Utilization of Lean Principles to Redesign Electronic Charting to Reduce Charge and Documentation Errors by Respiratory Therapists

Background:

In our health system, respiratory therapists (RTs) bill for services as they document within the electronic medical record (EMR). In the USA, hospitals lose millions of dollars in revenue annually because of documentation errors,1 and this is true in our institution. We aimed to use LEAN processes to review and implement changes to the EMR to reduce RT documentation errors and missed revenue.

Methods:

We began this initiative with a preliminary data collection phase where we obtained data from our auditing department to comprehend the severity of the situation. We started the Process Improvement and Implementation Phases by identifying stakeholders and holding a lean-focused event (5 days) led by a Continuous Improvement specialist and RT. After the identification of critical barriers and implementing changes during the Modification Phase, we reviewed data to ensure changes were effective.

Results:

Major barriers included duplicated charting rows, brand-specific labels, the inclusion of too many required fields, and incorrect order of line items for workflow. In total, 123 fields were removed, and 46 were modified during our Modification Phase. When comparing 2018 (before changes) to 2019 (after changes), there were 3,077 and 1,978 RT errors, respectively. The average error per month in 2018 was 256.4 (STD 45.7) and in 2019 was 164.8 (STD 78.4). In Q1 for 2019 there was in increase in total errors that was attributed to technology issues with duplicate charge rows appearing from our changes. Q2, Q3, and Q4 all saw improvement in charge errors in the EMR by 68%, 58%, and 54% (60 % improvement average). See Graph 1 for detailed data.

Conclusions:

Documentation errors made by clinical staff in revenue generating departments/EMRs directly impact accurate charges. Precise and complete documentation is required to generate a charge for the services RT’s provide. Without it, insurers will deny charges. In our institution we were able to decrease the number of documentation rows significantly while still being in compliance with procedural/legal standards. Additionally, we arranged the order of the EMR flowsheet to match the flow of care provided at the bedside, which made the documentation process more intuitive. These changes resulted in the department decreasing its overall documentation errors by 35.7%, which has the potential of saving the health system close to $2 million in gross billed revenue annually.

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Graph 1 displays the total number of EMR documentation errors by RTs in our institution from 2018 and 2019 before and after implmenting changes to our EMR process for ease of use.