Eisenhower Medical Center
Online Physician Orders: A Transformation to Overcome Lost and Illegible Orders
- 253-bed hospital located in Rancho Mirage, Calif. (Palm Springs area)
- Not-for-profit
- Centers of Excellence in Orthopedics, Cardiovascular, and Oncology
- The campus includes the Eisenhower Hospital, the Betty Ford Center at Eisenhower, the Barbara Sinatra Children’s Center at Eisenhower and the Annenberg Center for Health Sciences at Eisenhower
- 60 percent Medicare
The Problem: Inaccurate Physician Orders
In July 2005, the Chief Financial Officer of Eisenhower Medical Center (EMC) issued a directive that all denials were to be eliminated by year end. Medical Necessity and ABN-related denials for Laboratory services were continuing to climb to an all-time high of nearly $23,000 per month. Illegible and incomplete referring physician orders led to extended delays in patient registration, plunging satisfaction scores and unacceptable ambulatory wait times. Searching for a means to meet the challenge head on, EMC identified the primary culprit: inaccurate physician orders. The numbers in red made it painfully obvious that they needed more than an internal band-aid. EMC needed a solution that would permeate the referring physicians.
Comprised of a large medical complex located in Coachella Valley, California, EMC leadership concentrated their search by conducting a baseline performance assessment of the ABN-related order denials and registration process. As a result, EMC contracted with SCI Solutions to provide an innovative software solution. Still in its infancy, Order Facilitator was tasked with a comprehensive EMC system implementation followed by quantifiable results.
The EMC performance improvement benchmarks extended through the entire outpatient ordering process with the goal of lessening or eliminating non-compliant/illegible denials and improving overall workflow.
EMC identified the primary admitting/registration reasons for denials (in order of dollars denied):
- ABN issues related to Emergency Room services
- ABN issues related to Laboratory services
- No insurance benefits or eligibility
- No authorization.
A root cause analysis of the reasons for ABN laboratory denials identified the primary challenges as illegible and incomplete orders, lack of physician understanding of Medicare medical-necessity policies and a skill deficit among Admitting and Registration staff in the critical area of coding and medical terminology.
Discovering the impediments to placing an order for outpatient services was the first place to start. This entailed reviewing processes and tools used to complete orders, as well as the individuals responsible for placing the orders themselves.
“We had no organizational policy with respect to outpatient order compliance and completion,” said Linda Reagan, Office Manager. “Historically, our organization has never had any revenue cycle-related policies that were enforced within the physician community.”
As to the thousands of dollars that EMC was incurring each month in ABN-related denial charges, a root cause study found that all of EMC’s orders were handwritten.
“We had a really bad compliance problem because we didn’t have policy with respect to submission of accurate orders,” said Mark Gaulding, Director of Revenue Cycle, Admitting and Scheduling Services. “Registration was then tasked with the operation from start to finish, causing a lengthy registration process and stay for the patient due to poor clarity of orders and physician communication. Thus, confirming that the challenges EMC was facing were intrinsically linked to the physician orders.”
The Goal: Establish Quantifiable Objectives
EMC key indicators included poor Press Ganey patient satisfaction scores, increasingly lengthy patient waiting times, climbing denials totaling close to $23,000 dollars monthly and decreasing physician satisfaction scores. Using laboratory as a critical area of need for physician order improvement, objectives were formulated:
- Improve Patient Satisfaction Scores: Press Ganey Scores (patient satisfaction) had fallen dramatically since 8/05 (from a high of 92.8 to a low of 80.5 in 2/06), when EMC implemented comprehensive Medicare LCD review at registration for lab services.
- Reduce Patient Wait Times: Patient wait times for Laboratory services had fallen dramatically from a high of 89.2 to a low of 71.4 in 1/06, after EMC implemented comprehensive Medicare LCD review at registration.
- Eliminate ABN-related Denials: ABN-related denials for Laboratory services continued to climb from to an all-time high of $22,996 in October of 2005 for Medicare medical necessity-related denials.
