• September 2008 FEATURE ARTICLES •
RCM: Charge Capture: Case History
True Believer
A multispeciality early adopter implements a multidisciplinary charge-capture solution and streamlines continuity of care.
By Cynthia Trapp
Paperless medicine has been touted as the
vision of many progressive healthcare provider organizations
since the late 1990s. The notion that paper and its associated
administrative tasks — printing, collection, data entry, filing
and storage to name but a few — play a large role in the
inefficiencies plaguing healthcare is easy to believe, but
harder to address. While Lahey Clinic is now undergoing the
implementation of an electronic medical record (EMR) system, our
journey into paperless medicine started some eight years ago
when we realized that our approach to coding and billing, based
on the paper encounter form, was inefficient
and needed improvement.
Massachusetts-based Lahey Clinic is a large
and complex organization where more than 550 clinicians in 39
specialties see about 3,000 patients daily in both inpatient
(327 beds) and outpatient settings. Given this volume, even
losing just 1 percent of charges can have a sizeable effect on
the revenue cycle. In an effort to prevent loss, we initially
applied human resources to address these issues. While this
approach was effective when it came to finding missing forms,
identifying missing information, intervening around coding
inaccuracies and performing daily reconciliation, the reality
was that approximately six individuals handled each claim.
Finding a Better Way
Recognizing that our paper-based approach was
simply not sustainable for the long-term, given our size, we
decided to investigate available technologies. While electronic
charge capture systems are fairly commonplace today, this
certainly was not the case in the year 2000 when we started our
search for a solution. While our requirements were
straightforward, finding a mobile physician tool that provided
coding assistance, streamlined administrative workflow, and
yielded a measurable return-on-investment, proved to be
challenging.
Our initial implementation was a pilot of 15
physician users to establish system proof-of-concept based on a
number of quantitative and qualitative measures. Results such as
improved compliance, enhanced reimbursement, reduced revenue
loss and decreased charge lag days confirmed that the solution
met our requirements and was an effective replacement for
numerous manual processes. As of 2008, we now have more than 550
clinicians completing charge capture electronically on both
mobile
devices and workstations.
Early Adopter Advice
As an early adopter, Lahey Clinic often
serves as a resource for groups contemplating charge capture
system deployment. While much of what we typically impart
applies to any enterprise software project, such as establishing
realistic timelines, there are a number of insights that ring
particularly true for charge capture.
Create Transparency: An automated
charge capture implementation can be distressing to clinicians
and coders alike given the constantly changing complexity in
coding rules and regulations. However, by involving physician
leadership and coding resources, in addition to finance,
billing, IT and project managers, in early-stage project
planning, uncertainty can be effectively addressed and anxiety
reduced. Groups that wait too long to involve key stakeholders
often face adoption challenges
grounded in resistance.
Set Expectations: To practice
medicine at Lahey
Clinic, a clinician must accept that technology is the backbone
of our coding and billing processes and that he or she plays an
integral role in those operations. For new physicians this means
system set-up and training occurs as quickly as possible, which
has been key to gaining and maintaining
enterprisewide adoption.
Implement an Appropriate Support
Infrastructure: When we’re asked about our approach to
supporting
professional charge capture, our insight is that for a large
organization considering a mobile deployment, internal resources
are vital. Unique support challenges stem from the reality that
devices can be lost, dropped, forgotten or left uncharged. For
clinicians to consistently use technology after every single
encounter — perhaps up to 30 times a day — there has to be
confidence that regardless of what issue may arise, help is only
a phone call, e-mail or
short walk away.
