by Barbara Knight, MA, RHIA, CPHQ, and Elke Lewis, RHIT
Phoenix, AZ, is a city of sunshine, golf courses, and resorts. It is one of our nation's fastest growing regions with mild winters, lots of land, and a low cost of living. Yet, despite its geographic advantages, Phoenix-area hospitals are not immune to coder vacancies and physical space limitations in HIM departments. In fact, the coder shortage and space issues are so acute that our organization, Sun Health (a two-hospital integrated delivery network), decided to implement remote coding as a means to recruit and retain qualified clinical coders.
At the 2003 Arizona Health Information Management Association (AZHIMA) convention, we heard that other organizations had achieved zero percent coder vacancy rates and 100 percent coder retention rates by offering coders a work-from-home option. Our remote coding program, now a best practice model in our state, has been extremely successful, so much so that other Arizona hospitals have followed in our footsteps.
This article summarizes our experiences with remote coding, the successes and the challenges. We learned many lessons along the way, which are included in this article along with our benchmarks to help you achieve success with remote coding. This article gives an overview of three practical steps for implementing a successful remote coding program: rethink HIM processes and procedures; staff for remote coding; and keep track of your success. Once you've tackled the primary coding problemscoder shortages and space constraintsremote coding software can be used to move toward an economical and practical electronic record environment.
The Coding Landscape at Sun Health
Before remote coding, it seemed like Sun Health always had at least one open coder position, limited space within the HIM departments, and a lot of coder distractions within the office. The two hospitals, Boswell Memorial and Del E. Webb Memorial, constantly placed help wanted ads in health information publications and local and state newspapers. Despite the two hospitals having relatively new construction, workspace within the HIM departments was at a premium. Five coders were sharing a small office, and several were working second and third shifts to avoid the noise and constant activity during the day. Others wore headsets to block the noise. The most difficult obstacle at the time was minimizing coder distractions. Coders were located right in the middle of the traffic flow due to space limitations. There was just no other place to put them. This made distractions practically unavoidable and further hindered coder productivity.
Moving Forward with the Solution: Remote Coding
After two years of suffering through the coder shortage, space constraints, and slowly increasing discharged-not-final-billed (DNFB) we decided to implement an enterprise-wide home coding program. By allowing our coders to work from home, we would be better able to recruit and retain coders. Additionally, we could establish a central coding service whereby charts from either facility could be coded by the same team of home coders. This would improve coding consistency between the two hospitals and support cross training of coders. Coders who were focused solely on outpatient coding in the past could begin to learn how to code inpatient charts and vice versa.
Most importantly, we would gain valuable space within the department. Coders would have fewer distractions at home resulting in productivity improvements (at least 20 percent according to published benchmarks) and subsequent decreases in our DNFB.1 This became the primary driving force for our chief financial officer and ultimately, the key success factor for our program. Decision made, we proceeded with the implementation of our home coding program.
| Key Success Factors |
Six coders working from home
No coder vacancy
40 percent increase in coder productivity
$10-million reduction in DNFB*
*One time reduction. has remained below organizational mandate.
Step One: Rethink HIM Processes and Procedures
The first step is to evaluate all the record processing functions within your department and ask two questions:
- How will this function be affected if coders are no longer on site?
- Can this process be expedited if the record is available sooner or online?
With regard to the first question, we discovered that most of our record processing functions (e.g., deficiency analysis, release of information, filing) were not affected. The primary HIM function impacted by coders working from home was the physician query process. Healthcare organizations must establish a method to facilitate the communication of coders with physicians when questions arise regarding charts.
At Sun Health, the coders use a query template in Word, which is completed and e-mailed to an in-house documentation specialist. She logs in the query and prints and files it in the record. She is also responsible for following up with physicians to get the queries answered quickly. Once answered, the additional documentation and the query form are scanned, appended to the electronic record, and the chart is sent back to the responsible coder.
It was also helpful to always have at least one coder or a coding manager in the department on site to answer general coding questions from the business office, ancillary departments, physicians, or others.
