Spring Stephen F, Sandberg Warren S, Anupama Shaji, Walsh John L, Driscoll William D, Raines Douglas E
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
Anesthesiology. 2007 Jan;106(1):157-63. doi: 10.1097/00000542-200701000-00025.
Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors.
Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey.
After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification.
This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.
为了获得麻醉服务的报销，需要记录关键时间和事件。作者安装了一个信息管理系统来改善记录保存和计费绩效，但发现仍有大量记录无法及时计费，而且一些记录因存在文件错误根本无法计费。
开发了计算机软件，该软件可自动检查电子麻醉记录，并通过字母数字页面和电子邮件提醒临床医生注意文件错误。通过比较该软件实施前后的计费绩效，对其有效性进行回顾性评估。通过调查评估工作人员对该软件的满意度。
实施该软件后，无法计费的麻醉记录百分比从1.31%降至0.04%，纠正文件错误的中位时间从33天降至3天。将麻醉记录提交给计费服务的平均时间从3.0±0. 1天降至1.1±0.2天。超过90%的工作人员认为该系统有帮助，并且比以前用于错误检测和通知的手动流程更易于使用。
该系统使作者能够将纠正文件错误的中位时间以及从未计费的麻醉记录数量至少减少一个数量级。作者估计，这些改进使他们部门的年收入增加了约40万美元。
