Proper Electronic Order Linkage ofElectrocardiograms at a Large Children’sHospital Improves Reporting andRevenue

David S Spar, Wayne A Mays, David S Cooper, Lucille Sullivan, Terra Hicks,

Jeffrey B Anderson

To cite: Spar DS, Mays WA,Cooper DS, et al. ProperElectronic Order Linkage ofElectrocardiograms at a LargeChildren’s Hospital ImprovesReporting and Revenue. BMJQuality Improvement Reports2017;6:u217231.w6746.doi:10.1136/bmjquality.u217231.w6746

Received 19 November 2016Revised 16 March 2017

Cincinnati Children'sHospital, United States ofAmerica

Correspondence toDavid Spar david.spar@cchmc.org

ABSTRACTElectrocardiograms (ECGs) are performed to determinean individual’s cardiac rhythm. Approximately 25,000ECGs are performed yearly throughout our hospitalsystem. Historically only 68% of all ECGs wereperformed with the proper order linked to the electronicECG reading system (MUSE). Failure to link the ordersto the electronic reading system leads to problems inpatient safety, reporting and hospital revenue.Our aim was to increase the percentage of linked ECG

orders in MUSE compared to total ECGs performedfrom 68% to 95%.We created a detailed process map of ECG order

linking to the MUSE electronic system. FMEA and Paretochart creation were used to determine etiology ofprocess failures. Multiple interventions (LOR1 to LOR3)were implemented utilizing the PDSA technique. Processcontrol charts were used to evaluate change.FMEA and Pareto chart determined most common

failures were related to: 1) ECG order not electronicallyacquired properly, 2) duplicate ECGs and 3) ECG orderwas not electronically placed. We performed multipleinterventions including: 1) ECG performance education,2) created reminders on the ECG machines, 3)specialized electronic linking system for physicianreaders and 4) bar-code scanners for all ECG machines.These changes improved ECG order linking to MUSEfrom 68% to 95% over 6-months. In direct comparisonbetween fiscal year (FY) FY2014 to FY2015, the numberof ECGs performed increased 2% while billing increasedby 23%.Utilization of quality improvement methodology

allowed us to identify failures for ECG order linking. Weestablished multiple successful interventions amongstdifferent hospital locations and improved ourcompliance, billing and reporting of ECGs.

PROBLEMCincinnati Children’s Hospital is a large chil-dren’s hospital with 598 beds, over 35,000admission and 1.3 million patient encountersa year. The electrophysiology group alongwith the business team at the Heart Instituteat Cincinnati Children's Hospital noted a

long-standing problem with electrocardio-grams (ECG) being performed without alinked order in the electronic medicalrecord, in this case Epic. This lack of linkingorders to ECG performance created twoimportant problems, one clinical and relatedto patient safety and one financial. The clinicproblem was that in order to view the ECGwith the interpretation from the electrophysi-ologist directly reported in Epic (the elec-tronic medical record) the ECG had to belinked to an order. Also, an ECG may havebeen performed without the physician beingaware and or not indicated. Therefore, therewere an unacceptable number of ECGs thatcould not be read and posted to Epic for theordering physician to have the final resultsdirectly reported. Financially, this created aproblem because no study can be billed tothe payer without first having an order.Therefore all ECGs performed without firstbeing linked to an order were resulting in nocharges. Our SMART Aim was to increase thepercentage of linked ECG orders in the ECGelectronic reading system MUSE from 68%to 95% from February 2015 to May 2015.

BACKGROUNDCurrently we perform and read approxi-mately 25,000 ECGs a year. The percentageof ECG performed with orders was approxi-mately 68%. Performing and reading ECGsutilize resources including ECG techniciansand physicians. There are also costs of theECG machine and yearly maintenance. If30% of all ECGs are performed without alinked order there are issues with compli-ance, reporting and loss of revenue.

