How Boston Children's fixed charge capture and quality improvement issues with one software program
A few years ago, Boston Children's Hospital developed an application it calls Quality & Charge Capture to collect quality improvement-related data directly from clinicians overseeing care by linking it to something that each clinician is responsible for completing for every patient encounter: submitting charge information for professional billing.
The QCC application has been a major success in a complex academic environment spanning both inpatient and ambulatory care to facilitate collection and utilization of quality improvement data directly from clinicians.
"We currently have 77 active quality surveys across 26 clinical specialties," said Daniel Nigrin, MD, senior vice president and CIO at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School. "In 2017, more than 80,000 surveys were triggered and almost 800,000 charges were captured using QCC."
Since the program was designed by and for clinicians, Nigrin said they have been enthusiastic to work with the tools to minimize their investment of time, collect only information they find relevant, and harness functionality to do so efficiently.
"In an era in which medical professionals are inundated with documentation and compliance requirements that are often considered inefficient nuisances, they find QCC refreshing," said Nigrin. "The ability to collect real-time data for clinical quality analysis and improvement has been very powerful in our environment of continuous quality improvement initiatives."
One app, two problems
The QCC application grew out of two seemingly unrelated problems in a fashion in which one system could solve both issues.
"The first problem was professional charge capture," Nigrin explained. "Prior to QCC, most of our physician charges were captured using a variety of paper charge tickets and a series of different vendor systems, which subsequently required manual entry into our billing systems. We felt that charge capture performed directly by clinicians would generate more timely and accurate data collection."
But standard, out-of-the-box descriptors for CPT codes from the American Medical Association and ICD codes from the World Health Organization are often neither clinician-friendly nor specific to the conditions treated and procedures performed in the quaternary pediatric institution, Nigrin said.
"Thus, we sought to facilitate clinician-chosen descriptions with many-to-one descriptor-to-code mapping," said Nigrin. "We used a commercial vendor for part of this work, but also built upon it with additional Boston Children's-specific terminologies, as we found that some of our very unique patients and their care needs were not captured by the code sets nor the vendor."
The second problem it addressed was capture of quality/outcomes data elements at the time of service – for specific populations of patients chosen by age, gender, specialty, diagnosis, procedure or other parameters. Like most organizations, quality improvement efforts often occurred retrospectively, conducted by individuals not involved in the care of the patient, and usually using only information stored in the EHR.
"Since clinicians would now be performing charge capture electronically, survey questions could be triggered by the chosen combination of codes and patient demographics, allowing collection of patient-specific quality improvement data while fresh in the clinician's mind, and that might be difficult or impossible to extract from the medical record at a later time," said Nigrin.
How QCC works
After completing a clinical encounter, a physician can access QCC from a desktop icon, an intranet homepage menu or directly from within the Cerner EHR. If entering from the icon or menu choice, they can find the patient of interest in a list patients scheduled that day, a "pending charges" list, or by searching name or medical record number.
If they enter QCC from the Cerner PowerChart embedded tab, QCC loads the patient whose clinical record is currently open. The clinician name and place of service are pre-populated. If appropriate, a choice of encounters will be presented. The physician will enter the procedural or evaluation and management descriptions and codes by search, by choosing from specialty-specific "favorites" menus, and/or selection from previously used diagnoses and services.
They are presented with diagnoses previously used by clinicians in their specialty as well as those chronic conditions chosen by other specialists, which can be used to populate the patient's problem list in PowerChart.
"If any of the entered data triggers a quality survey, they respond to those questions most typically by choosing from multiple choice radio buttons," Nigrin explained. "The user interface is clean and elegant but robust, allowing all data entry activity to occur from a single screen. By design, we aim to have the quality surveys take seconds and not minutes to complete. The transaction is completed by clicking a Sign button attesting to their entry."
If a mid-level provider or trainee initiates data entry, the attending provider will be presented with this pre-populated information that can be edited or amended prior to the transaction being completed by clicking an attestation, he added.
"It should be mentioned that creation and maintenance of the quality surveys is managed by clinical departments themselves, and not by IT," said Nigrin. "We created a survey editing tool that allows for streamlined, easy development of the quality surveys that clinicians respond to by the responsible quality improvement experts within the clinical areas themselves."