Case Study Module 4

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University of California, Los Angeles *

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Health Science

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Feb 20, 2024

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docx

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Uploaded by PresidentHorse4119

During the Design phase of the System Development Life Cycle, organizations should create and later implement a robust change management plan It has come to my attention that our organization may be losing significant inpatient revenue due to declining reimbursement rates from payors and heightened scrutiny from payors resulting in increasing denials. For example, I was recently made aware of a complex gynecology oncology case at UCLA Health that resulted in $400,000 in unreimbursed charges. What the video shows - This presentation demonstrates how UCLA Health leveraged their electronic health record (EHR) to save two million dollars per year in denials. How they did it - Through automated error detection and notification systems, this project utilized existing resources for cost-effective solutions that do not place additional burden on the provider. Your job – identify potential sources of stakeholder resistance to the implementation of this automated error detection and notification system. Problem  a patient came to the transfer center for a gynecology oncology problem. When the patient came to the transfer center, the resident wrote a “transfer patient” order and updated patient class to “inpatient” without writing an inpatient order. Patient stayed at UCLA for 23 days and was discharged without the patient ever having an admission order. This resulted in 400,000 in charges that UCLA was not reimbursed for. Context: Reimbursement rates from payors were declining and scrutinizing reimbursements heavily resulting in fewer reimbursements. UCLA leadership was thus growing concerned. These are areas of the problem that they choose to focus on:  UCLA Utilization review relies on time-consuming manual audits to catch common admission order errors. These errors are easily missed and result in reimbursement denials and regulatory non-compliane o SO  Practioners are committing admission order errors that result in reimbursement denials and non-regulatory compliance that can further cost the hospital even more money with they are auditing further down the line. Ex. Admit to inpatient order is the Doctors sign off that the patient needs to be admitted to the hospital  Barriers: the person who writes the orders is usually the intern. Interns are the most junior members of the team and have the least training in hospital documentation requirements. Once the patient actually leaves the hospital no modification can be made to these orders. They assigned key stakeholders within the overall workflow. Each key stakeholder mapped out their specific portion of the workflow. The process map that was created held, the roles identified within the

problem, the steps that each role completes in their workflow, and potential ways to improve a particular step and then prioritized opportunities based on how often they happen and their impact. The broke the project up into subteams. The subteam that they focused on for the video is the MD informatics team that mainly looks at the order portion. The utilized currently standing meetings between operations leaders in the following areas to discuss important opportunities that affected related portions of the process map: They identified 2 areas for potential high reimbursement loss: 1. Missing inpatient IP order and Medicare < 2 midnight (medicare patient discharged before 2 midnights). They then sought out the individuals are integral to the admission of patients. So they decided either physicians or case managers would need to be targeted either at admission or at the least before the patient is physically discharged. They decided to minimize added burden for providers and minimize changes to the existing workflows by leveraging what they currently had. Proposed Solutions: 1. Creating an alert to the provider discharger the patient to contact case manager for scenario 1 and 2. This solution was ultimately not implemented because they recognized that a physician may not recognize the need for delaying discharging the patient. And may fail to contact the case manager in a timely manner, if they contacted the case manager even at all.

2. Alter the provider if IP order missing after the first 24 hours after admission. This solution was not pursued out of fear that the Doctor may ignore the alert due to alert fatigue or cause annoyance. 3. Alert to case manager that IP order is missing. This solution was not pursued because in their daily workflows, case manager occasionally open patient charts so the advisory alert wouldn’t always be seen or triggered. Implemented Solutions: They decided to enlist 4 solutions to scenarios 1 and 2.  Case manager patient list displays patient with missing IP order (preemptive)  aka it is highlighted in a color that informs the case manager that an order had not been generated  Automatially generated daily e-mail of inpatient discrepancies prior to discharge (preemptive)  application analyst created this alert and this is proven particular useful and effectiving a resolution within the first 24 hours  Pager notification to Case Management prompted by discharge order placed when IP order missing (fail-safe)  sends virtual Page to the case management team and the case manager will have to determine whether the patient meets the criteria for admission, that the patient has been there for more than 2 nights, and the provider documentation is adequate. If the patient is a surgery patient, the case manager will make sure that the primary procedure is part of the CPT list.  Pager notification to Case Management prompted by discharge order placed for Medicare patient IP < 2 midnights (fail safe) Scenario 1: Missing IP Order Priorities  A. Obtain inpatient order as early as possible in the hospitalization. B. Obtain inpatient order at least prior to patient leaving the room, which is about 2 hours after discharge order is signed Scenario 2: Medicare staying less than 2 midnights  A. Get the patient in the right patient class in the right time by alerting the case manager B. Provide appropriate staff in near real-time the need for case review to comply with mandates Potential sources of stakeholder resistance:

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