Consolidating your EHR after a merger or acquisition [podcast]

If your organization is going through a merger or acquisition, you may consider your EHR consolidation just one item on a laundry list of "to-dos" to kick off your new partnership. But in fact, a consolidated, optimized EHR can set the stage for a positive relationship between your two organizations and make the rest of your organizational priorities easier to accomplish. 

In this podcast, industry expert Kate Grimm and Nordic optimization experts Jake Aleckson and Rick Shepardson sit down to discuss how organizations can standardize workflows, optimize the system, and get the most out of their EHR following a merger, acquisition, or Community Connect extension. If you prefer to read rather than listen, the transcript to the podcast is below. And as always, don't hesitate to reach out with any questions or to talk with our experts.


Call notes

[00:00] Intros
[2:58] The factors of a successful post-M&A implementation
[7:35] What can happen if you don't plan well?
[13:22] The role of population health post-M&A
[17:05] Getting people to buy into change
[21:58] Design sessions and processes
[27:26] Supporting the system long-term



Jake: Hi everybody, welcome. My name's Jake Aleckson. I'm a manager on the optimization team here at Nordic, and I'm with Kate and Rick.

We're looking forward to our discussion today on mergers and acquisitions. Lots going on right now in that space, and we'd like to really talk about some of the common challenges and opportunities in this area, as well as a few different types of variabilities that we've encountered along the way.

So Kate, why don't you kind of kick us off. Tell us a little bit about yourself, and then we'll jump in.

Kate: Sure! I'm Kate Grimm. Mergers and acquisitions are increasingly common. It's sort of a mentality of "eat or be eaten." So I'm really looking forward to talking a little bit more about what we've seen in that space and some opportunities for incorporating optimization of the EHR in collaboration with a merger or acquisition.

Rick: It's a good pick-up, Kate, because I love optimization. My name is Rick Shepardson, director of optimization here at Nordic. Jake and I come in and help organizations figure out how they can standardize their work flows, or how they can get the most out of their EHR. Oftentimes, the fact of the matter is, you can build and use some cool new features or get the latest functionality implemented, but that doesn't actually help you work well as a newly-formed, large organization that really needs infrastructure as its backbone.

I think there's a lot of opportunity in that space of standardizing the toolset from the foundation, making sure that as you move into this new merger and acquisition space or as you bring on your new partners, you have the foundation that you need to collaborate and build on your health system and get some better economies. So I think that's where we kind of look at it from an optimization space, and I think that moving forward, we have more and more opportunity to work together with the affiliate group and make sure that these groups are well-supported and ready to move into the future.

Jake: So what are some of those factors that contribute to a successful implementation during a merger or acquisition?

20170620-22-Nordic-Sales-3500-3600.jpgKate: Well, I think the interpersonal challenges can sometimes be the biggest area of complexity. It looks like it might be the EHR, but really when you're coming together with two organizations who have different cultures, it's bringing that together. The EHR's sort of a manifestation of all of the change that's going on as an organization, so we really do try to help with that. And when I talk about mergers and acquisitions, there are a lot of different types of groups that we could be working with here, so hopefully anyone listening to this podcast gets a little bit out of it.

We wanted to make things applicable enough to all of these different types of groups, so it could be two very large organizations who are already on the same EHR, such as Epic, who have their own instances and need to come together as part of a merger and acquisition. It could be two organizations who have different EHRs. Or a third example could be a small organization that doesn't have an EHR yet and is being acquired by a large organization who will be bringing their EHR platform together. We're hoping whatever your situation and scenario, that you can get some ideas and techniques out of today's discussion.

Rick: So in those circumstances, the big fish and the big fish merging, or the big fish helping out the little fish and working together in the ecosystem. You mentioned some of the cultural considerations and leadership; do you see any trends? You know, if there are two really large organizations, do they try to come together and merge their mission and vision in how they're gonna deliver care? What has your experience been?

