The Hospital Journey to a Paperless Revenue Cycleaipam.net/doc/The_Hospital_Journey_to_a_Paperless_Revenue_Cycle… · The Hospital Journey to a Paperless Revenue Cycle Ken R. Cassell,

©2012 THE WHITE STONE GROUP, INC. - Proprietary Materials

The Hospital Journey to a Paperless Revenue Cycle

Ken R. Cassell, MBA SVP |The White Stone Group, Inc.

Janet L. ZeBell, MHA BSRT (R)

System Manager Central Ambulatory Scheduling and Order Processing St. Vincent Health, Indianapolis


Ken Cassell Senior Vice President of Business Development

The White Stone Group, Inc.

About The White Stone Group

• Specialize in Improving Healthcare Communications

• Experts in Healthcare Voice Technology

• Hospitals from Coast to Coast


• Document communication with payers for proof to overturn denials caused by communication breakdowns.

• Monitor phone calls in revenue cycle departments to improve customer service and issue resolution.

• Improve customer service to patients and clinical staff members by tracking faxed orders through a paperless, enterprise-wide solution.

Learning Objectives


• Workflow efficiency

• Denial prevention

• POS collections

• Patient satisfaction

• Behavior modification

• Quality assurance

Why document?


• Physician orders

• Patient precertification & financial clearance

• Out-of-pocket estimates

• Managed care discussions

• And much more…

What should be documented?


Patient

Payer

Hospital

MD Office

Case Management Authorizations

Verification of Benefits

Eligibility

Notification of Admission MD Orders

Notification of Discharge

MD Office Communication

Managing Communication is Complex!

Precertification

Customer Service

Call Center

Concurrent Review

Physician Query

Patient Instructions

Financial Counseling Important Message

Read-back Instructions

Patient Satisfaction Calls

Call Monitoring & Training

Patient Status Changes

Pre-registration Calls

Scheduling Verification

Patient Out-of-Pocket Instructions

Pharmacy Benefit Eligibility

Verification of Precert

Billing Inquiries


How do most hospitals document now?

Current State of Documentation

• Hand-written notes

• Typed info from web sites

• Voicemail messages

• Recollection from memory

This information is subjective, deniable and disputable.

Desired State of Documentation

• Recorded phone call or voicemail

• Capture of web page with date

• Fax confirmation with date/time stamp

• Record of notification to another party

This information is objective, undeniable and undisputable.

The he-said, she-said is over!


What is it?

A central repository to capture all elements of communication that support the business side

of patient care.

An EMR for the Revenue Cycle


Electronic Revenue Record (ERR)

Technology-based solution that documents all communication (voice, fax, and electronic) on

the business side of patient care (with patients, payers, physicians and between providers).

Records archived in a central repository and automatically indexed to the patient account for

processing, routing and retrieval.

Documenting Revenue Cycle Activity

Printer

Scanner

Memory

Note Pad

File

Cabinet

Computer

CD-ROM

DVD

Tape

Recorder

Fa

ce

-to

-Fa

ce

Co

nve

rsatio

ns

Printer

Scanner

Memory

Note Pad

File

Cabinet

CD-ROM

DVD

Tape

Recorder

Computer


Tools of the Trade

Inbound Calls

Outbound Calls

Voice Mails

Live Conversations

Inbound Faxes

Outbound Faxes

Paper Documents

Notifications

Web Pages

Emails

Images, Documents

Electronic Forms

Voice Fax Electronic


Solution Features

Central Record Storage

Web Tracking System

Index and Archive

Date-and-Time Stamp

System-Wide Access

Easy Retrieval and Routing



Electronic Records

Inbound Fax Records

Outbound Fax Records

Voice Records



Voice Records


Business Office

Scheduling

Eligibility

Authorization

Pre- Registration

Patient Discharge

Continued Stay

Registration

Patient

Streamline Workflow

19

Janet L. ZeBell, MHA BSRT (R)

System Manager Central Ambulatory Scheduling and Order Processing

St. Vincent Health, Indianapolis

20

About St. Vincent

• A member of Ascension Health, the nation’s largest not-for-profit Catholic Healthcare System

• The state’s largest healthcare employer, with 20 health ministries serving 47 counties in central Indiana

• Named by Thomson Reuters as one of nation’s 5 best health systems in large health system category