BASELINE MEASUREMENTOur measurement was percentage of ECGslinked to an order in MUSE, an electronic

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ECG reading system. The rationale for the project wasthat unlinked ECG orders in MUSE create issues inpatient compliance, reporting and revenue. Thismeasure will determine the number of ECGs linked tothe EPIC order in MUSE. The ‘gold standard’ value ishaving a proper EPIC order placed for each individualECG performed, and the order utilized to perform theECG. The population was all ECGs performed at ourinstitution and satellite locations. Data sources included:Epic, MUSE, and creating of Excel spreadsheets withdata from all locations where ECGs were performed. Wecollected daily data and reported the data weekly. Thetotal ECGs were subdivided by location performed. Thecalculation of ECG linked to MUSE was: (ECG linkedMUSE)/(ECG total) × 100 = % ECG linked. We gatheredclinical information from Epic as well as our ECG system(MUSE) and billing data from our finance team. Weexamined baseline data from January 2015. During thismonth there were >2,300 ECGs performed and only 68%of the ECGs were performed with the proper linkage ofan order in Epic to our ECG reading system MUSE.

DESIGNWe utilized the Model for Improvement for this project.Initially we observed and walked through the process ofECG ordering in Epic and linking to the MUSE system.We identified problems with registration, ECGsperformed without orders (often occur weekends andevenings, and occur when ECGs are performed byuntrained staff), ECGs performed with an order but notproperly linked to MUSE system, and finally ECGsperformed in multiple. A Process Map was created docu-menting the ECG ordering and linking system. FMEA andPareto charts determined most common failures were

related to: 1) ECG orders in Epic not electronically linkedto the MUSE system properly, 2) multiple (or duplicate)ECGs performed at the same time and 3) ECG ordersnot electronically being placed in Epic (figure 1).

STRATEGYWe created a SMART Aim with a goal to increase thepercentage of linked ECG orders in MUSE compared tototal ECGs performed at our institution and satelliteclinics from 68% to 95% by May 2015.PDSA Cycle 1 Emergency Department (ED)

Education for those who perform ECGs. There are alarge volume of ECGs obtained in the ED with many dif-ferent technicians and nurses that perform the ECG.The technicians and nurses in the ED were educated onproper use of ECG order and linking to MUSE. Therewas coordinated nurse education that was started withmanagers and spread to all providers that performECGs. The education process was effective with improve-ment in proper order linkage but the level of reliabilitywas low. There is also significant turnover in staff andrequires multiple cycles of education throughout theyear. This intervention improved ECG order linkingwithin the ED from 35% to 85%.PDSA Cycle 2 Creating specialized electronic in-baskets

in MUSE. Certain hospital or clinical locations that werepoor performers had specialized electronic baskets thatallowed our technicians to link the order prior to beingfinalized. We worked with the IT department and suc-cessfully routed these ECGs to a specific electronicin-basket. Out ECG technicians then were able to suc-cessfully link the order to the ECG prior to being routedto the reading Electrophysiologist. This change improvedECG order linking within these specific locations from

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14% to 94%. This system continued to rely on a properorder placed by the ordering provider prior to the ECGbeing performed by the technician or nurse.PDSA Cycle 3 Stop sign reminder on ECG machines.

This change was easy to implement but over time didnot have a significant impact. The change did notimprove ECG order linking. Low level of reliability buteasily seen and placed next to confirmation button.PDSA Cycle 4 ECG readers trained to link order if not

performed. Prior to confirmation of ECG, our fourtrained ECG readers evaluated if an order was placedand linked. If the order was present but not linked theECG reader would link prior to confirmation. There wereonly 4 Electrophysiologist to train and this was a simplestep requiring a single change in the MUSE electronicreading system. The change improved ECG order linkingby 1%, overall from 91% to 92%. This change was later inour project and we had already seen substantial increasesin ECG order linking at the start of this PDSA.PDSA Cycle 5 Added a scanner to all ECG machines.

High level of reliability requiring the technician or nurseto have an order placed in Epic so the bar-code scannercould access the order and link electronically to theMUSE ECG system. The system was easy to use (most tech-nicians and nurses were already using a bar-code scannerfor other tests). We allowed for a manual override foremergency type situations. This was first tested in selectunits that were high performers (high ECG order linking)including our own Cardiology ECG technicians. Afteridentifying minor issues the change was slowly spread toall outpatient and inpatient units successfully. This systemrelied on an order being present prior to performing the

ECG and if not present the scanner would not work.Once scanned, the order was automatically linked to theECG in our reading system. Since implementing thischange the ECG order linking from 92% to 95%.

