Health Management Technology

The complicated and manual approach to traditional charge capture is leading savvy healthcare providers to consider revamping this paper-based process. Providers are aggressively assessing all aspects of the revenue cycle, with a focus on improving labor-intensive, high-cost operations. This mindset is what led Dana-Farber Cancer Institute, a leading cancer research and care center, to seek an automated solution capable of eliminating paper while supporting the timely and accurate capture of charges.

Cutting-Edge Care and Technology

Located in Boston, Dana-Farber Cancer Institute is a principal teaching affiliate of the Harvard Medical School and a founding member of Dana-Farber/Harvard Cancer Center, a National Cancer Institute-designated comprehensive cancer center. More than 300 providers and 100 nurses deliver care to thousands of patients, performing roughly 185,000 adult and pediatric outpatient clinic visits and infusion services annually.

In recent years, our clinicians adopted a number of software tools aimed at improving workflow efficiencies across our busy clinics, including an electronic medical records system—specifically the Longitudinal Medical Record (LMR), Chemotherapy Order Entry (COE), Results, and a robust Notes application.

Given Dana-Farber’s accepted use of technology within the clinical setting, we saw an opportunity to re-engineer our charge capture process, which was clearly out of synch with our numerous other streamlined workflows. Further, deciding to implement an electronic charge capture application only strengthened our organization’s commitment to providers around automating processes related to the patient visit.

Choosing the Best Fit

In order to identify the optimal charge capture solution for our environment, we assembled a multidisciplinary team of subject matter experts from the clinical operations, information technology, compliance, health information systems, and billing and finance areas to drive the evaluation process. Additionally, clinical leaders were involved during the process. A major component of our group’s approach was defining key system attributes. In summary, Dana-Farber was looking for an easy-to-use, Web-based technology that would seamlessly integrate with the LMR to expedite provider documentation processes. Additionally, the tool would need to support our administrative staff with timely reconciliation, leading to a decrease, if not total elimination, of missing and late charges.

The review committee took several months to assess available solutions. The group leveraged experience in evaluating other technology solutions and interviewed clinicians to define the functional requirements. Aside from meeting these requirements, two important pieces of the vendor selection process included the demonstration of a strong—and achievable—projected financial benefit analysis, and clear-cut, positive user adoption attributes. In other words, we needed to be certain that the chosen technology would enhance our revenue cycle, while recognizing that success would be driven by our organization’s ease in adopting the system.

In order to help gauge usability, we evaluated each potential vendor based on their demonstration of specific scripted features and functionality. Project team members scored these demonstrations, allowing us to compare scores among different vendors. While these scores would prove vital in our ultimate system selection, the committee also contacted existing vendor clients as a reality test, ensuring the vendor and technology solution withstood the real-world clinical setting.

By early 2006, we concluded our review process and selected locally-based MedAptus as our vendor of choice. This decision was based on the company’s “score,” as well as the look and feel of its solution, which we perceived to be consistent with some of our other technologies, allowing for faster user acclimation.

Rapid Roll-out

Upon finalizing the terms of our agreement, we began implementation planning for the deployment of Physician Workstation, MedAptus’ Web-based charge capture solution that supports capture of diagnosis and procedure code information for professional exam and procedure services. Wanting to capitalize on our significant momentum around evaluating the application, Dana-Farber set an ambitious goal to start implementation that summer.

For more information on
MedAptus charge capture solutions,
www.rsleads.com/708ht-200

Over the next several months, our project team devised an adoptable electronic workflow for users, identified appropriate system customizations to support workflow, and defined the criteria for accessing Physician Workstation from within LMR, including various entry points via one-click.

Some highlights of this automated workflow, which is designed to support Physician Workstation adoption and ongoing usage, include a real-time interface from the Dana-Farber scheduling system which feeds visit and patient demographic data to MedAptus. At the conclusion of a patient appointment, the clinician accesses LMR from a computer workstation to document the visit information. From the patient’s LMR record, the provider launches Physician Workstation. Specifically, the clinician is taken directly to the same patient’s MedAptus encounter record to document the professional charge component, using specialty-specific sets of commonly used procedure and diagnosis codes (each set designed with clinician input). As the MedAptus record is saved, a number of compliance rules assess the entered charge data for appropriateness. Alternatively, the provider may access Physician Workstation solely, without entering through the LMR. Providers may select to go this route if they want to enter all encounters for the day at one time.

