University of Michigan Health System

Program and Operations Analysis

Document Processes for Sending Results and Clinical Documents to ReferringPhysicians

Final Report

To: Matt Plachta, Director, Business and Operations Support Services, AmbulatoryCare Services

Richard J. Coffey, PhD, Director, Program and Operations Analysis

From: JOE 481 Project Team, Program and Operations Analysis

Nathan Gelino

Stephen Lipner-Bernstein

Jesse Wilson

H. SunnyWu

Date: April 20, 2006

TABLE OF CONTENTS

Executive Summary

Introduction 1

Background 1

Key Issues 1

Goals and Objectives 2

Expected Impact 2

Project Scope 2

Project Plan 3Approach and Methodology 3

Studying and Recording Current System Performance 3Stage 1: Examination of CTS, M NE7 and CDR 3Stage 2: Individual Department Stu4y 4

Developing Recommendations 4

Description of Current System 5Clinical Data Repository (CDR) 5Central Transcription Service (CTS) 6MNET 6MarketScope 6Patient Management 7Medical Clinical Department Processes 7

Internal Medicine 7Neurosurgery 7

Adult 8Pediatric 8

Obstetrics and Gynecology (OB/GYN) 8Orthopedic Surgery 8

MedSport 8Pathology 8

UMHS Patients 9MLabs 9

Pediatrics and Communicable Diseases 9Physical Medicine and Rehabilitation 9

Occupational and Physical Therapy 9Orthotics and Prosthetics 9Speech-Language Pathology 9

Radiology 10Transcription 10Faxing and Mailing 10

Surgery 10Cardiac 10Pediatric 10Pediatric Plastic 11Plastic 11Thoracic 11

Findings and Conclusions 11Duplication between M NET and CTS 11Multiple Sources for Referring Physician Contact Information 12Use of Courier to Transport Documents to Medical Clinical Departments 13Possibility of HIPAA Violations 14

Referring Physicians’ Desire for Electronic Records Access 14

Recommendations 14Develop Centralized Printing and Mailing System 14Develop Universal Source for External Referring Physician Contact Information 15Implement New Document Flow Process 15Develop Referring Physician Web Portal 16Conduct Study of Investment in Regional Health Information Organization (RHIO) 17

Implementation Plan 17Expansion of CTS Mailing 17Inclusion of External Referring Physician Information into the EMPI 17Expansion of M NET Document Filter List 18Development of Carbon Copy Faxing Functionality within M NET 18

Outcomes of Recommendations 18

Appendices 19Appendix A: Medical Clinical Departments 20Appendix B: Clinical Department Administrators Survey 21Appendix C: University Health Consortium Questions 23Appendix D: Clinical Data Repository (CDR) Production Environment 24Appendix E: Central Transcription Service (CTS) Document List 25Appendix F: Central Transcription Service (CTS) Flowchart 27Appendix G: Central Transcription Service (CTS) Average Monthly Printed Volumes by Department .28Appendix H: M NET Document Filter List 29Appendix I: M NET Flowchart 33Appendix J: Radiology Department Flowchart 34

LIST OF FIGURES AND TABLES

Figure 1. Recommended Document Flow Process ivFigure 2. Current Process Flowchart 5Figure 3. Sources for Referring Physician Contact Information 13Figure 4. Recommended Document Flow Process 16Table 1. Contact Information for Computerized System Interviewees 4Table 2. Lower and Upper Bounds on Monthly Duplications and Duplication Cost 12

Executive Summary

Introduction

Historically, each of the medical clinical departments within The University of MichiganHealth System (UMHS) functioned independently. As technology evolved, much ofUMHS was integrated; however, the integration is not complete. Currently, there is nostandardized methodology within UMHS for sending results and clinical documents toexternal referring physicians. Some physicians receive multiple copies of these resultsand clinical documents while some receive none. The belief of Matt Plachta, Director ofBusiness and Operations Support Services for Ambulatory Care Services, is that thecurrent system has led to confusion and dissatisfaction among external referringphysicians and patients. To address the perceived confusion and dissatisfaction, Mr.Plachta asked us to determine the current processes for sending results and clinicaldocuments to external referring physicians. We were also asked to record the process,starting when the results and clinical documents are completed and ready for distribution,and ending when the results and clinical documents leave UMHS.

Project Scope

The project scope included:• Computerized components of the result and clinical document flow. The primary

components were Central Transcription Service (CTS), a document transcription,printing, and mailing system, M NET, UMHS’s referring physician fax network,and the Clinical Data Repository (CDR).

• Nineteen medical clinical departments of UMHS.• Outpatient results and clinical documents.• External referring physician contact information sources.

The project scope excluded:• Inpatient documents other than discharge summaries and operative reports.• Referrals made by internal UMHS physicians.• The processes for determining patients’ external referring physicians.• The external referring physicians’ success in receiving the results and clinical

documents.

Approach and Methodology

Analysis was conducted in two broad phases: studying and recording current systemperformance, and determining recommendations. The studying and recording phase wasconducted in two stages: examination of CTS, M NET, and CDR, and individual studyof each medical clinical department. We interviewed key personnel from CTS, M NETand CDR and maintained correspondence with these groups throughout the project’sduration. An electronic survey was sent to the Clinical Department Administrator’semail list on March 24, 2006, to determine each medical clinical department’s current

methodology of sending results and clinical documents to external referring physicians.Four of the 19 medical clinical departments responded to the survey. Responses fromPathology, Radiology, and Obstetrics and Gynecology were not required as thesedepartments were known to be using systems other then CTS and M NET’. Therefore,the team interviewed personnel from these departments to determine their methodologyfor sending results and clinical documents to external referring physicians.

Description of Current System

Based on our investigation of the processes used in sending results and clinicaldocuments to external referring physicians, the main computerized systems involved insending results and clinical documents to external referring physicians are CDR, CTS,and M NET.

Clinical Data Repository (CDR)The Clinical Data Repository (CDR) is UMHS ‘ s patient information database. CDR isfed daily by medical clinical departments, CTS, and a variety of other sources.

Central Transcription Service (CTS)The Central Transcription Service (CTS) is used to transcribe documents that have beendictated by physicians. If a document is to be sent to an external referring physician,CTS either remote prints the document to the medical clinical department that initiatedthe transcription or prints the document locally. If the document is remote printed, thedepartment is responsible for its preparation and delivery to the external referringphysician. If CTS prints the document locally, it then sends the document via MetroDelivery courier service to the medical clinical department that initiated the transcriptionand the department either faxes or mails the document to the external referring physician.

MNETM NET is UMHS ‘s referring physician fax network. The system utilizes an algorithm topull documents from CDR and fax them to referring physicians that are members of thenetwork.

Findings and Conclusions

Based on interviews with CTS, M NET, CDR, and medical clinical departmentpersonnel, as well as analysis of the clinical department administrators survey, the teamidentified the following inefficiencies in the process of sending results and clinicaldocuments to external referring physicians.

Duplication between CTS and M NETCurrently, physicians who are members of M NET will receive multiple copies of anyresults and clinical documents that are both automatically faxed by M NET andtranscribed and printed by CTS. There are currently 9 document types being sent in

l Information provided by Lynne Nickle, Associate Director, IT Systems, Medical Information Services

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duplicate. The approximate cost per letter sent is $0.782; the lower bound on total yearlyduplications is 45,734 while the upper bound is 120,684. The lower bound on totalyearly duplication cost is $35,672, while the upper bound is $94,133.