21

Central Ambulatory Scheduling

• Scheduling Call Center handles Ambulatory Scheduling for Central Indiana

• Serves 2 hospitals and several outpatient facilities

• Receive orders for documentation to support ambulatory procedures

22

Challenges Pre-Solution

• Too much paper, file cabinets

• Lost orders

• Physician frustrations

• Delayed or canceled procedures

23

Solution

• Implemented fax solution in March 2008

• Receive faxes electronically

• Manage and tie to appointments

• Notify other areas – no more passing paper

24

Process

*Additional connection we notify “all” groups in the event patient arrives at wrong location

Notify registration

Identify walk in or wait list patients if not currently scheduled

Index to patient info in McKesson if previously scheduled

Review order(s)/faxes for completeness

Receive faxes in web-based tool

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• Route all documentation to a single fax number

• Index records to patient

• Notify clinical areas

Scheduling efficiency

• Retrieve all records pertaining to patient

• Reduce phone calls between departments

• No opportunity to lose paper Record-sharing

• Communicate easily with off-campus facilities

• No courier/fax/office supplies Off-site access

Benefits

26

Employee buy-in

The paper “crutch”

Staff training and adjustment

Overcoming Obstacles

27

Overcoming Obstacles

Leadership mandated electronic piece even if staff decided to keep

the paper

Didn’t take long to completely eliminate paper once electronic process became the

standard

28

Centralized records to reduce calls, faxes and emails; filing and duplication

Improved productivity; reallocated staff resources

Financial ROI

Saved on paper and toner supplies

Results

29

Rapid Cycle Improvements

Lean events to address efficiency and work flows

• Chart Prep Team: “Paper Stalkers”

• Surgery Scheduling: “Tetris Maniacs”

• Surgery Evaluation Center (SEC)

30

Chart Prep: Reasons for Action

• Incomplete charts can create 30 min delay/per case

• Case delays cause downstream delays

• Multiple phone calls and faxes made to collect required chart information

• Decreased associate productivity due to multiple chart touches before completion

Boundaries:

Trigger: Patient scheduled for surgery

Done: Chart completion (ready for surgery)

Current/Initial State: Chart Prep

• Highly dedicated and motivated staff

• Redundant/duplicative work

• Complicated process with numerous reworks

• Many customers with “exception” requests

• Organized “chaos”

• Legacy rules (we’ve always done it that way)

Measure Initial State

Average minutes for chart creation (approximately 60 patients per day) 23 (1380 tot)

Percent of SEC charts reworked for surgery prep 100%

Cost of 4-color discharge instruction forms $7.83/day

# of phone calls to MD office per day for missing/incomplete items 20

Amount of PHI disposal $6240/year

Target State: Chart Prep

• Implement communication check sheet for required information

• Implement eFax technology to receive & track chart documents

• Reduce rework (increase single touch chart prep process)

• Reduce number of steps required to complete chart

• Reduce paper waste due to printing charts for cancelled patients

• Reduce or remove physician “exceptions”

• Consequences for incomplete chart documents/info

Measure Initial State Target State

Average time for chart creation 23 13.8

Percent of SEC charts reworked for surgery prep 100% 0%

Cost of 4-color discharge instruction forms $7.83/day $0 (B/W)

# of phone calls to MD office for missing/incomplete items 20 0 (all elec)

Amount of PHI disposal $6240 $4680

33

Gap Analysis: Chart Prep

Gap

Communication – No standard process for receiving chart information; inconsistent communication methods with physician practices.

Hard copy faxes/chart set up -vs- using an electronic process

Surgery scheduling exceptions list; establish standard for receiving information for chart completion prior to surgery.

Multiple documents for similar purpose; for example, four different charge sheets.

Lack of standard chart forms; create standardized packets for inpatients and outpatients, Pav A & B, and where the forms are placed in charts.

E

Solution Approach: Chart Prep

Tight Connections

Standard Work

1x1 Flow

6S

Standard chart preparation Registration assistance

Consistent chart guts Communication checklist

One charge sheet SEC Addendum

eFax technology IHIE Registration

eFax Technology/ Dual Monitors Communication checklist Pre-populated 5 universal chart forms

SEC Addendum eFax Technology

IHIE

Utilize the Flow Cell to Create New Process

35

Rapid Experiments: Chart Prep

Electronic Indexing System

Electronic processing of received faxes is 6:17 mins

Reduces chart prep to 13:47 mins

Dual monitors would provide additional benefits

http://www.nashnet.co.uk/english/revisit/revisit08733.jpg

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Confirmed State: Chart Prep


Target State

Confirmed State

Average time for chart creation 23 min 13.8 13.47

Percent of SEC charts reworked for surgery prep 100% 0% <1%

Cost of 4-color discharge instruction forms $7.83/day $0 $0

Number of phone calls to MD office for missing or incomplete items

20 0

(all elec) <2

Amount of PHI disposal and paper cost $6240 $4860 50%

reduction

• Converting black and white forms = $5.00 savings/day

• 5 reams of paper saved each week.

