Developing an ED Facility Charge Calculator March 3, 2016 4:00pm Neal Kothe, The Ohio State University Wexner Medical Center Carol Gray, The Ohio State University Wexner Medical Center
Conflict of Interest Neal Kothe Carol Gray MSN, RN, CCRN, CEN SANE-A Has no real or apparent conflicts of interest to report.
Agenda Local Problem and Intended Improvement Evaluation Development Integration Integrated workflow Testing Results Sustainability Financial considerations
Learning Objectives Create an ED Facility Level of Service Calculator Implement an Integrated Level of Service Calculator Validate Facility Levels of Service
1.6 M outpatient visits annually 57,000+ admissions annually 1,100 attending physicians 800+ residents and fellows 117,000+ ED visits annually 3,200+ registered nurses 132,000+ OSUMyChart users 18,000+ end users
Local Problem and Intended Improvement Prior to the facility charge calculator implementation, OSUWMC s two Emergency Departments followed different charging methodologies. University Hospital used specifically trained ED coders to apply codes. University Hospital East had all nurses apply codes on paper. The charging methodologies led to a number of inconsistencies and potentially lost revenue. Epic offered the opportunity to correct these issues. Singular charting and charging system allowed for uniform charging across multiple locations.
Intended Improvements To address the inconsistencies, Epic: Provides automatic charging, working from documentation as it was entered in the chart. Provides consistent charging across patients. Removes the need for the nurse to interpret and apply the level of service that could negatively impact revenue. Allows for a cumulative assigned level when multiple activities are performed on the patient.
Alternative Solution We were concerned about our revenue, and we had a third-party evaluation to determine whether we were capturing revenue appropriately. The third party evaluation showed potential lost revenue: They estimated an increase of roughly $15 per Emergency Department visit. Fees for the third party s solution were $3.65 per patient, for an estimated annual total $401,500. The solution could result in increased revenue of $1,650,000 annually.
Developing the Charging Rules Development of charging tool Team consisted of one IT person and 2 nurses. Weekly development meetings for 2 months. Several calls with current Epic customers. Most customers didn t test as much as OSU. Rules developed by nursing.
Developing the Charging Rules These rules incorporated the normal workflow for the ED users and each rule would help build the FCC level. While a nurse documents in the normal workflow, a level of service accumulates a score that in turn assigns the proper level of service for hospital service charges. Rules automatically assign level of service based on complexities documented in the patient s chart.
Old Charging Methodologies Poorly supported by medical record documentation Required recall of nursing to the events of the patient visit Involved interpretation and recall of charging definitions by nursing. Did not allow for patients receiving multiple activities of the same level to be assigned a higher level
New Charging Methodology Rule Name Charge Rule Description # of points per action Cumulative? ED VITALS SCORE Number of times a set(2 or more) vitals are entered up to a total of 8 times(80 points max) 10 yes ED DISPO Points based on the patient ed discharge disposition of ambulatory 1 no ED DISPO Points based on the patient ed discharge disposition AMA 30 no ED DISPO Points based on the patient ed discharge disposition ambulance 100 no ED DISPO Points based on the patient ed discharge disposition wheelchair 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Police 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Private Ambulance 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Air 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Hospital Transport 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Other 5 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Private Vehicle 1 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Taxi 1 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of Public Transport 1 no ED MEANS OF ARRIVAL Points based on the patient's arrival method of EMS 30 no ED MEANS OF ARRIVAL Points based on the patient's