Kate: I think we see things both angles.  If I understand you correctly, you're talking about the idea of, "Do we come together as a group of joint stakeholders and figure out culturally how we get together, and then maybe tackle the EHR stuff after that"? Or in some cases, maybe we start with our EHR and that's the project that brings us all together.

Obviously that is a way that you can make things consistent really quickly, but if it's not tackled in the right way, it can cause a lot of pain and anguish, because changing the EHR that a user is working in day-to-day really changes their whole working life, as well as the way patients are treated. So either way could work, but I would say it works better when you have the chance to really come together culturally and think through what your joint mission is, so that you can standardize some of those things and make it a little less rocky for your users and patients.

Rick: Yeah, that is what I'm getting at. Change is hard. No matter what you're changing or how big you are, change is not always easy and smooth, and there's uncertainty. What are we gonna look like on the outside, on the other side of this acquisition or merger?

One of the organizations that I've been working with, they merged years ago, and when they brought on this other organization, they didn't touch their EHR. They left a lot of the same rev cycle work queues and some of the same workflows in place and they had different contractual agreements even built in. And as now we're working with them, one of our big initiatives is, "Well, how do we make everyone's workflows the same?" And, "How do we get them all into the same workqueues, and structure their prioritization for what work they're doing when in the right way"? As we try to go through and look at this, I think there are a lot of organizations who are a little more adverse to change, and are hesitant to kind of glue it all together or standardize. Then there are others that kind of take that on a little more proactively. I think either method works, it's just a matter of what's gonna be best culturally for the organization.

Jake: Do we see long-term detrimental impact on some of those situations, maybe where they don't tackle some of those operational challenges right off the bat or workflows right off the bat?

Rick: One of the things that I've seen is now they have a EHR team, a support team, that has multiple sets of workflows and workqueues, and whatever else to maintain. They have to have separate sets of rules, and it's almost like maintaining two systems. They're not really staffed to maintain two systems, you're barely staffed to maintain one system.

Kate: So apart from the costliness of your IT teams supporting different things, one of the things I knew we wanted to touch on today is, just from a patient care perspective, if you have clinical users who might be working at the two different organizations on different sets of workflows, that have not yet been optimized to become standard, there could be some issues with patient care as well as clinician satisfaction.

Rick: Yes. If you are now one organization, and you go, and you have a primary care visit, and they end up sending you to a specialist who's a part of the other care system, and they're not following the same protocols, you have a surgery eventually. You have some therapy, and you have to go back to your old system again. You kinda go back and forth between different clinics or surgery centers, or inpatient stays, and everyone's not using the same order sets. They're not using the same protocols. Then you can't track that continuity of care very easily. And you end up being more reliant on the EHR to act as a compilation point, but it's not clearly compiled. Doctors, as they try to use this system, have to navigate and look and say, "Oh well, they were seen at this old hospital A group, and that means it's gonna be stored over here and that way, and then they're going to B." Not only are there inefficiencies for the doctors, but to your point Kate, there's also varying standards of care and ways that patient disease states are being addressed. That's not good for anybody.


Kate: Exactly, so as we were talking about, you can do your optimization and standardization at any point, but to really get the most bang from your buck, we talked as a group about some of the areas that we would point our clients to. We'd say, "If you are going to look at anything, these are the few areas that we would highly recommend that you take a look at." So for the first one, standardizing the formulary or CDM.

Rick: That's kinda your backbone, right? It's your medications, it's your charge codes, your CDM. If you have different price points, prices on your same charge codes, and the patients are seen at Hospital One, and when they get seen at Hospital Two they get a different price, they can't understand it on their statements. They just start to get confused. The ability to standardize at the base and make sure then that those charges and those medications flow through the rest of your system is big. And from there, you can move upstream. You start to standardize your order sets. That's the next big area to work on: standardizing your order sets, your flow sheets, your documentation. If you have that foundational setup in place, basically EAP, ERX from an Epic's perspective, but medications and orders and charges. Then you look at how and where those are used, so those end up getting used inside of these order sets. They get documented against. As they become charges, they fall into workqueues. That's an area that we hadn't necessarily talked about from a rev cycle perspective before, but that's the next place to sort of standardize from a rev cycle perspective.