Use of Courier to Transport Documents to Medical Clinical DepartmentsCurrently, if a transcribed document is not remote printed to a medical clinicaldepartment by CTS, the document is forwarded to the department using Metro Deliverycourier service, at which point the department assumes responsibility for delivery toexternal referring physicians. Approximately 19,301 printed CTS transcriptions permonth are transported via courier. This process is entirely non-value added and decreasestimeliness of result and document delivery to external referring physicians.

Multiple Sources for Referring Physician Contact InformationNo universal source for external referring physician contact information currently exists.The 3 major sources that the medical clinical departments use to retrieve referringphysician contact information are MarketScope, Patient Management, and the referringphysician him/herself. Of the medical clinical departments and divisions that respondedto the clinical department administrators survey or were interviewed, 62.5% have usedMarketScope, 62.5% have used Patient Management, and 87.5% have asked the referringphysician directly. Also, 62.5% of the departments and divisions have consulted anothersource for referring physician contact information, such as the American MedicalAssociation or the patient himself/herself. These percentages add up to more than 100%because 63% of the departments and divisions have used more than one of these methodsto retrieve physician contact information.

Referring Physicians’ Desire for Electronic Records AccessThe 2004 Biennial Statewide Physician Referral Survey data of referring physicianscollected by Interactive Marketing showed that “at least two-thirds of referringphysicians would find value in having online access to routine reports, forms, andscheduling. Access to clinical reports garnered the greatest interest (79%), followed byreferring physician guidelines (72%) and e-mail consultations with UMHS physicians(70%).”

Recommendations

Based on our findings and conclusions, we have developed recommendations to improvethe process of sending results and clinical documents to external referring physicians anda plan to implement these recommendations.

Develop Centralized Printing and Mailing SystemTo reduce mailing costs and delivery time for results and clinical documents, acentralized printing and mailing system should be developed to handle all mail being sentto external referring physicians and carbon copied physicians. An automated mailing

2 Based on postage, envelope, and FTE costs provided by Central Transcription Service

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system will reduce postage costs by approximately $0.06 per letter3 for 399,330 lettersper year printed by the Central Transcription Service, which yields an approximateannual savings of $23,960 on postage alone. This savings figure does not includedocuments created and mailed by individual medical clinical departments.

Develop Universal Source for External Referring Physician Contact InformationThe data from this project supports the Enterprise-wide Master Person Index (EMPI)Project proposal to include referring physician contact information in the EMPI. Werecommend information regarding the referring physician’s participation in M NET to bestored in the EMPI along with the physician’s contact information. CTS should use theEMPI as their source for referring physician contact information and delivery preference.

Implement New Document Flow ProcessTo reduce the number of duplicate results and clinical documents sent by CTS and MNET a new document flow process is being recommended, see Figure 1. This documentflow eliminates the duplication between CTS and M NET and removes the need for acourier to transport documents to the medical clinical departments. Also, this flowincorporates the above recommendations for centralized printing and the utilization of auniversal source for external referring physician contact information.

Savings per letter estimated by the Information Systems Applications Systems Analyst, MedicalInformation Systems, David DeLauter“Central Transcription Service Printing Statistics from September 2005 — February 2006

1rClinical Dataf\

Repository(CDR)

Figure 1. Recommended Document Flow Process

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Develop Referring Physician Web PortalTo satisfy external referring physicians’ preferences for electronic access to results andclinical documents and to reduce costs intrinsic to mailing and faxing these documents, aweb portal should be developed.

Conduct Study of Investment in Regional Health Information Organization (RHIO)“The purpose of a Regional Health Information Organization (RHIO) is to electronicallyexchange health information in a secure format so that the receiver can use theinformation.5”

A study should be conducted to determine if the potential benefits to UMHS outweigh thehigh cost of investment. The study should include a cost/benefit analysis, as well as adetermination of the optimal time to invest.

Implementation Plan

Implementation of the recommended document flow process requires several changes inestablished systems.

Expansion of CTS Mailing CapabilityCTS should expand its mailing capacity to include all transcribed documents. All directmailing of results and clinical documents to external referring physicians should beconducted by CTS. CTS should bill the corresponding department/section for themailing costs.

Inclusion of External Referring Physician Information into EMPIThe EMPI should incorporate external referring physicians’ contact information,including name, unique ID, address, phone, fax number, email address, and status of MNET participation.

Expansion of M NETM NET should expand its document filter list to include all types of documentstranscribed by CTS. M NET should also develop carbon copy faxing functionalitybecause patients often receive health care and treatment from multiple referringphysicians.

http://www.himss.org/asp/topics rhio.asp

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Introduction

Historically, each of the medical clinical departments within The University of MichiganHealth System (UMHS) functioned independently. As technology evolved, much ofUMHS was integrated; however, the integration is not complete. Currently, there is nostandardized methodology within UMHS for sending results and clinical documents toexternal referring physicians. Some physicians receive multiple copies of these resultsand clinical documents while some receive none. The belief of Matt Plachta, Director ofBusiness and Operations Support Services for Ambulatory Care Services, is that thecurrent system has led to confusion and dissatisfaction among referring physicians andpatients. To address the perceived confusion and dissatisfaction, Mr. Plachta asked us todetermine the current processes for sending results and clinical documents to externalreferring physicians. We were also asked to record the process, starting when the resultsand clinical documents are completed and ready for distribution, and ending when theresults and clinical documents leave UMHS. The purpose of this report is to present thecurrent processes used to send results and clinical documents to external referringphysicians and recommend process improvements to eliminate inefficiencies andredundant processes.

Background

In the past, UMHS medical clinical departments had functioned completelyindependently. This independent operation was necessary because technology toefficiently integrate the medical clinical departments was not available. As technologyhas evolved, a centralized process for sending results and clinical documents fromUMHS to external referring physicians has become feasible. Several systems such as theCentral Transcription Service (CTS) and M NET have been developed to integrate andstreamline this process; however, full integration has not been achieved. According toMr. Plachta, the lack of complete integration has resulted in dissatisfaction amongreferring physicians about the reliability and timeliness of receiving results and clinicaldocuments. Maintaining positive relationships with external referring physicians isimperative to UMHS, since a large percentage of UMHS revenue is generated fromreferrals. By providing an accurate record of the current processes and recommendingopportunities for improving reliability and timeliness of the processes, this project’s goalwas to increase reliability of sending results and clinical documents to external referringphysicians. This project supplements several projects that are currently taking place,including the Clinical Documents Delivery Project (CDDP), and the Misdirected andUndeliverable Test Results Analysis and Tracking Project.

Key Issues

The following key issues were the main impetus for this project:• Perception that referring physicians are dissatisfied with the reliability of

receiving results and clinical documents from UMUS.

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• Copies of results and clinical documents are occasionally sent to referringphysicians in duplicate, while some results and clinical documents are notreceived.

• Results and clinical documents have been forwarded to incorrect physicians,resulting in the possibility of Health Insurance Portability and Accountability Act(HIPAA) violations.

• Lack of a standardized methodology for sending results and clinical documentsdeviates from UMHS goal of total system integration.

Goals and Objectives

To record the process of sending results and clinical documents to external referringphysicians, the team has accomplished the following tasks:

• Recorded the process of computerized UMHS systems involved in sending resultsand clinical documents to referring physicians.

