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August 12, 2002

Fashionable Software Turns Heads
By Hannah Fiske

A Minnesota hospital has implemented a program custom-tailored to the endoscopy department
that promises to give coding procedures a makeover as well.

By improving workflow and enhancing patient care, computer software plays an integral role in the modern healthcare facility. Unlike physicians, nurses, and other clinicians, however, HIM is often responsible for bringing science and finance together in a way that benefits the hospital, its employees, and the community of patients it serves.

At Methodist Hospital, a division of Park Nicollet Health Services in St. Louis Park, Minn., an innovative software program has been instrumental in improving the daily workflow of the endoscopy department and enhancing the efficiency of the hospital’s coding system.

ProVation MD, developed and marketed by ProVation Medical Inc., a Minneapolis, Minn.-based company specializing in technology-based solutions for medical professionals, allows physicians to quickly document medical procedures. Since June 2000, the software has also included a coding module that adds the proper coding to the record to assist staff in generating better reimbursements. ProVation MD is available for use in gastroenterology (GI), pulmonology, orthopedics, and urology departments, according to Sean Benson, vice president of technology.
“This is an unusual product geared for multiple specialties and with an interface that physicians can understand and enjoy using,” Benson adds. “It is also the only program to offer this type of coding module. Many companies offer a list of CPT [Current Procedural Terminology] codes in an electronic format, but this is actually a complex rules engine that analyzes all of the documentation and arrives at the appropriate codes.”

For many years, the endoscopy department at Methodist Hospital utilized a traditional automated dictation system, but as the new millennium approached, the need to update the system became obvious, says Betty Loewen, RN, CGRN, nurse manager for the department. “We reviewed many other dictation systems and determined that ProVation had developed and now offers an excellent language system for the physicians to use,” she recalls. “The program was easy to integrate, and actually using it wasn’t awkward or difficult.”

The fact that ProVation’s headquarters are located near the hospital was also a factor in the decision, Loewen admits. During the implementation process, information technology staff members from both Methodist and ProVation met several times to develop a strategic plan. Once the software was in place, the software company also placed personnel at the hospital for several days for training purposes.

Loewen says one of the primary reasons she supported the implementation of ProVation MD is because of the program’s language. “They spent a lot of time defining a common GI language that could be used throughout the country,” she explains. “If a nurse or physician needs to conduct a literature search for a certain kind of polyp, it will always be documented under the same name—we won’t have situations where two physicians are giving it different names.”

The common language is a feature also enjoyed by physicians who can use keywords to locate specific details in the text, she comments. From a management point of view, Loewen adds, the program captures information and offers reports to determine how busy specific rooms are, as well as what times of day and days of the week are busiest. “Those details were important to me as a manager,” Loewen says. “They allowed me to examine and assess our business patterns.”

She explains that each procedure room in her department is equipped with a computer, which, during endoscopies, colonoscopies, and other procedures, is connected to the scope so physicians can take “pictures” during the procedure. These images are captured to the database, along with the patient’s name, address, and other demographic information. Once an exam is completed, the physician can go to a dictation room, log in to a local area network, and pull up the patient’s data.

“Using this software, certain common words will automatically pop up,” she says. “If the procedure was a colonoscopy, the system will ask the physician what the indications and findings were, and he or she will be asked colonoscopy-specific indications and findings, which is important.”

Pop-up windows and menu choices offer physicians the opportunity to choose how best to describe the procedure. Once the report is complete, he or she simply presses a button, generating a dictated report that includes the pictures taken during the exam.

The program also prints patient instructions, including information drawn from the electronically dictated report. “The software-generated patient instructions give the physician’s name, phone number, and recommendations,” Loewen explains, “along with instructions that are specific to our department.” These instructions—which may also include the images taken during the procedure—are popular with physicians, nurses, and patients alike for their customizable content.

ProVation MD offers another feature that is especially meaningful to hospital administrators who need to keep a close eye on accreditation requirements: virtually immediate access to procedure notes throughout the hospital.
The Joint Commission on Accreditation of Healthcare Organizations specifies that patient reports should be dictated before the patients leave the department. Loewen explains that this could be important if complications occur and the patient arrives at an emergency department (ED) later the same day. “With immediate dictation, the report will be available to the ED staff,” she says, “not sitting on a desk somewhere waiting to be transcribed.”

When Methodist Hospital’s endoscopy department updated its ProVation MD software this year, it received a version containing the coding module, which automatically generates CPT and International Classification of Diseases (ICD) codes based on the content choices physicians enter as they dictate their notes, Benson says.

He explains that in a typical hospital workflow, a physician dictates by telephone or tape recorder, and then a medical transcriptionist types the report. The physician also circles billing codes on a piece of paper, and the transcribed notes and billing slip are forwarded to a coder who reviews the codes, determines if they are correct, makes any necessary changes, and sends the bill out for payment. “This is a complex process,” Benson says. “The main problem is that as the doctor dictates the note, he or she is thinking about the clinical aspect of the procedure, rather than the coding impact the note will have on the facility’s revenue.”

If physicians forget to include an aspect of the procedure during dictation, the hospital will be unable to charge for it. “It is also not uncommon,” he adds, “for physicians to describe an exam too vaguely so that coders are unable to justify usage of a certain code.”