Jake: Back to the clinical side, you mentioned the order sets. I think another area is the care coordination. So now you have one medical record, you have the opportunity to take data or visits from multiple sites. So having that plan of care for that patient, there's an opportunity to be able to merge those reports or make sure that both organizations are seeing similar longitudinal planes of care as well.

Rick: That's a good point, Jake. And to expand on that, as we are in this MACRA world, ACO world, it's more important than ever that you have good visibility and transparency over what measures you're trying to address. And your members, your providers, are all being held accountable for the same quality measures, for the same cost reduction and the same outcome needs. If your newly merged or acquired organizations are not aligned, and organization one wants to report on this set of measures, and organization two wants to report on those, or they're not providing the same level of continuity for the patient, you're at risk that your care coordinators don't know what they're following up on. And the patients don't know what they're supposed to be doing to improve their outcomes or stay engaged. There ends up being some risks there.

Jake: So, Rick, this is our area. We kinda took this down the pop health, the pop health route. But Kate, I ask, is population health an area that is concentrated on during a merger and acquisition or is that usually one of those areas that kind of gets pushed off?

Kate: I think it definitely can be a factor in organizations even having the desire to have that kind of affiliation. I'm sure it varies from organization to organization, but absolutely I think that is a key driver, and something that is becoming increasingly important in the industry too. As we talk about things like core measures that may not be top of mind to think about from a leadership perspective to standardize, it actually can be an incredibly valuable way to have as an example of bringing those groups together at the very beginning to talk through what they really want for the long term outcomes of the partnership.

Rick: That almost brings it back full circle to the culture and where are we at from a leadership perspective. I think it's so critical to ... As we do any sort of optimization projects, we really talked about, so what metrics are we trying to hit? Are we trying to best represent patient risk through an HCC score? Are we trying to achieve economies of scale on the rev cycle side and reduce our overall cost to collect? Are we trying to standardize patient care and throughput to support research, or to support these evidence based protocols? There's a reason why organizations merge or acquire. Some of it's big fish, little fish certainly. Or eat or be eaten, right? But you know, Kate, from your experience have you ... As you've worked with organizations, to what extent have they set those guidelines or those guiding principles, or their reasons for the merger, for the acquisition up front? And to what extent have you seen those followed through and executed on?

Kate: Those are certainly best practices that we would always like to recommend. I think that often there could be a driving factor to quickly implement your EHR, that some of those guiding principles get lost, but certainly we would recommend that the best leaders are the ones who can communicate that vision, that every employee working for them in the system understands the big picture of why we're doing this. Which hopefully ties back to that mission of better patient care. That more aspirational kind of goals that anyone, no matter their role at the health care organization, can really get behind and understand why a partnership might be changing, because the cultural change is gonna be hard no matter what side of the equation you're on. And changing your day to day is gonna happen a little bit, with give and take for everyone.

Rick: Yeah, so that's some of the best practices, right? That's one of the best practices. Let's set clear, consolidated, mission and vision and direction for the organization.

Kate: Right, because the change is gonna be hard so you really need people to get behind, "Hey, here's the reason why we're going to make some changes. Here's the reason why we need to pull some governance committees together, to talk about some decision making. And we know that if we both have current policies and workflows, we're gonna have to give a little and take a little on both sides." Getting people to buy into the change is incredibly important.

Rick: And the way I have found that you can get people to buy in to change is with data.

Kate: I thought you were gonna say "free food". Which I also recommend, but data is a good one.

Rick: Yeah, data and transparency, and being able to demonstrate performance. And opportunities to achieve an ROI or to improve a patient outcome. And you know, taking that data and consolidating it into meaningful reports, and making that transparent throughout the organization is really one of the only ways I find to get doctors on board especially. They are so data-driven. And rev cycle is kind of a nice one, like, "Hey, we've got these metrics, let's go".

Kate: Right, I think everyone's a little competitive and even if you're only measuring against yourself last year, it's really cool to see those numbers increase.

