Pediatric Practice Plan: Current Operations and Workflow

PFF Operations Ambulatory Clinic Encounters E&M Billing and Coding Workflow Analyses ICU Workflow Cardiology Workflow Performing a Business Analysis

PFF Basic Statistics Physicians 185 Out patient visits 100,000 In-patient admissions 6,600 In-patient average length of stay    6.8 days Emergency room encounters 50,000 Procedures 5,000 Bills generated 275,000 Phone calls (COAs) 300,000

The Pediatric Faculty Foundation, Inc. (PFF) is a not for profit corporation through which the academic faculty in the Department of Pediatrics practice medicine. It is therefore a critical and important arm of the Department necessary to support the professional, research and educational missions. There are approximately 185 Members from each of the divisions of the Department of Pediatrics, CMIER research factuly. Virtually all clinical training programs utilize PFF resources.

PFF internal operations have utilized Microsoft's basic office software, primarily Word and Excel. Other technologically intense activities such as scheduling, utilizes Epic's Cadence, which is supported by CMH. The billing technology for PFF has been out-sourced to two external vendors. Dictated progress notes, consultative reports and letters to referring physicians are sent via telephone to an outside vendor, or are done internally using division-based support staff. Transcribed documents are emailed from the vendor to division support staff via unsecured internet email. Data analysis has consisted of some canned Cadence reports, extractions from the Epic Clarity database, and standard outputs from the billing vendors.

It has been difficult and cumbersome for PFF to perform custom extractions of data either for business operations or management information. This shortcoming has major implications for PFF. Appointment reminders, transcribed letters, basic communications (phones, faxes, letters) are all manually performed at great expense and often with burdensome, error prone processes. Implementation of clinical triaging for patients requesting and appointment, as well as other management algorithms has been impeded by lack of technology support.

PFF has relied on CMH for its technology infrastructure. It has also relied of CMH IM employees to provide technologic support. This latter strategy has been a particular problem because the reporting relationships and incentives are not aligned with PFF interests. CMH has strongly encouraged PFF to identify competent staff with sufficient time and resources to interface with the CMH IM department. Responding to this, and its other internal needs, PFF has recently restructured and added a new position of Special Projects Manager. This position is currently occupied by a 0.5 FTE. The resources dedicated to this effort need to be increased in the FY 2005 budget in order to effectively implement the planned rollout of Epic modules.

Ambulatory Clinic Encounters

PFF has 100,000 ambulatory visits per year and CMH, Clark Street, Glenbrook, Northwest Community,Tinley Park, and Westchester satellites. New patients are currently calling Kids Doc or division offices for appointments. Data is entered manually for the appointment itself. Registration is subsequently completed by the Kids Doc registration staff at a later time. Reminders of appointments are done at Kids Doc, the division offices and satellite offices in a haphazard manner, either by phone, postcard reminders, or letters. The demands of other work make this a low priority and duplicative work process. There has been little or no screening of new patients requesting appointments and variable or no application of algorithms or pathways that might enhance revenues or other clinical or business agendas. The difficulties can be addressed by better application of technology.Andrea Rahlf, MA, CMPE

Evaluation & Management Billing and Coding

Billing for medical services involves complex algorithms incorporating a) the number of points recorded in the clinical history, b) the number of elements of a physical examination, and c) the complexity of the clinical problems and level of medical decision-making required. Levels of service are determined based on these input variables and this, together with the type of service (new, return, consultation, procedure) is used to identify the appropriate Current Procedural Terminology (CPT) code for billing. Billing also requires a diagnosis, coded using the ICD-9 code.

At the present time the selection of the CPT and diagnostic code is made by the physician at the time of the encounter using a division-specific superbill (printed form). In the ambulatory arena this is a triparate form which is manually separated by the point of service staff. One sheet is returned to the division office, one to the patient and one to the billing department. The latter are Fed Ex’d to the billing company. Inpatient superbills are hand carried to the PFF Finance office at their Clark Street location. The remainder of the billing process completed by the external billing vendors.

PFF has developed ambulatory encounter tracking systems using Excel spreadsheets. Separate spreadsheets with completed appointments are downloaded as a batch report each evening. These batch reports are manually copied and pasted for a) each clinic session and b) then sent to the billing clerk in the Division who enters verification of receipt of the paper superbill and the batching data . The Division billing clerk batches the superbills daily, pooling those from multiple clinics and physicians and excluding bills not yet ready for transmittal. The Division billing clerk enters the batch data into the second batch spreadsheet (b) and at the same time notes the batch information in the first spreadsheet (a) for the clinic session. Batches of superbills are sent by Fed Ex to SSC. Registration data about patients from the Epic electronic master patient index is sent via an electronic interface from CMH to SSC and Evergreen Billing Services. This data is not uniformally used by the billing vendors in order to submit claims, as it does not always match the vendor’s demographic database. This is done independently of the superbill transmission, which is a manual process. At the billing vendors’ office, data from the paper superbill is manually entered and matched with the demographic data. A month later, the Division billing clerk next receives a printed paper report, called the monthly charge entry report. The division billing clerk is responsible for reconciling this report with the Excel spreadsheets to insure that every bill transmitted to SSC is actually entered into the IDX system utilized by SSC.

