July 2015

How Togetherness Can Divide
By Julie Knudson
For The Record
Vol. 27 No. 7 P. 16

Mergers can increase efficiency but also can disrupt workflows and create IT system upheaval.

In recent years, health care has experienced a slew of mergers. That trend is expected to continue and, in fact, accelerate. Deloitte predicts the next decade may see the number of unique health systems cut by one-half as hospitals increasingly look to build cost-saving and market-dominating alliances with one another. Whether organizations enter into strategic partnerships, merge with synergistic systems, or outright acquire other hospitals, the HIT and HIM groups will have their hands full.

Solving the HIT System Puzzle
In many mergers, the array of systems existing in each individual organization eventually will be consolidated down to one of each type. There are other scenarios, though, where the merging facilities will discover they have common platforms. Joining them should be simple, right? Maybe not. "Just because you both have Epic or you both have Cerner, for example, doesn't necessarily mean your versions and your platforms are identical," says Steven M. Berkowitz, MD, chairman of the Texas Institute of Health Care Quality and Efficiency, and president and founder of SMB Health Consulting.

Similar systems may help simplify some aspects of a merger, but Berkowitz stresses there are many nuances likely to cause challenges. At some point, the vast majority of health care organizations have introduced customizations into nearly every system they use. "It's those workarounds and customized things that are the most complicated because they're the most idiosyncratic," Berkowitz explains. Just because a fix was implemented for a particular application in a particular organization doesn't mean the same fix can be easily deployed at the second installation. "It doesn't always work," Berkowitz says. "In fact, it usually doesn't work."

There are times when organizations may be faced with the prospect of moving forward with multiple systems simply because there are few alternatives. This could be the case when IT concerns aren't considered during the early stages of merger discussions. As a result, the funding needed to accomplish the consolidation never makes it into the larger financial picture.

"It happens more than it should to CIOs," says John Hoyt, FACHE, FHIMSS, executive vice president of HIMSS Analytics, referring to the tendency to overlook technology-related concerns until after the deal is done. Rather than including IT in the larger process, the teams are left to work out amongst themselves where workflow and system interoperability issues may exist. "It isn't even part of the due diligence, and that's just inept," Hoyt says.

Getting the various platforms to mesh—or removing and replacing those that won't be staying—isn't cheap, but it must be taken into account. "It's part of an acquisition expense," Hoyt says.

Workflows Require Close Attention
Two reasons hospital organizations merge are to increase efficiency and to reduce fixed costs. Aside from strictly IT-related issues, this often results in a drive to centralize services. "[For example], there's no reason you need two or three revenue cycle groups," Hoyt says. A single, central business office—sometimes located several states away—may be established to support the merged entities. This will prompt workflow changes for at least one of the affected groups as it transitions away from established protocols. "It's all about standardizing and centralizing where you can. And it means workflows, it means process redesign," Hoyt explains.

Front-facing workflows also are likely to change as the transition gets underway, which can cause significant angst within the organization. "It's in the workflows where you're engaging patients and where providers are working together," says Gregg Mohrmann, MPA, PMP, a director at The Chartis Group. Any time patient interactions come into play—registration, charts, portals—and wherever clinical processes must change, resistance is possible. "Those are always the hardest because externally, if there's a problem, everybody sees it because it's about your brand," Mohrmann says. "People are very sensitive to that."

Those sticking points, though they may seem the least challenging from a technology standpoint, may actually require more attention to ensure both internal and external issues are addressed, he adds.

All of the image-generating disciplines within a hospital—radiology, cardiology, gastroenterology, etc—contribute to a workflow concern all their own. "Being able to consolidate all those PAC [picture archiving and communication] systems that are out there—and different ones at different facilities—and then trying to set up the workflows for exchanging those images and managing them is very, very difficult," says Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, principal at Dak Systems Consulting.