ProVation MD’s coding module was developed and reviewed in conjunction with the firm’s in-house coders and physicians, who clarified, “tweaked,” and adjusted the program’s medical content to ensure it was essentially coder-ready. With the medical content in place, it was directly mapped to CPT and ICD codes within the program.
For example, if a physician enters notes for an upper GI endoscopy and writes that he or she advanced the scope into the second part of the duodenum and performed a biopsy, those three facts would be included in a formula that derives the codes used to bill for the procedure. “The details and information are gathered ‘on the fly,’” Benson notes. “Then, the system makes a determination to come up with the appropriate codes based on the physician’s documentation.”

Until receiving the upgrade, staff members in the endoscopy department did not have the ability to participate in the coding process, Loewen explains. She adds that the plan will be to print out the ProVation MD-suggested codes for each patient and pass them on to the hospital’s coding staff to review as they extract information from the physicians’ dictated notes.

Loewen expects that incorporating the coding module as part of the software program will cause physicians to notice the codes they are generating and question if they accurately reflect the procedure and how it should be billed.

“It might help them notice if they forgot to include something in their dictation,” she says. “We have had a huge initiative in our hospital to help physicians utilize better language to get better coding. The facility hired consultants to work with the physicians and to help them clarify in their notes what they actually performed during the procedure.”
The consultants also taught physicians what various codes mean with hopes that assisting them to code more accurately might improve the overall billing process and enhance revenue. Bar code technology is also available with the system, she adds, so that each piece of equipment used could be scanned into the system to help make coding more thorough and accurate.

Rather than serving as an eventual replacement for medical coders, ProVation’s coding module serves as a support system—a sort of second opinion, explains Loewen. “There are a lot of gray areas in coding,” she says. “Coders and insurance companies try to interpret reports and are continually learning from each other.”

Additionally, coders often need to wait for pathology reports to arrive before they code for a specific patient because the pathology findings may change the outcome. Using the new system, she points out, endoscopy department staff will collect the pathology report and forward the complete file for coding, decreasing the waiting period.

Benson agrees and adds that the coding module exists to make coders more efficient, not obsolete. “Hospitals are understaffed and often don’t have a coder in the workflow,” he explains. “All too frequently, physicians dictate notes, circle the codes on billing sheets, and then send that information to a data-entry person who types it into the system without a coder to review it.” ProVation MD supplies coders with an electronically generated procedure note and automatically generated CPT and ICD codes. “If all runs smoothly,” Benson says, “the records they receive will be 80% complete, so the coders can step in, finish it off, put the icing on the cake, and send the codes down to the billing area.” The result, he stresses, will not be an electronic replacement for coders, but a tool to help hospitals challenged by the shortage of medical coders to help the few they do have on-staff to work more efficiently.

Perhaps the most important benefit, according to Loewen, is the fact that the dictated report is completed immediately after the procedure and placed in the patient’s chart. That is a benefit for the HIM department, she adds, because the chart is complete when it leaves the endoscopy department, including an electronic signature that will decrease the time spent waiting for physicians to sign off on their notes.

Referring physicians also appreciate the program because it enables them to review exam findings from the department before they see the patients for a follow-up visit to determine their next stage of treatment.
“The program also helps track pathology because we attach pathology reports with the dictated report before sending it to the physician’s office,” Loewen says. “That way, physicians have all of the information together and are not getting one report before the other.” This ability is also a boon to patients, who benefit from efficient processes by receiving exam results usually within one week.

When ProVation MD was first installed at Methodist’s endoscopy department, several physicians who were less technically oriented needed some extra coaching to become familiar and comfortable with the process, Loewen recalls. “That quickly smoothed out, and now our routine procedures can be dictated into this system as quickly as they were by telephone,” she says. “More unusual or complicated exams aren’t harder; they just take a bit longer.”
Physicians appreciate the ability to add notes to their reports and to program personal keywords for dictation purposes (though these cannot be located in a search). “The physicians realize that the system makes them more accurate,” Loewen notes. “It won’t allow them to continue with the dictation until they answer certain key questions, such as, ‘What is the distance and length of the hiatal hernia?’”

Some physicians were initially critical of the software, Loewen adds, because they felt it was similar to “cookbook medicine,” not allowing them to add personal touches and opinions about patients to procedure notes. “The problem with adding extremely individualized statements, though, is that their own language often can’t be searched for by other physicians. It makes the report less scientific,” she says. If physicians need to add specific or personalized notes, the program allows them to do so.

“If there is any single drawback to this program from an HIM point of view, I would say it would be that when the system goes down, it can be tough to determine if it is our server or ProVation’s that is experiencing a problem,” she continues. “If that happens, we just need to make a few telephone calls to determine where the problem lies.”

Overall, Loewen describes the process of implementing ProVation MD software as “smooth sailing,” adding that although they may not be aware of financial returns on the investment in the endoscopy department, that does not mean they don’t exist.

“The company’s studies have shown that there has been financial gain in other hospitals that have used the program,” she says.

In Methodist’s endoscopy department, though, the return is more immediate and personal. “We have become so accustomed to using this system, and the physicians are so pleased about having their reports in hand and in the charts immediately. I don’t think we would ever be able to convince them to go back to the old methods of dictation.”

— Hannah Fiske is a staff writer at For the Record.

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