• Seamless test result communication to physician offices

• Patients receiving key documents at point of registration reduces batching and increases use of patient and staff time.

37

Chart Prep: Metrics Post Event

Measure Target State 30 Days 60 Days 90 Days and is still current process

Average time for chart creation

13.8 min 15.7 min Before new chart prep experiment

12.3 min Implemented

new chart experiment

12.3 min Post new chart

process

% of SEC Charts reworked for surgery prep

0% 0% 0% 0%

Decrease the cost of PHI disposal and paper/forms used

$4860, a one time savings

n/a n/a Removed 2 Fax Machines ($246 x2) Total annual savings

$492; Removed 2 Printers

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Reasons for Action: Surgery Scheduling

• Less than 30% first-pass scheduling success

• Incomplete/inaccurate booking sheets (follow-up and rework)

• Numerous special “scheduling exceptions”

• Coordination of ancillary services cumbersome

• Collecting/documenting need to know vs. nice to know information

Boundaries:

Trigger: Physician office calls/faxes for scheduling case

Done: Schedule finalized 1630 day prior to surgery day.

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Current/Initial State: Surgery Scheduling


Average # of Incoming Fax/Phone Calls Per Scheduled Case 5.5

• Highly dedicated motivated staff

• Redundant/duplicative work

• Complicated process with numerous reworks required

• Specialized/silo knowledge

• Too many customers

• Confusion

• Legacy rules (we’ve always done it that way)

40

Target State: Surgery Scheduling

• Standardized booking “form” (required data elements)

• Electronic Web page submission (Phase II)

• Reduced errors/rework (increase first-pass yield)

• Reduced steps required to successfully schedule

• Reduced scheduling exceptions

• Consequences for inaccurate/incomplete info

Measure Initial State Target State

Old form/paper fax/1 monitor VS. New form/e-fax/2 monitors 3:43 2:10

Average # of Incoming Fax/Phone Calls Per Scheduled Case 5.5 3.0

41

Gap Analysis: Surgery Scheduling

Gap

Standardized booking “form” (data elements)

Consequences of inaccurate/incomplete information

Surgery scheduling exceptions

Coordination of ancillary services; and unnecessary H&P type documentation (need to know vs. nice to know)

Electronic submission

Solution Approach: Surgery Scheduling Solution (Do’s) Expected Result Experiments

( Y / N )

Implement eFax system 1. Reduced data entry/processing time

2. Reduced paper waste

3. Reducing physical storage space

4. Reduced phone line expense

Y

Y

Y

Y

Standardize booking “form” with minimum set of REQUIRED data elements

Reduced follow-up due to incomplete and inaccurate information

Y

Reduce exceptions to scheduling (75 item on exception list) and coordination of ancillary services (19 list)

1. Increased processing time

2. Reduced silo knowledge

Y

Y

Flags in PHS to signal special rooms and conditions

1. Increased processing time

2. Reduced reworks

Y

Y

Reduce unnecessary H&P type documentation (need to know vs. nice to know)

1. Increased processing time Y

43

Rapid Experiments: Surgery Scheduling

“Tetris Maniacs” at work

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http://www.nashnet.co.uk/english/revisit/revisit08733.jpg

44 44

Rapid Experiment: Surgery Scheduling

Finally a standard booking sheet

45

Confirmed State: Surgery Scheduling

• Dual monitors work well • Standardized (required data elements) form

down to 41 fields • eFax increases efficiency

45

Measure Initial State Target State Confirmed

State

Old form/paper fax/1 monitor VS. New form/e-fax/2 monitors

3:43 2:10 2:40

Average # of Incoming Fax/Phone Calls Per Scheduled Case

5.5 3.0 4

46

Conclusions From Both Events

• Chart Prep now functions with 2 instead of 4 associates – Other associates redeployed to positions

• Everyone has clear expectation of what is needed to achieve the desired customer experience

• Staff empowered with confidence in the new process

• “If we don’t have it, you didn’t send it.”


Questions?