Electronic reminders improve procedure documentation compliance and professional fee reimbursement

Abstract

Background: Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting.

Methods: We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders.

Results: A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement.

Conclusions: The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.