• Determined current document forwarding processes within the medical clinicaldepartments.

• Identified opportunities for improving the timeliness and reliability of sendingresults and clinical documents to external referring physicians.

• Identified opportunities to remove non-value added work.

Contained within this report are:• Flowcharts of the current processes.• Recommendations for standardizing the processes.

Expected Impact

This study included a thorough recording of the current process used to send results andclinical documents to external referring physicians. This study also identified areas ofnon-value added work and redundant processes. Recommendations that will lead to morereliable and timely result and clinical document flow were generated as a result of thisanalysis. This improved flow will raise the level of satisfaction among referringphysicians and patients. As a secondary outcome, the improved flow will reduce costs byeliminating non-value added work.

Project Scope

Our analysis of the process began when a result or clinical document was completed andready for distribution. Our analysis ended when the result or clinical document leftUMHS.

The project scope included:• Computerized components of the result and clinical document flow. The primary

components were Central Transcription Service (CTS), a document transcription,

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printing, and mailing system, M NET, UMHS’s referring physician fax network,and the Clinical Data Repository (CDR).

• Nineteen medical clinical departments of UMFIS.• Outpatient results and clinical documents.• External referring physician contact information sources.

The project scope excluded:• Inpatient documents other than discharge summaries and operative reports.• Referrals made by internal UMHS physicians.• The processes for determining patients’ external referring physicians.• The external referring physicians’ success in receiving the results and clinical

documents.

Project Plan

The Program and Operations Analysis team recorded the current methodology of sendingresults and clinical documents to external referring physicians. Each of the 19 clinicaldepartments, such as Radiology, Pathology and Neurology (See Appendix A for a fulllist), was examined. In addition, computerized systems that affect document flow, suchas CTS and M NET, were studied to determine their role in sending results and clinicaldocuments to external referring physicians.

Approach and Methodology

The analysis was conducted in two broad phases: studying and recording current systemperformance, and determining recommendations. The studying and recording phase wasconducted in two stages: examination of CTS, M NET, and CDR; and individual studyof each medical clinical department. Recommendations were based upon observations ofcurrent system performance, literature review of strategies used by other health systems,and consideration of external referring physicians’ preferences and technologicalcapabilities.

Studying and Recording Current System PerformanceAs stated above, the studying and recording phase was conducted in two stages:examination of CTS, M NET, and CDR, and individual study of each clinical department.

Stage]: Examination of CTS, M NE1 and CDRThe first stage of the project was to examine the primary UMHS systems involved in theprocess of sending results and clinical documents to external referring physicians: CTS,M NET, and CDR. Table 1 shows the contact information for interviewed personnelfrom each of the 3 systems. All interviews were supplemented with subsequent emailcorrespondence throughout the duration of the project.

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Table 1. Contact Information for Computerized System IntervieweesComputerized System Contact

CTS (Central Transcription • Diane Repshinska, Manager, Health InformationService) Management Services, University of Michigan

Hospital (UMH) Medical Information Services. Synthia Winnie, Supervisor, Health Information

Management Services, UMH Medical InformationServices

M NET • Andrew Jarvis, Associate TelecommunicationsAnalyst, UMH Public Relations and MarketingCommunications/Interactive Marketing

• John Boufford, Software Developer Senior, UMHMedical Center Information Technology

CDR (Clinical Data Repository) • Lynne Nickle, Associate Director, IT Systems,Medical Information Services

Stage 2: Individual Department StudyTo determine each medical clinical department’s current methodology of sending resultsand clinical documents to external referring physicians, an electronic survey (AppendixB) was sent to the clinical department administrator’s (CDA) email list on March 24,2006. We received responses from 4 of the 19 medical clinical departments. Responsesfrom Pathology, Radiology, and Obstetrics and Gynecology were not required as thesedepartments were known to be using systems other then CTS and M NET6.

The team conducted interviews with staff from medical clinical departments that usesystems besides CTS and M NET to send results and clinical documents to externalreferring physicians. From these interviews, flow charts were created to show theprocess each department uses to send results and clinical documents to external referringphysicians. Document forwarding volume and cost data were collected from eachdepartment when available.

Developing RecommendationsVolume and cost data collected from CTS, M NET, and medical clinical departments wasused to quantify inefficiencies within the processes of sending results and clinicaldocuments to external referring physicians.

The team created and delivered a set of questions to the University Health Consortium(Appendix C), to determine the processes health systems similar to UMHS use to sendresults and clinical documents to external referring physicians. The responses from theUniversity Health Consortium were used to develop strategies for our recommendations.

6 Information provided by Lynne Nickle, Associate Director, IT Systems, Medical Information Services

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To measure external referring physicians’ current satisfaction levels and preferences forcommunication with UMHS, the team examined the 2004 Biennial Statewide PhysicianReferral Survey conducted by the Interactive Marketing department. The teamconsidered these satisfaction levels and preferences when developing recommendations.

Description of Current System

Based on our investigation of the methodology of sending results and clinical documentsto external referring physicians, the main computerized systems involved in sendingresults and clinical documents to external referring physicians are CDR, CTS, and MNET. The main computerized systems used to retrieve referring physician contactinformation are MarketScope and Patient Management. A current process flowchart ofthe interactions between these systems and the 19 medical clinical departments is shownin Figure 2.

Figure 2. Current Process FlowchartSource: CDA Survey and Departmental Interviews

Clinical Data Repository (CDR)

CDR is UMFIS’s patient information database. CDR is fed daily by medical clinicaldepartment, CTS, and a variety of other sources. See Appendix D for a flowchart ofCDR’s interactions with other UMHS systems.

Sources:*Synthia Winnie, Supervisor, Health Information Management Services, UMH Medical

Information Services (Referring Physician**Refeing Physician Portal Capital Funding Request, ITSAC Presentation, March 2, 2006

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Central Transcription Service (CTS)

CTS is used to transcribe documents that have been dictated by physicians (see AppendixE for a complete list). First, a document is dictated by a physician to CTS. It is thentranscribed by CTS and sent to the physician for an e-signature. After the document hasbeen checked for errors and signed, it is printed if it is to be delivered to an externalreferring physician. CTS either remote prints the document to the medical clinicaldepartment that initiated the transcription or prints the document locally. If the documentis remote printed, the department is responsible for its preparation and delivery to theexternal referring physician. If CTS prints the document locally, it is printed and put inan envelope for all physicians who need to receive a copy. CTS then sends the documentvia Metro Delivery courier service to the medical clinical department that initiated thetranscription. Discharge summaries are the only documents that CTS mails directly toexternal referring physicians. CTS sends all transcribed documents to CDR in real time(see Appendix F for a flowchart, and Appendix G for printed transcription volumes bydepartment).

MNET

M NET is UMHS’s referring physician fax network. There are currently approximatelyiO,0007 external referring physician members. An external referring physician is auto-enrolled into the network when he or she first refers a patient to UMHS. After beingauto-enrolled, an external referring physician can customize which results and clinicaldocument he or she would like to receive, or opt-out of the network.

The system utilizes an algorithm to pull documents (see Appendix H for complete list andAppendix I for a flowchart) from CDR and fax the results or clinical documents toexternal referring physicians that are members of the network. The system is completelyautomated. The algorithm runs at 12:15 AM and pulls any documents from its documentfilter list that were changed on the previous day and faxes the documents to thecorresponding external referring physicians. Currently, M NET is not capable of faxingto carbon copied physicians.

