With one large teaching hospital, 26 clinics at 13 off-site locations, and 200 clinic-based physicians, the University Medical Center (UMC) of Southern Nevada, Las Vegas, has always had medical record access challenges. But in 2000, they became a logistical nightmare after we implemented the ambulatory payment classification (APC) system and moved to a centralized coding process to improve quality. Our records were in paper format, and bringing them all to one location threatened to sacrifice timely access for accuracy. We found the solution in a Web-based document imaging system, eWebCoding, from ChartOne Inc., Burlington, Mass., which scanned paper documents and shared them with authorized users simultaneously via the Internet.
The move to centralize
We have more than 700,000 patient visits throughout our network of urgent care and primary care clinics annually, generating a million claims--about $250 million. As it does at most provider organizations, the introduction of APCs brought tighter scrutiny of outpatient coding and billing practices. Internal audits found more than $1 million in lost charges, inconsistencies in clinic coding, and issues with documentation and compliance. It was time for centralized clinic coding, which became the responsibility of patient financial services. Three project goals were identified:
· Reduced unbilled days at minimal cost
· Better customer service for physicians, payers and patients
· Improved documentation for coding and billing compliance
To accomplish these goals, we created an Ambulatory Coding Services Department in 2000. All clinic coding moved to one location, and 12 credentialed coders were hired to handle the workload for the 26 clinics. However, photocopying medical records and couriering copies from the clinics to the coding office was taking extra time, causing coding delays. And we soon found that records were getting lost along the way.
Turning to the Web
UMC had been discussing implementing a complete, computerized clinic record for 10 years and had even tested an online clinic record. However, physicians rejected the system because of the time required to input data. Then we discovered Web-based document imaging.
Two vendors demonstrated their products, and we reached a decision primarily on product functionality. Pricing was also attractive: As an application service provider, ChartOne provided the image repository, all system support and maintenance, backups and upgrades as part of its per-chart transactional fee, allowing us to recognize the system as an operational expense. We incurred no up-front capital costs for software and pay no incremental license fees, although we did purchase new PCs and scanners for each location. UMC can add functionality one step at a time, which made the initial project manageable while allowing future possibilities.
Now, records are scanned at each location. The digital images are encrypted and sent via the Internet to the vendor's host server. Records are then immediately available to UMC coding staff as well as caregivers at remote locations. Charts can easily be assigned and reassigned to coders electronically.
Implementation lessons
Implementation took only about nine months for 12 locations because no complex interfaces or bar coding was required. The system is easy to use and intuitive, so people began using it immediately. We piloted implementation at one clinic and then rolled out the system to other locations, allowing us to make improvements with each implementation and break training into bite-sized chunks. Of course, there were a few hiccups.
We discovered the importance of planning for unexpected Internet glitches. During our pilot, a systemwide computer virus caused Internet lock-down throughout the organization. Since we rely on Internet access to upload and view scanned records, we learned that a rapid, reliable Internet connection and back-up plans for unexpected downtime are critical.
We also learned not to underestimate the amount of time, effort and space needed for scanning. Our decentralized scanning approach required us to train "super users" at each location and to find space for the sizeable equipment. Vendors can help estimate scanning volumes and suggest appropriate equipment and staffing, which are important because scanning backlogs and downtime can lead to user dissatisfaction downstream. We recommend purchasing the full-support option for scanners and keeping replacement parts on hand.
Another lesson we learned the hard way is to make sure your PCs can handle the workload. Because we rolled out the system so rapidly, we neglected to inventory what applications were being used on each workstation. As a result, PCs did not have enough memory to support the volume of documents being scanned. Users received error messages and were kicked off the system. Today, we purchase the best available PCs for any new users to ensure rapid response times for all applications, both Web-based and internally hosted systems.
Coding transformation
Just six months into the project, the five-day delay between chart availability and coders' access to the charts was eliminated, thereby reducing unbilled days. An additional 30 charts were being coded each day, which represented a 25 percent increase in coder productivity. And the need for two FTEs, whose job had been to request charts and make photocopies, was eliminated because, with access to online records, billing staff could print out the documentation they needed to attach to claims.
The software's advanced security tools, certificates and complete event logs give us much tighter control over access to charts than we had in the paper environment. And we've gained a strategic advantage over our competitors in terms of coder recruitment and retention because coders can perform their jobs remotely.
Customer service improvement
We were given a push toward our enhanced-access goal by a surprise visit from the Occupational Safety and Health Administration. During a demonstration, one of our physicians saw first-hand how a record could be retrieved instantly via the Web. Before the week was out, it seemed that every clinician was clamoring for access.
Today, the system has nearly 2,000 users. Because we serve a transient population, clinicians value the ability to quickly and easily view records from the various clinics. The ability to track patients and communicate between facilities has significantly enhanced the continuity of care UMC provides. According to a recent clinician survey, 72 percent of users view records online at least 11 times a month, 56 percent use the system to view records from other clinics, and 76 percent believe the system has improved their efficiency.
In addition, when payers need documentation, we can respond to their requests quickly. We truly believe that having records available online has not only improved our billing cycle and financial performance but also enables our clinics to provide better care.
Future plans
The next rollout of this technology will be in the emergency department of our flagship teaching hospital, a 544-bed, level-one trauma center. Having emergency department records available online will streamline patient follow-up at our clinics as well as expedite coding and billing.
UMC realized significant value from its investment in a Web-based document imaging system. Sometimes perceived as only a temporary solution, document imaging is a critical component of our long-term electronic medical record strategy and has helped us connect our clinics in ways we never thought possible.
Carrie Ayala, CCS, is outpatient coding manager and Jim Perez is director of patient financial services, University Medical Center of Southern Nevada, Las Vegas.