Beyond Numbers
While one could say that the implementation
of
professional charge capture has proven successful because all
initial requirements were met, a better measurement is our
continued usage several years later. Most published case studies
on the adoption of charge capture technology focus primarily on
the hard results of usage, such as the decreases in cost and
increases in revenue. Clearly the system has delivered in that
realm, however, a number of other benefits not initially
foreseen or commonly discussed also have been experienced:
Enhanced Physician Awareness: Beyond
being cumbersome to update and collect, paper encounter forms
are additionally prohibitive in terms of code selection. In
other words, on a single piece of paper, there is only so much
room to list procedure and diagnosis codes. Once the forms were
eliminated and electronic access to entire coding dictionaries
became available, many users were enlightened to the complexity
of professional coding. From the ability to effectively bill for
services rendered outside of one’s specialty — a daily event for
some physicians — to newfound knowledge of compliance rules,
regulatory guidelines and the importance of coding accuracy,
usage of the tool has created an awareness that our clinicians
enjoy.
Enhanced Communication: Another
cultural impact has been the improvement of communication. The
tool itself has evolved tremendously since version one with many
new features aimed at more closely connecting users. The net
result is easier collaboration stemming from anytime/anywhere
access to encounter notes
and history.
In addition, these communication features
have bridged the gap between coding staff and providers. Coders
now function as an extension of the provider as charge capture
experts who can train and support the application and respond in
real-time to physician-generated queries. Without the paper
chase, their training and education are far better utilized
today than they were years ago.
Continuity of Care
It may surprise some to learn that an
application designed to streamline coding and billing workflow
has helped Lahey Clinic improve our continuity-of-care efforts.
We have more than 40 multispecialty centers that deliver care
for the more complex conditions. Charge capture supports this
multidisciplinary approach because regardless of who treats a
patient or where that patient is physically seen in the
hospital, we can easily ensure correct assignment of
reimbursement and relative
value unit credit.
Reducing the administrative burden for
our nurses has been one of the most significant benefits of adoption, giving them more time to tend to patients.
The phrase "paperless medicine" evokes
another popular phrase that, while truer 10 years ago, has yet
to be completely debunked: "physician aversion to technology."
When Lahey Clinic first started to deploy the MedAptus tool,
there were concerns that it would be too hard for doctors to
learn, take too much time, or be a distraction. In response, we
created a methodical roll-out plan and assembled a support team
comprised of both application and coding experts. We also
implemented clinician-centric training that could be completed
in 30 minutes and included one week of practice time prior to
live usage.
Expanding Paperless Medicine
While it is true that implementing charge
capture automation at Lahey Clinic eliminated significant paper
from the patient encounter process, one challenge we continued
to struggle with was documenting the facility charge portion.
For outpatient clinic visits, doctors used professional charge
capture to code the encounter, yet nurses still relied on paper
to record facility utilization.
Determined to eliminate yet more paper and
provide our nurses with a solution on par with that which the
providers had become accustomed, in 2006, we approached
MedAptus about partnering again, this time on the development of
facility charge capture.
Lahey Clinic is currently deploying the
vendor’s
facility charge capture solution to more than 20 outpatient
areas. The tool provides nurses with a fast and easy way to
document their tasks, as the output is in a facility
evaluation and management code that is automatically derived
from what was entered. This component is reconciled along with
the rendering physician’s professional charge data. Such a
comprehensive approach prevents potential compliance issues and
ensures that a patient’s entire visit is completely and
accurately coded — all from one screen. Reducing the
administrative burden for our nurses has been one of the most
significant benefits of adoption, giving them more time to tend
to patients.
Over the years, Lahey Clinic has invested a
great deal of time and resources into professional charge
capture. The significant payoff has taken us well beyond the
measurable revenue cycle improvements so commonly associated
with charge capture technology. As a platform, the solution has
allowed us to address a variety of requirements and requests,
whether governmental (code changes, PQRI), organizational
(system integration) or individual (enhanced patient management
tasks). The tool has served us well and will continue to play an
important role in day-to-day operations.
Cynthia Trapp, CHFP, CMPE, CPC, CPC-I, CCS-P,
CHC, is the director of professional coding at Lahey Clinic
Medical Center in Burlington,
Mass. Contact her at Cynthia.A.Trapp@lahey.org.
