Today’s electronic health record (EHR) market continues to expand its offerings of next generation, fully integrated platforms designed to enhance the clinical and patient experience. Yet, several EHR market shifts have become apparent over the last few years.

• Consolidation continues as vendors race to offer a single integrated platform across acute and ambulatory sites, in conjunction with both revenue cycle and practice management.
• Major industry players are shifting to eliminate the need for ancillary clinical products, bolt-on technologies, and data intermediaries.
• A heavy focus has been placed marketwide on enhancing patient accessibility and ownership of the healthcare experience, especially regarding management of increasing patient balances (as high as 10% over the last five years, according to HFMA).
• Revenue cycle operations (and the technology to support them) are creating a more retail market-driven approach in conjunction with proactive outreach and patient population health engagement.

Historically, Epic and Cerner have offered comparable and competitive clinical applications (each have been the top two enterprise suite leaders, according to leading independent ranking service KLAS). Taking advantage of meaningful use requirements and their early entry into the integrated clinical and revenue cycle product space, a significant market trend continues towards Cerner and Epic as the two preeminent long-term EHR platforms:

• Over 70% of the EHR market is provided by these two solutions, according to provider data reported annually to Medicare. Epic already owns 44% and 46% of the respective acute and ambulatory market share by gross patient revenue, with Cerner following at 27% and 26%, respectively.
• According to 2016 KLAS survey results, Epic (98%) and Cerner (93%) are the vendors with the highest rates of clients who plan to maintain their existing EHR solution, and they are the top two vendors selected to replace existing solutions.
• According to HIMSS analytics database (2016), Cerner and Epic are two of just three vendors to grow market share year over year (in addition to athenahealth). 

It is worth noting that while Cerner Patient Accounting (built to integrate with the primary clinical application suite, Millennium PowerChart) is not as mature a platform as others in the market, it continues to improve as reported active implementation volumes grow year over year. According to the recently published 2018 KLAS Patient Accounting survey results, provider organizations are prioritizing the benefits of Cerner’s fully integrated solution rather than previous “best-in-breed” technology adoption approaches, which resulted in complex interfaces and bolt-ons. When functioning well, numerous value-add benefits exist that nonintegrated organizations cannot achieve. Just a few examples are:

• Order integration and the linkage of clinical charge capture elements to the charge description master (and complementary missed revenue reporting).
• Enhanced advanced beneficiary notice and medical necessity notifications up front at time of service, resulting in reductions of avoidable write-offs. 
• Push of downstream edits and errors up front to the root cause department, eliminating unnecessary and redundant claim touches.

However, there are many common EHR implementation challenges that can disrupt revenue cycle and financial metric success post go-live:

• The system implementation is focused primarily on the technical conversion and need to “get live,” fostering a lack of proper attention to operational change management needs.
• Emphasis on “out-of-the-box” system use does not lead to holistic success, as it is critical to tailor workflows and functionality to the provider organization.
• Providers tend to underestimate the need to adjust organizational structure and operations to best align with new system functionality.

Any EHR implementation is a costly and potentially risky undertaking. Vendor implementation methodology needs to primarily focus on technical system build, which can lose sight of impacts to operational workflows. It is important to provide rigor and standards to supplement the implementation methodology, enabling consistent quality results. Several key risks within these vendor implementations exist:

• Standard staffing models include a day-to-day lead paired with an advising consultant for each solution included in the implementation. However, most lead consultants have limited client experience, so satisfactory subject matter expertise depends on level of involvement of the advising consultant.
• Vendor staff typically do not travel onsite full-time during implementation, resulting in sporadic travel weeks across a standard 18-month implementation.
• Implementation focus tends to occur in silos within each application rather than across all applications in an integrated fashion, resulting in unforeseen upstream/downstream go-live issues.
• Without cross-client standard vendor methodology for focused revenue cycle testing efforts, the amount and scope beyond must be proactively determined by the provider organization.

An average performing EHR go-live does not guarantee success. Organizations can often see extended claim delays, revenue loss, and disruptions to cashflow performance. Health systems must aim to achieve top-performing metric results to realize holistic KPI improvement. In addition to comprehensive revenue cycle design, testing, and training, best practice go-live metric management focuses on performance of leading indicators that directly result in cash generation and quicker returns to cumulative payment baseline:

• Cumulative gross revenue generation should stabilize to 100% of baseline within one month.
• Claims should be generated by end of week one, with an eventual 8-10 discharged not final billed (DNFB) accounts receivable (AR) day stabilization prior to two months post-live. 

How do you achieve a top-performing go-live?

While these results may seem alarming, it is possible to achieve top-performing go-live metric results across the revenue cycle by focusing on these core strategies:

• Heavy operational focus on key risk areas early and often during implementation.
• A willingness to invest in resources and expertise that allow for more independent long-term support of the platform, rather than overly relying on the vendor. 
• Ensuring future state revenue capture methods are documented, trained, and adopted by all clinical areas. Clinical departments must own their own revenue at go-live, and be held accountable as such. Establish multidisciplinary committees (often owned by a revenue integrity department) that review daily revenue cycle performance and relevant issues, progress, and next steps to increase clinical charge capture.
• Ensuring all business office account management and worklist accountability is transparent and metric goal driven. 
• Adapting operations to meet the best practice use of the new system (do not simply just recreate what’s being done today). 
• Thoroughly defining end-to-end integrated and bulk volume testing strategies across all workflows, charge generation methods, claims production, and payment processing.
• Mandating a holistic, results-driven implementation with overall system design and testing strategies to achieve a metric outcome, not just to “go-live” with a new system.

Leveraging these guidelines and best practices, our clients have achieved EHR implementation go-live successes, including:

• An average of more than 103% of cumulative gross revenue capture to baseline within one month of go-live (often achieving pre-baseline levels in just two weeks). 

• Candidate for bill balances averaging just four AR days (defined as DNFB less standard bill hold).

Check out these individual success examples:

• AnMed Health's Rapid Revenue Cycle Transformation Drives Top Quartile Epic Go-Live Results
• St. Luke's Transforms Revenue Management During System-Wide EHR Implementation