The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

RESPIRATORY THERAPY CHARGE CAPTURE ASSOCIATED WITH SWITCHING TO A NEW ELECTRONIC MEDICAL RECORD SYSTEM IN THE EMERGENCY DEPARTMENT.

Elizabeth Cooper, Scott Pettinichi, Mark Haggard; Emergency Department/ Respiratory Care, Cincinnati Childrens Medical Center, Cincinnati, OH

BACKGROUND: Electronic patient care charting can be accomplished using a variety of different methods. In November of 2009, our institution’s emergency department went from using a system called (Emergency STAT corporation) EMSTAT, which has been used since June of 2000, to a system called (EPIC ASAP corporation) EPIC ASAP for charting. While the flow from one charting system to another for the staff was relatively an easy one, capturing charges from EPIC ASAP has shown to be more difficult. All staff was educated on the appropriate documentation within the medical record. Charge capture is performed by an outside company who pulls charges from the medical record. Several months after EPIC ASAP was implemented in the emergency department, it was noted that the continuous albuterol charges were not being billed; charge capture decreased to zero (see Table 1). It was observed that there was nothing built into the documentation system that allowed for the charting of the transfer to the critical care unit while the patient was still receiving the continuous treatment. METHOD: A chart audit was performed in EPIC ASAP from the go live date (11/11/2009) to obtain all patients who received continuous therapy in the emergency department. A listing from the outside billing company who produced charges from that date forward was obtained. It was found that zero charges where found while the patient was in the emergency department receiving continuous albuterol. Contact was made with the EPIC ASAP design team to immediately build a system that allowed the proper data to be charted before the patient left the emergency department. This change was made within one week and staff was educated on its usage. RESULTS: Charge capture significantly rose from 29% percent between November 2009 to April 2010 to averaging 80% charge capture from April 2010 to June 2010. There are still 20% of charges unaccounted for due to improper documentation procedures. CONCLUSION: While this data collection is still new for the billing team, it has significantly increased our charge capture dollars. Further improvement is expected through chart audits and staff education to enable charge capture. Sponsored Research - None Table 1