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TECHNOLOGY, COMPUTING, AND SIMULATION

Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement

From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.

Address correspondence to Sachin Kheterpal, MD, MBA, 1H247 University Hospital Box 0048, 1500 East Medical Center Drive, Ann Arbor, MI 48103. Address e-mail to sachinkh{at}med.umich.edu.

	Abstract

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 
BACKGROUND: Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting.

METHODS: We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders.

RESULTS: A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement.

CONCLUSIONS: The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.

	Introduction

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Clinical documentation suffers under conditions of high clinical volume and acute care situations (1). In the 1990s, the Centers for Medicaid and Medicare Services established not only guidelines for the supervision of resident physicians, but also strict rules on the documentation required to attest compliance with these guidelines (2). Since then, many commercial payors have applied similar documentation requirements to nonteaching hospitals (2). As a result, professional fee reimbursement is directly linked to the completeness of clinical documentation (3). Missing documentation clearly decreases reimbursement (4). Complete and timely medical documentation may also improve patient safety and reduce medical liability risks (5,6).

Some institutions have adopted more detailed documentation of minor procedures in order to meet expanding medicolegal, clinical, and reimbursement requirements. Our departmental guidelines require the completion of a template-based minor procedure note when anesthesia personnel place arterial or central venous catheters, perform any regional block technique, or manage an urgent airway consult. In this study, we sought to measure and improve our compliance rate for the documentation of arterial catheter placement in the perioperative setting.

	METHODS

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After obtaining IRB approval for data retrieval, data from adult and pediatric patients undergoing scheduled elective surgery were prospectively included in this trial. Inpatient cases were excluded because the arterial catheter may have been placed by emergency room, intensive care unit, or general care floor staff before the patient’s arrival to the operating room. Because no clinical interventions were studied, and no patient identifiable data used, signed patient informed consent was waived per the IRB approval.

For each anesthetic case, an intraoperative record and appropriate minor procedure notes were documented using an anesthesia information system (Centricity® from General Electric Healthcare, Waukesha, WI). The intraoperative record keeper automatically acquired and recorded vital signs from the physiologic monitor (Solar 9500® from General Electric Healthcare, Waukesha, WI USA). Continuous invasive arterial waveform blood pressure readings were identified as arterial catheter data by the physiological monitor and automatically recorded by the anesthesia information system. A case was deemed to have included invasive arterial blood pressure monitoring if five valid values (diastolic blood pressure >10 and <200) were noted in the anesthesia record. These criteria eliminated spurious readings or cases in which an arterial catheter transducer may have been connected, but no arterial catheter placed. A validation sample of 75 intraoperative records was manually reviewed and confirmed the accuracy of this algorithm.

In many cases, arterial cannulation may be performed by the resident, certified registered nurse anesthetist (CRNA), or attending anesthesiologist assigned to the operative case. In some cases, a distinct preoperative holding room team comprised of three residents and one attending performs minor procedures before the patient is brought to the operating room. The decision to use invasive arterial blood pressure monitoring was made by the attending anesthesiologist for the case and was not controlled as part of this study. Our departmental guidelines require documentation of a procedure by one of the providers involved in the procedure.

Procedure notes are completed using a template-based user interface (Fig. 1). Departmental defaults are altered by the clinician for a specific patient and a prose note is created in a mail-merge format with standardized verbiage for protocol-driven aspects of the procedure (Fig. 2). The user can correct any inaccuracies in the procedure note verbiage before it is saved to the medical record. Because of the template-based procedure note, all arterial catheter procedure notes are saved using the same template system number, allowing easy identification of documentation of an arterial catheter note.

View larger version (77K): [in this window] [in a new window]   Figure 1. Arterial catheter documentation template user interface. Users use templates to document the details of any minor procedure (arterial catheter placement, epidural placement, etc.). Common default entries are pre-selected to minimize user effort. If the default is inconsistent with the actual procedure details, the user chooses from a pick-list of alternatives or may type in a free-text response. For example, the user may choose brachial, dorsalis pedis, ulnar, or femoral rather than the radial artery default.

