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 [email protected].

September 2008