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Background: A home-based record (HBR) is a health document kept by the patient or their caregivers, rather than by the health care facility. HBRs are used in 163 countries, but they have not been implemented universally or consistently. Effective implementation maximizes both health impacts and cost-effectiveness. We sought to examine this research-to-practice gap and delineate the facilitators and barriers to the effective implementation and use of maternal and child health HBRs especially in low- and middle-income countries (LMICs)., Methods: Using a framework analysis approach, we created a framework of implementation categories in advance using subject expert inputs. We collected information through 2 streams. First, we screened 69 gray literature documents, of which 18 were included for analysis. Second, we conducted semi-structured interviews with 12 key informants, each of whom had extensive experience with HBR implementation. We abstracted the relevant data from the documents and interviews into an analytic matrix. The matrix was based on the initial framework and adjusted according to emergent categories from the data., Results: We identified 8 contributors to successful HBR implementation. These include establishing high-level support from the government and ensuring clear communication between all ministries and nongovernmental organizations involved. Choice of appropriate contents within the record was noted as important for alignment with the health system and for end user acceptance, as were the design, its physical durability, and timely redesigns. Logistical considerations, such as covering costs sustainably and arranging printing and distribution, could be potential bottlenecks. Finally, end users' engagement with HBRs depended on how the record was initially introduced to them and how its importance was reinforced over time by those in leadership positions., Conclusions: This framework analysis is the first study to take a more comprehensive and broad approach to the HBR implementation process in LMICs. The findings provide guidance for policy makers, donors, and health care practitioners regarding best implementation practice and effective HBR use, as well as where further research is required., (© Mahadevan and Broaddus-Shea.)

Aims: Monitoring risk-based approaches in clinical trials are encouraged by regulatory guidance. However, the impact of a targeted source data verification (SDV) on data-management (DM) workload and on final data quality needs to be addressed., Methods: MONITORING was a prospective study aiming at comparing full SDV (100% of data verified for all patients) and targeted SDV (only key data verified for all patients) followed by the same DM program (detecting missing data and checking consistency) on final data quality, global workload and staffing costs., Results: In all, 137 008 data including 18 124 key data were collected for 126 patients from 6 clinical trials. Compared to the final database obtained using the full SDV monitoring process, the final database obtained using the targeted SDV monitoring process had a residual error rate of 1.47% (95% confidence interval, 1.41-1.53%) on overall data and 0.78% (95% confidence interval, 0.65-0.91%) on key data. There were nearly 4 times more queries per study with targeted SDV than with full SDV (mean ± standard deviation: 132 ± 101 vs 34 ± 26; P = .03). For a handling time of 15 minutes per query, the global workload of the targeted SDV monitoring strategy remained below that of the full SDV monitoring strategy. From 25 minutes per query it was above, increasing progressively to represent a 50% increase for 45 minutes per query., Conclusion: Targeted SDV monitoring is accompanied by increased workload for DM, which allows to obtain a small proportion of remaining errors on key data (<1%), but may substantially increase trial costs., (© 2019 The British Pharmacological Society.)

Aim: The misuse and abuse of Enduring Powers of Attorney (EPAs) by attorneys, particularly in relation to financial decision-making, is a growing concern. This paper explores the opportunities to enhance accountability of attorneys at the time of the execution of the document in Queensland., Method: A four-stage multi-method design comprised a critical reference group; semi-structured interviews with 32 principals or potential principals, attorneys and witnesses; two focus groups with service providers and a state-wide survey of 76 principals, attorneys and witnesses., Results: Across all methods and user groups, understanding the role and obligations of the attorney in an EPA was consistently identified as problematic., Conclusions: Promoting accountability and understanding can be addressed by greater attention to the role of the attorney in the forms/ guidelines and in the structure and witnessing of the forms, increased direction about record keeping and access to appropriate advice and support., (© 2013 ACOTA.)

The permanent adjustments ​​since 2003 to the G-DRG system have made the system even less understandable, so that many users have the feeling of feeding data into a black box which gives them a result without them being able to actively use the system itself. While chief physicians, senior physicians, and nursing managers are responsible to management for the results of the billing, they are in most cases not involved in the steps of DRG coding and billing. From this situation, a common question arises: "How well does my department code?" This uncertainty is exploited by many commercial vendors, who offer a wide variety of approaches for DRG optimization. The goal of this work is to provide advice as to how coding quality can be determined.