Rick: It is. And so when you start to talk about your EHR, which is really in some ways now your home for all the data. If you don't do some work to standardize it and get to a point where you're able to report on it in a meaningful way and share metrics across these new merged or consolidated organizations, you're almost kinda shooting yourself in the foot because how can you drive change, or show the outcomes, or show what winning looked like, if you don't have the data in a standard format or standard set? I think that there's a lot of ways that you can work on standardization or consolidation early, or you have the resources, you wanna kick the can down the line on some of these areas, but getting to that shared data set, that shared metric set, so that you can be able to show the outcome of the change, and monitor that in a meaningful way, I think is just so critical and kind of a must do from the start.

Jake: Those are some good best practices on data. Do we have other best practices? We talked about some of the issues, some of the areas of concentration right off the bat. Rev cycle, the clinical side of the house, we mentioned pop health. Those are some of those focus areas, challenges that we've seen. What are some other best practices that we've seen?

Kate: One that I like to point out is that at some point, you're gonna need to equalize everyone from an HR perspective in terms of job titles and things like that. That can be a low-hanging fruit since you know you have to do it anyway and will have some good outcomes for your Epic, or whatever your EHR security is. So if you can kind of talk through all of those things early on, I think that's something people can wrap their heads around easily. Everyone knows their title and their job functions and stuff like that so it's one of those quick wins that I think you can put in. So that's another best practice that I like to recommend.

Rick: Yeah, and along with that then is you have the roles, responsibilities, you can align your EHR with the user roles and the security configurations so that at least all the people who are the same, look the same in the system and they have standard workflows to start. They're not totally standard workflows, but you manage their security in a way and then you can start to get some efficiencies on the user side there.

Jake: Another area is patient-facing workflow. So MyChart. There might be two different patient portals that we need to do a gap analysis of, and determine what do we actually want to show our patients. Maybe they stay separate for some of the patient-facing, but most of the time I would think that -

Rick: I think it depends on what type of merger it is. So if it's a true merger, then your MyChart or your web portal is truly your branding in some ways, and so I think you need to standardize and consolidate that branding, and get up to a best-in-class MyChart experience or web portal experience. I don't know if that's the same case with the affiliates. Do they share a web portal often, or do they usually have their own?

Kate: It would depend if they are coming from having an EHR, and fully up to that portal already. I think that is a great opportunity to raise awareness of your partnership by branding what the new program or organization is gonna look like through your portal, as well as other marketing materials and other campaigns that you're working on. That may be one of the first things that makes sense to tackle while you deal with all of the behind-the-scenes infrastructure, which may be a little trickier and a little more political to deal with as two organizations come together.

Jake: I think we're heading on some good best practices here, I think let's keep going with it. As far as the process of leading an organization through a merger or acquisition, what type of design sessions or processes do we guide an organization through?

Kate: From a Nordic perspective, we can adapt our processes and methodology for what may work best for that scenario. But as kind of a general practice, we have the ability to get the groups together, where we would may have done a gap analysis ahead of time to take a look at both systems, talk to the users and directors who are in the system day-to-day and flag those areas that seem the most disparate right now. That would be the key areas we'd want to focus on since they would be the areas of greatest change for one group or the other to bring together. That's one approach that I think works pretty well, is to have a Nordic team do a gap analysis ahead of time and then flag things to be prioritized. Since you may not have the bandwidth to talk as an organization about the decisions that you might need to make for a huge list, we can help prioritize that.

Rick: Yeah, I think prioritizing the variable spots is key. One of the other opportunities is always gonna be from economies perspective, your third party vendors. If you have multiple clearing houses now, or you have multiple statement vendors, or you have multiple supply vendors, those are some of the obvious spots that people try to standardize early. But there's also opportunities there when you rip and replace one, or you plug the other one in. There's some touch points to end user work flows, there's some touch points within the EHR, and so it may seem like a no brainer to use this new clearing house or move to this new supply vendor, but if you don't focus on some of the integration within the EHR and set yourself up with a firm data platform and standardized work flows, then you might kinda be shooting yourself in the foot.