RESULTSThe project measured ECGs that were performed butdid not have an EPIC order linked to the MUSE readingsystem. We reviewed the percentage of appropriatelylinked ECGs in the system. This measurement was per-formed by evaluating the number of appropriatelylinked ECGs over the total ECGs performed in a timeperiod. FMEA and Pareto chart determined the mostcommon failures were related to: 1) ECG order not elec-tronically linked properly, 2) duplicate ECGs and 3)ECG order was not electronically placed. We performedmultiple interventions including: 1) ECG acquisitioneducation, 2) created reminders on the machines, 3)specialized electronic linking system for physicianreaders and 4) bar-code scanners for all ECG machines.When the project started 68% of the ECGs performed

at our institution had an appropriate order linked to theECG reading system MUSE. After our described interven-tions, 95% of the ECGs were linked appropriately (figure2). When evaluating locations outside of CardiologyDivision, only 35% of the ECGs were linked appropriatelyand increased to 90% at the end of the project (figure3). The individual improvements were described in theStrategy section under each PDSA. The improvement inECG orders linked to MUSE allowed our institution todirectly report results in EPIC improving patient safety. If

Figure 2

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an ECG order was not linked to MUSE, the ECG wouldnot be reported directly into our hospital electronicsystem. To find results the provider would have to enterthe electronic record and then search specifically for thatindividual ECG result. If the order is directly linked toMUSE, the result is automatically sent to the orderingprovider and required that provider to review and sign-offon the result. Therefore, the percentage increase in ECGlinkage was directly related to resulting the order to theprovider. In addition this project has resulted in improvedbilling and resultant revenue. In direct comparisonbetween fiscal year (FY) 2014 to FY2015, ECG acquisitionincreased by only 2% while billing for ECGs performedincreased by 23%. So over the past year our billingimproved by over 20% with only a small increase inoverall ECG performance, which was directly related toan increase in the electronic order linked to the ECG.This proper order allowed for the hospital to bill appro-priately for the performance of the ECG.

LESSONS AND LIMITATIONSECGs are performed by many different technicians andnurses at our institution. Within the Cardiology depart-ment we were able to train our staff and subsequentlyhave a high appropriate linking of ECGs early on. Themajority of poor performers occurred outside ofCardiology and required interventions with higher levelsof reliability. When there are large numbers of techni-cians and nurses performing studies, education alone isnot reliable enough for long-term success. We createdsystems including electronic in-baskets to link ECGs

prior to being confirmed, allowing readers to link ECGsthat were not appropriately linked and utilization ofbar-code scanners that were simple and reliable tocreate an improvement in appropriate linking of ECGorders to our electronic reading system. For patientsafety we felt that we could not remove ECG machinesfrom all clinical settings which continues to allow a lowpercentage of ECGs performed incorrectly.

CONCLUSIONUtilization of quality improvement methodology allowedus to identify failures for ECG order linking to our elec-tronic reading system MUSE. We established multiplesuccessful interventions amongst different hospital loca-tions and improved our compliance, reporting andpatient safety, and billing of ECGs performed in a busyChildren's Hospital.

Declaration of interests Nothing to declare

Ethical approval According to the policy activities that constitute research at(Cincinnati Children's Hospital Medical Center) this work met criteria foroperational improvement activities exempt from ethics review.

Open Access This is an open-access article distributed under the terms ofthe Creative Commons Attribution Non-commercial License, which permitsuse, distribution, and reproduction in any medium, provided the original workis properly cited, the use is non commercial and is otherwise in compliancewith the license. See:• http://creativecommons.org/licenses/by-nc/2.0/• http://creativecommons.org/licenses/by-nc/2.0/legalcode

REFERENCE1. Langley G, Moen R, Nolan K, et al. The Improvement Guide. 2nd ed.

San Francisco: Jossey-Bass, 2009.

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