Objectives: To develop a database for documenting pharmacist intervention through a web-based application. The secondary endpoint was to determine if the new, web-based application provides any benefits with regards to documentation compliance by clinical pharmacists and ease of calculating cost savings compared with our previous method of documenting pharmacist interventions., Setting: A tertiary care hospital in Saudi Arabia., Method: The documentation of interventions using a web-based documentation application was retrospectively compared with previous methods of documentation of clinical pharmacists' interventions (multi-user PC software)., Main Outcome Measure: The number and types of interventions recorded by pharmacists, data mining of archived data, efficiency, cost savings, and the accuracy of the data generated., Results: The number of documented clinical interventions increased from 4,926, using the multi-user PC software, to 6,840 for the web-based application. On average, we observed 653 interventions per clinical pharmacist using the web-based application, which showed an increase compared to an average of 493 interventions using the old multi-user PC software. However, using a paired Student's t-test there was no statistical significance difference between the two means (P = 0.201). Using a χ² test, which captured management level and the type of system used, we found a strong effect of management level (P < 2.2 × 10⁻¹⁶) on the number of documented interventions. We also found a moderately significant relationship between educational level and the number of interventions documented (P = 0.045). The mean ± SD time required to document an intervention using the web-based application was 66.55 ± 8.98 s. Using the web-based application, 29.06% of documented interventions resulted in cost-savings, while using the multi-user PC software only 4.75% of interventions did so. The majority of cost savings across both platforms resulted from the discontinuation of unnecessary drugs and a change in dosage regimen. Data collection using the web-based application was consistently more complete when compared to the multi-user PC software., Conclusions: The web-based application is an efficient system for documenting pharmacist interventions. Its flexibility and accessibility, as well as its detailed report functionality is a useful tool that will hopefully encourage other primary and secondary care facilities to adopt similar applications.

Inspired by recent scholarship that calls for a more critical engagement with archives and knowledge production, this article plots the biography of an archive in Cape Town. Unravelling the layers of paperwork, it locates the origins of the archive in a repressive state project of excluding Indian immigrants and controlling those within the borders of the Cape Colony. The paper trail reveals documents of identity and the state’s attempts to verify identity. In seeking to answer the question as to how the historian should approach such an archive of control and surveillance, it concludes that a social history and gendered approach to migration is possible and the real treasures are those documents that enter the archive beyond the limits of state intentions.

Genetic testing is becoming a common component of medical practice and is used to determine definitive diagnoses for several adult pulmonary diseases. It is important for pulmonologists to know when to use genetic tests for diagnosis and medical management. This article describes diagnosis of rare hereditary pulmonary disease in adults and the role of genetic testing. A summary on coding and reimbursement is included.

Background and Study Aims: Gastrointestinal endoscopy investigations are frequently requested by gastroenterologists, general practitioners and other physicians. In addition to the classic methods of report writing, several electronic endoscopic report systems are currently available. The aim of the study was to evaluate the costs of three different ways of producing reports; by hand, by dictation, or by computer., Methods: Three methods of report writing were compared, with special attention to costs. The endoscopy process was analyzed, from arrival of the patient to sending the report to the referring doctor, and including production of endoscopic images or video, logging of used endoscopes and their disinfection, and storage costs for endoscopy data., Results: During the first 5 years, the mean costs per procedure were Euro 4.78 for handwritten, Euro 6.39 for dictated and Euro 8.90 for computerized reports. Due to depreciation, after this initial period, the respective costs declined to Euro 4.37, Euro 5.20 and Euro 5.13, respectively. Despite high initial costs, a cost-benefit analysis already revealed a financial benefit from a computerized system after 3 years., Conclusions: The electronic production of an endoscopic report turned out to be the most expensive way of report writing during the first 5 years, due to high initial costs. After 5 years the costs of the different systems were comparable with each other. Cost-benefit analysis showed a positive financial benefit for computerized reports after 3 years.