You might just think that you can go up on these new workflows or these new areas, and it's really the same, it's just plug and play, but you're kinda just slapping a bandaid on it and you're getting some of that quick win juice without necessarily setting yourself up for long-term success. Once you identify those areas that you really want to standardize or that are the most variable, or the spiniest from a change management perspective, then looking at those strategically and looking at, "Well, we know we want to standardize our order sets for this specific area," right? Well, think about all the implications of those, and focus on optimizing or standardizing small chunks at a time. But don't just do them in isolation. Do them with some of the other touchpoints, so that you gradually sort of spider out further into the organization and standardize the other pieces that are around it that are most relevant.

So maybe you end up impacting some navigators or you end up making some really smart choices around the procedure documentation workflows. But you don't have to take it on all at once. It doesn't have to be some massive project, but just do this work intelligently. Don't just try to isolate it just for the sake of isolation because that may not drive the best change management outcomes.

Kate: And really what you're talking about is choosing things that help build excitement for the project, for the initiative.

Rick: Yeah.

Kate: That get people behind the reason we are changing.

Rick: Yeah. We're just having that conversation right now. There's a group of affiliates that we're talking to, and they were implemented a long, long, long time ago. And they didn't have some of the standard functionality that's available now, "standard," related to RTE workflows for instance, right? And so, if you don't have the right eligibility verification up front, you don't know the patients have the right insurance when they walk in the door. Well, you've got so much risk downstream for denials and increased AR, and so much confusion that can happen. There's marginal change that has to happen, right? Now, somebody doesn't have to look up the insurance, or call the insurance company when the patient's arrived. We can do it in real time.

There is a change, there's slight change to the workflows, but there's so much added benefit. Once you start to get organizations focused on, "Well, look at this. We 'standardized' but we got all this win out of it." Well, then standardization is not such a scary term, right? So focus on some of those early, quick wins, that you know are gonna drive an ROI, or you know are going to get physicians or other users excited about this, and then build the momentum from there.

Jake: Makes a lot of sense, good advice. One of the areas we wanted to touch on was support. So, now once the merger and acquisition's hopefully successful, what are organizations doing to support the system long term?

Rick: Well, what I've seen there is again, sometimes you might have multiple teams that are left to do the support. And sometimes that can become overwhelming. And so figuring out how to gradually reduce that support cost, either through standardizing work flows, through outsourcing that standardization, you know that's something that we've been doing more work around. Whatever you can do to reduce the cost of maintaining those additional organizations is gonna be critical to your overall bottom line.

Kate: Right, and that's true when we think about different systems, different workflows, it's not just the long term support, but even the training that's going on too. So it definitely can be pretty costly, so it's probably in everyone's best interest to get things to a more standard state for work flows and training, and long term support. So just as Rick mentioned, it could be outsourcing some of the work to optimize and standardize the systems. It potentially could be outsourcing some of the support as well. Either having certain groups focus on just the legacy areas, or certain groups outsource the affiliate support itself to a third party.

Jake: Great discussion here today guys. I think we've done a nice job as far as calling out some of those areas of focus where there may be issues, and talking about best practices. Any final word from the two of you?

Rick: You know, I think the writing's on the wall. We're just gonna see more and more consolidation over the years here. And it's gonna be big consolidation, small consolidation. Getting the strategy around how you're going to grow your organization, how you're gonna integrate those other organizations around you, is gonna be important not just to be successful within the industry but also to be successful in the shift to population health. And being able to have continuity of your record and hit the quadruple aim. Keep the provider satisfied, keep the patients engaged, reduce cost, and improve outcomes. So being able to do this successfully, easily, at the right price point and the right culture point if you will for your organization, it's gonna be only increasingly more important in the future.

Jake: Yeah. And we love to see organizations be successful, so feel free, if you're out there and you're in this situation, to reach out. We'd love to talk to you more about it. Thanks guys.

Rick: Yeah, thank you.

Kate: Thank you.


Topics: mergers and acquisitions, Epic Community Connect, podcast