Structured Reporting: Boosting Patient Care, Refining Billing

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Akron-General-Heart-Vascular-Center.jpg - Akron General Heart & Vascular Center
Akron General Heart & Vascular Center

Akron General Heart & Vascular Center is a leader in STEMI care in Northeast Ohio, each year besting the national average for STEMI mortality rates. At the core of swift decision-making is a well-experienced team and immediate access to patient information. State-of-the-art structured reporting and coding is an enabler, bringing together patient data, anatomical diagrams and coding and quality improvement essentials for physicians, as well as administrators looking after the center’s economic health.

Akron General Heart & Vascular Center is part of Akron General Health System, a not-for-profit healthcare organization based in Akron and founded in 1914. The health system includes Akron General Medical Center, a 532-bed teaching and research medical center, Edwin Shaw Rehabilitation Institute, Akron General Partners, the Akron General Health & Wellness Centers, Lodi Community Hospital, Community Health Centers and visiting nurse services. Together, they strive to offer the best in progressive community care.

About five years ago, the cath lab team knew it was time to get out of the world of paper, paying by the line for dictation, using templates that weren’t user friendly, and manual signing and faxing of report. Their focus was on structured reporting and coding. “We needed a system that would work for interventional cardiologists who want an easy to use system and for administration to recognize efficiencies in time and money,” recalls S. Leslie Tobias, MD, medical director of the heart catheterization labs at the Akron General Heart & Vascular Center.

Other priorities included finding a vendor partner that offered “no nonsense software and administration,” according to Tobias, the physician champion for the project, and a vendor both fluent and experienced in every aspect from planning to implementation, training and support. The Akron General team also needed confidence that the product they purchased would be intuitive, continue to expand in its capabilities and evolve over time.

Step one was a survey of the health system’s immediate and longer term needs for cath lab reporting from the clinical perspective of physicians and administrative perspective of hospital leadership. A team of physicians, nurses, cardiology administrators, IT leadership and technologists offered their opinions and looked at the technology available as well as vendor integration skills and longer term vision and plans. Akron General team members focused on uniting physician reporting, diagraming and coding, and ensuring the new solution would work well with their hospital information system, hemodynamic monitoring, echocardiography systems, and hybrid EMR system, recalls Systems Specialist Tamara May, RT (R) (CV), MCSA. May was part of the initial team and today manages and monitors servers and software, serves as the center’s liaison to the IT department, and is the coding and billing liaison to financial services for the H/V Center.

“The physicians went to administration and said ‘we need this,” May says. “That is unusual. This request was taken very seriously by administration who assessed the expenses, looked at the ROI, and studied the integration and infrastructure. ProVation MD was the only choice.”

ProVation MD is a structured reporting and coding solution that provides clinically relevant, intuitive software that can ensure hyper-accurate documentation. The system includes a medical content database, updated biannually, that offers comprehensive peripheral vascular and coronary content. “The algorithms to create a good report are excellent,” Tobias notes.

The patented DocuDiagram feature makes coronary tree documentation more efficient by allowing physicians to modify unusual anatomy, quickly document findings and interventions and navigate easily through complex cases. While the cardiologist is filling in the DocuDiagram, the medical content database is completing the procedure note in the background. The coding engine then applies the appropriate reimbursement codes based on what is documented. Reimbursement codes are updated quarterly and ICD-10 ready. 

“The reports read in the same language the physician speaks,” May notes. “It is clear that ProVation works hand in hand with physicians to make the reports as accurate and realistic as possible, and this in turn helps us provide efficient and effective patient care. We were excited to be buying a reporting system that is capable of coding the note based on the actual documentation.”