Background: Artificially influencing the case mix of hospitals may have several deleterious consequences for the hospital care system. One distinguishes over-evaluation (up-coding) and under-evaluation (under-coding) of the case mix. Apart from its financial consequences, miscoding may cause a fracture in epidemiological time series and, by increasing artificially the severity of illness, may affect the assessment of the quality of hospital care, based on administrative data., Methods: Fixed effects models were used to assess deviant coding behavior at the hospital level. To do so, we examined the linear evolution over time of characteristics such as length of stay and of 21 "triggering" conditions susceptible to increase the case mix of a stay. In case of deviant coding, these triggering conditions were checked to direct the audit towards fraud-suspected discharge abstracts. Hereto, a method consisting in comparing a single hospital's linear evolution over time with the national linear evolution over time was developed, using an interaction term between linear evolution over time and hospitals. To test this methodology, fraud-directed audits were carried out in addition to the usual, at random audits., Results: Important inter-hospital differences in the linear evolution over time of several characteristics of Belgian hospitals were identified, as well as evidence not only of improving coding practices, but also of up-coding, fraudulent under-coding and of numerous coding errors without financial impact. The coding errors, ascertained in the at random audit, resulted in a wrongful gain for the faulty hospitals of 28.23 days in 258 stays, whereas in case of fraud-directed audits these figures amounted up to 642.68 days in 334 stays., Conclusion: Fraud-directed audit may constitute a valuable tool in the quality assurance of administrative databases, improving their use in epidemiology and assessment of the quality of care.

Objectives: The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient., Methods: The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student's t-test and repeated-measures analysis of variance, as appropriate., Results: The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was 282.82 USD, which increased to 301.94 USD in the second phase (p = 0.0004)., Conclusions: The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).

Background: We propose that excess risk-adjusted, postoperative length of stay (poLOS) is a valid indicator of an adverse outcome., Methods: Hospital administrative claims data for elective colon resection, coronary bypass graft surgery, and total hip replacement were used from the 100 largest-volume hospitals in the Health Care Cost and Utilization Project for 2005. Risk-adjusted poLOS linear models were designed and outliers were determined using control charts. Costs of hospital care were examined by the presence of coded complications (CCs) and/or being a poLOS outlier., Results: Patterns of CCs and risk-adjusted poLOS outliers were significantly different (P < .0001, chi-square test). For all procedures, costs of care were similar with or without CCs if the patients were not poLOS outliers. For patients who were poLOS outliers, costs were significantly different (Tukey-Kramer test) independent of whether CCs were present or not., Conclusions: Adverse surgical outcomes are better defined by risk-adjusted poLOS and cost criteria rather than coded or surveillance observations.

Introduction: Within the NHS, operations are coded using the Office of Population Censuses and Surveys (OPCS) classification system. These codes, together with diagnostic codes, are used to generate Healthcare Resource Group (HRG) codes, which correlate to a payment bracket. The aim of this study was to determine whether allocated procedure codes for major head and neck operations were correct and reflective of the work undertaken. HRG codes generated were assessed to determine accuracy of remuneration., Patients and Methods: The coding of consecutive major head and neck operations undertaken in a tertiary referral centre over a retrospective 3-month period were assessed. Procedure codes were initially ascribed by professional hospital coders. Operations were then recoded by the surgical trainee in liaison with the head of clinical coding. The initial and revised procedure codes were compared and used to generate HRG codes, to determine whether the payment banding had altered., Results: A total of 34 cases were reviewed. The number of procedure codes generated initially by the clinical coders was 99, whereas the revised codes generated 146. Of the original codes, 47 of 99 (47.4%) were incorrect. In 19 of the 34 cases reviewed (55.9%), the HRG code remained unchanged, thus resulting in the correct payment. Six cases were never coded, equating to pound15,300 loss of payment., Conclusions: These results highlight the inadequacy of this system to reward hospitals for the work carried out within the NHS in a fair and consistent manner. The current coding system was found to be complicated, ambiguous and inaccurate, resulting in loss of remuneration.

Effective October 1, 2007, the Centers for Medicare and Medicaid Services has changed its methodology for determining the diagnosis-related group for hospitalized patients. In an effort to more accurately reflect severity of illness, the 538 diagnosis-related groups have been converted to 745 new Medicare severity diagnosis-related groups. In addition, selected hospital-acquired complications not identified as present on admission will no longer be reimbursed. The changes will have profound effects on reimbursement for hospitalizations. To minimize financial losses under the new rules, hospitals and physicians will have to devote significant resources and attention to improved documentation. This article will discuss the new payment system, the physician's role in ensuring that all clinically important diagnoses are captured by coding specialists, and strategies that can be employed to respond proactively to the challenge.

Without administrative terminologies there is no revenue to manage. The use of healthcare IT to capture the codes for administrative and financial support functions will impact the revenue cycle and the management of it. This is presumed to occur because clinical data coded at the point of care becomes the source for claims data. Thus, as electronic health record system applications utilizing terminologies are implemented, healthcare providers need to systematically consider the effect on the coding function and management of the revenue cycle. A key factor is the sequence of events changes, i.e., instead of a health information management professional selecting billing codes at the conclusion of an encounter based on the review of the record, clinical data generates the claims data via mapping. Efficiencies and management challenges result.