Solving the workflow complexities of exchanging images between facilities can take a surprisingly long time, sometimes years, to settle, she says. When different PAC systems are involved, "maybe they consolidate them, maybe they don't," Kohn says. "But whatever they do, the workflow is disrupted in a big way."

As workflows are retooled to suit the needs of the merged entity, semantics are a factor, according to Dean F. Sittig, PhD, a professor at The University of Texas Health Science Center at Houston School of Biomedical Informatics, a member of the UT-Memorial Hermann Center for Healthcare Quality and Safety, and executive director of the Clinical Informatics Research Collaborative. "The hard part is that, a lot of times, different organizations have different ways of defining things," he says.

For example, calculating length of stay can bog down the transition to a new workflow structure. "Some organizations go from midnight to midnight; others mark the time a patient left," Sittig explains. Depending on the disparity between the organizations' foundational processes, it can be a huge culture change for teams all along the operational chain, including coding and billing. To further complicate matters, these issues can fall outside the view of hospital leadership teams. "Mergers are incredibly complicated for the people who actually do the work," Sittig says.

Disruptions in HIM
Mergers can disrupt HIM in several ways, especially if each hospital uses a different encoder. "Someone in IT—typically the CIO—will decide if they are going to merge into vendor A or B, or if they will be allowed to keep both going," Kohn says. No matter the final selection, it spells change for at least one group and perhaps for everyone. "If the billing system is a shared billing system, that means two interfaces," Kohn says, pointing out that downstream decision making and process retooling also must occur. Each of these system tiers must be examined to determine whether the organization will consolidate to a single platform or allow multiple systems to coexist.

Issues with the definition of what constitutes the legal medical record also can hamper HIM workflows. "Chances are the two organizations define the legal medical record differently, and that impacts the systems they use as well as the processes," Mohrmann says.

If one hospital has more or less detail built into its existing workflow, the amount of effort to effect a systemwide change could be tremendous. In addition, each hospital system likely will bring its own structure for dealing with physicians and chart deficiencies. Rarely can those two frameworks meld without a workflow overhaul. "They might have two disparate ways of doing that, both systematically and from a process perspective," Mohrmann explains. "It could be a culture shock because you've got to fix that quickly."

Competing Cultures
Whenever two or more health care organizations come together under one umbrella, differing cultures and care models must learn to live together. Operational issues often take center stage but cultural issues also are a big deal.

To reduce the potential for efficiency-sapping conflicts, Mohrmann suggests bringing stakeholders from all sides to the table when making decisions. "I'm not just talking about the leadership of both organizations. I'm talking about the frontline end users, too—your staff on the floors," he says.

Creating planning committees and a governance structure that combines constituencies from both sides eliminates those situations where the acquiring organization simply dictates how life will be for everyone. It's also an opportunity to evaluate where successful practices exist in both organizations, so they can be adopted going forward.

However, sometimes there's just no getting around cultural issues, which have the potential to hamper progress no matter how finely tuned the integration plan. "You can have a strategy for how you're going to roll out your EHR, but the culture of these organizations can easily derail anything like that," Sittig says.

There could be any number of causes behind the culture clash, from a difference in how much autonomy the individual departments enjoy to how much faith they put in IT to resolve technology problems. "I don't think there are easy ways of changing culture," Sittig says. Whether groups of employees are losing power or are required to learn a host of new workflows, the transition team needs to be attentive to how the process is playing out in real time.

Cultural differences and concerns may actually be one of the biggest challenges of the entire merger process, Berkowitz says. "It's all at ground level," he notes. "It's not on a spreadsheet. It's on an actual human workforce." The effects will be felt at the most fundamental levels although they will undoubtedly ripple across the entire organization.

Productivity is likely to slip for many of the affected employees. "On the physician side, we can see a 15% to 20% reduction in overall productivity when you're going through this process," Berkowitz says. It's nearly impossible for staff to adapt to new systems and processes without losing a few steps along the way, even if they're engaged and committed. "It's not pretty, and it's going to be very stressful on all your employees," says Berkowitz, who advises organizations to anticipate the tension, roll up their sleeves, and get on with it.

