That Pesky Denominator

Posted on May 3, 2009 I Written By

As a consultant, I’ve had the pleasure to work with several large clients, and almost every single one has made the same request of me —

“How can we get a report telling us patient volume by (insert ‘data cut’ here) in a timely manner?”

And boy, is that a doozy.  I’ve filled out lots and lots of joint commission reports, and one of the main data points they want is ‘how many,’ yet many of my clients find that number frustrating, if not impossible, to get to.  So many times, I’ve heard CEO’s, CFO’s and the like complaining that two reports from two different people on the same number come out with different results.

Considering that many of them had EHR’s in place – why is this number so hard, when it seems it would be the simplest?

The answer I’ve come to (and always seem to come to) is that it depends on who the client is.

The definition of a ‘patient’ in a capitated sense is different from a ‘patient’ in a clinical setting, yet both of these are reasonable numbers.

Consider — I worked for network oncology operations (so, the operation of all clinics)  in one place.  They considered a patient to be someone who had started a course of treatment.  However, the clinical operations  considered a patient to be someone who walked through the door.

Both of these are valid numbers, but when finance asked for ‘how many patients did you see,’ the two came up with wildly different numbers.

It’s easy to see why, isn’t it?

In this situation, we held a five hour meeting during which we attempted to come to a resolution between all involved on what these key performance indicators were, and how we would define and derive them.  Five hours later, we barely had defined what a patient was, and it seemed on the surface to many involved that the old fashioned method of having people keep count and report to us with a phone call still seemed rather sweet.  After all, the biggest concern for everyone was that we didn’t present the CFO with different numbers, but we couldn’t make the clinic and overall operations agree on which was the more accurate statistic.  But, I pushed back, and pushed back hard that we should not be spending four to five analyst hours per day on gathering the number when we could do it from the system with just a little more effort.

We called another meeting — and I took over and suggested a compromise.  We ended up implementing my plan, which was a simple one — we would define the statistics more carefully, and report all of them to the CFO — so he could pick which numbers he wanted to use after having a full understanding of what they mean.  We ended up with Patient Starts, Patient Consults, and Patients.

Was it a pain?  Not as painful as the meetings where we were all upbraided because we couldn’t report a seemingly simple number.  Yes, two five hour meetings discussing the definition of patient was painful.  No way around that.  But it was necessary.  From these three definitions we were able to leverage the information in our EHR and create reports that were meaningful — they just reported three numbers, and the analyst FTE was changed instead to a database script.

While examining the output of these reports, we found several instances in which the system was not being correctly used, and used our ‘data goal’ to come up with new internal policies and training guides to ensure our clinics were entering what we needed — and if they needed more staff to support, we were able to comply — we now had an analyst FTE’s that could assist the clinic in proper EHR utilization, instead of just calling people and asking for a number.  She was much more challenged in this role, and a happier employee, and it stopped the angry calls from admin to the clinics for numbers.

So, if you are thinking of implementing an EHR, I would strenuously suggest that reporting be a key factor in selection, configuration, and implementation.  It’s far less painful (and expensive) to have reporting requirements out of the gate than to try and rig a system around poor configuration ex post facto, or to completley change front desk and clinical worfklows far after initial implementation.  EHR may be a clinical concept, but it touches all areas of healthcare operations, and COO’s, CFO’s, and CEO’s are stakeholders in these systems in addition to CMO’s, CTO’s, and CIO’s.