MarketScope

MarketScope is UMHS’s external referring physician database. It can be searched forinformation on Michigan and Northern Ohio physicians including name, city, specialty,address, phone number, and fax number.

Approximation received from Josephine Aguirre, Director of Physician and Consumer Communications

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Patient Management

Patient Management is UMHS ‘ s patient registration system. The system supports thecollection of patient information, which includes referring physician contact information.

Medical Clinical Department Processes

Each of the 19 medical clinical departments within UMHS must send results and clinicaldocuments to external referring physicians. The departments do not use a centralizedsystem or have one standardized process but rather use a combination of the systemsmentioned above and their own individual processes.

The following departments are believed to exclusively use CTS and M NET to transcribeand send results and clinical documents to external referring physicians8:

• Anesthesiology• Dermatology• Emergency Medicine• Family Medicine• Neurology• Ophthalmology and Visual Sciences• Otolaryngology• Psychiatry• Radiation Oncology• Urology

The following are descriptions of the processes used by each medical clinical departmentand their divisions that confirmed their process of sending results and clinical documentsto external referring physicians through the CDA survey or interviews.

Internal MedicineThe Internal Medicine department faxes all results and clinical documents, except forendoscopic reports, directly to external referring physicians. Endoscopic reports arefaxed before signature; therefore the department prints and mails a signed hard copy tothe external referring physician. The department retrieves external referring physiciancontact information from MarketScope, Patient Management, or directly from theexternal referring physician. MarketScope is consulted first for referring physiciancontact information.

NeurosurgeryThe Neurosurgery department is split into two programs: Adult and Pediatric.

8 Based on the belief of Matt Plachta, Director, Business and Operations Support Services, AmbulatoryCare Services

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AdultThe Adult Neurosurgery program uses CTS to transcribe results and clinical documentssent to external referring physicians and then mails these results and clinical documentsdirectly to external referring physicians.

PediatricThe Pediatric Neurosurgery program uses CTS to transcribe results and clinicaldocuments sent to external referring physicians, and then mails or faxes these results andclinical documents directly to external referring physicians. The program retrievesexternal referring physician contact information from Patient Management or directlyfrom the patient.

Obstetrics and Gynecology (OB/GYN)The team interviewed Anne Marie Piehl, Clinical Nurse Specialist, Women’s BirthCenter, to determine the process OB/GYN uses to send results and clinical documents toexternal referring physicians.

The OB/GYN department dictates information to CTS for transcription. CTS remoteprints the transcribed documents to a designated OB/GYN printer. OB/GYN personnelprepare the documents for mailing. The department retrieves external referring physiciancontact information directly from the patient or from MarketScope.

Orthopedic SurgeryThe team interviewed Karen Collins, Executive Assistant, to determine the processOrthopedic Surgery uses to send results and clinical documents to external referringphysicians. The Orthopedic Surgery department uses CTS to transcribe results andclinical documents and then mails the results and clinical documents directly to externalreferring physicians. The department retrieves referring physician contact informationdirectly from the patient.

MedSportThe MedSport division sends Progress Notes, Plan of Care, Plan of Care Recertification,and Discharge Summaries to external referring physicians. The division creates thedocument and sends it directly to the external referring physician.

PathologyThe team interviewed Kathy Davis, Manager, Pathology Data Systems, and ThomasMorrow, Assistant Administrator, to determine the process Pathology uses to send resultsand clinical documents to external referring physicians.

The Pathology department interacts with two different types of referred patients. Thefirst type of patient is referred to UMHS for care and has a sample sent to Pathology fortesting. The second type of patient is one whose external referring physician sends asample directly to Pathology for testing. The second type of patient is covered under theM Labs marketing name.

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UMHS PatientsFor UMHS patients, the Pathology Department only interacts with the UMHS physicianwho orders the test. All test results are stored in CareWeb. For external referringphysicians to receive the test results, the external referring physicians need to bemembers of M NET. M NET faxes 7 Pathology test results. Thus, not all test resultsfrom Pathology are sent to external referring physicians.

M LabsFor M Labs patients, the Pathology department sends test results directly to the orderingexternal referring physician using remote printing, fax, or mail. PathNet, Pathology’scomputer database, automatically sends test results via remote printing or fax, accordingto the physician’s preference. The physician’s preference for methods of receivingresults and clinical documents is stored in PathNet. M Labs retrieves referring physiciancontact information from the referring physician directly.

Pediatrics and Communicable DiseasesThe Pediatric and Communicable Diseases department uses CTS to transcribe results andclinical documents sent to external referring physicians. The department retrievesreferring physician contact information from MarketScope or directly from the externalreferring physicians.

Physical Medicine and RehabilitationThe Physical Medicine and Rehabilitation department is split into 7 divisions. Each oneacts independently in sending results and clinical documents to external referringphysicians. The following divisions confirmed their process for sending results andclinical documents to external referring physicians:

Occupational and Physical TherapyThe team corresponded with Jose Kottoor, Director, to determine the process the divisionuses to send results and clinical documents to external referring physicians. TheOccupational and Physical Therapy division mails, faxes, or emails results and clinicaldocuments to external referring physicians.

Orthotics and ProstheticsThe team corresponded with Anita Liberman-Lampear, Administrative Director, todetermine the process the division uses to send results and clinical documents to externalreferring physicians. The Orthotics and Prosthetics division uses CTS to transcribe thedocuments that it sends to external referring physicians. The division occasionally hassecretaries transcribe documents and mail them to external referring physicians.

Speech-Language PathologyThe team corresponded with Elaine Ledwon-Robinson, Director, to determine the processthe division uses to send results and clinical documents to external referring physicians.The Speech-Language Pathology division uses CTS to transcribe the results and clinicaldocuments sent to external referring physicians. The division occasionally has secretariestranscribe documents and mail them to external referring physicians.

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RadiologyThe team interviewed Stephen Ramsey, Director, Unit Data Systems, and MaryDavidson, Office Administration Associate Supervisor, to determine the processRadiology uses to create and send results and clinical documents to external referringphysicians.

TranscriptionThe Radiology department utilizes 2 systems to transcribe documents that are dictated byphysicians. Approximately 1,200 documents are transcribed per day, 85% of which aredictated to Dictaphone, the remaining 15% are dictated to Radiology Transcription. Thetranscribed documents are electronically signed in Dictaphone or in the RadiologyInformation System (RIS). The document is stored in RIS which updates the CDR in realtime with preliminary and final drafts of the document.

Faxing and MailingM NET executes all faxing of results and clinical documents from Radiology.Approximately 825 documents are mailed per month to the corresponding externalreferring physician and carbon copied physicians. Each of the 1,200 documentstranscribed daily is printed, sorted, and placed in an envelope in the Radiology mailroom. This task requires an average of 11 hours per night, at a rate of $11.00 per hour.The average monthly cost of the task is $3,788, including envelopes, and envelopesealing tape. External referring physician contact information is retrieved from MedicalCenter Information Technology (MCIT). If the contact information is missing or foundto be erroneous, the correct information is retrieved and MCIT is manually updated. Onaverage, 250 letters are returned per month because of erroneous addresses9. SeeAppendix J for a flowchart of the Radiology Department process.