Unexpected Benefits: Online Record Viewing, Faster Record Completion, and Remote Auditing Capabilities
The second question yielded some unexpected benefits when we implemented remote coding. With this program, hospitals scan records using software provided by a remote coding vendor. These records are then encrypted and sent via the Internet to the vendor's host image server where they are stored for coding, viewing, and other purposes. Whether you are using your own coders, like we did at Sun Health, or an outsourced coding agency, you gain the benefit of an imaged recordwithout the high costs and implementation headaches associated with traditional document imaging systems.
With two locations and HIM responsibilities for both, management gained an advantage in being able to view records online from either facility when remote coding was implemented. Once scanned for coding, records are available for other HIM functions, freeing up record bottlenecks within both departments. There is no more waiting while charts sit on coders' desks; we immediately saw improvements in all areas of HIM.
For instance, once the record is scanned, the deficiency analysis and chart completion process can proceed immediately. Records can be given to the physician without waiting for the coding process. Currently the record is given to the physician within two to three days of discharge and the deficiency rate is less than 20 percent at both facilities.
Another area impacted by having online access to records was the coding audit function. Sun Health uses an external auditing service to perform coding audits. In the past, we would pay all travel costs for the Texas-based auditors to spend one week a quarter at Sun Health. Now we simply scan the records the auditors request, which they view remotely via the Internet. The auditors are trained remotely and use teleconferencing to perform exit conferences with our coders.
Going Forward with the TechnologyFuture Plans
As we roll out the system to other internal users, the function of pulling, filing, and re-filing will also be impacted. Instead of pulling records for other departments and record reviews, we will simply grant these users access to online records.
Finally, we expect to streamline additional HIM functions such as release of information as more and more users within our two departments gain access to online records. Later in 2004, we expect to use the scanned record in combination with electronic signature to allow physicians to complete charts from any location, further improving our chart completion process.
Step One: HIM Processes Impacted by Remote Coding and Online Records
|HIM Function Impacted ||Best Practice Suggestion ||Sun Health Benchmark|
|Physician Query Process || || |
|Chart Completion ||Scan immediately for coders and then perform deficiency analysis and route charts to physicians for completion. ||Get chart to MD within two to three days after discharge. Maintain deficiency rate of less than 20 percent at both hospitals.|
|Coding Audits ||Give auditors access to online record, coders' notes, etc. All reviews performed remotely. ||Reduce travel expenses by $10,000 a year.|
|Phase II: Chart Pulling/Filing/Re-filing ||Once online, grant other internal users access to records, dramatically decreasing the number of charts needed to be manually retrieved and re-filed. ||Goal is to eliminate .5 FTE in each hospital in first year for chart pulling/filing/re-filing. File room staff will be transitioned to other positions. |
|Phase II: Online Chart Deficiency Analysis and Completion ||Allow deficiency analysis staff to work from home or any remote location. Allow physicians to view and complete charts online from any location. ||Goal is to reduce chart deficiency rate by 50 percent to less than 10 percent.|
Step Two: Staff for Remote Coding
Working from home is not for everyone. In the second phase of implementation, you will need to identify which staff will be working from home and which staff will be assigned scanning and coding management responsibilities on site. When selecting coders to work from home, look for the following skills:
- ExperienceIn one group interviewed by AHIMA, home coders averaged 14 years of coding experience.2
- Self-directed work ethic
- Conducive home office environment
- Competency with software such as Citrix, Word, Hospital Information Systems, and troubleshooting software as needed with technical staff
Productivity and quality should be measured before the coders are sent home to get a baseline and then at one-week, two-week, and one-month intervals after they begin working from home. Productivity should increase dramatically once coders are comfortable with coding from an imaged record. Sun Health coders made the transition very quickly, and productivity rates at home were the same as baseline within one day and have increased ever since.
In the past we would give the coders 20 to 25 charts a day to complete. Now, each coder is assigned up to 40 charts a day to code. In the majority of cases, all 40 charts are completed. Even using a very conservative calculation, our productivity rate increased more than 40 percent. In fact, we had to place a mandatory five-day hold on the coding process so that a more complete record would be available at the time of coding because coders were coding so quickly.