arrival method Wheelchair 10 no ED MEANS OF ARRIVAL Points based on the patient's arrival method State Vehicle 30 no ED BEHAVIORAL RESTRAINTS Points based on the patient's documentation of restraint order 300 no ED ASSISTIVE DEVICE Points based on the patient's documentation of assistive devices 5 no ED DISCHARGE TEACHING Points bases on the patient's documentation of simple/moderate teaching 1 no ED DISCHARGE TEACHING Points bases on the patient's documentation of complex teaching 30 no ED CARDIAC MONITORING Points bases on the patient's documentation of 3 lead monitoring 100 no ED CARDIAC MONITORING Points bases on the patient's documentation of 5 lead monitoring 100 no ED ENEMA Points bases on the patient's documentation of enema type 100 no ED WOUND CARE Points bases on the patient's documentation of negative pressure wound 30 no ED WOUND CARE Points bases on the patient's documentation of negative pressure setting 30 no ED WOUND CARE Points bases on the patient's documentation of wound packing 10 no ED WOUND CARE Points bases on the patient's documentation of dressing wound 10 no ED WOUND CARE Points bases on the patient's documentation wound irrigation 10 no ED WOUND CARE Points bases on the patient's documentation wound interventions 10 no ED PELVIC EXAM Points bases on the patient's documentation of pelvic exam chaperoned 30 no ED CAST APPLICATION Points bases on the patient's documentation any cast type 10 no ED EYE IRRIGATION Points bases on the patient's documentation of eye irrigation fluid 30 no ED EAR IRRIGATION Points bases on the patient's documentation type of irrigant used 30 no ED INCONTINENCE CARE Points bases on the patient's documentation of bladder or bowel incontinence 30 no ED HYPO/HYPERTHERMIA Points bases on the patient's documentation of hypothermia or hyperthermia 3000 no ED PACER Points bases on the patient's documentation of pacer placement location 3000 no ED FHT Points bases on the patient's documentation of fetal movement 30 no ED VISUAL ACUITY Points bases on the patient's documentation left visual acuity 10 no ED VISUAL ACUITY Points bases on the patient's documentation right visual acuity 10 no ED VISUAL ACUITY Points bases on the patient's documentation bilateral visual acuity 10 no
New Charging Methodology Rule Name Charge Rule Description # of points per action Cumulative? ED CHEST TUBE Points bases on the patient's documentation of a chest tube 300 no ED CONTACT ISOLATION Points bases on the patient's documentation of contact isolation initiated 100 no ED CONTACT ISOLATION Points bases on the patient's documentation of contact isolation maintained 100 no ED IV INSERTION Points bases on the patient's documentation of preripheral iv insertion 100 yes ED LAB Points bases on the patient's documentation of a lab hold 30 yes ED LAB Points bases on the patient's documentation of a venipuncture performed 30 yes ED O2 DEVICE Points bases on the patient's documentation of an O2 device 100 no ED VENT Points bases on the patient's documentation of type of vent 3000 no ED IMMUNIZATION Points bases on the patient's documentation of immunization teaching 30 no ED NGT Points bases on the patient's documentation of naso/oral tube 30 no ED L&D Points bases on the patient's documentation send patient to L&D from triage 30 no ED EKG Points bases on the patient's documentation of a 12 lead ECG 30 no ED NON VIOLENT RESTRAINT Points bases on the patient's documentation of non-violent restraint type 100 no ED VIOLENT RESTRAINT Points bases on the patient's documentation of violent restraint type 300 no ED POCT RAPID STREP A Points bases on the patient's completed POCT procedure order of rapid strep order 10 no ED POCT OCCULT BLOOD STOOL Points bases on the patient's completed POCT procedure order of occult blood stool 10 no ED SEIZURE PRECAUTIONS Points bases on the patient's documentation seizure precautions 30 no ED INVASIVE VITALS Points bases on the patient's documentation of central venous pressure 3000 no ED INVASIVE VITALS Points bases on the patient's documentation of mixed venous oxygenation 3000 no ED INVASIVE VITALS Points bases on the patient's documentation of central venous saturation 3000 no ED RAPID INFUSER Points bases on the patient's documentation rapid infuser 3000 no ED XRAY Points bases on the patient's order of xray 10 yes ED ULTRASOUND Points bases on the patient's documentation