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The Heart of the Matter

Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography

Sanford, Joseph A. MD; Kadry, Bassam MD; Oakes, Daryl MD; Macario, Alex MBA, MD; Schmiesing, Cliff MD

doi: 10.1213/XAA.0000000000000169
Case Reports: Perioperative Services
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Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.

From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

Accepted for publication January 29, 2015.

Funding: None.

The authors declare no conflicts of interest.

This report will be presented, in part, at American Society of Anesthesiologists Practice Management 2015.

Address correspondence to Joseph A. Sanford, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr., H3580, Stanford, CA 94305. Address e-mail to jasanford@gmail.com.

Although the Affordable Care Act has hastened the adoption of electronic medical records (EMRs), health care providers and organizations are challenged to maintain or improve the quality of care while adapting to new and often nonintuitive record-keeping tools.1,2 Additionally, the “meaningful use” mandate expects providers to improve clinical processes in 2015 and demonstrate outcome improvements.a Poorly designed record-keeping tools can hinder clinical workflow, resulting in lost productivity, incomplete data collection and analysis, and difficulty in documenting and communicating important clinical findings.3

Structured entry documentation4 can improve both the timeliness and accuracy of records and billing.5,6 After Stanford moved to an EMR system (Epic version 2014, Epic Systems Corporation, Verona, WI), we reexamined the workflow for intraoperative transesophageal echocardiography (TEE) with the goal of implementing a process to facilitate data entry and increase final report quality. Our efforts resulted in a simplified and more accurate billing process. We present the lessons learned from extending the EMR through agile development7 and rapid iteration from stakeholder feedback. We also discuss our estimated projects costs and the length of time before these costs are recuperated.

The Stanford IRB reviewed and approved this project because it was necessary to access patients’ protected health information to determine the incidence of TEE.

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PROJECT DESCRIPTION

Our TEE documentation process before implementing the EMR was:

  1. Perform intraoperative examination and report findings to the surgeons.
  2. Upload the images to the image management system (Philips Xcelera Cardiology Enterprise Viewer, Koninklijke Phillips N.V., Amsterdam, the Netherlands).
  3. Read the examination formally using a template at an Xcelera-enabled hospital workstation.
  4. If read by a fellow, note on paper those examinations requiring a final reading.
  5. Once complete, notify billing manually through the offices of cardiovascular anesthesia.

The examination could not be read in real-time because reports could only be generated after the entire study was finalized at case end. The common practice was to complete the study in the anesthesiologists’ spare time, which typically occurred days after the procedure and required between 30 and 60 minutes. This process often resulted in final TEE reports that did not meet the American Society of Echocardiography/Society of Cardiovascular Anesthesiologists continuous quality improvement guideline recommending the report be placed in the chart within 24 hours of the procedure.8

A count of all cardiac surgeries and liver transplants between August 14 and October 18, 2013 (the prior year’s range from go-live to present) showed that only 60 of 168 cases (approximately 36%) involving the routine use of a TEE examination were billed. Discussions with the cardiovascular anesthesia team revealed that the primary issues affecting report creation and billing were: (1) work duplication and frustration with report creation, (2) a reporting chain that required micromanagement, and (3) suboptimal final reports. To address these issues, we created a new report interface using a condensed base template (Fig. 1). Scripting enabled quick entry of normal findings, thereby allowing most of the physician’s time to be spent documenting any significant findings (Fig. 2). Color was used judiciously to stratify by anatomic region and maintain legibility during examination entry (Fig. 3). To maximize quality, the generated report underwent significant iterations to produce a concise, complete, and highly readable document. The procedure note was designed so that an attending signature was required to finalize the report and close the encounter, which automatically notified billing. Workflow changes are illustrated in Figure 4. The clinical management of the patient was unchanged.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Several physicians contributed to the project, though there was no formal budgeting for their time. The lead informatics physician on the project was allocated 1 day/week to complete various information technology (IT) projects. The lead cardiac anesthesiologist contributed nonclinical time. Approximately 95 physician hours were required during the 12-month build, split disproportionately between the first 2 months (45 hours) and the 8 months of development and testing (50 hours). The proof-of-concept and feasibility stages involved mapping the existing workflow (approximately 20 hours) and the billing process (5 hours), and identifying compliance issues before being able to identify points of breakdown and draft the target design specifications (20 hours). Physician responsibilities during development are discussed below.

