Examining the Durability of an Inexpensive Intervention for Improving Point-of-care Ultrasound Documentation Rates

Abstract

Background:

Point-of-care ultrasound (POCUS) has become a widely used diagnostic tool in emergency departments (EDs), and proper documentation is essential for both patient safety and reimbursement. POCUS is often underdocumented, and therefore, underbilled, by emergency medicine physicians. The absence of POCUS documentation can result in significant revenue loss for both providers and hospital administration.

Methods:

This study is a follow-up study to the manuscript published by Lahham et al. and primarily examines POCUS documentation rates for a 15-month billing period following the initial intervention of a personalized e-mail reminder. Data included rates of documented and phantom scans from three separate 11-day periods (April 2019, July 2019, and July 2020) after the performance feedback intervention in March 2019.

Results:

Documentation rates steadily declined from April 2019 to July 2020 following the intervention, with the highest success rate being immediately after the e-mail intervention.

Conclusion:

This study demonstrates that there is limited durability to a single e-mail reminder as an intervention to improve POCUS documentation in the ED and suggests that there is a need for repeated interventions to prevent deterioration of documentation rates.

INTRODUCTION

In an effort to improve emergency department (ED) patient care, point-of-care ultrasound (POCUS) has become a widely used, safe, and cost-effective diagnostic tool.[1,2] POCUS is defined as ultrasonography done at the bedside by a provider who interprets the findings in real time. The benefits of POCUS are ample: decreased ionizing radiation exposure with imaging, increased speed of clinical decision-making, and decreased overall health-care costs per visit.[3,4] In recent years, the scope of POCUS has expanded, and it plays a key role in many hospital settings including emergency and critical care.[5] POCUS examinations are also an integral part of emergency medicine residency training per the American College of Emergency Physicians guidelines.[6] In addition, for the 2018–2019 academic year, up to 80% of American and Canadian medical schools surveyed by the Association of American Medical Colleges required ultrasound training as part of their official curricula.[7]

Proper documentation is essential for both patient safety and reimbursement. POCUS, like any other procedure performed during the course of a patient’s medical care, should be documented appropriately both with a procedure report and with archived images, as others on the care team should be able to view the results of a scan and how it was interpreted.[4] Accurate medical and procedural documentation is necessary to facilitate communication between health-care professionals and has been shown to reduce medical errors, such as delays to care or errors in patient treatment, especially during transitions in care.[8]

Unfortunately, POCUS is often underdocumented, and therefore, underbilled, by emergency medicine physicians.[9,10] Specifically, resident physicians reported that one of the major barriers to ultrasound utilization in the ED is unfamiliarity with billing systems and documentation. Prior studies have noted that with purposeful interventions, like in-person educational sessions for ED physicians, many of these barriers can be addressed.[11] Other POCUS-specific interventions for improving documentation include online image-based billing systems,[12] the use of resident physician task forces to identify barriers to documentation and solicit feedback from providers regarding billing practices,[13] and automated online billing protocols.[14] The absence of POCUS documentation can result in significant revenue loss for both providers and hospital administration. There is a need for actionable and effective interventions in the ED to promote POCUS documentation rates.

To address this need, a study from the University of California, Irvine Department of Emergency Medicine by Lahham et al. examined the use of a personalized e-mail reminder sent to residents and attending physicians in an effort to increase ultrasound documentation rates over a 6-week period.[15] They found that there was a significant increase in documentation rates in the 6-week period following the personalized e-mails. No study has yet examined the long-term effects, or the durability, of the e-mail intervention as described by Lahham et al. This study is a follow-up study to the manuscript published by Lahham et al. and primarily examines POCUS documentation rates for a 15-month billing period following the initial intervention of a personalized e-mail reminder.

METHODS

We performed a retrospective review of the POCUS database from ED-performed examinations as part of the weekly quality assurance process at our tertiary, academic, level-1 trauma ED. Every scan in the database for an 11-day period was reviewed and cross-referenced with a procedure note in the electronic medical record (EMR) to calculate the provider documentation rate. We repeated this process for three separate 11-day periods following the performance feedback intervention which occurred on March 1, 2019 (described by Lahham et al.[15]): April 2019 (1 month after intervention), July 2019 (3 months after intervention), and July 2020 (15 months after the intervention). We sought to determine the level of compliance with documentation and if or how the rates declined after the performance feedback intervention. This study was exempted from the IRB.

All POCUS studies were performed on the Mindray TE7 ultrasound machine. Types of studies performed included extended focused assessment with sonography for trauma, cardiac echocardiography, thoracic/pulmonary ultrasound, general abdominal ultrasound, biliary ultrasound, renal ultrasound, small-bowel obstruction abdominal ultrasound, abdominal aortic aneurysm ultrasound, inferior vena cava ultrasound, obstetric and gynecologic ultrasound, ocular ultrasound, and soft-tissue ultrasound. When a POCUS study is performed at the treating provider’s discretion, patient information is entered into the machine either manually or through an automated worklist. If the automated worklist is used, the captured and saved images are attached to the patient’s chart in the EMR system (EPIC). The documentation process involves writing a procedure note in the EMR with the findings noted during the POCUS examination, as well as the interpretation of those findings. This process is separate from entering the patient information into the ultrasound machine and saving images. The billing department bills for studies based on procedure notes recorded in the EMR. If there is no documented procedure note, the study is not billed for. Phantom scans refer to studies in the ultrasound database (i.e., captured and saved images on the ultrasound machine) that do not contain patient information or correct patient information (i.e., missing data or incomplete data). Phantom scans were not included because the absence of medical record numbers on the scans made it impossible to identify the patient to whom the scan belonged.