View larger version (36K): [in this window] [in a new window]   Figure 2. Arterial catheter documentation note. After choosing specific template details for minor procedure documentation, a prose note is generated. The note combines standard verbiage (e.g., sterile prep technique) with patient-specific details (artery catheterized, side, catheter used, etc.). This note serves as documentation for clinical, medicolegal, and reimbursement purposes.

We first reviewed 12 mo of electronic intraoperative anesthesia records to identify operative cases including a valid invasive arterial blood pressure tracing. Each case including an invasive arterial blood pressure tracing was reviewed to check for the electronic minor procedure note. Inpatient cases were excluded. This established the baseline compliance rate of 80% (1963 of 2459 arterial catheters were documented). Our institution’s professional fee charge for an arterial catheter is $310. After accounting for rejected claims and partial reimbursements, our institution is reimbursed an average of $83 per arterial catheter charged.

Before initiation of the study, residents and CRNAs were randomly assigned to a control group or an experimental group by computer. Once assigned to a group, the provider remained in the group for the remainder of the study period. The experimental group received automated electronic reminders via alphanumeric paging and e-mail. The resident or CRNA signed into the intraoperative case or scheduled for the case was the target of the reminder. The holding room team did not receive a reminder. When surgical incision was documented in the electronic record keeper, a reminder routine checked for a valid invasive arterial blood pressure tracing as defined above. If a procedure note was not observed, the resident or CRNA was sent an automated alphanumeric pager message indicating the need to document the arterial catheter placement procedure note for the current case. At anesthesia end, the reminder routine once again examined all cases for a valid invasive arterial blood pressure tracing and procedure note documentation. If documentation was still missing, an automated e-mail and alphanumeric pager message was sent again. In cases in which the arterial catheter was placed after surgical incision, this reminder at anesthesia end would be the first reminder sent. Each morning for the next 2 days, an automated e-mail reminder was sent if documentation was still delinquent. If documentation was present at any of these checkpoints, no further reminders were transmitted. Because of software programming resource limitations, an on-screen prompt in the anesthesia record keeper was not feasible during the study period. Three days after each case involving an invasive arterial blood pressure tracing, a final record was made of whether or not a note was eventually documented.

The reminder pages and e-mails were only sent to residents and CRNAs in the experimental group. Residents or CRNAs in the control group received no pager or e-mail message. No attending physicians received reminders of any form.

No departmental announcement mentioning this study, the reminder systems, or the need to document arterial catheters was made. As a result, participants in the control and experimental group were both initially blinded to the study itself. They were unaware of the randomization scheme and unaware of the observation and measurement of compliance rates. During the conduct of the study, it is possible that providers became aware that some clinicians were being reminded while others were not.

Power analysis assuming an increase in compliance from 80% to 90% required a total of 200 arterial catheter placements to be randomized to control and experimental group to achieve a power of 80%. A P value of <0.01 was considered significant. As a result, a 2 mo study period was prospectively established.

It was prospectively determined that if the study period demonstrated a statistically significant improvement in compliance associated with automated electronic reminders, all residents, CRNAs, and attending staff would receive the reminder for delinquent documentation in Phase II of the study.

	RESULTS

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The reminder and control groups were similar in a number of ways (Table 1). Over the 2 mo study period, 267 arterial catheters were placed and documented before surgical incision, 159 by reminder group providers and 108 by control group providers. They did not require a reminder. Four hundred three arterial catheter placements were not documented at the time of surgical incision; 201 in the reminder group and 202 in the control group (Fig. 3 and Table 2). In the reminder group, 177 of 201 (88%) arterial catheters were documented. In the control group, 152 of 202 (75%) arterial catheters were documented (P < 0.001). Combining the 159 arterial catheters documented before incision with the 201 randomized to the reminder group, 336 of 360 lines (93%) were documented by reminder group individuals. Combining the 108 arterial catheters documented before incision with the 202 randomized to the control group, 260 of 310 lines (84%) were documented by control group individuals (P < 0.001) (Table 2).