This process involves at least four people: PFF Data Qualtiy Coordinator, setting up spreadsheets; the division billing coordinator; the CMC IM staff who transfers demographic data; and the SSC or Evergreen Billing Service data entry person. It also requires multiple human steps which could be averted by a direct entry of billing data into an electronic terminal. The paper superbill moves from the a) clinic to b) the Division office to c) the billing vendor or to the PFF Clark street office and then, by FedEx to d) SSC. The current system requires many days for the bill to be entered into the IDX system.

Andrea Rahlf, MA, CMPE and David A Stumpf, MD, PhD Typical Workflow in the Pediatric Intensive Care Unit

This is a typical workflow presented as an example of the data needs in a clinical practice and the disadvantages of a paper medical record.

1. Arrival between 6:30-6:45 to begin pre-rounding on some of the patients.
2. Rounds with residents, pharmacy, and nutrition begin at 7:30. They may be interrupted for Firms or Grand Rounds.
3. Data needed during rounds include:
   1. Orders (past and those currently being written)
   2. Medications
   3. Lab results
   4. Radiology results
   5. Other diagnostics (echo, etc.)
   6. Information from earlier hospitalizations, clinic visits, etc.
4. Plans made, etc.
5. At each patient bedspace, the attending writes down pertinent information provided by the resident such as medications, ventilator settings, selected labs, and the like onto a templated two-ply carbonless progress note form.
6. At the end of rounds (around 11-11:30) the team reviews X-rays.
7. The attending then examines every patient, meets with families, and completes the paper progress note for each existing patient.
8. The attending then takes the stack of completed paper notes and places stickers on each sheet. The top form is ripped off and placed in the chart at the bedside. The copy on the second sheet is retained for billing. The superbill on the reverse of this sheet is completed.
9. Meanwhile, new admissions are arriving throughout the day. The attending examines each as they arrive. The admit note for these patients is completed in Carevue. A separate superbill form is used for new admissions.
10. The attending may also go to the inpatient floors to evaluate patients for admssion and to the ED for the same.
11. The Carevue note is copied and compared to the superbill by the biller to ensure that documentation is appropriate.
12. Late afternoon/early evening (sometime between 4 PM and 6 PM the attending rounds with the on-call resident and fellow to review events of the day.
13. Clinical conferences occur twice a week. On Tuesdays multidisciplinary rounds the needs of all patients are reviewed. Attendees include physicians, clinical nurse specialist, chaplain, social work, OT, PT, speech, etc. On Fridays all the critical care physicians gather to review the cases of the week. Succinct summaries are provided, augmented as needed with lab results, radiology, etc.
14. Family care conferences also occur as needed for major updates and decisions. These are in addition to daily bedside updates.

Denise Goodman, MD Cardiology Workflow

The Division of Cardiology runs many laboratory tests. These use different data repositories that are physically and geographically separated (see diagram). Summarizing a cardiology patient's data requires a considerable amount of effort as will be evident in a workflow analysis.



ECGs have been digitally stored since September of 2000. All ECGs done in CMH are transtelephonically transferred to the ECG Lab onto the MUSE Computer. Some ECGs from Evanston, Glennbrook and Northwest Community are also sent to the MUSE. There is no other access to this computer besides the one desktop that is in the ECG lab. Access is limited to 22 users. To log on, you must know your user number as well as your own chosen password. There is no other fail-safe paperless record of ECGs. Both clinical files and Epic Hyperspace grossly under record ECGs, because patients rarely register for an ECG.

Catheterization data has been digitally stored since 1998. PedCath is specific software for Pediatric Cardiologists developed by Scietific Software Solutions out of University of Virginia. It is not easily matched because of the large cartoon registry of almost all congenital heart disease and accompanied surgical palliations. No audiovisual files are presently stored despite complete digital acquisition. Reports and letters to referring physicians are transcribed in Word and linked to PedCath. These reports, minus the helpful diagrams/cartoons, are also stored on the J Drive.

Echo reports are accessible to most through the Portal. Reports are generated within one day. Some of the reporting is confusing because of the “dropdown” design, (e.g., "hypoplastic left heart – ruled out" can be misleading). There is plenty of flexibility with macros however. Additional objective data (e.g., LV function) can be retrieved and graphed, if the users knows the system.

Thus, in preparation for a cardiology visit, it may be necessary to open four sites on the CMH Portal, two cardiology computer terminals, retrieve and load an optical disk, and extract paper reports from four cardiology offices/labs. In addition, separate systems are in place to track phone messages, prescriptions and consultant reports. There are access and security controls in place and thus multiple login and security steps are required. Stephen Pophal, MD

Business Analysis using Scheduling and Billing Information

The data is very complex and you cannot see anything without a lot of processing (parsing, importing, SQL, etc.). Data itself comes from at least 3 sources: CMMS, Springfield Service Corportation (SSC) and Clarity Reports (managed by CMH IM). The former provides CPT codes and associated names, RVUs (total, work and malpractice), modifiers, reimbursement rate, etc.; it is in a set of files with way over 50mB of delimited text. SSC can provide an extraction of billing transactions (two types in fixed field text files) – it took 6 months to acquire this for Neurology, but updates should now be easy. Clarity extracts out the appointments, insurance class, and referring physicians, etc.; it also required > 6 month for Neurology to gain access to Clarity. Clarity also exports to intermediary formats that must then be integrated with other data sources. Having gone to these lengths, the data loses a lot of its value because linking or relational variables are present in only about 20% of the SSC records. Thus, much of the data is unlinkable between SSC and Epic as it is now constituted.

David A Stumpf, MD, PhD