of returning from ultrasound 10 yes ED CT Points bases on the patient's documentation of returning from CT 100 yes ED BLOOD CULTURE Points bases on the patient's documentation of blood cultures being sent to the lab 100 yes ED AIRWAY Points bases on the patient's documentation of airway 300 no ED OTHER PROCEDURE Points bases on the patient's documentation of a procedure not accounted 100 no ED AIRBORNE ISOLATION Points bases on the patient's documentation of airborn isolation initiated 30 no ED AIRBORNE ISOLATION Points bases on the patient's documentation of airborn isolation maintained 30 no ED DROPLET ISOLATION Points bases on the patient's documentation of droplet isolation initiated 30 no ED DROPLET ISOLATION Points bases on the patient's documentation of droplet isolation maintained 30 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to OSU ER 30 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to L&D after ER treatment 30 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to outside facility as direct admit 300 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of med surg admit 100 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of telemetry admit 300 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of psych bed admit 100 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of OR admit 300 no ED ADMITS/TRANSFERS Points bases on the patient's documentation of ICU admit 3000 no ED ESCORT FOR TESTING Points bases on the patient's documentation of monitored escort for testing 300 no ED NEUTROPENIC ISOLATION Points bases on the patient's documentation of neutropenic precautions initiated 10 no ED NEUTROPENIC ISOLATION Points bases on the patient's documentation of neutropenic precautions maintained 10 no ED VASCULAR ACCESS Points bases on the patient's documentation of single/double lumen port 300 no
New Charging Methodology Rule Name Charge Rule Description # of points per action Cumulative? ED INTRAOSSEOUS Points bases on the patient's documentation of intraosseous insertion 300 no ED STRAIGHT CATH Points bases on the patient's documentation of intermittent cath 30 no ED PEAK FLOW Points bases on the patient's documentation of peak flow treatment 30 no ED TRAUMA LEVEL Points bases on the patient's documentation of any trauma level 3000 no ED PHOTO DOCUMENTATION Points bases on the patient's documentation of photo evidence collection 100 no ED BLOOD BANK Points bases on the patient's completion of blood bank orders 100 no ED URINE Points bases on the patient's order of random creatinine urine 30 no ED TRAY SET UP Points bases on the patient's order of tray set up 10 no ED SALINE LOCK Points bases on the patient's order of saline lock 30 no ED SPLINT APPLICATION Points bases on the patient's documentation a splint/brace 30 no ED SITTER Points bases on the patient's documentation of ED sitter 300 no ED ARTERIAL LINE Points bases on the patient's documentation of arterial line insertion 3000 no ED INTARCRAINIAL Points bases on the patient's documentation of intracanial pressure 3000 no ED PERITONEAL DIALYSIS Points bases on the patient's documentation of peritoneal dialysis 300 no ED BIRTH Points bases on the patient's documentation of ED birth 300 no ED IV GUIDANCE Points bases on the patient's documentation of ultrasound or vein mapping guidance 300 no ED CATH Points bases on the patient's documentation of indwelling catheter 30 yes ED MED ROUTES II Points bases on the patient's medication administered via subq 30 yes ED MED ROUTES II Points bases on the patient's medication administered via infiltration 30 yes ED MED ROUTES II Points bases on the patient's medication administered via IM 30 no ED MED ROUTES III Points bases on the patient's medication administered via brain cath 100 yes ED MED ROUTES III Points bases on the patient's medication administered via intratumoral 100 yes ED MED ROUTES III Points bases on the patient's medication administered via intracameral 100 yes ED MED ROUTES III Points bases on the patient's medication administered via nebulization 100 no ED MED ROUTES III Points bases on the patient's medication administered via intraosseous 100 yes ED MED ROUTES III Points bases on the patient's medication administered via intravenous 100 no ED MED ROUTES Points bases on the patient's medication administered via oral 10 yes ED MED ROUTES Points bases on the patient's medication