View larger version (25K): [in this window] [in a new window]   Figure 3. Arterial catheter randomization and results. During the two month study period, an automated reminder routinely evaluated whether an operative case used invasive arterial blood pressure monitoring. If the patient did not have a preexisting catheter and there was no documentation of arterial catheter placement, the case was enrolled in the study automatically. Providers randomized to the experimental group received alphanumeric pages and e-mail reminders whereas providers randomized to the control group received no reminders.

Given the statistically significant increase in compliance in the reminder group, the reminder protocol was expanded as planned to include all anesthesia residents, CRNAs, and attending anesthesiologists. During the subsequent 2 mo period, 256 arterial catheter placements were documented before surgical incision and did not require a reminder. Three hundred fourteen arterial catheter placements were not documented at surgical incision and received a reminder. Three hundred nine were subsequently documented (98%), resulting in an overall documentation compliance of 565 of 570 catheters (99%). This is a statistically significant improvement when compared with the 80% baseline compliance rate observed in the 12 month period before initiating the study (P < 0.001).

Extrapolating the overall observed compliance rate (99%) to the previous year of arterial catheter billing indicated that of the 496 undocumented procedures, 488 would have been documented if the reminder system had been in place. Given the stable charge ($310 per catheter) and reimbursement ($83 per catheter) rate, this would have resulted in an incremental $151,000 in professional fee charges and $40,500 in professional fee reimbursements. The reminder routine required one week to develop. Using a $60,000 annual full time equivalent salary for a software programmer to develop and implement the reminder routine, the one-time cost was $1111.

	DISCUSSION

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 
This prospective, randomized study indicates that automated electronic reminders can improve compliance with medical record documentation. This documentation has not only inherent clinical and medicolegal value, but also a reimbursement benefit. We were also able to demonstrate that a more comprehensive reminder system that included attending staff further improved documentation compliance.

There is a large body of literature evaluating the efficacy of electronic reminders on compliance with clinical practice guidelines outside the operative setting. The data are mixed, offering encouraging results in the inpatient setting (7) and conflicting results in the management of chronic conditions such as diabetes and coronary artery disease (8). An information system can retrospectively assist with facility cost calculation and containment (9). In addition, it has recently been shown that an information system can improve adherence to surgical infection prophylaxis guidelines through retrospective provider-specific feedback (10). Reich et al. (11) reported on the revenue cycle management benefit of an anesthesia information system to billing system interface. Blum et al. (12) recently demonstrated that electronic reminders may increase the frequency of faculty and resident evaluations at academic medical centers. However, we are unaware of any prospective randomized trials assessing the impact of real-time automated electronic reminders on anesthesia clinical documentation or reimbursement.

There are several studies assessing the quality and completeness of physiologic vital sign documentation in paper and computerized anesthesia records (13,14). There are no large studies assessing the quality, accuracy, and completeness of procedural documentation. Therefore, we are unable to assess whether our baseline compliance rate of 80% is consistent with other centers’ paper or electronic anesthesia records. Although there are anesthesia resident trainees in our department, the anesthesia information system had been in use for more than 5 yr when the study was performed. As a result, departmental processes for user training, compliance checking, and documentation were very mature at the time of study. In addition, the study was performed during January and February, when Clinical Anesthesia-1 residents are experienced and familiar with departmental processes and policies. Though some centers may have a higher rate of compliance with the typical invasive monitor checkbox located on the intraoperative anesthesia record, this is not sufficient documentation, as noted on the American Society of Anesthesiologists’ website: "A checked-off box on the anesthesia record does not document the anesthesiologist’s performance of the service" (2).

The randomized, blinded phase of our study demonstrates that timely electronic reminders can improve documentation compliance and professional fee reimbursement. The compliance improvement from 75% to 88% in the reminder group is encouraging. The exciting element of this statistically significant improvement is that it occurred with only an automated electronic reminder as the intervention. No additional training, incentives, punishment, announcement, or systems were created.

Some may question why the experimental group compliance rate was limited to 88%. Though we cannot be certain given the data collected, it is likely that some of this noncompliant documentation occurred in instances where a holding room resident conducted the procedure and failed to document. The alerting system would not have reminded this resident, it would have paged the resident or CRNA in the case itself. This provider, unfamiliar with the details of the procedure (number of attempts, complications, use of local anesthesia) may have felt uncomfortable documenting another provider’s actions. Because the randomized phase of the study did not remind the attending anesthesiologist, no provider spanning this continuum was involved in the alert.

