As part of our ongoing series of in-depth, one-on-one interviews with CIOs regarding their experiences with revenue cycle management automation, HCI Editor-in-Chief Mark Hagland this month interviews Paul Conocenti, senior vice president, vice dean, and CIO at the three-hospital, 1,069-bed NYU Langone Medical Center in New York City, regarding his experiences in this important area.

Healthcare Informatics: Your revenue cycle management strategy is part of a much broader overall strategy. Please tell us how those strategies have evolved forward.

Paul Conocenti: As many who are moving from best-of-breed to enterprise-wide solutions, we're undergoing a transition in the revenue cycle management area, as well as more generally. NYU has had over the past five to seven years ago a history in which we've had a governance committee and weekly meetings around revenue cycle management. Historically, revenue cycle management activity had really focused around patient scheduling and the billing folks. But over time, the conversation began to focus around capturing charges accurately, and looking at the whole revenue cycle from a financial point of view-where we were dropping charges, where we were not charging enough appropriately, and how we could use business decision support systems to bring all the data together and look at the variables around contracting, with the ability to compare types of cases. Suddenly, we were realizing that, whoops, we haven't been charging for implantables; or, whoops, some of our supplies from yet a different [information] system aren't documenting charges. And we've done very well, actually, in terms of the basic blocking and tackling in terms of charges. So we've been very successful in that area.

WE REALIZED THAT CLINICAL DOCUMENTATION IS AN AREA WHERE WE WEREN'T DOCUMENTING THINGS WE WERE IN FACT DOING, IN ORDER TO OPTIMIZE CHARGES.

Then we moved into a different phase of this, saying, we think we've got the charges not erroring out for various reasons, now. But we then asked ourselves, what can we do to optimize revenue? And we realized that clinical documentation is an area where we weren't documenting things we were in fact doing, in order to optimize charges. And looking at documentation that tells us if a patient is coming in, in a very critical condition, we're not documenting that; and all of a sudden, because we didn't document all that in a discrete format, we're losing on the coding of those things. So we brought some consultant help in during the early phase of looking at charge capture. And we also brought consultants in for that second phase we're now in, around optimizing clinical documentation. So we actually changed our clinical ordering system, to be able to capture those necessary elements, in terms of the orders we're placing, within the workflow.

WHAT WE'RE LOOKING TO DO IS TO HAVE REVENUE CYCLE AND THE CLINICAL PROCESSES ONE AND THE SAME, BECAUSE THEY FEED EACH OTHER, ESPECIALLY AS WE MOVE INTO A MORE NETWORKED SYSTEM.

HCI: In other words, as a result of this ongoing analytical process, you've been changing aspects of your CPOE [computerized physician order entry]?

Conocenti: Yes. We started with a real charge-capture orientation; now we're focusing on clinical documentation, and we're looking at how physicians and clinicians order things. And by the way, that also helps to support clinical care, because you're documenting to a greater degree of granularity. We began this about two years ago, and have had great success with it. Then we began applying our lean management process to this, and we're now looking at our operational processes around the whole clinical process, which includes the documentation element around clinical care. We came to recognize that we had gone as far as we could go with our old, fragmented system, one that had a different patient access system, a different inpatient CPOE system, a different billing system, and a different inventory management system. So we're putting in an enterprise-wide Epic system [from the Verona, Wis.-based Epic Systems Corp.], including the revenue cycle piece as well as the clinical. And that's where you're really driving workflow, because when you start doing the Lean management work, you realize you're constrained by the lack of integration of your information technology.

So in March, we're going live with the Epic revenue cycle solution, and we're now in the process of improving workflows, and in that regard, we're bringing together a number of systems-health information management, physician and nursing documentation, and the OR information system, which is notoriously separate-in order that the workflows in those areas will drive efficiencies, not only in the clinical process, but also in the revenue cycle process. And that's because we realize that the clinical process really drives the revenue cycle process.

Looking forward, consider the national healthcare reform scenario, with ACOs [accountable care organizations], and bundled payments, and the medical home. How do you do bundled payments without integrated information systems? And how do you share referrals without a community-type system? And what's driving all this is all the Baby Boomers not being followed by the same people, which is causing our healthcare system, and the nation, to blow up. And a true driver of reform, in many ways, is the payment model.

So what we're looking to do is to have revenue cycle and the clinical processes one and the same, because they feed each other, especially as we move into a more networked system. And at the end of the day, the incentive model is going to be more about keeping people healthy and not spending money. Right now, the sicker you are, the more money we make.

HCI: Are you actively thinking about participating in ACOs and bundled payments?

Conocenti: We're actively thinking about them, though, like everyone else, we don't yet know exactly where all of that is going. So we need to figure out where we fit into that, whether we want to be a member of an ACO or lead one, for example. But what's clear from a technology point of view is that the foundation for such participation will involve having an enterprise clinical information system that's tethered to the revenue cycle piece; having a very, very robust business decision support system, as well as a robust clinical decision support system, to drive decisions within community models; and, at the heart of it, health information exchange, because other [participants in the same collaborative groups] will have other platforms. So you have to have a health information exchange that's robust enough to deal with these new models. And you can wait for the National Health Information Network or the state health information network, or you can take a bold step. And some are creating their own health information exchanges within their own communities; and that's something we're piloting. And you combine that with meaningful use, which people will say is all about clinical, but at the end of the day, it's also about revenue cycle.

HCI: So you're seeing the interrelatedness of all this?

REVENUE CYCLE AND QUALITY AND CLINICAL CARE ARE CONVERGING. AND YOU KIND OF NEED TO THINK ABOUT BOTH.

Conocenti: Yes. And revenue cycle and quality and clinical care are converging. And you kind of need to think about both, when we all know that what's coming down the road is, you need to make a profit on Medicare and Medicaid, and that's not an easy thing, so you need to put these systems in place. And what I like as a CIO is that the technologies we put into place for one, enable three other things. And then you add your clinical analytics report writing system, and combine that with your business report writing system and revenue cycle management system, and then you've got a pretty powerful set of tools. So from the CIO's point of view, it's really about bundling those tools together across your entity, and even the community.

HCI: So from your viewpoint, best-of-breed is simply going to have to go away, because of the complexity of interfacing?

Conocenti: Yes. I think there will be two approaches. What happened with Allscripts and Eclipsys, and why? Eclipsys had a great inpatient system, and nothing in outpatient, and with Allscripts, the reverse. The big question is, is it going to be truly integrated when they piece it together, or will it be two different systems, interfaced, with lots of workarounds?

HCI: So you believe in the same vision that Epic and the most integrated vendors are pursuing?

Conocenti: There are a couple that are similar, and we just happened to pick Epic; but the issue of integrated versus not integrated, is the point. Our new dean had just come into his position a year or two ago, and we had just implemented CPOE; and his vision was, I want one system. That was at the CEO level. Because he had turned around his department with an integrated technology solution, and once he had that, he did things with that system that made his department a world-class department. And three years later, I really do believe that an integrated system enables an organization to do a lot more, and more quickly. Still, the technology is not everything, it's just an enabler. But it does enable things. And you hit a point in the maturity cycle where you hit a roadblock, and you need to do something to get to the next step.

Healthcare Informatics 2011 January;28(1):36-39