Case Study: Southern Ohio Medical Center

ProVation® MD Improves Documentation and Coding, Billing Processes

Challenge: Incomplete Procedure Documentation

For years, Southern Ohio Medical Center (SOMC) utilized cardiology-specific procedure documentation as part of their full-scale cardiology software. However, while the system supplied cardiologists with a documentation diagram to support procedure documentation, it ultimately created a number of challenges to their process.

For instance, because the diagram did not include the level of detail necessary for certain cardiology procedures, cardiologists were often required to enter a great deal of text in their procedure notes prior to the procedure. In addition, a number of cardiologists still utilized voice dictation for procedures that were not supported by the system, such as intra-aortic balloon pumps or pericardiocentesis.

"Because information was transferred from the system into a text document, there were also instances where it would not necessarily pull something over correctly and documentation was incomplete," said Nikki Arnold, RN, clinical data analyst.

As a result, the billing department often did not have the documentation needed to bill procedures appropriately.

"More often than not, we did not have the documentation needed from the system or the voice transcriptions to bill people adequately," said Julia McGraw, CMA, CPC, CMSCS, manager, physician billing. "So we approached the Technology Committee about the issues with the system and determined that we wanted a system that would improve the quality of the documentation."

Solution: ProVation MD for Cardiology

Having successfully implemented ProVation MD for multiple specialties, including gastroenterology, pulmonology and general surgery, in addition to ProVation® Order Sets, powered by UpToDate® Decision Support, SOMC ultimately decided to implement ProVation® MD Cardiology to improve procedure documentation in its cardiac catheterization lab.

"We had so much success with ProVation MD in the GI lab that we started expanding to implement the software in other specialties. However, it was ultimately the success with ProVation MD Gastroenterology version 5.0 that led us to implement Cardiology version 4.2," said Dennis Ward, information services application manager. "In addition, ProVation fulfilled our need for more compliant documentation."

The only dedicated procedure documentation and coding solution that provides clinically relevant, intuitive software that ensures hyper-accurate documentation, ProVation MD Cardiology allows cardiologists to efficiently capture robust detail
from even the most complex procedures, then automatically generates clear, complete procedure notes and appropriate reimbursement codes - quickly, easily and without dictation.

Backed by an extensive library of medical content and driven by the unparalleled DocuDiagram feature, ProVation MD allows cardiologists to document procedures quickly and completely. By automatically applying the appropriate reimbursement codes and disseminating critical procedural information, ProVation MD Cardiology ensures appropriate payment, reduces costs and streamlines quality reporting while improving clinical communication and care coordination.

"It really came down to consistency," said Arnold. "We wanted a system that would get all of our cardiologists to document procedures in the same way and get them all on board with automated procedure documentation. The DocuDiagram was also a key feature that we looked for."

Results: Improved Documentation, Billing

Since implementing ProVation MD Cardiology, SOMC has seen improvements to the accuracy and efficiency of procedure documentation and coding and, as a result, billing processes.

"We have seen an increase in the quality of documentation as well as the turn-around time between documentation and coding, which is now just minutes rather than days or weeks," said McGraw. "In addition, the reports are much cleaner and have all of the important information we need to get bills out the door in a timely manner and create confidence in that what we are billing is accurate."

Physician satisfaction with the documentation process has also improved, particularly after upgrading to ProVation MD Cardiology version 5.0.

"Currently, all of the cardiologists in our cath lab are utilizing the ProVation MD software," said Arnold. "With the improvements in version 5.0, particularly the look and functionality of the system, they have all found it incredibly easy to use and like that they can add their favorites to the home screen, which streamlines the process for them."

Version 5.0 also allowed SOMC to integrate the cardiology software with the other ProVation MD specialties, thus streamlining updates to the facility's client software and eliminating the need for two separate servers and platforms. In addition, the software has simplified information sharing via the CliniSync HIE by enabling the exchange of base64-encoded PDF files embedded in HL7 results messages.

"The reports coming out of ProVation MD are so concise that it has made it easier to take that information and supply it to the individual practices that need it, via our health information exchange," said Ward. "In addition, because we can create reports in a PDF format, physicians can consume that information without having to print or fax."

With the transition to ICD-10 less than a year away, SOMC is also confident in knowing that their procedure documentation and coding solution will meet specificity requirements in the new coding environment.

"Documentation and coding in ICD-10 will require that software systems allow physicians to be as specific as possible," said McGraw. "And I am confident that that ability lives in ProVation MD."

Customer Profile

Southern Ohio Medical Center is a 222-bed not-for-profit hospital in Portsmouth, Ohio, providing emergency and surgical care, as well as a wide range of other healthcare services to the surrounding community. The facility currently employs
2,200 full-time and part-time personnel and has a medical staff of more than 140 physicians and specialists.

SOMC was named one of Fortune Magazine's 100 Best Places to Work in America and has been ranked first on Ohio's Top Employers list for five consecutive years. It is fully accredited by The Joint Commission and is the first hospital in the region to achieve the American Nurses Credentialing Center's highest honor, the Magnet recognition status. In addition, SOMC has been awarded the Voluntary Protection Program Star Designation, a cooperative program of the Occupational Safety and Health Administration (OSHA) that places SOMC in the top one percent of hospitals nationwide in safety excellence.

SOMC is a part of the CliniSync Ohio Health Information Partnership, a nonprofit entity dedicated to assisting physicians and other providers with the adoption and implementation of health information technology and creating a secure, sustainable health information exchange throughout Ohio.