This investment was necessary to determine exactly what the project would need to accomplish systematically. The project benefited from physicians with expertise in both the clinical and technical domains so that poor assumptions were not made, which could have had disproportionate downstream effects. The complexity and scale were then assessed by IT to determine the technical feasibility of moving forward. Total IT time was approximately 300 hours (6 hours/week for 49 weeks), with an estimated final project cost of $31,375 (Fig. 5). This time estimate only accounts for resources at Stanford. It does not account for consulting work from the EMR provider team as build challenges were encountered.

Figure 5

Figure 5

Once the new system was in place, 99 of the 117 (84.6%) cases performed between August 14 and October 18, 2014 were billed. From this increase we anticipate full project cost recovery in approximately 18 weeks. It is worth noting that the old billing process was subject to volatility due to the micromanagement required to create a charge. The decreased billing for the months immediately before go-live is attributed to focus being shifted to deploying the new system. This explains why a year-on-year analysis was done rather than comparing against the preceding months. We anticipate this volatility will be reduced by the new system.

User response has been positive. Chart review is easier because the TEE note is immediately available for referral by the other clinical teams. In addition, the departmental expertise gained can be applied to planning or consulting on future projects. The template for the procedure note is available for reference and use at other institutions using the same EMR vendor. Finally, quality control reviews have been facilitated now that all TEEs are indexed in a searchable database.

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DISCUSSION

When proposing a wish-list for improving an EMR, misconceptions of what is possible, feasible, and cost-effective can and will occur. Clinicians with no background in computer science may not realize the complexity of what seems a simple request. Software engineers with no clinical knowledge may not be focused on the clinical utility of their product. We found that including experts from clinical and IT domains provided the flexibility necessary to address issues quickly while maintaining the project’s momentum. It is also important to remember that most project costs occur in the development phase. Money spent up-front to thoroughly define the problem and assess feasibility will limit ballooning costs later.7 Ultimately, such projects should have well-defined returns on investment. Is the goal clinical utility, revenue, knowledge, prestige, or some combination? Explicitly stating the targeted outcomes will allow setting reasonable expectations.

Any new system will be met with some pushback from users. Change is difficult. Successful implementation is aided by early and frequent feedback, an agile design methodology that is effective.7 Iterative prototypes help users of the system quickly and clearly define what they want. To accomplish this, the lead cardiac anesthesiologist demonstrated in-progress versions to colleagues often throughout development so that the final tool was clinically useful. As is often the case, feedback was most forthcoming when done one-on-one. The flexibility to create either a brief, basic report or a detailed, technical one from the same template was highly valued. Users also valued the ability to add free text findings to the mandated template fields. Frequently seeking input kept end-users personally invested in the creation of the new system. It also increased general familiarity with the system, which ultimately enabled a smoother transition.

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NEXT STEPS

The complexity of the TEE examination and the extensive use of scripting pushed the EMR to its functional limits. It required significant system resources to load and save the procedure note and associated macro. Template responsiveness remains an unresolved issue. It may also be useful to test the process against a mock audit to discover remaining weaknesses.9 Notably, the system does not force the attending to finalize the archived images as it does with the EMR report. Finally, the question of who should benefit from the derivative value created by distributable projects like these is largely unanswered. The considerable investment of time and resources to develop this procedural note are now available to any Epic licensees. Solutions that encourage development of similar projects rather than incentivizing a wait-and-see attitude remain an open debate.

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CONCLUSIONS

Although the former system was sufficient to provide good clinical care, the EMR was underutilized despite being able to provide a faster, more efficient, and more consistent workflow. It is not enough that health care providers merely adapt to these new tools. Organizations should have expert clinical users who can identify areas where improvement can be made and lead projects to use EMRs to greater effect. The financial investment alone should prove well justified. Any additional benefits derived from increasing institutional expertise will be useful for future projects and for advising others who are attempting to tackle similar problems. Lastly, while Meaningful Use was not the primary objective, this project added value to the clinical process by bringing another component of care into the queryable database.

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ACKNOWLEDGMENTS

The authors wish to acknowledge Zhi Liang and Elizabeth Baptist for their assistance in providing detail for this manuscript.

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FOOTNOTE

a CMS Meaningful Use EHR Incentive Programs. Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/. Accessed October 19, 2014.
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