a claim is created, A/R has not begun. If segregation of ancillary services to separate encounters has been completed, the charge may go to insurance for adjudication immediately. Waiting for clinical encounter sign-off, lab, or radiology service results creates unnecessary delays.
Managing A/R. Unless it is a separate business or operation, health systems generally work in order of declining balance. The urgent care business is often ignored by centralized follow-up staff if there are higher priorities. If appropriate eligibility and closed clinical encounters have been created and completed, patients can be asked to pay for the estimated charges of the encounter before leaving the urgent care center. Credit card on file results in faster pay and fewer calls to customer service.
Collections policies. Urgent care centers may elect not to see patients whose charges are already placed with a collection agency.
More touches, more waste. Each time a person touches an account, it results in lost time and costs money to process. If not completed inside the encounter, coding takes time and results in longer days in pre A/R (as it is pre-claim). Failure to sign notes results in longer pre A/R. Incomplete claim items result in delays in A/R. Not completing the injury section for injury diagnoses, and failure to have the EMR updated with the latest insurance protocols and Medicare information results in rejections and follow-up appeals as well as time in A/R. Statements are generally not sent until the final adjudication/appeal process is complete. Other items that should be obvious but often can be missed are having the wrong codes for the payer, incorrect or missing injury information or notes, or incorrect/incomplete notes or incorrect Place of Service codes associated with the urgent care center.
No Time like the Present
The urgent care industry is now going through a major transition from a highly decentralized unsophisticated industry to one that is chain-dominated and highly optimized. Urgent care operators have no choice but to ensure quick and accurate patient throughput. But especially for health systems, speed and accuracy are easier said than done. Most enterprise EMRs serve a broad spectrum of specialties or service lines and generally are not built for on-demand medicine. Technology and process design are usually a root issue for struggling urgent care centers. This kind of work is tactical and in-the-weeds, but necessary to a smooth functioning and highly competition operation.