Tech with a Twist

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ED software makes an impact at a New Hampshire hospital, but the real credit for improvements goes to interdepartmental collaboration.

Healthcare providers are justifiably excited about the money for electronic medical records in the $787 billion stimulus package signed into law in February. The law contains $19 billion for hospitals and physicians to obtain an EMR system, but Catholic Medical Center in Manchester, NH, says the benefits from its EMR have been well worth the price it paid to get it installed long before the government was paying providers to do it. And the benefits came not so much from the technology itself, but from the interdepartmental cooperation it helped foster. In a time where access to capital can be extremely dear and difficult to find, such operational improvements are going to be the order of the day for the foreseeable future.

The 227-staffed-bed hospital's emergency department, which installed an EMR about four years ago, sees about 36,000 patients a year, but the key to its profitability was getting paid quickly for the work it was doing. That wasn't happening.

"Some of the charging was very subjective," says Lucille Mulla, the vice president of emergency services and disaster management at Catholic Medical Center. In the old system, a nurse might check off items on a piece of paper that noted the equipment she utilized. That paper would go to billing where a bill would be generated.

"It would depend on how busy a day she was having whether those charges were even billed on a timely basis," Mulla says. "Our turnaround wasn't that great to get them over to billing, and we knew we had to do something. We weren't doing very well making money in that ED."

Those days are long gone. In fact, from 2007 to 2008, Catholic Medical Center has increased its revenue from the ED by 48% thanks to a host of improvements. But both Mulla and Kevin Kilday, the hospital's chief financial officer, attribute most of the improvement to a formal partnership between the clinical and financial arms at the hospital to help decrease bad debt and qualify eligible ED patients for financial assistance. The overhaul was prompted by a challenge from the system's CEO, Alyson Pitman Giles, to improve ED revenue, but also to improve customer service in the ER, where about 17% of the hospital's inpatient admissions are generated. "We partnered with finance, which a lot of systems and hospitals don't really do," Mulla says. They built an ED-finance committee that meets monthly, involving representatives from medical records, corporate compliance, and various members of the finance team.

Through those meetings, the team discovered that the glaring need was in documentation and the "stuff that fell through the cracks" in that area. The hospital installed Picis' ED PulseCheck software in 2005 and linked the EMR and ED chargemaster as an attachment to its ER in 2007—not only to help with documentation, but to help triage patients quickly and efficiently. Kilday and Mulla agree, however, that the technology improvements constituted a small piece of the initiative.

"We utilized the EMR to assist us in capturing those lost charges," says Mulla. "The system was set up in such a way that through the completeness of the documentation we were able to let the system help us identify the charges that we could capture."

The previous system was manual and on paper. The supplies provided to the ED came with a sticker that would be placed against the patient account and someone would enter that into the system. In the new system, which they call "charge-by-doc," the charges are tied directly to the documentation.

"The sell to the clinical staff is that we're not asking them to be charge detectives, we're asking them to use a clinical documentation system and that documentation, invisible to them, is hard-linked to a chargemaster that just happens to be sending the appropriate charges to the billing system," says Kilday.

Part of the collaboration included hiring a charge capture specialist to work alongside clinicians in the ED to make sure anything used in the treatment of the patient generated that charge.

"The only way the procedure and supplies can make it onto a bill is because the clinical documentation stated it took place," says Kilday.

To make sure that's true, Catholic Medical Center brings in an outside auditor quarterly to review charge capture in various departments in the hospital by pulling a sample of charts to review documentation vs. billing. "It's gone without issue in the ED," Kilday says, adding that "anytime you can marry the documentation with the charging process and get the clinician out of the charge police role and into the documentation specialist role, you'll win."

Kilday is happy to give credit to the technology for helping the hospital collect what it's owed from its ED work. However, he's also careful to stress that while technology is an aspect, the interdepartmental dialogue is the true great success. "Anytime you have a business-clinical partnership around a service line, the whole is greater than the sum of its parts."

Philip Betbeze

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