Electronic medical record can save millions
Cincinnati hospital’s time-saving technology
Rehabilitation hospitals will need every advantage they can get from technology to help cut costs and maintain the quality of patient care in coming years under the prospective payment system (PPS). For instance, suppose your hospital’s leadership believes it’s a good time to expand, opening new satellite offices in underserved areas. How can you do this without greatly increasing support staff costs?
One solution might be to upgrade your information technology and become fully computerized with an electronic record that makes it easy for therapists to update charts and access patient information. An electronic record also can eliminate the need for transcriptionists and support staff, providing it’s developed with guidelines for each discipline and staff are trained to type in a few notes and follow computerized pathways instead of dictating or writing notes in longhand.
Sound too good to be true? It can be done, and Children’s Hospital Medical Center in Cincinnati serves as proof. The hospital’s joint occupational therapy (OT) and physical therapy (PT) department created a complicated but financially rewarding electronic record that enabled the hospital to open seven sites without funding new support staff positions, saving the hospital $1.12 million a year in potential salaries.
"It allowed us to expand very quickly and grow rapidly without adding tremendous support staff to do the expansion," says Rebecca D. Reder, OTR/L, director of OT and PT. Reder collaborated on the project that resulted in an electronic medical record. "We’ve been able to do that because we’ve centralized all operations from the base hospital, using the same support staff," she adds. "All referrals are received centrally, so we have five core people who do the clerical and office administration tasks for 80 people at seven locations for OT and PT."
The electronic record, which the PT and OT department began to use in 1995, also eliminated the need for transcription services, saving the hospital money and saving therapists several hours of dictating and proofreading reports each week. Instead of dictating their reports and sending them to a transcriptionist, therapists type their reports directly into the computer.
The reports are designed for easy use. Instead of typing in every word, therapists can choose various links that automatically call up treatment details. Because the reports are faxed to physicians immediately after they’re created, this has shaved six weeks off the traditional transcription process, which included extensive proofreading and rewriting before reports could be faxed to physicians. The hospital had to train the staff to use the new electronic reports, but that involved only a four-hour inservice session.
Also, the electronic record has saved employees a considerable amount of time in making and reviewing schedules. "Everyone’s schedule is right on-line, so no matter where they work, they can access their schedule with the stroke of a key," Reder says.
She explains how an electronic medical record works and where it provides the greatest benefit:
• Tracking patients and documenting care. The electronic record enables departments to automate the entire patient care cycle. Providers fax patient referrals into the system, and department employees enter patient demographic, referral, and insurance information as soon as referrals are received. Therapists track the patient’s progress through the initial evaluation, treatment, and discharge. Everything is tracked on-line, including patient charges, insurance authorizations, and appointment history. The system easily identifies unbilled appointments and expiring insurance authorizations, and it can compose standardized letters to parents, insurance companies, and physicians.
The record contains databases pertaining to patient documentation, scheduling, and referrals. (See description of databases, p. 123.)
Children’s Hospital managers and clinicians helped develop more than 35 standard evaluation forms that allow therapists to compose reports on the computer. The process took about a year. (See sample treatment form, p. 120.)
"We asked clinicians to compose templates for each area, and we said, Tell us what you most commonly say when you look at range of motion? What grids do you use? And what are the most common mistakes?’" Reder says.
Part of the electronic record’s charm is that it allows all department locations to share data instantly. Patient documentation is signed electronically and can be faxed instantly to physicians or insurance companies. Therapists use laptop computers while in the field and then copy their work to the system when they return to the office.
The software includes a database that shows, for each therapist, when a patient was seen and when the patient’s report is due. The department requires therapists to complete reports within one week for outpatient cases and within eight working hours for inpatient cases. "We can monitor the turnaround time in a report," Reder says. "If you have a therapist who is not performing, this tells you who that therapist is."
She notes that just having an electronic and public means of checking up on employees has resulted in better performance. "People are affected by peer review, and they know anyone can pull up their documentation information if they’re late with a report."
• Tracking patient charges. The record eliminates the possibility of losing charges because of misplaced paperwork or a therapist’s omission. Once a case is entered into the system, the record automatically creates a charge form and progress note. All patient information is carried from the initial reports to the charge form and subsequent reports, so therapists never have to enter the same data twice, Reder says.
• Tracking unbilled charges. Managers can check regularly for unbilled charges and then remind therapists to complete the charges. When therapists complete a progress charge form, the electronic medical record refers to the referral form for demographic information. It also includes progress note findings, both subjective and objective, and it includes the actual charge section that shows the services provided, the numbers of each service, the charges per unit, and the amount of charges.
"All the therapists have to add is how long they saw the patient that day, the services they provided, and the response of that patient to the treatment in the progress note," Reder explains.
In addition to making it easier to track charges, the electronic record has resulted in better reimbursement, she says. Department staff can pull up authorization information to make sure a visit or service meets an insurer’s guidelines, and the electronic reports show insurers exactly how well patients progress in treatment. "Because we can send them such comprehensive documentation, it’s easily reauthorized," Reder says.
The software sends reminders to therapists each time they complete a charge for a patient. The reminders tell them how many visits they have left and when the visits expire. When therapists see that the visits are about to expire, they can let the department’s insurance specialist know reauthorization might be necessary.
"We’ve saved hundreds of thousands of dollars through better collection of billed services because we can substantiate the services provided," she says. "Now when we have audits, we can provide back-up documentation for when the patient was seen, how many units of care were provided, and what were the outcomes of care."
Before the department switched to an electronic record, it never could provide such extensive details to payers, she adds.
• Patient care. "Of all the things we were attempting to do, that was the biggest," Reder says. "The major improvement in clinical care is we can get the patients into appointments faster because of electronic scheduling."
The department can track when patients don’t show up for appointments and exactly what has happened from their referral into the system until their discharge. That ability to track patients proved essential when the hospital opened its satellite offices. "When you open up satellites, you usually have a problem of patients showing up at suburban locations while their charts and referrals are somewhere else," Reder explains. "The electronic record eliminated that problem because all of the charts are at the touch of the finger." (See discharge summary database, p. 121.)
Wherever a patient shows up, the therapist can pull up a scanned copy of the physician’s referral and use that for reference. "And it’s improved clinical care as well, because we are able to get back to the physician much more quickly with the patient’s outcomes," she says.
Overall, the electronic record has helped keep the departments flexible in a changing rehabilitation environment, she adds. "We have been able to respond to changes in health care without having to increase our expenditures, and, in some cases, [we’ve been] able to decrease them."
The only drawback is the development time and financial investment, which can cost as much as a million dollars initially. The hospital later sold the electronic record, called Chart Links Rehabilitation Products, to a company called Chart Links Ltd. Partnership in New Haven, CT.
Hospitals that buy electronic documentation software will have to recoup the cost, which for many hospitals will be a less-expensive option than developing their own. Rehabilitation hospitals that use an electronic record could realize a cost savings within six months, says Ron Miller, MD, president of Chart Links. "We estimate the return on investment is three to six months depending on the individual organization. This product is appropriate for organizations with 10 therapists or 500 therapists, and savings are different depending on the organization."
Working with software consultants, Reder and other hospital managers spent several years developing and fine-tuning the record. Since the hospital sold it to Chart Links, the new owner has taken over the continuing research and fine-tuning efforts. Chart Links also has an electronic record for speech pathology and has been working on similar electronic records in other rehabilitation areas, including psychology and audiology. The company has created a tool for a rehabilitation team conference, as well. "We’re just about to begin building our audiology product, case management product, and later this year we’re going to build products for rehabilitation nursing and physical medicine," Miller says.
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