SurgeryThe Surgery department is split into 7 divisions. Each one acts independently in sendingresults and clinical documents to external referring physicians. The following divisionsand service levels were contacted:

CardiacThe Cardiac Surgery division uses CTS to transcribe the results and clinical documentssent to external referring physicians. The division uses Patient Management andMarketScope to retrieve external referring physician contact information.

PediatricThe Pediatric Surgery division uses CTS to transcribe the results and clinical documentssent to external referring physicians. The division uses MarketScope and PatientManagement to retrieve external referring physician contact information.

Cost estimates and average letters returned obtained from Mary Davidson, Office AdministrationAssociate Supervisor, Radiology Department

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Pediatric PlasticThe Pediatric Plastic Surgery division uses CTS for transcription and then directly mailsresults and clinical documents to external referring physicians. The division uses PatientManagement and direct contact with referring physicians to retrieve external referringphysician contact information.

PlasticThe Plastic Surgery division uses CTS to transcribe results and clinical documents andthen directly mails results and clinical documents to external referring physicians.Occasionally, secretaries from the division dictate letters and send them directly toexternal referring physicians.

ThoracicThe Thoracic Surgery division uses CTS to transcribe patient letters that are sent toexternal referring physicians. The department then mails the letter to the physician. Ifthe department deems there is something in the letter that the physician should knowimmediately (patient started chemotherapy, transplant medications, etc.) the departmentwill also fax a copy to the external referring physician. The department usesMarketScope to retrieve external referring physician contact information.

Findings and Conclusions

Based on interviews with medical clinical department personnel and the CDA survey, theteam identified several inefficiencies and areas of non-value added work in the currentsystem. The 2004 Biennial Statewide Physician Referral Survey and the UniversityHealth Consortium questionnaire provided information regarding external referringphysician preferences and peer health system practices.

Duplication between M NET and CTS

Currently, physicians who are members of M NET will receive multiple copies of anyresults and clinical documents that are both automatically faxed by M NET (Appendix G)and transcribed and forwarded by CTS (Appendix D). A comparison of these documentlists shows there are 9 document types currently being sent in duplicate. Theapproximate cost per letter sent was found to be $0.7810. Table 2 contains the lower andupper bounds on estimated number of duplications per month for each document type aswell as estimated duplication cost per month. The lower bound on monthly number ofduplications for each document type was calculated using the following formula:

Lower bound on monthly number of duplications = (Average monthly volumetranscribed and printed by CTS)*(Number of M NET subscribing ph1sicians /Total number of active physician addresses within UMHS database)

Based on postage, envelope, and FTE costs provided by Central Transcription ServiceIT The components of this ratio were estimated to be 10,000 M NET subscribers and 26,388 activeaddresses by the Director of Physician and Consumer Communications, Josephine Aguirre

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This value represents the lower bound on monthly number of duplications because itassumes both M NET and non M NET subscribing physicians are equally likely to referpatients to UMHS for care. The 10,000 M NET subscribing physicians most likelyrepresent the majority of physicians who refer patients to UMHS and thus the majority ofreferrals. The upper bound on monthly number of duplications is the average monthlynumber of documents transcribed and printed by CTS.

Table 2. Lower and Upper Bounds on Monthly Duplications and Duplication CostLower Bound Lower Bound Upper Bound Upper Boundon Number of on Monthly on Number of on Monthly

Monthly Duplication Monthly DuplicationDocument Name Duplications Cost Duplications Cost

ConsultationReport, Inpatient 7 $5.46 20 $15.60

ConsultationReport, Outpatient 633 $493.74 1670 $1,302.60

DischargeSummary 100 $78.00 263 $205.14

EmergencyDepartment Note 39 $30.42 103 $80.34Letter, Inpatient 59 $46.02 156 $121.68Operative Report 24 $18.72 64 $49.92Letter, Outpatient,

Return Visit 2757 $2,150.46 7274 $5,673.72Note, Outpatient,

New Patient 185 $144.30 488 $380.64Procedure Note 7 $5.46 19 $14.82

Total 3811 $2,972.58 10057 $7,844.46Source: David DeLauter, Information Systems Applications Systems Analyst, MedicalInformation Systems, Sample Period: October 15, 2005 — April 15, 2006

Multiple Sources for Referring Physician Contact Information

Based on the CDA survey results and clinical department interviews, the team hasidentified the lack of a universal source for external referring physician contactinformation. Figure 3 shows the various sources used by medical clinical departments toretrieve external referring physician contact information. The percentages indicate theproportion of the 8 medical clinical departments either surveyed or interviewed that usethe source.

12

100%

90%

80%

5 70%(ø

60%

. 50%*-o.

a) G)

.5 30%a)2 20%a,

10%

no’‘i/o

MarketScope

Figure 3. Sources for Referring Physician Contact InformationSource: CDA survey conducted 3/24/06 — 4/07/06 and Departmental Interviews

The lack of a universal source for external referring physician contact information isproblematic because departments must perform the non-value added work of searchingfor this contact information. Also, when referring physician contact information ischanged, the updated information is only seen by medical clinical departments that utilizethe specific source that has been updated. This lack of communication can result inerrors of omission in which results and clinical documents are not received by externalreferring physicians or in HIPAA violations in which protected health information (PHI)is sent to an incorrect address.

Use of Courier to Transport Documents to Medical Clinical Departments

Through interviews with CTS personnel, the team identified the current practice offorwarding transcribed documents to medical clinical departments using Metro Deliverycourier service. Approximately 19,301 printed CTS transcriptions per month aretransported by Metro Delivery to the corresponding medical clinical department, whichthen sends the documents directly to external referring physicians. This process is non-value added and decreases the timeliness of results and document delivery to externalreferring physicians. The courier service picks up the results and clinical documentsfrom CTS Monday thru Friday at 1 p.m. The results and clinical documents are deliveredto the department overnight.

Patient Directly from OtherManagement Referring Physician

Source

13

Possibility of HIPAA Violations

The current practice of having CTS remote print to departments could result in HIPAAviolations. The results and clinical documents that CTS remote prints may containprotected health information (PHI). This information is required to remain private at alltimes. If the remote printers are not in secure rooms, unauthorized individuals may gainaccess to PHI.

Referring Physicians’ Desire for Electronic Records Access

The 2004 Biennial Statewide Physician Referral Survey data of referring physicianscollected by Interactive Marketing showed that “at least two-thirds of referringphysicians would find value in having online access to routine reports, forms, andscheduling. Access to clinical reports garnered the greatest interest (79%), followed byreferring physician guidelines (72%) and email consultations with UMHS physicians(70%).”

Over 75% of external referring physicians have access to the Internet in their office andtherefore would be able to access records electronically.’2

According to responses from the University Health Consortium questionnaire, theUniversity of Nebraska currently has a web portal for external referring physicians toaccess results and clinical documents, and the University of Connecticut andNorthwestern University are attempting to allow external referring physicians access totheir clinical repository.

Recommendations

Based on our findings and conclusions, we have developed recommendations to improvethe process of sending results and clinical documents to external referring physicians anda plan to implement these recommendations. We have also developed recommendationsfor the direction that the process of sending results and clinical documents to externalreferring physicians should take in the future to take advantage of external referringphysician technological capabilities and satisfy their preferences.

