1. Preceptor: Louise A. Mawn, M.D. May 30, 2008

2. Medical Documentation Medical record serves many functions For health care providers it facilitates: Communication with other providers Preservation of information Continuity of care The medical record and its documentation is also used for: Billing, physician reimbursement Medicolegal issues Clinical Research Internal auditing and quality assurance by hospital administration

3. Medical Documentation Reasons for improving documentation: Enhance the quality of medical care Improve legibility for other providers and for data collection (clinical research, medicolegal defense) Optimize for billing and reimbursement Reduce the time spent recording data Many experts consider electronic health records the solution to improving documentation and quality of health care Schriger DL, et al. JAMA. 1997;278:1585-90. Wrenn K, et al. Ann Emerg Med. 1993;22:805-12. Chaudhry, et al. Ann Intern Med. 2006;144:742-52.

4. Medical Documentation StarPanel is Vanderbilt’s electronic medical record The Ophthalmology Consultation Form was implemented in the summer of 2006. The purpose of this study is to compare the electronic medical record to the paper record to help optimize our electronic consult form.

5. Compare the electronic medical record to the paper record to help optimize our electronic consult form. Assessment of documentation through record of billing level of service Determining the lagtime in posting billing charges as a measure of efficiency Evaluation of completeness of documentation by examining a specific diagnosis

6. Methods Retrospective chart review All adult and pediatric consultations performed between two twelve month periods were identified: July 1,2005 to June 30,2006: Paper record = 1,038 consultations September 1, 2006 to August 31, 2007: electronic medical record= 1,064 consultations

7. Consultations performed during the two 12-month dates of service 577 461485 579 Dates of Service Number of Consultations 1,0381,064

8. Methods: Question 1 Is there a significant difference in the level of billing between the two groups? The level of service to bill is determined by a specific quantitative algorithm of three categories: history, physical exam and medical decision making. This is translated into a 5-digit CPT * code (9925x). The billing level for each consultation performed during the two 12-month periods was recorded numerically 1-5. *Current Procedural Terminology Silfen E. Am J Emerg Med. 2006;24:664-78.

9. Results Billing Codes Number of Consultations Frequency of Billing Codes

10. Results Mean level of billing: Level of Billing

11. Methods: Question 2 Is there a significant difference in the lag time to billing? Lag time: Number of days between date of service and the posting of the charge

12. Results Mean lag time in billing, in days

13. Methods: Question 3 Is there a significant difference in the quality or completeness of documentation of consultations? In order to answer this question, a specific diagnosis was chosen. Wrenn K, et al. Ann Emerg Med. 1993;22:805-12. Kanegaye JT, et al. Ambul Pediatr. 2005;5:253-7.

14. Methods: Question 3 233 consultations with a diagnosis of orbital floor fractures in the two periods of interest were identified using the ICD * -9 codes: 802.6 and 802.7 92 26 102 13 105 128 Number of Consultations *International Classification of Disease

15. Methods: Question 3 Nature of injury Diplopia Visual acuity Pupillary exam Motility/Forced Ductions Deviation/Strabismus Infraorbital sensation Orbital Rim Palpation Interpretation of Orbital CT scan Based on the American Board of Ophthalmology’s Office Record Review Module on “Blowout Fracture of the Orbit”, 9 aspects of the history and physical were identified as being key elements that should be included in the medical record.

16. Example of a consultation recorded by free-text on paper

17. Example of a consultation recorded on the electronic record form

18. Methods: Question 3 Each consultation was reviewed and the following recorded: The total sum of categories fulfilled in each consultation Initials of the consultant Mental status - if the patient was awake or sedated at time of the initial consultation

19. Results Mean number of categories fulfilled: Number of categories

20. Results There were 21 consultants – too many to include as a variable Mental status:

21. Results Multivariate analysis Awake/sedated status did have a significant effect on the number of categories fulfilled (p<0.0001) When considering the mental status as a separate variable, the difference in the outcome of the number of categories fulfilled between the paper and electronic records did not depend on whether the patient was awake or sedated (p=0.2107)

22. Conclusions Higher level of billing for consultations that were on paper record EMR re-examined and changes made to form Less lag time in posting charges with implementation of EMR form Improved legibility, immediate availability of EMR form More complete documentation of patients with floor fractures on paper record compared to the EMR

23. Limitations and Recommendations for Future Studies There were 3 coding specialists during the two 12- month periods studied Repeat with 1 coding specialist Completeness of the medical record only studied for a single diagnosis Examine other diagnoses

24. Limitations and Recommendations for Future Studies Is the difference in billing level and lag time meaningful? Analyze the amount billed and the actual money generated No gold standard for measuring the quality of documentation

25. Acknowledgements Thanks to: Preceptor: Louise A. Mawn, MD Statisticians: Chun Li, PhD and Pengcheng Lu, MS