Once charges are entered, those that the MedAptus rules engine identifies as clean are batch delivered to our billing system overnight. Those that have potential rules violations are placed in a holding bucket, where coders or other administrative users may have to connect with the provider for clarification around that charge. Once updated and approved, these charges are added to the queue for billing.

Securing Full User Adoption

When it came time to train users on the new workflow and system features, we opted to utilize a “train-the-trainer” approach. MedAptus first trained a number of Dana-Farber project team members, and then those experts in turn facilitated our training classes. We elected to have two sequential trainings: (1) Users were introduced to the project and provided information around coding practices: and, (2) Small group classroom application training, where each provider accessed MedAptus in the testing environment and was led through charging examples. Through physician leadership involvement and disease center support, we were successful in familiarizing our providers with the new charge capture tool before it was implemented. We focused on keeping training sessions to one hour, or less, and also prepared practice-specific training materials.

On July 31, 2006, Dana-Farber went live with Physician Workstation. Day One represented 74 charges for the genitourinary and gastrointestinal disease centers; providers entered all of these charges electronically by 10:00 a.m. the following morning. As for informal user feedback, one clinician was overheard noting how easy the system is to use, while others were thrilled to eliminate yet one more piece of paper from the patient visit experience.

Over the next five months, Dana-Farber continued rolling out Physician Workstation to capture exam and procedure services across 20 disease centers. Our approach was to select groups based on their “geographic” building or floor location to help ease the provision of support, delivered onsite for the first week following each go-live. The rollout schedule was rapid. As soon as we completed support for one staged rollout we would move onto training, support, and finalizing the disease-center diagnosis and procedure code sets for the next rollout. By December of 2006, all physician and midlevel providers were using MedAptus, processing approximately 3,000 outpatient charges per week.

Saving Time, Saving Trees

Perhaps the most obvious result stemming from our implementation of electronic charge capture is the eradication of encounter forms. Beyond benefiting from a reduction in forms printing, handling and overhead, the entire billing process is expedited given there are no forms to batch and courier for processing, which previously had taken a full day. Additionally, we have eliminated the risks of lost forms and manual processing errors.

With the elimination of paper comes increased efficiency for the provider. Through a single sign-on to LMR, the provider also can access MedAptus, allowing a clinician to rapidly complete documentation tasks, which is crucial given Dana-Farber’s high patient volume. If providers are unsure of the status of specific charges, rather than speaking with the operations manager or billing department, they can simply access an online reconciliation screen, which clearly identifies missing charges. Providers would never have had such transparency with a paper- based process.

Dana-Farber will realize further system benefits once we complete automating our infusion room workflow. Since charging for infusion services requires specific attributes that Physician Workstation was not designed to manage, we are working closely with MedAptus to create an infusion room module as part of its Facility Charge Capture application. Once this application goes live (projected for late summer this year), more than 100 nurses who deliver infusion services also will benefit from streamlined documentation of charge-related information.

Key Takeaways

Our project team is proud of our rapid implementation and 100 percent staff adoption. A large part of our success can be attributed to three key areas of emphasis:

Training: Any group interested in undertaking a new technology project cannot underestimate the value of end-user training—early and often. A major training strength of ours included the offering of disease-center specific classes on a frequent basis. If a provider could not attend any class, a project team member sought him or her out, even across the street at another hospital, to deliver training content. We learned early on that it is just too difficult to train providers on-the-fly, rather, training must be formalized and supported by downstream touch-points, including brief follow-up sessions approximately one month after go-live.

Support: In addition to thorough training procedures, Dana-Farber also instituted a number of support mechanisms designed to yield user success. Beyond onsite support during initial go-live for each group, our project team implemented brief daily calls with department administrators to address any developing user issues. As challenges were identified, our team devised strategies to resolve issues quickly. We also trained a number of department administrators on system features, to create another line of day-to- day support.

Monitoring: We evaluate how well our training and support approaches have paid off via various system monitoring activities. We stress the importance and desirability of completing charge capture within 24 hours of a patient visit. Our escalation procedure around delinquent charges is well documented and enforced, yielding high provider compliance. Additionally, throughout system rollout, we performed chart reviews, outside of the ongoing auditing process, comparing charge data to clinical notes to identify any unintended consequences of transitioning from paper to an automated format.

Stacy Rosenbloom is project manager, Information Technology,
for Partners HealthCare, an integrated health system in Boston.
Contact her at srosenbloom@partners.org.