Develop Centralized Printing and Mailing System

To reduce mailing costs and delivery time for results and clinical documents, acentralized printing and mailing system that meets the United States Postal Service’sautomation rate criteria should be developed to handle all mail being sent to externalreferring physicians and carbon copied physicians. An automated mailing system willreduce postage costs by approximately $0.06 per letter’3 for 399,33014 letters per year

12 Referring Physician Portal Capital Funding Request, ITSAC Presentation, March 2, 200613 Savings per letter estimated by the Information Systems Applications Systems Analyst, MedicalInformation Systems, David DeLauter“ Central Transcription Service Printing Statistics from September 2005 — February 2006

14

printed by the Central Transcription Service, which yields an approximate annual savingsof $23,960 on postage alone. This savings figure does not include documents created andmailed by individual medical clinical departments. This centralized location should besecure, providing no possibility for public access to PHI.

A centralized printing and mailing system would eliminate the need for a courier,therefore significantly reducing the delivery time for 58% of documents printed by CTS.Eliminating the use of a courier would improve the performance of “timeliness incommunicating patient discharges” and “timeliness in contacting about unexpectedoccurrences” which have been identified by the 2004 Biennial Statewide PhysicianReferral Survey as having an unacceptable rating.

CTS is recommended as a candidate for the centralized printing and mailing systembecause CTS already has the capability to print, place in an envelope, address and mailresults and clinical documents. Also, because the results and clinical documents areready to be mailed before they leave CTS, it would be non-value added work to transportthese documents to another system for mailing.

Develop Universal Source for External Referring Physician Contact Information

The data from this project supports the Enterprise-wide Master Person Index (EMPI)Project proposal to include referring physician contact information in the EMPI. Werecommend information regarding the referring physician’s participation in M NET to bestored in the EMPI along with the physician’s contact information. CTS should use theEMPI as the source for determining referring physician contact information and deliverypreference.

Using the EMPI as the single source of contact information and delivery preference forexternal referring physicians will reduce the likelihood of a physician not receivingresults and clinical documents due to an incorrect address. The EMPI will also decreasethe possibility of HIPAA violations from mailing results and clinical documents toincorrect addresses, and reduce the time spent searching for and determining the accuracyof contact information.

Implement New Document Flow Process

The team recommends a new document flow process to reduce the number of duplicateresults and clinical documents sent by CTS and M NET. Figure 4 displays therecommended document flow process.

15

After a physician has dictated a document to CTS and it has been transcribed, CTS wouldsend the document to CDR in real time and consult the EMPI for information regardingthe delivery preference and status of M NET membership of the external referringphysician and each carbon copied physician.

If an external referring physician is not a member of the M NET fax network, thephysician’s contact information would be obtained from the EMPI. The document wouldthen be printed, placed in an envelope, addressed, given barcode postage and mailed byCTS. The recommended document flow assumes that CTS is providing centralizedmailing services.

If a physician is a member of the M NET fax network, CTS would take no further action.At 12:15 am daily, M NET checks CDR for updated results and clinical documentsagainst its document filter list. Upon finding an updated result or clinical document, MNET would automatically fax the result or clinical document to the correspondingexternal referring physician.

Develop Referring Physician Web Portal

To satisfy external referring physicians’ preferences for electronic access to results andclinical documents and to reduce costs intrinsic to mailing and faxing these documents, aweb portal should be developed. During the development of the web portal, theUniversity of Connecticut and Northwestern University should be consulted to determinemethods to complete this task that will not result in HIPAA violations.

Figure 4. Recommended Document Flow Process

16

Conduct Study of Investment in Regional Health Information Organization (RHIO)

The Healthcare Information and Management Systems Society defines a Regional HealthInformation Organization (RHIO) as “a group of organizations with a business stake inimproving the quality, safety and efficiency of healthcare delivery. The purpose of aRHIO is to electronically exchane health information in a secure format so that thereceiver can use the information.

A RHIO would provide UMHS with an automated method of receiving complete medicalinformation about incoming patients. RHIOs would also negate the need for UMHS tocollect demographic information and medical history from the patient, thus reducing thepossibility of receiving erroneous information (incorrect or incomplete referringphysician information, incorrect or incomplete medical history, etc.).

A RHIO would also provide a secure electronic medium for the transfer of medicalrecords nationwide. UMHS would continuously update the RHIO with new results andclinical documents, so the external referring physicians could use the RHIO to accesspatient information. The RHIO would lessen, or even negate UMHS’s need to sendresults and clinical documents directly to external referring physicians.

In light of the benefits of a RHIO, a study should be conducted to determine if thepotential benefits to UMHS outweigh the high cost of investment. The study shouldinclude a cost/benefit analysis, as well as a determination of the optimal time to invest.

Implementation Plan

Implementation of our recommended document flow process requires several changes inestablished systems.

Expansion of CTS Mailing

All direct mailing of results and clinical documents to external referring physiciansshould be conducted by CTS. CTS should bill the corresponding department/section forthe mailing costs.

Inclusion of External Referring Physician Information into the EMPI

The EMPI should incorporate external referring physicians’ contact information,including name, unique ID, address, phone, fax number, email address, and status of MNET participation. The system should also accommodate the fact that a physician maypractice at multiple locations; thus, the ability to keep track of multiple locations shouldbe implemented. Furthermore, the EMPI should include external referring physicians’preference of delivery methods.

I http://www.himss.orgjasp/topics rhio.asp

17

Expansion of M NET Document Filter List

M NET should expand and synchronize its document filter list to include all types ofdocuments transcribed by CTS. If a referring physician is an M NET member and he orshe opts to receive faxes only, CTS will not mail the same results and clinical documents,thus eliminating potential duplication.

Development of Carbon Copy Faxing Functionality within M NET

M NET should develop carbon copy faxing functionality because patients often receivehealth care and treatment from multiple referring physicians.

Outcomes of Recommendations

Implementation of the above recommendations and action plan will lead to:• Increased reliability of results and clinical documents delivery process.• Increased timeliness of results and clinical documents delivery.• Increased level of satisfaction among external referring physicians.

18

61

)S3IpUddV

Appendix A: Medical Clinical Departments

Anesthesiology DermatologyEmergency Medicine Family MedicineInternal Medicine NeurologyNeurosurgery Obstetrics and GynecologyOphthalmology and Visual Sciences Orthopedic SurgeryOtolaryngology PathologyPediatrics and Communicable Diseases PsychiatryPhysical Medicine and Rehabilitation Radiation OncologyRadiology SurgeryUrology

20

Appendix B: Clinical Department Administrators Survey

Ambulatory Care Services is working on a project to improve the delivery of clinicaldocuments to internal ordering providers and external referring physicians. As part ofthis effort, we are working with Matt Plachta to document the various processes andsystems used to send clinical documents (consult letters, procedure notes, test results,etc.) to external referring physicians.

Some clinical departments may use a variety of methods to send clinical documents at thedivision, section or service level. If this is the case, please forward this surveyrequest to managers in these areas.

Thank you,Nathan GelinoStephen Lipner-BernsteinJesse WilsonH. Sunny Wu

1. Check the medical clinical department that you work for.Anesthesiology DermatologyEmergency Medicine Family MedicineInternal Medicine NeurologyNeurosurgery Obstetrics and GynecologyOphthalmology & Visual Sciences Orthopedic SurgeryOtolaryngology PathologyPediatrics & Communicable Diseases Physical Medicine & RehabilitationPsychiatry Radiation OncologyRadiology SurgeryUrology Other (please specify)

2. List the division, section, or service level that you work for within your medicalclinical department. If you do not work for a division, section, or service level within themedical clinical department, answer “none”.

