Q&A: Bling to the EMR
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Erskine recently spoke with CMIO about EMR implementation, filling functionality gaps and capturing charges.
Did VCUHS want to automate any particular segment of workflow?
When we piloted our implementation of PatientKeeper in 2006, we wanted to find out [if] use of electronic charge capture—which was the primary module we were interested in at the time—[would] improve overall charge capture for these units.
We were also interested in mobilizing the physicians’ access to clinical data as well as using Patientkeeper as a shadow EMR, as a downtime solution and “bling to the EMR,” something that we could use on top of our current [Cerner] EMR, where it may have some holes or need further enhancements.
What installation challenges did you encounter?
It became clear that for physicians to absorb hardware changes, software changes and workflow changes all at once was too much. We began thinking about how we [could] improve [our] implementation strategy.
We [created] an office of clinical transformation, and gave a group of clinicians, associated nurses and others formal training in clinical informatics and biomedical informatics to help translate the clinical needs into IT specifications and the other way around.
They set up a series of councils that were responsible for things like documentation, charge capture, clinical decision support and so forth … and [made] sure that as thoughts and ideas came in, they would manage/prioritize suggestions for the IT folks. They sat in between the clinical enterprise and IT enterprise.
We went back to pilot users [and achieved] a much more accelerated rate of implementation across the practice plan. We have 19 clinical departments associated with that practice plan and had just tested it out in one and wanted to deploy it out further.
Were there any surprises in the results?
We [conducted] an analysis of charges that were captured the year prior to and after we had gone live with PatientKeeper. What we found in these [pilot] departments was that we were missing about 30 percent of charges, which was much more than we anticipated: We had thought the paper-based system was a reasonably good system, but it was a very difficult system to audit.
In the electronic workflow, we set up a process by which the next day, if a patient had been in a hospital bed and there was no charge, [the physician] would get a page. So the billers that in the past were focused on interpreting physician handwriting on paper cards were now making sure charges were being posted.
But more importantly, [the billing department] developed almost a new relationship with those physicians in helping them with the actual coding process. The physicians now [can] questions and get clarification on billing rules they need to know to post their charges.
That relationship ended up providing much more accurate, more comprehensive charges in less time. So we had both a boost in revenue in terms of how quickly the charges come in … as well as the number of charges that are arriving. [We’re seeing] an influx of cash three months earlier than we were seeing before as well as a higher volume.
With that success we went to the practice plan and said ‘let’s do this for everybody else.
How has this enabled you to provide better patient care?
About a year after we put in Patientkeeper, we went to full electronic documentation [and] we created a report that basically identified every patient on the census, [whether] they had a charge and if they had electronic documentation that particular day. With 30,000 discharges a year, you end up with a majority of patients who end up with a charge and an electronic note, [and] not all of them had electronic note and electronic charge for that particular day.
That ended up being an extraordinarily useful report, not only to identify charges, but also in terms of quality of care to make sure that all notes that were supposed to be written were being written in a timely fashion. It ended up going beyond just charge capture toward other aspects of auditing quality of care.