Expanding access department tackles revamp of medical records

We just reorganized the way people worked’

When the director of medical records at the Philadelphia-based University of Pennsylvania Medical Center-Presbyterian left for another position, it presented yet another opportunity for the hospital’s proactive patient access department to take a leadership role.

The medical records director and Anthony M. Bruno, MPH, MEd, director of patient access and business operations, both reported to the director of finance, he explains, so it was natural that Bruno volunteered to help fill the void the departure created, at least in the short term. But as Bruno and his boss discussed the situation, they took the idea a step further, he adds. "We thought about the advantages of incorporating medical records into the patient access department. From an operations perspective, it seemed to have some logic."

With its processes and controls — staff training resources, its own systems analyst and solid organizational expertise — firmly in place, the access department could offer a strong base of support, Bruno explains. "We felt we could fix some [medical records] issues." Being part of a larger department, he theorized, would allow medical records to offer more resources to tasks that it otherwise wouldn’t have enough staff to accomplish.

Initially billed as interim management — "to make sure we could do what we thought we could do and to leave some wiggle room in case this was not the right direction" — Bruno and his team went to work.

The move also constitutes the latest step in Bruno’s shaping of a new patient access department at Presbyterian, a process that Hospital Access Management has been following since soon after he joined the organization in July 2001.

Key players were Raina Harrell, manager of access and financial systems, and Tanya Coleman, a former pre-cert coordinator for oncology who was hired in November 2003 as manager for medical records, as well as Marilyn Williams, the department’s systems analyst, and Lachell Potts, its manager for quality assurance & training, Bruno says.

By late February — three months and "some new gray hairs" after the effort began — the access team was confident the new strategy was the right one, he adds. "We just reorganized the way people work," says Harrell, noting that the success was a reflection of "the right person, the right job," one of Bruno’s favorite mottos.

An immediate challenge, she notes, was notice from the state of Pennsylvania that the hospital’s medical records delinquency rate — more than 50% for the month of November 2003 — was too high. "Physicians are required to complete certain portions of the patient’s chart," Harrell explains. "If any part is incomplete for more than 30 days after discharge, [the chart] becomes delinquent."

"We realized there was a lot we could do to make improvements," she says. "We went to work talking to physicians, talking to administrators, sending physicians weekly e-mails and pushing charts to them so they could complete them." A report was sent each Friday to department chairmen or administrators, saying, "These charts need to be completed," Harrell adds.

Physician confidence restored

In tackling the problem, the access department was able to draw on the strong relationship it had established with the hospital’s physicians, Bruno points out. Physicians had lost confidence in the medical records department, Harrell notes, because of "things that had fallen between the cracks." She visited medical records departments at other hospitals in the area and talked to personnel there about how their information flowed, Harrell says. "I took what worked from each department and said, This is what we can do.’"

One of the things she did was to reorganize the room where incomplete charts were held. The room had been organized by medical record number, Harrell says, which meant physicians had to identify themselves to a clerk, then wait for the clerk to pull the charts for them. Now there is a box with each physician’s name on it, containing the charts that need attention, she adds. "In the same box, there is also a folder for those that just need a signature. That’s one of the easy fixes."

Another goal, Bruno says, was to increase consistency in monitoring uncoded inpatient and outpatient accounts. While efforts by the patient access department have dramatically reduced the number of accounts on hold in the discharge not final billed [DNFB] and outpatient exception queues, he notes, "it seemed [the medical records] piece of that project was not quite getting done."

Medical records already had an experienced staff of coders, and a clinical data coordinator overseeing them, Harrell points out, but they needed support to get records from the nursing floors in a timely manner. In addition, she says, "pieces of records lacked operative reports.

"We were able to focus the clerical staff to get them," Harrell says. "[The existing department] had the medical records basics. Most of the staff had been here 20, 25 years, so we relied on them to know their jobs. They knew what the outcome needed to be. We helped them to get there."

With medical records working more collaboratively as a part of patient access, she adds, the process of registering the patient, obtaining the chart, getting it coded, applying charges to the account, and having the account drop off the DNFB list became "a nice continuum."

One of the issues targeted by Coleman, the new medical records manager, involved another regulatory requirement. "We found we were not meeting all the deadlines on state reporting of patients in certain diagnosis-related groups (DRGs)," she explains. Among the 15 or so DRGs included, for example, are acute myocardial infarction and community-acquired pneumonia, Coleman adds.

The state requires not only the number of patients, but also abstracts of their medical records, Harrell points out. "Tanya worked with the senior system analyst to run reports showing which patients meet those DRGs, and make sure the report was designed to capture all these patients," she explains.

Coleman then established a process flow for pulling the charts and getting the abstracts to the state, she adds. "Before she got started with that, she had to learn all the medical records computer systems. There is a coding system, a chart tracking system, and then you have to go into the registration system –— she had to learn all that in a very short time."

In the past, reports to the state weren’t accurate, Harrell notes. "Reports weren’t monitored and reviewed. As requirements changed, some DRGs (diagnosis-related groups) were included that didn’t need to be, and some that were needed weren’t there."

Chart turnaround reduced

Coleman, along with the clinical data coordinator and the systems analyst, went through the reports "with a fine-toothed comb," Harrell adds, eliminating some unnecessary DRGs and, in the process, reducing the costs to the hospital, which pays an outside company to abstract the reports.

One of the challenges Coleman has taken on is reducing the turnaround time for charts. "When we came in," Harrell notes, "the time it took to assemble and analyze our records, including getting them from the floor, putting them in the right order, and examining them for anything missing, was 20 days." At last count, Coleman says, chart turnaround time was down to 48 hours. "We just needed to come together and see what we had to do to change that. [It took] offering resources to staff, getting involved, and improving communication with [nursing] floors."

The initiative required "a lot of PR work with physicians," Harrell adds. "There was some distrust there. Physicians would become delinquent after 30 days, but often would not find out there was a problem until after 20 days."

As a result of the improvements that took place during the initial three-month effort, Bruno says, the move to have patient access manage medical records is permanent. "We’re getting support for additional resources down the road," he adds. One of his recommendations, he notes, is to hire a supervisor to oversee chart completion. While the focus of patient access is always on the revenue cycle — and the medical records initiative did make improvements there — the project presented some daunting challenges outside that realm, he points out. "We didn’t know what we were getting into as far as all the other medical records requirements." At that point, Bruno says, the commitment had been made and there was no thought of not carrying through with what resulted in "reorganizing and redesigning the entire department."

"It was a new approach for patient access," adds Harrell. "On the front end, there’s patient access, medical records and clinical resource management. We’ve taken two of those areas and merged them, so they’re working seamlessly."

[Editor’s note: Anthony Bruno can be reached at (215) 662-9297 or by e-mail at anthony.bruno@uphs.upenn.edu.]