Weekly debriefings were key
Cooperation and collaboration have been the keys to success in the trial run of a new process for screening orders for medical necessity at the point of care — in the physician’s office — and electronically sending them to the hospital, says Margie Winfield, RNC, manager of the same-day surgery and presurgical testing departments at Advocate Good Samaritan Hospital in Downers Grove, IL.
The initial reaction of the office staff was, “’Oh, my gosh — we’ll never have time for this,’” Winfield notes. But she says weekly meetings of hospital and physician office personnel with representatives of Oakbrook Terrace, IL-based Nebo Systems, designers of the electronic order system, eventually led to “an upward swing on the learning curve.”
The regular Thursday updates and debriefings — at which vendor representatives made a work list they took to Nebo programmers — resulted in some unexpected side benefits, Winfield adds, including an innovation the hospital expects will be a big selling point as it rolls out the process to other physician practices.
The hospital’s goal with this piece of the project, which ultimately will involve a total redesign of the outpatient testing process, is to “eliminate unintentional conflict between diagnosis and procedure codes on outpatient physician orders prior to the delivery of service.”
Tackling the problem with code scrubbing
The problems occur, she says, when patients arrive at the hospital for testing with incomplete, handwritten orders that might or might not include a diagnosis. That diagnosis might or might not meet the Medicare criteria for medical necessity for the procedure being ordered, and there is “no coding information at all,” Winfield continues. Recognizing that many of its physicians have not made the transition to computer technology, the hospital’s “code-scrubbing” team developed a noncomputerized form containing “a pretty comprehensive list of frequently ordered tests,” she says.
With participation from all the departments that provide outpatient testing, the team “assigned codes where appropriate, and gave a sample listing of diagnoses and codes for some major [procedures], like CAT scans,” Winfield says. “We let them know that it wasn’t a comprehensive list, and we referred them back to Medicare regulations [if more information was needed], but it gave us a much cleaner order from the get-go,” she adds.
That form, which is an improvement on the old prescription pad orders, can be faxed to the hospital from the physician’s office, if the office is not equipped with the electronic order system, Winfield continues. “We are hoping to increase physician office staff, hospital staff, and patient satisfaction.”
Even in the case of the three physician offices participating in the pilot program implementing the Nebo eOrder system, she explains, “we had them fax the order in the beginning, until we got through the learning curve, to see if the forms would work. For a while, we were doing both [faxing and sending electronically] until their comfort level increased.”
Now the pilot office puts the forms in the exam room, where the physician uses them, instead of the prescription pad, to write the diagnosis or description of symptoms, Winfield adds.
“Then the front-desk [employee] enters the order into Nebo’s eOrder system,” she says. “If the diagnosis and description do not meet the requirement for that test, a red stop-sign symbol comes up. If it goes through, there’s a nice green pass sign.”
Although the medical necessity screening is required only for the orders of Medicare patients, Winfield notes, “we decided it was easier to have them put all the orders through the system.”
Doing the screening on-site, she says, gives staff the ability to ask the physician for more information before the order leaves the office. “They can ask, ‘Is there something you didn’t put down?’”
That opportunity for clarification, she adds, “gives the order a much better chance of passing all the rules and regulations.”
The eOrder product is part of the vendor’s web-based practice management system, Health Nautica, but also can be used independently of that system, notes Katherine H. Murphy, CHAM, patient access coordinator for Nebo.
Training of the office staff, primarily entry-level employees with no coding background, “was very basic at first,” Winfield says. Their feedback on the Windows-based Nebo product, however, “was that it was user-friendly,” she adds, noting that most of the employees had Internet skills and were accustomed to accessing the hospital’s CareNet. It helped that the office’s billing clerk had some knowledge of coding and meeting diagnosis requirements, she says.
Tweaking the process
One of the issues office personnel brought up in the weekly meetings, Winfield says, was that if they found a diagnosis that met the test criteria, they then had to enter it into the eOrder system themselves. “They said, ‘Why can’t we just click on it, and have it populate the screen?’”
Nebo programmers tweaked the system to make that possible and, in response to another concern, added a field where, if necessary, staff could put clarifying remarks that could be printed on the copy of the order that is given to patients, she explains. “Before some tests, for example, you have to [fast] for 12 hours; and for some, you have to make an appointment, while for others, you can just walk in,” Winfield adds. The order screen the hospital receives, she notes, “looks totally different” than the version that is printed out for patients, “because we don’t need all the information they get.” (See sample screen.)
One stumbling block that needed to be removed had to do with the hospital’s need to receive, along with the order, the demographics of the patients, Winfield says. “Unfortunately, the office management system in the pilot office was old and didn’t integrate with the Nebo system,” she adds, “so we had all the demographics in one file, but they couldn’t be pulled over to populate the Nebo file.”
The hospital ultimately decided to cover the cost of updating the office management system, Winfield says. “That way, when the patient’s name or Social Security number is typed into the Nebo product, the demographics can be pulled over automatically, so the [office employee] doesn’t have to enter them,” she notes. “It’s very time-intensive to do that in a physician’s office, and we wanted to make the process as streamlined as possible.”
The office staff now are extremely pleased with the new process, which has dramatically reduced the phone calls to and from the hospital in pursuit of a complete and accurate order, Winfield adds. There still are a few orders that need to be tweaked by hospital coders, she says, in some cases, because they required a code the office staff were not aware of. “[Coding] is a skill that people go to school to learn,” she points out. The ironing out of those glitches, Winfield adds, has been another example of how collaboration and cooperation have prevailed.
An unexpected benefit
One of the side effects of the project — and “almost the biggest perk of the whole thing,” according to the office manager — was an update by the vendor that made it possible to run a report on all the orders that had been put through for each patient, she says. Thanks to that modification, she notes, the physician’s office “will have a viable list of orders that have been given to patients, and as the results come back to the office, can check that off.”
“They can see that, ‘Oh, we ordered an EKG for Mrs. Smith, and she hasn’t had it yet,’” Winfield says. “Before, there was no way to tell unless they went through every chart.”
With the liability concerns associated with patients who don’t follow through on physicians’ orders, she adds, the ability to keep that checklist is a huge advantage.
An important benefit of the eOrder process, in general, is the built-in patient-safety enhancement, Murphy notes.
When patients who have difficulty communicating — those with a language problem, for example — arrive at the hospital for a test or attempt to schedule an appointment over the telephone with just a scribbled physician order, there always is the danger of a misunderstanding, she points out. “Normally, hospital staff can’t see the order, but now they’ll have it,” Murphy adds.
[Editor’s note: Margie Winfield can be reached at (630) 275-1720. Katherine Murphy can be reached at Nebo Systems at (630) 916-8818, ext. 34.]