administered via intranasal 10 yes ED MED ROUTES Points bases on the patient's medication administered via both ears 10 yes ED MED ROUTES Points bases on the patient's medication administered via left ear 10 yes ED MED ROUTES Points bases on the patient's medication administered via right ear 10 yes ED MED ROUTES Points bases on the patient's medication administered via both eyes 10 yes ED MED ROUTES Points bases on the patient's medication administered via right eye 10 yes ED MED ROUTES Points bases on the patient's medication administered via insuffilation 10 yes ED MED ROUTES Points bases on the patient's medication administered via topical 10 yes ED MED ROUTES Points bases on the patient's medication administered via sublingual 10 yes ED MED ROUTES Points bases on the patient's medication administered via Per NG tube 10 yes ED MED ROUTES Points bases on the patient's medication administered via Transdermal 10 yes ED MED ROUTES Points bases on the patient's medication administered via Peg Tube 10 yes ED MED ROUTES Points bases on the patient's medication administered via Inhalation 10 yes ED POCT GLUCOSE Points bases on the patient's documentation of POCT Glucose 10 yes ED BLADDER SCAN Points bases on the patient's documentation of bladder scanning device 30 yes ED INSTRUCTED ON DEVICE Points bases on the patient's documentation ortho device teaching 30 no ED SECLUSION Points bases on the patient's documentation of seclusion 300 no
New Charging Methodology Points Level of Service* 0 to 10 Level 1 11 to 30 Level 2 31 to 99 Level 3 100 to 299 Level 4 300 to 2999 Level 5 3000+ Critical Care *No level of service for sexual assault exam
IT and Nursing Integration 1. Coordinated the implementation of documentation and levels of service to be charged. 2. Reviewed one week of patient charts from each ED, which totaled 642 charts, and compared their charges to charges calculated based on proposed levels and point assignments. 3. Tested on paper and in the EMR before implementation (160 hours). 4. Verified that the charges were compliant.
The New Tool: Embedded Example of documenting means of arrival.
The New Tool: Embedded Charging is now embedded in the normal nursing workflow. Every patient is assigned a level of service.
How it Works Assigned Level is visible as points accumulate Points drop as care is documented Total point value is continually updated. The final total reflects a level. Upon accepting in tool the level is automatically selected in the charge capture tool.
Where Charges Appear
Post Live Governance Daily reports ran post live for three weeks until the data normalized. Revenue continually monitoring by business office and clinical areas. Meetings by group to review possible changes when necessary. Susceptibilities Decrease in throughput Charting discrepancies
Post Live Governance Upgrade Testing Content Management Adaptability Ability to quickly make changes and test on real data as needs arise Implemented at our Community Connect site in April 2013 and shared with other Epic organizations.
Pre Live Data 45% 40% 35% 30% 25% 20% Pre Live U.S. Ave 2010 15% 10% 5% 0% ED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC
Testing Results 50 45 40 35 34 30 30 25 26 23 20 15 46 45 39 37 34 Blue (diamonds): Previous LOS Red (squares): Paper testing Orange (squares): Electronic testing 10 5 0 2 1 7 2 Level 1 Level 2 Level 3 Level 4 Level 5 CC ED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC 11 3
Actual Results 4 Months Post Live ED Levels System Impact Nov 11 - Feb 12 0.4 0.35 0.3 0.25 0.2 0.15 Legacy SMS ASAP Epic 0.1 0.05 0 ED LEVEL 1 ED LEVEL 2 ED LEVEL 3 ED LEVEL 4 ED LEVEL 5 ED CC
Sustainability 50% 45% 40% 35% 30% 25% 20% 15% U.S. Ave 2014 AMC Ave 2014 Pre-Live 2012 2013 2014 2015 10% 5% 0% ED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC
Financial Considerations Labor costs: $54,480. Conceptualization, build, and testing performed by staff Year Volume Dollar % Increase From Pre-Live Volume % Increase From Pre Live Pre-Live 107,458 - - 2012 118,022 39% 10% 2013 114,688 41% 7% 2014 115,922 42% 8% 2015 124,144 49% 16% With improved Level of Service assignment, our gross revenue increase has been about $50 million per year.
Questions Neal Kothe 640 Ackerman Rd. Columbus, OH 43202 Neal.Kothe@osumc.edu Carol Gray MSN, RN, CCRN, CEN SANE-A 1492 E Broad St. Columbus, OH 43205 Carol.Gray@osumc.edu