Engage Physicians
Although caregivers may interact with only a handful of technology platforms, transitioning to these services and systems can be difficult for them. "It's hard on the physicians," Sittig says. "Even in medical records, one of the big issues is how the physicians sign the note, sign the encounter."

Everything from EHR systems to the use of transcription technologies can impact how clinicians do their jobs. Because their focus is on providing care, physicians typically want to avoid spending additional time relearning supporting activities. "There are a lot of issues to consider [when getting physicians on board with the merger]," Sittig says.

"It's a question of getting the correct communities together," says Jim Giordano, president and CEO of CareTech Solutions, adding that reviewing protocols may be more effective when like minds connect. "You get the cardiology teams together, you get the neurology teams together, and you have the chiefs sit down with the key folks and say, 'OK, let's take a look at this.'"

Giordano believes physician attitude plays a huge role in the success of any merger. "The good ones will say that it's a new opportunity to challenge themselves relative to quality," he says, noting that the clinical staff should be on board with the organizations' goals to increase efficiency and improve care.

Hoyt says when it comes to merging hospital technologies, there's a cold reality: There inevitably will be those in the acquired organization who aren't interested in learning a new system. "That should be calculated as part of the due diligence expense," he says. "You have to go through training classes because it's a reimplementation."

There will be some testing activities that must be repeated. "You've got to march all these people back through classes," Hoyt says, noting that the choice of instructors is also important. "Those trainers should be gentle because they've got a room full of people who are scared." If those leading the sessions come off as arrogant or impatient, it can make the merger process more arduous.

Expect Challenges Regardless of Facility Size
Is the grass really greener on the other side? Large organizations may assume that smaller groups have smaller hurdles, sporting systems that aren't as far-reaching and with fewer users and patients to impact. On the other side of the fence, small health care systems may speculate that bigger organizations—with their deep pockets and expansive resources—have an easier time overcoming technology issues. The truth is likely that neither side of the fence is filled with tender green delights. "I would think that the larger the facility, the more complex [the impact]," Kohn says. "But that doesn't mean that smaller systems don't have complex changes to make. It's just that they're smaller and they're different."

"If you look at some of the big organizations, you have larger infrastructures in place. You have more personnel, but you also have more problems amongst more hospitals," Berkowitz says. That supporting infrastructure can help address numerous issues as well as introduce its own set of challenges. "In a way, it makes it more difficult because no matter what you say, you've got idiosyncratic things going on in those different hospitals," Berkowitz says.

Even when a hospital system makes a concerted effort to eliminate those quirks, they're likely to always exist to some degree. Berkowitz recommends that merging organizations, regardless of size, try to foresee where differences exist. "Thus, the [problem] that really worries people doesn't occur because you've already anticipated it and taken some corrective actions," he says. "It's always the ones you don't think about."

Giordano says that while large health care organizations may have a more difficult road because of their complex inner workings, their operational nuances may provide tangible benefits. "Because it's a larger infrastructure, it's better practiced, more well oiled," he explains. But it's often a double-edged sword. The bigger the organization, the less agile it may be when changing how things are done. "Sometimes a large organization can be a little less flexible or nimble than a smaller organization," Giordano says.

On the whole, experts tend to agree that organization size is not a major factor in determining a merger's difficulty. The efficiency of existing systems is a better barometer. "Where we see it work the best is where there are good internal processes for bringing on additional facilities," Mohrmann says. "If it's a big system and they've built hospitals and they've acquired hospitals, then over time they've developed a really good model for how they do that."

Seasoned organizations quickly delve into the important questions such as which technologies each team is using and how operations are structured. "If they've done that before, then it makes it much easier to do a merger or acquisition," Mohrmann says.

— Julie Knudson is a freelance writer based in Seattle.