Data analysis was performed using IBM SPSS Statistics (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY). Proportions are presented as point estimates and 95% confidence interval. Chi-square for trend was used to examine the change in documentation over time. P <0.05 was considered statistically significant.

RESULTS

During the 11-day period in April 2019, 203 total POCUS examinations were performed and 51 failed (25.1%, 19.3%–31.7%) to have subsequent report documentation. During the 11-day period in July 2019, 181 total POCUS examinations were performed and 77 failed (42.5%, 35.2%–50.1%) to have subsequent report documentation. Finally, during the 11-day period in July 2020, 257 total POCUS examinations were performed and 124 failed (48.2%, 42.0%–54.5%) to have subsequent report documentation. The decline in documentation rate was statistically significant from April 2019 to July 2019 (P < 0.001). However, the decline from July 2019 to July 2020 was not statistically significant [P = 0.238, Figure 1].

Figure 1.

Documentation rates for three separate 11-day periods after the performance feedback intervention

DISCUSSION

Documentation rates steadily declined from April 2019 to July 2020, with the highest success rate being in the period immediately after the intervention of a personalized e-mail reminder (74.9% success). The steepest decline in documentation rate was observed at the 3-month mark following the e-mail intervention (57.5% success), which was statistically significant, and the decline was less severe and not significant the following year at the 15-month mark (51.8% success).

The gradual and nonsignificant decline between 3 months and 15 months may demonstrate a return to baseline documentation rates sometime between the 1-month and 3-month marks, making the change at 15 months not significant and thereby demonstrating the lack of durability of a single e-mail reminder as an intervention. This was a follow-up study to that done by Lahham et al.[15] who reported a baseline documentation rate of 60.1% before the intervention; this study similarly shows a documentation rate of 57.5% at the 3-month mark and 51.8% at the 15-month mark, likely representing the normal variation in baseline documentation rates.

Various trends have been observed in the literature related to similar and differing interventions; there are several factors that could explain these trends and the possible etiology behind the decrease seen in our study. Prior literature has examined the use of multiple interventions over a period of time, while this study examines the durability of a single intervention without any follow-up reminders. Prior studies with multiple interventions generally did not find a decline or a statistically significant decline. A prior study by Ng et al. described the use of multiple interventions (direct physician education and feedback, standardized billing protocols, and a new EMR documentation template) to improve ED POCUS documentation rates as opposed to a singular intervention.[4] With regard to the durability of those interventions, after an initial increase following the intervention, the documentation rates continued to stay stable at that improved rate for a 6-month period, however, no documentation rates were described following the 6-month, postintervention period.[4] A study by Lewiss et al. also utilized multiple interventions (individualized meetings and feedback, reminder e-mails, increasing workstation logout time, and laminated reminder cards at workstations), and noted that their documentation rates at both 3-and 6-month intervals increased or stayed the same.[13] Other studies analyzed documentation rates also with multiple interventions such as educational sessions, new workflow protocols, and resident-specific reminder e-mails.[16,17] In a study by Aziz et al., documentation rates were analyzed during four 10-day periods over the course of 2 months; an increase in documentation rates was observed, though the authors also concluded this likely was too short of a window to accurately assess the durability of their intervention in the long-term.[16]

Although the interventions differed, our study results are similar to those noted by Rong et al., who used educational sessions, a new workflow, and a specific reminder e-mail for each new resident “schedule block.”[17] In this study, they reported a decrease over a 3-month period after their intervention. The authors did not offer an explanation for the decrease nor did they include the frequency or timing of the resident reminder e-mails.[17] Based on our results and the above studies, some strategies to improve the durability of the e-mail intervention would be to increase the frequency of the e-mail reminders and implement multiple strategies such as regular educational sessions and personalized provider documentation feedback in addition to e-mails alone.

Regarding the potential lost revenue due to phantom scans, during the selected period in July 2020, there were 257 total POCUS examinations performed and 124 (48.2%) failed to have subsequent report documentation (51.8% success). This can be estimated to result in approximately $4000 in lost professional charges and an estimated $12,000 in lost technical charges. Sending a regular e-mail reminder is an intervention that costs only a small amount of time yet may significantly improve documentation rates, thereby improving revenue capture.

There are several limitations to this study. The new academic year at our institution begins in July of each year, thus there are likely groups of residents, fellows, and attendings that did not receive the initial intervention e-mail that was sent out before their start date. In addition, the new residents and fellows are taught to use the POCUS machines and document in the EMR during their orientation week just before July 1. This may have had an effect on and explain the nonsignificant decline from July 2019 to July 2020 as noted in our results. Finally, due to the size of the institution and the high utilization of POCUS in our ED, missed billing charges were substantial, which may not reflect the missing billing at a smaller institution.

CONCLUSIONS

This study demonstrates that there is limited durability to a single e-mail reminder as an intervention to improve POCUS documentation in the ED and that the effects of a single intervention do not last long. At both the 3- and 15-month time points, we observed that POCUS documentation rates decreased as compared to 1 month following the e-mail reminder intervention. This study builds upon prior research and shows that there is a great need for repeated interventions to prevent the deterioration of documentation rates. Further areas of study could investigate different combinations of interventions at standardized time points to identify patterns in POCUS documentation rates and POCUS user behaviors, and whether these interventions lead to decreased billing failure rates, increased hospital revenue, and improved patient safety.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.