3. Does your clinical department send results and/or clinical documents to externalreferring physicians using systems other than the Central Transcription Service?

4. Check the computerized system(s) that is/are employed by your clinical department insending results and/or clinical documents to external referring physicians?

Central Transcription Service (CTS) CentricityOb TraceView Radiology Information System (RIS)PathNET ProvationFax, excluding all previously mentioned methodsMail, excluding all previously mentioned methodsNone of These

21

5. On a scale of 1-5 rank the computerized system’s performance & ease of use. (1= laborintensive, 5= automated)

Central Transcription Service (CTS) CentricityOb TraceView Radiology Information System (RIS)PathNET Provation

6. Check the source(s) that your clinical department retrieves contact information forexternal referring physicians from.

MarketScope Patient Management (PM)Directly from external referring physician Other (please specify)

7. List any concerns about the current system employed by your clinical department tosend results and/or clinical documents to external referring physicians?

8. List any concerns from external referring physicians, regarding the current systememployed by your clinical department to send results and/or clinical documents to them?

9. In your opinion, what are the most time consuming activities in the process of sendingresults and/or clinical documents to external referring physicians?

10. In your opinion, what are the most error prone activities in the process of sendingresults and/or clinical documents to external referring physicians?

11. Name:

12. Email address:

13. Phone number with extension number:

14. Job Title:

22

Appendix C: University Health Consortium Questions

We are trying to improve our results reporting service to referring physicians (includingturn around time) and would like to know the following about your organization:

1. Do individual medical clinical departments (e.g. Radiology, Surgery) within yourhealth system send results and clinical documents directly to external referringphysicians or is this process accomplished through a centralized system?

2. What methods are used to send results and clinical documents to externalreferring physicians? (e.g. web portal, mail, email, fax, etc)

3. Do you maintain a centralized database for external referring physician contactinformation or do medical clinical departments within your health systemmaintain individual databases for this information?

4. Are there any projects scheduled to change the process(es) of sending results andclinical documents to external referring physicians?

23

Appendix D: Clinical Data Repository (CDR) Production Environment

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24

Appendix E: Central Transcription Service (CTS) Document List

iment Type ocumentjtot çlescription) iong24 AMB BP RPT 24-Hour Ambulatory Blood Pressure Monitoring ReportADDENDUM AddendumADM HIST & PHYS Admission History and PhysicalADULT CATH Adult Cardiac Catheterization ReportALERTNOTE Alert NoteATTESTATION Attestation (Teaching Physician Statement)AUDIOLOGY RPT Audiology ReportBONE MARROW ASP Bone Marrow Aspirate ReportCERTIFICATION CertificatonCOCH IMPLT RPT Cochlear Implant ReportCODE EVENT Resuscitation / Code Event NoteCONSULT - IP Consultation Report, InpatientCONSULT - OUT Consultation Report, OutpatientCONSULT REQUEST Consultation RequestCONSULT- IP-F/U Consultation Report, Inpatient, Initial EvaluationCONSULT-IP-NEW Consultation Report, Inpatient, Follow-up After Initial EvaluationCONT CARE PLAN Continuing Care PlanDISCHARGE SUMM Discharge SummaryDISEASE MGT NT Disease Management NoteD-MGT ASTHMA Disease Management Note - AsthmaDX CODING NOTE Diagnosis Coding NoteED CONSULT Emergency Department Consult ReportED NOTE Emergency Department NoteED PSYCH NOTE Emergency Department Psychiatry NoteE-MAIL NOTE E-Mail NoteENDOREPORT Endoscopic Procedure NoteETHICS CONSULT Ethics Consultation ReportFETAL MGT NOTE Fetal Management NoteFINAL PLAN Final PlanHEALTH MAINT EX Health Maintenance ExamINITIAL EVAL Initial EvaluationINITIAL PLAN Initial PlanINTERIM PLAN Interim PlanINTERIM ORDER Interim OrderINTERIM SUMMARY Interim SummaryLETTER - IP Letter, InpatientLETTER - NP Letter, Outpatient, New PatientLETTER - RV Letter, Outpatient, Return VisitMEDS MGT NOTE Medication Management NoteMULTIDISC NOTE Multidisciplinary NoteNO-SHOW/CANCEL No-show / Cancel

25

NOTE - NP Note, Outpatient, New PatientNOTE - RV Note, Outpatient, Return VisitNOTIFICATION NotificationNURSING NOTE Nursing NoteNUTRITION NOTE Nutrition NoteOPER-REPORT Operative ReportOT IP EVAL Occupational Therapy Inpatient EvaluationOT IP NOTE Occupational Therapy Inpatient NoteOT IP RE-EVAL Occupational Therapy Inpatient Re-evaluationOT OP EVAL Occupational Therapy Outpatient EvaluationOT OP NOTE Occupational Therapy Outpatient NoteOT OP RE-EVAL Occupational Therapy Outpatient Re-evaluationOUTSIDE RECORDS Outside RecordsPT OP EVAL Physical Therapy Outpatient EvalPAT ED NOTE Patient Education NotePAT DISCHRG RPT Patient Discharge ReportPAT ED ASSESS Patient Education AssessmentPH PROBE pH Probe ReportPHARMACY NOTE Pharmacy NotePHONE/TRIAGE NT Telephone Message / Triage NotePREADM TRNSFR Pre-admission TransferPREOP H&P Preoperative History and PhysicalPROCEDURE NOTE Procedure NotePROC-EP Procedure Note, ElectrophysiologyPROGRESS NOTE Progress NotePSL UPDATE Problem Summary List UpdatePSYCH EVAL NOTE Psychiatry Evaluation NotePT IP EVAL Physical Therapy Inpatient EvaluationPT IP NOTE Physical Therapy Inpatient NotePT IP RE-EVAL Physical Therapy Inpatient Re-evaluationPT OP NOTE Physical Therapy Outpatient NotePT OP RE-EVAL Physical Therapy Outpatient Re-evaluationPT/OT ORDER Physical Therapy or Occupational Therapy OrderRECERTWICATION RecertificatoinRESULTS MGT NT Results Management NoteSOCWK IP ASSESS Social Work Assessment, InpatientSOCWK NOTE Social Work NoteSOCWK OP ASSESS Social Work Assessment, OutpatientSUMMARY - OP Summary, OutpatientTEST TestTNOTE Teaching NoteTOBACCO NOTE Tobacco NoteTRANSFER NOTE Transfer NoteTX PLAN - OP Treatment Plan, OutpatientVESTIB TEST RPT Vestibular Test Report

26

Appendix F: Central Transcription Service (CTS) Flowchart

Document is sent toCareweb document

viewer tab for viewing

Clinician Dictates/Document is sentvia FDI (foreign

doc import)

Patient Document isCTS Checreturned as error

to sender

DRNOSenderrE:sPatient name

Patient Reg# (other QA)C OK?ISDO

YES

V

Documents that are to beesigned in CareWeb are ser

to the clinicians INBOX for

signature (STAR & OW)Are there any corrections

needed?