- Improve Physician Satisfaction: Physician satisfaction for Laboratory services was plummeting
(dramatic increase in daily complaint calls to administration) due to:
- Patient’s frustration with wait time and length of stay
- On average 20 faxed orders per day were lost or not received
The Solution: Order Facilitator
Charged with choosing the appropriate software solution from one of several reputable Access Management organizations, Gaulding was impressed with the physician friendly component of Order Facilitator. “We were confident that SCI Solutions’ Order Facilitator would rise to the occasion and demonstrate real return, we just had no idea how fast it would happen. We are only in the early stages of implementation and are already seeing marked improvements,” says Gaulding.
EMC set out to achieve 100 percent electronic outpatient order capture with medical necessity checks and authorization details; the elimination of lost, missing, incomplete, and illegible orders; better communication between the hospital staff and physicians and check ins without patient delays associated with order issues.
Following the assessment, the next steps for EMC and SCI Solutions involved the development and implementation of ordering solutions (including updating policies, procedures, job descriptions and identifying supporting technology build requirements.) Ongoing management of performance measurement activities and the project itself kept EMC on time and on track.
“Partnering with SCI Solutions versus trying to do all the work ourselves allowed us to maintain the quality of care for our patients and to minimize the drain on clinical resources,” said Gaulding.
The Results
EMC implemented SCI Solutions’ Order Facilitator on April 28, 2006 in all of its ancillary services: Outpatient Imaging Center, Laboratory, Radiology, Cardio-Pulmonary, Physical Rehab, Nuclear Medicine, Infusion/ Transfusion, Respiratory and Sleep Lab.
The goals were simple. First, Gaulding hoped to improve workflow. Next, he aimed to manage 100 percent of orders, including faxes and to significantly lessen or eliminate ABN-related denials. Finally, he could only hope that physicians would respond.
The results following implementation considerably surpassed EMC’s leadership’s forecasted expectations. Initial Order Facilitator volume estimates were 300 to 500 per month. Today, the volume averages more than 3,230 orders monthly! More than 25 physician practices (representing 46 physicians), as well as multiple clinics, are participating with an average of two new practices adopting Order Facilitator each week.
Patient satisfaction for registration processes more than doubled since implementation. With Order Facilitator, patient order information is distributed to pre-registration and ancillary departments automatically. Each order is signed, authorized and verified for payment before the patient arrives, attacking the challenge of patient satisfaction and the registration process head on.
Most significantly, Order Facilitator enabled Gaulding to not only improve upon the denial rate, but to eliminate the challenge altogether. From close to $23,000 lost in laboratory alone to zero losses in denials monthly (see Exhibit A).
Exhibit A
Denials (ABN related) write offs to bad debt for laboratory services have dropped precipitously from 3/06 (approx $20,000) to $4,671 for 6/06 and $0 in 7/06.
“Before implementing Order Facilitator, our telephone capacity wasn’t sufficient to accommodate all the telephone and fax orders coming in and we were losing an average of 20 orders daily,” said Gaulding. “Now we don’t have those missed calls or misplaced faxes because everything is coming through the Order Facilitator.”
Considering that physician communication had been one of the toughest barriers to overcome, EMC leadership was pleased they had finally found a tool to increase and improve communication between physician offices and EMC facilities.
“I haven’t done a paper requisition in months and I wouldn’t go back to that ever again,” said Linda Reagan, office manager of one of the first physician offices to implement. “This cuts down on time faxing or calling as follow up to sending written orders.”
The response to Order Facilitator from the staff at EMC has been overwhelmingly positive. Gaulding comments, “This is one of the first times that we’ve seen patient access staff happy with a tool that we’ve provided.”
Today, EMC is proud to set an example to healthcare organizations across the nation with its technological advances in ordering. Knowing where the challenges are means that leadership had a clear vision of how to overcome those challenges. Ultimately EMC transformed how care was delivered by bridging the gap between a “hospital problem” to illicit measurable physician support.
Just what the doctor ordered.client quote:
“SCI Order Facilitator has streamlined our orders workflow, increased provider and patient satisfaction and reduced operational delays.”
Mary Godwin, Manager Centralized Scheduling
Baptist Health Care
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