Scanning TechniciansThe Wind Beneath Our Wings
|Tip for Hiring Scanning Technicians: |
Staff should be comfortable using computers, a mouse and the Internet.
At Sun Health, it became immediately obvious that home coder productivity and scanning productivity were closely related. With the vendor's software, the scanning process was fairly simple. Records were indexed at the encounter level with only a few demographic data elements required at the time of scanning. Records could also be scanned in batch mode (good for emergency department and ancillary visits). If your organization already has medical record number, patient name, encounter number, or any other demographic data in barcode format, your scanning process will be even faster than our experience (see below table for benchmark scanning productivity).
When we first implemented the system, we transitioned several senior file clerks to the role of scanning technician. We made the assignments based on seniority with Sun Health. One of our challenges was that the older members of our staff were not comfortable with computers or the Internet. Ultimately, we had to rethink this decision. We resolved this issue by retraining the scanning technicians and making sure that newly hired technicians were computer literate. The process is now much faster and has been running smoothly.
Step Two: Sun Health Scanning and Coding Benchmarks
| ||Best Practice Suggestion ||Sun Health Benchmark|
|Scanning Process ||Limit amount of data indexed |
Use barcoded demographic data if available
Hire computer literate staff for scanning
Scan 24 hours a day, seven days a week to ensure coders always have charts to code
|1015 inpatient records an hour|
|Coding Productivity ||Measure before sending coders home for baseline |
Measure several times within first 60 days of home coding implementation
Continually monitor using system reports
|45 inpatient records an hour|
|Coding Quality ||Measure before sending coders home for baseline |
Measure several times within first 60 days of home coding implementation
Continually monitor using system reports
|Our standard is 95 percent coding accuracy and 97 percent DRG accuracy. |
If coders do not maintain this accuracy requirement, bring coders back into the hospital.
Step Three: Track Your Success
As with any project, the proof is in the pudding. Because we measured our coding landscape before implementing the home coding program, it was easy to measure our success. Our most significant improvement was in DNFB reductions ($8.3 million at Boswell and $2.4 million at Web). This was a one-time reduction that instantly got the attention of our chief financial officer.
In fact, the staff was so up to date with coding that final documentation was lacking in many of the charts. It was at this point that we decided to delay the coding process five days after discharge to accumulate as many reports, results, and other documentation as possible before coding. This internal decision along with some reallocation of coding staff to auditing roles has not allowed us to maintain more than $10 million in DNFB reductions. However, we have been able to keep DNFB well below administration mandates.
Home coding was the answer to our coding crisis at Sun Health. It helped us recover valuable space and improved coder productivity by eliminating the typical office distractions. Coders are much happier at home and we have a list of qualified clinical coders waiting to work for us. And, most importantly for our CFO, the program has reduced DNFB and subsequently improved accounts receivable.
Implementing a home coding program has other benefits for HIM departments. Functions such as deficiency analysis and chart completion will be expedited. Record processing logjams where people must wait for a record until coders are done with the chart disappear. Other reviewers, such as auditors, physicians, and the business office have easy access to online records. This can have a dramatic reduction in chart pulling, filing, and re-filing.
The bottom line is that the home coding software can be used to solve the number one issue for integrated delivery networks: simultaneous user access to medical records.3 As such, hospitals can smooth the transition to electronic records by taking practical steps within the HIM department. For Sun Health, this meant solving the coder crisis first. Our second step toward electronic records will be to improve our chart completion process by allowing physicians to complete their records online.
We'll continue to learn lessons along the way and apply them to our next project.
1. Friedman, Beth. "Open the Door to Home Coding Improve the Bottom Line." Presented at AZHIMA, May 2003.
2. Zeisset, Ann. "Coding on the Home Front." Journal of AHIMA 73 no. 4 (2002): 735.
3. Fourth Annual Medical Record Institute Survey of Electronic Health Record Trends and Usage, 2002. Available for purchase at www.medrecinst.com.
Barbara Knight (firstname.lastname@example.org) is director of medical records, and Elke Lewis (email@example.com) is manager of medical records at Sun Health Corporation in Phoenix, AZ.
|Source: AHIMA Communities of Practice, 7/6/04)|