Document isElectronically

Signed

Clinician is contacted andinstructed to sign up for esig,document may be printed for

hard copy signature oralternative esigner

CTS Clerical Staffmake corrections

and reprintdocument

Manual QA Rptsworked by CTS

L_._.j Clerical Staff,documents are

corrected

Documents are bundledand sent via courier to

hospital/clinics

Delivery is managed byRMU staff

Document is Transcribed/Received1 -CTS Internal Transcnptionist2-Agency Transcribed (80%)3-SUR-Created in STAR4-MVN-Createci In Michigan Visiting Nurses program, sent to OTS5-CWB-Created via Create Document in CareWeb6-CEN-Created in Centricity (anesth)7-OIS-Created in OB Tracevue

Documents from External Systems -

Documents are imported into CTS asa pass through to CareWeb for

viewing(MPU ENDO Rpts, PAC-Fetal Assmt

Cntr) SCR-Cardiac Surgery DCSummaries CEN-Centricity

Documents NONE OF ThESE AREESIGNED VIA CAREWEB

YES

Documents are printed:1 -CTS puts together, sends to clinics for

mailing2-Remote printed directly to clinic printers

(their staff process)3-DC Summaires are mailed by CTS Staff

Is document OK?

27

Appendix G: Central Transcription Service (CTS) Average Monthly PrintedVolumes by Department

Department VolumeAnesthesiology 2Dermatology 1529

Emergency Medicine 113Family Medicine 67

Neurology 1344Neurosurgery 567

Obstetrics and Gynecology 945Ophthalmology and Visual Sciences 326

Orthopedic Surgery 1345Otolaryngology 1498

Pediatrics & Communicable Diseases 2958Physical Medicine & Rehabilitation 1151

Psychiatry 72Radiation Oncology 550

Surgery 2183Urology 1946

Other 16682Total: 33278

Source: MCIT QuerySample Period: 10/15/2005 - 4/13/2006

28

Appendix H: M NET Document Filter List

Department Description CodeCardiology Adult Cardiology Report Card

All Reports For ThisCardiology Department ***Alfrpt***

Cardiac ElectrophysiologyCardiology Implant Report EpimpiCardiology Cardiology Ep Report EpCardiology Catheterization Report CathCardiology Echocardiography Report EchoCardiology Ett Report EttCardiology Holter Report loiterCardiology Pacemaker Clinic Report EpclinInformation AndNetworking Services Discharge Notice DischInformation AndNetworking Services Inpatient Status Report StatusIns Admit Notice AdmitIns Appointment Notice Appt-NoteIns Death Notice DeathIns Noshow Report NoshowIns Operative Note Oper-Report

Adult CatheterizationMedical Records Report Adult CathMedical Records Clinic Note NoteMedical Records Clinic Note-New Patient Let/Note-Np

Dermatology TreatmentMedical Records Center Summary Derm TxMedical Records Discharge Summary D/C Summary

Discharge SummaryMedical Records Report Case SumMedical Records Emergency Room Note Ed NoteMedical Records Emergency Room Note ErMedical Records Emergency Room Note ErMedical Records Endoscopy Report Endo RptMedical Records Endoscopy Report EndoreportMedical Records Inpatient Consultation Consult_IpMedical Records Inpatient Letter Letter_IpMedical Records Operative Note Or NoteMedical Records Outpatient Consultation Consult-OutMedical Records Patient Discharge Report Pat Dischrg Rpt

29

Medical Records Physician Letter LetterMedical Records Return Visit Note LetlNote-Rv

Ambulatory Cassett EegNeurology Report Acr

Angiographic Closed-Neurology Circuit Tv Eeg Monitoring lap

Brainstem AuditoryNeurology Evoked Potentials Baep

ElectroencephalographicNeurology Report Eeg

ElectroneuromyographicNeurology Report Emg

Extraoperative CorticalNeurology Function Mapping Elm

Extraoperative VisualNeurology Mapping Evm

Intraoperative CorticalNeurology Function Mapping Jim

Long-Term Eeg-VideoNeurology Monitoring Reports Ltm

Pattern Reversal VisualNeurology Evoked Potentials VepNeurology Pediatric Ltm Plt

Neurology Pediatric Stm PstSep Median Nerve

Neurology Stimulation SsemSep Median Nerve

Neurology Stimulation SaepShort-Term Eeg-Video

Neurology Monitoring Reports StmNeurology Sleeping Disorder Psg

Somatosensary EvokedNeurology Potentials Sep

Strobe-Flash VisualNeurology Evoked Potentials Sfvep

Subdural Grid MonitoringNeurology Report Sgm

All Reports For ThisNeurology Department Department * * *Alli.pt* * *

All Reports For ThisNucmed Department ***Allrpt***

Nuclear Medicine PatientNucmed Status Report NucntPathology Diagnostic DgynPathology Non-Gyn Review Cnrev

30

Pathology Path Report Cnadd CnaddPathology Path Report Gadd GaddPathology Sp Final SpfPathology Surgical AdsgPathology Thin Prep Pat Tgyn

All Reports For ThisPedscard Department ***Allrpt***

Pedscard Echocardiography Report EchoPedscard Exercise Report ExerPedscard Holter Report loiter

Interim DischargePedscard Summary Report DcsumPedscard Outpatient Notice OutPedscard Oxygen Saturation Report OxysatPedscard Procedure Notice Proc

All Reports For ThisPulmonar Department ***Allr.pt***

Pulmonar Pulmonary Function Test PftRadiology Radiology Report Radiology ReportRadiology Radiology Report - Chest Radiology-Chest

All Reports For ThisRadiology Department Department * * *Allrpt* * *

All Reports For ThisVasr Department ***Allrpt***

Vasr Arterial Duplex ArtdVasr Carotid Study Caroti

Duplex Scan AbdominalVasr Aortic Aneurysm Aaa

Duplex Study Of The IliacVasr Vasculature IliacVasr Greenfield Filter Study Greenf

Inferior Vena Cava DuplexVasr Study Ivc

Lower Extremity ArterialVasr Bilateral Study Leartb

Lower Extremity ArterialVasr Duplex Leartd

Lower Extremity ArterialVasr Plethysmography Leapg

Lower Extremety DeepVasr Venous Thrombosis LEDVT

Lower ExtremityVasr Photoplethysmography Leppg

31

Lower ExtremityPseudoaneurysmVasr LepseuLower Extremity Venous

Vasr Bilateral Study LevenbVasr Other Arterial Study OtheraVasr Other Venous Study OthervVasr Renal Arterial Study RenalaVasr Superficial Vein Mapping SupervVasr Trans-Cranial Doppler TcdVasr Upper Extremity Ueartb

Upper Extremity ArterialVasr Duplex Ueartd

Upper Extremity DeepVasr Venous Thrombosis Uedvt

Upper ExtremityVasr Pseudoaneurysm Uepseu

Upper Extremity VenousVasr Bilateral Study UevenbVasr Venous Doppler Vendop

32

Appendix I: M NET Flowchart

Fax thedocument to the

referring48,333 reports! month* physician

Source: *Referring Physician Portal Capital Funding Request, ITSACPresentation, March 2, 2006

NO

NO

33

Appendix J: Radiology Department Flowchart

YES

825documents!

month*

*Source: Steven RamseyDirector, Unit Data Systems**Source: Mary DavidsonOffice Administration Associate Supervisor, UMH Radiology

Source: Andrew Jarvis, Associate Telecommunications Analyst, UMH PublicRelations and Marketing Communications/Interactive Marketing

month***

34