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.

Background: Asthma and COPD can significantly affect patients and pose a substantial economic burden for both patients and managed-care plans. This study compares utilization outcomes in patients with asthma, COPD, or co-occurring asthma and COPD in a Medicaid population, and assesses the incremental burden of COPD in patients with asthma., Methods: We queried medical claims of Medicaid patients aged 40 to 64 years with asthma and/or COPD filed between January 1, 2001, and December 31, 2003, from encounter data. COPD patients were identified based on at least one claim with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes 491, 492, 496; and asthma patients were identified on the basis of ICD-9 code 493 as diagnosis. We analyzed annual utilization and cost of hospitalizations, physician, and outpatient services attributable to asthma and/or COPD., Results: The analysis included a total of 3,072 asthma, 3,455 COPD, and 2,604 COPD/asthma patients. COPD/asthma co-occurring disease has higher utilization of any service type than either disease alone. Compared with asthma patients, COPD patients were 16% and 51% more likely to use physician (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.01 to 1.34) and inpatient services (OR, 1.51; 95% CI, 1.31 to 1.74), respectively; and 60% less likely to use outpatient services (OR, 0.40; 95% CI, 0.35 to 0.46). Compared with asthma patients, COPD patients and COPD/asthma co-occurring patients cost 50% (OR, 1.50; 95% CI, 1.3 to 1.74) and five times (OR, 5.25; 95% CI, 4.59 to 6.02) more for total medical services, respectively., Conclusion: Our data suggest that patients with COPD and co-occurring COPD/asthma were sicker and used more medical services than asthma patients. The incremental burden of COPD to patients with asthma is significant.

Hospitals can take these steps to meet payment reform challenges: Analyze the financial impact of payment changes. Benchmark performance against peers. Audit and educate physicians. Implement a concurrent documentation program. Focus on length of stay. Get ready for RACs. Take charge of charge capture. Prevent coding duplication. Conduct a pricing review. Validate payment reconciliation processes.

Background: The German diagnosis-related group (G-DRG) system is based on the belief that there is only one specific coding for each case. The aim of this study was to compare coding results of identical cases coded by different coding specialists., Material and Methods: Charts of six anonymous cases -- except final letter and coding -- were sent to 20 German departments of urology. They were asked to let their coding specialists do a DRG coding of these cases. The response rate was 90%., Results: Each case was coded in a different way by each coding specialist. The DRG refunding varied by 6-23%. The coding differences were caused by different interpretations of definitions in the DRG system and also by inaccurate chart analysis., Conclusion: The present DRG system allows a wide range of interpretation, leading to aggravation of the ongoing disputes between hospitals and insurance companies.

Background: Adoption rates for electronic health records (EHRs) have been slow, despite growing enthusiasm. Cost is a frequently cited obstacle to implementing an EHR. The body of literature citing a positive return on investment is largely anecdotal and infrequently published in peer-reviewed journals., Study Design: Five ambulatory offices, with a total of 28 providers, within the University of Rochester Medical Center, participated in a pilot project using an EHR to document the return on investment. A staged implementation of the Touchworks EHR (Allscripts) was undertaken from November 2003 to March 2004. Measurements of key financial indicators were made in the third calendar quarters of 2003 and 2005. These indicators included chart pulls, new chart creation, filing time, support staff salary, and transcription costs. In addition, patient cycle time, evaluation and management codes billed, and days in accounts receivable were evaluated to assess impact on office efficiency and billing. The savings realized were compared with the costs of the first 2 years of EHR use to determine return on investment., Results: Total annual savings were $393,662 ($14,055 per provider). Total capital cost was $484,577. First-year operating expenses were $24,539. Total expenses for the first year were $509,539 ($18,182 per provider). Ongoing annual cost for subsequent years is $114,016 ($4,072 per provider). So, initial costs were recaptured within 16 months, with ongoing annual savings of $9,983 per provider., Conclusions: An EHR can rapidly demonstrate a positive return on investment when implemented in ambulatory offices associated with a university medical center, with a neutral impact on efficiency and billing.

This study estimates a fixed effects ordered logit model physician office visit billing using claims data from South Carolina Medicaid and the State Employees Health Plan. The results find code creep increasing expenditures on physician office visits at a rate of 2.2 percent annually for both programs, with no significant difference in the rate between the two. The models also indicate that physician billing patterns differ between the programs, with the Medicaid claims averaging 1.3 percent less per visit than comparable State Employees Health Plan claims.