Revenue Cycle Management and the EHR: Looking at an Important Intersection

Hospitals and health systems are under financial and operational pressures as never before. In the wake of the hardest months of the COVID-19 pandemic and a relatively weak financial recovery, health system leaders are doing everything possible to help move their organizations forward while facing a welter of ongoing challenges.

And one element in all this is the interaction between the electronic health record (EHR) and its coding-based challenges, and the revenue cycle management (RCM) area, and how organizational leaders can optimize their processes to make sure to, as the classic saying goes, “not leave any reimbursement on the table.”

One senior health system executive who can speak to those issues is Joe Galdi, vice president of revenue cycle systems at the Ocean Port, New Jersey-based RWJ Barnabas Health system, a 14-hospital health system that encompasses a 1,000-provider medical group and serves a large swath of New Jersey. Galdi, who has been working in operational areas in healthcare for 32 years, oversees a team of 50 analysts and 25 contractors at RWJ Barnabas Health; he joined the health system in December 2019, after years at Jefferson Health in Philadelphia. He spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland about current issues in his area. Below are excerpts from that interview.

One thing that has changed since the onset of the COVID-19 pandemic has been that the very idea of locus has changed, since as many operational people in health systems as could work remotely were relocated remotely. One unforeseen impact has been that patient care organization executives are now having to compete nationwide to hire in revenue cycle management and other areas. What has your experience been in that area?

We’re living that reality right now; I’m hiring resources nationally. To me, it’s awesome to be able to do so right now, but time will tell. But you’re right, the resource pool has grown to be nationally. The quality of applicants is higher. And it hasn’t impacted us negatively because of where we are geographically. But I suspect over time that the pay scales will change, and people will be offered benefits in accordance with the geographical area where they work, rather than where their health system is located. That hasn’t caught on yet here, but will. And human resources and payroll are struggling to keep up with that, because everything is becoming nationalized.

What are the biggest challenges you’re handling right now?

I’m knee-deep in a huge implementation, implementing an EHR [electronic health record] in 14 hospitals and a medical group with over 1,000 providers; so we’re in the middle of that, and that’s really my day-to-day. And one of the major challenges involved is the consolidation of operations. Our organization is made up of a combination of mergers and acquisitions from the past six or seven years. These partnerships and mergers are done on paper, but for the people on the front lines, the consolidations happen later. So this project is helping to drive consolidation; so we’re consolidating services and personnel across the board, and that’s challenging. But also, standardization of workflows is an ongoing challenge.

There are significant staffing shortages emerging nationwide in RCM. Has that been true for you also?

I was feeling that pre-COVID, when all our recruiting was done on a local level; right now, nationwide, we’re benefiting from the situation.

What about the technological tools needed to support RCM, including business process automation and artificial intelligence?

Most healthcare organizations preparing to take on an implementation are facing something like this: we had nine different EHR systems and 650 downstream systems—including lab, radiology, respiratory systems—all connected to the EHRs. That’s crazy in itself. And everybody is looking to put the patient first in all of this, right? Well, when you look at that, you’re talking about patient information existed in multiple places. And this is where integrated EHRs like Epic benefit us. Everyone’s on the same system, and everyone can see what kinds of care a patient has had. The fact that revenue cycle and clinical workflows—that the lines are not so distinct any longer—charging is being triggered by clinical activity, rather than someone in revenue cycle having to manually trigger a process. So look at respiratory care—everything they’re doing is being triggered automatically off their activity. It’s making things so much easier from a revenue cycle perspective, minimizing the tasks involved in charge/capture.

Do you see AI and machine learning in your future? If so, when?

Machine learning itself, I don’t see it yet with revenue cycle. I’m seeing things like using technology available today like handheld devices to enhance the patient experience, making it easier for patients to schedule appointments, etc. Things like protecting patient information using biometric technology.

What about AI and machine learning for sorting through claims and sorting?

Yes. Eligibility with a payer—there’s a lot being done in that area. Payers are making information available online, and we have the technology in place to grab it and determine what information is provided, and to act on it. Where there’s still room for growth and enhancement—there’s a foundational standard that they’ve been asked to adopt, but have adopted it in different ways. And the payers use different procedures. So eligibility and authorizations—that’s an area where healthcare systems are having to do authorizations manually in-house or via third party. That’s where could actually help.

What does the next few years look like for your team?

Our plan for the next few years is to continue with these rollouts of the new EHR; that’s on our map for the next two or three years. We have another 10 hospitals of the 14 to move over to the EHR; we have four on Epic and another ten to go. And the medical group with 1,000-plus providers—we have about 80 percent of providers on the new system, but there are constant acquisitions and partnerships.

What are the data integrity issues that you’re facing?

It’s a nightmare for healthcare organizations with so many information systems. And if a patient has multiple records in the system, the clinical teams are not getting all of a patient’s records at once. So we partnered with a third-party vendor, Intellis, to help us with our cleanup in that area. And during the height of consolidation of all of these records, we had over 300 people working on this at once. Just to get each patient to a single record. Because we’re in the same general region of New Jersey, patients can be seen in multiple places. And so with nine EHRs—a patient might exist in three different EHRs. And then we have approximately 650 different downstream systems. So a patient’s records could exist in numerous places. And now, our duplicate-record rate is sitting at 2 percent, which is pretty incredible considering we’re in the middle of this huge implementation. The national average is probably about where we are right now; but we were much higher. Many organizations are in sitting in the 3 to 4 percent range.

Do you have any advice to share with your colleagues nationwide, based on your journey so far?

The biggest thing that I would say is that if you’re going into a large EHR implementation, partner with a group that’s done it. Don’t make the mistakes that others have made, just to try to keep loss at a minimum, because it will bite you in the end. Partner with a third-party partner that’s done it; check their references and make sure they’ve had a lot of success with prior implementations.