There was a notable increase to 98% compliance when attending staff were reminded in phase II of the study. We hypothesize that several factors are involved. First, the attending bears ultimate responsibility and liability for the medical record. Second, the attending served as a bridge in situations when a holding room resident performed the procedure yet failed to document. By notifying the staff of delinquent documentation, we provided the information to someone who could direct the correct resident or CRNA to document. Finally, a generalized increased awareness of the need to document catheter placement was likely in place after several months of the reminder system. Attendings in our department do not have a direct incentive system based upon personal billings or charges. Though there are a variety of incentive systems throughout academic anesthesiology programs in the United States, it remains unclear whether these effectively achieve their purpose (15,16). In the case of minor procedure documentation, it appears that incentives may not be necessary to improve compliance.

There are few studies objectively assessing the value of accurate and complete clinical documentation. Poor documentation and communication are commonly cited as possible causes of medical errors (17). Providers intuitively believe there is a linkage between clinical documentation and medical liability (18). Our study was not designed to assess the patient safety or medical liability impact of improved documentation. However, few would argue against complete and accurate documentation. Though an intraoperative automated alphanumeric page may be a nuisance to some, we doubt that the medicolegal value of the documentation is offset by the patient safety impact of the interruption (19). Some studies do suggest that automated record keepers in the perioperative setting may improve cost containment and facility diagnosis-related-group reimbursement (9,20,21). Our data indicate that these record keepers can also improve professional fee reimbursement.

There are several implications to our findings. First, the procedure documentation compliance at a tertiary care academic medical center leaves significant room for improvement. Some anesthesia providers may believe that their institution’s compliance rate is better than the 80% observed at our institution. We were unable to identify any data in the literature to support this belief. Second, electronic reminders can easily and effectively increase documentation compliance without requiring complex time-consuming training or incentives. The reminder can help in cases in which forgetfulness and multiple patient care handoffs are the root cause of missed documentation. Given that the reminder group documented 50% more procedures before incision over the course of the study, there may be a learning phenomenon independent of each individual reminder. Finally, these reminders can quickly and easily increase professional fee reimbursement. The $150,000 increase in charges was achieved without any additional staff or recurring costs. The effect was significant enough that our billing leadership has requested that the reminder system be expanded to include transduced central venous access catheters and pulmonary artery catheters. As the financial situation of academic anesthesiology programs continues to remain tenuous, the financial boost gained from improved minor procedure documentation could be a helpful, though minor boon (22).

There are several limitations to our study. Most importantly, the implementation of anesthesia information systems remains limited (23). The automated alerts we evaluated are not possible at most medical centers. Nevertheless, our data may serve as additional impetus for anesthesia information system deployment. Second, other institutions may have much higher documentation compliance and lack the need for reminders. Additional studies evaluating documentation compliance at institutions with and without anesthesia information systems are necessary. Furthermore, departmental documentation requirements vary from institution to institution. The minor procedure notes generated by our information system have been deemed "compliant" by our institution and our payors. However, other institutions may have variant definitions. Finally, high operative and minor procedure volume is necessary to observe the absolute reimbursement benefit that our data suggest. Small centers that do not perform as many arterial catheter placements may not experience an appreciable absolute financial benefit. In any case, the inherent value of complete documentation would still be realized.

In summary, automated electronic reminders improve minor procedure documentation compliance. This improvement is optimal when all providers involved in the care process, residents, CRNAs, and attending anesthesiologists, are incorporated into the process. The documentation can have a direct and significant professional fee benefit.

	Footnotes

 
Accepted for publication November 29, 2006.

Conflicts of interest: Dr. O’Reilly is a paid consultant for and has received honorarium from GE Healthcare. Dr. Kheterpal was a principal in the development of the perioperative clinical information system utilized to collect data for this study. He was an employee of GE Healthcare before joining the University of Michigan Department of Anesthesiology. He has no financial, consultative, legal, or contractual relationship with GE Healthcare or any other vendor.

Reprints will not be available from the authors.

	REFERENCES

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999