Apr 13, 2018
Connectedness of automated RT workflows in MOSAIQ helps Allegheny Health Network slash billing errors and insurance denials, streamline treatments
Care plans and MOSAIQ IQ Scripts reduce documentation and billing errors by 35 percent – Insurance denials down dramatically – Completion rate for EMR QA improved by 30 percent
In its gradual transformation from an all-Siemens to all-Elekta enterprise and encompass treatment delivery systems and oncology information software – the radiation oncology services staff of Allegheny Health Network (AHN, Pittsburgh, Pennsylvania) knew they would need to fine-tune their workflows to account for human behavior.
Staci Strickland, Manager, Operations Radiation Oncology, AHN
“We were very proud how we maximized the use of LANTIS and MOSAIQ®, but the orders in both workflows were disconnected and completed in a piecemeal fashion,” says Staci Strickland, Manager, Operations Radiation Oncology. “We were always backtracking to confirm that each AHN person in the treatment chain completed their tasks to ensure there were no breaks in the workflow. But breaks in the process would happen, forcing us to continually implement process improvements to repair the breaks.”
In researching which vendor would supply the radiotherapy treatment hardware and software, Strickland and her colleagues had visited the Centre Intégré de Cancérologie de Laval (CICL) in Laval, a Montreal suburb. A MOSAIQ user, CICL had implemented care plans and MOSAIQ® IQ Scripts™ in its radiation oncology and medical oncology MOSAIQ workflows to create a more precise, systematic patient care structure.
Integrated into MOSAIQ, a care plan is a standardized treatment plan that provides evidence-based (NCCN) guidelines for a given diagnosis, including recommended consultations, medical regimens, tests, RT planning and patient-specific quality control.
Standardizing case management with care plans helps caregivers provide the same high-quality care to patients regardless of which clinician they see, making care plans physician-independent.
IQ Scripts is a sequence of activities connected together and launched by a triggering event, such as creating an order or entering a change to patient data. IQ Scripts, which use simple scripting preferences to link together tasks in a chain, automatically trigger the presentation of one or more new QCLs or an assessment when a previous QCL or assessment is completed.
Everything at CICL seemed so organized with care plans and IQ Scripts,” Strickland recalls. “We couldn’t believe how efficient their whole process was. Essentially, IQ Scripts is the engine that drives the execution of care plans.”
Strickland and her colleagues began efforts to implement care plans and MOSAIQ IQ Scripts at AHN, with the first step a care plan summit meeting that involved the network’s 15 radiation oncologists.
Elekta’s Cynthia Stroud, Education Solutions Specialist
“Over two days we gathered the doctors in a room and created the care plans for our most common disease sites: breast, prostate, lung and head-and-neck,” she says. “Elekta’s Cynthia Stroud, Education Solutions Specialist, coordinated the meetings.”
“We asked the physicians what their orders are for a given disease site – from simulation through treatment planning and how they image, to the patient’s weekly visit with the doctor, all the way to the first follow-up appointment,” recalls Stroud. “I assimilated all this information and a month later presented the ‘Future State.’ With the help of Staci and Senior Radiation Therapist Missy Fortunato, we printed out the documents for care plans decided upon in the summit for each doctor and asked: ‘Is this what you do for a prostate patient? For a breast cancer patient?, et cetera.’”
Key components of that were two Super User Training summits in which all managers in physics, nursing, dosimetry and therapy met with Stroud, Fortunato and Strickland and worked to process map their respective workflows.
“This was where we accounted for every step in each workflow, from the minute the patient walks into the department to when the doctor puts in the consult and gets his orders in and what gets launched from that,” Fortunato says.
Once again, Stroud took this information and created a Future State for the workflows and returned to train the managers, who would in turn train others in their departments.
“I then trained Missy how to create IQ Scripts and build the care plans in MOSAIQ,” she says. “The care plans consist of orders, documents, assessments, quality checklists [QCLs] and even drugs from the pharmacy. All have to be built and put into the system because MOSAIQ IQ Scripts are generating and triggering from those items and in a particular order.”
AHN went live with their new processes.
Automated workflows usher in new order
AHN, now a year into their care plan/IQ Scripts regime, has enjoyed simplified, more orderly radiotherapy workflows, after some initial challenges adjusting to the imperatives the new system brought.
“Care plans are set up to be driven by doctors’ orders, so physicians need to approve them quickly, otherwise the entire chain of QCLs will not be triggered in a timely fashion,” Strickland says. “The clinicians needed to attend to their work lists in MOSAIQ and retrain their work habits. They had to put orders in immediately after they consult with the patient, which will initiate the nurse scheduling the patients and the biller getting authorizations so we can get the patient treated promptly.”
“One thing we struggled with at first was just letting the process happen; people were accustomed to rushing through the process,” she observes. “With IQ Scripts, the process is streamlined to move from one task to the next within the expected timeframe and in sequence. For example, most people wanted to jump from ‘plan complete’ to ‘schedule patient.’ They would prematurely go on to the next step and not allow the QCLs to work as intended.”
The workflows are not radically dissimilar to the previous workflows, Strickland emphasizes. The main difference is the greatly increased workflow automation that IQ Scripts brought.
“When someone completes a QCL, it automatically sends the next task down the chain, removing human error,” she says.
Over the course of their first year, care plans and IQ Scripts also have reduced documentation and billing errors by 35 percent, Strickland adds.
“A care plan is pre-populated for a number of fractions and fields like ‘whole breast’ or ‘partial breast,’ which not only saves time for physicians but also decreases human error,” she explains.
Fortunato adds that these errors used to cause excessive insurance denials.
“The insurance companies often would not reimburse us if the documentation was mismatched or we hadn’t obtained the correct authorization to switch something mid-treatment,” she says. “For example, if there’s a plan change from IMRT to 3DCRT, that requires completely different authorizations and documentation. If it’s not sent in, the insurance company will deny it.
“I can’t stress enough how important it is that IQ Scripts’ automated throughput is pre-programmed,” Fortunato adds. “The messages are relaying more accurately and denials went down dramatically.”
Strickland also reports that the completion rate for EMR QA in each specialty area has improved by 30 percent.
“IQ Scripts definitely decreased the number of random QCLs and helped eliminate QCLs that were assigned to nowhere,” Fortunato adds. “For instance, if you assign a QCL to a staff member or location, frequently the person might get distracted and forget to complete the entire form. Then you would find many QCLs just ‘floating out in space’ that should have been sent somewhere because it concerns a patient. An IQ Script is all connected to the patient and it’s automated. They have done so much for our network.”
Smooth sailing a year post go-live
The diligence with which Elekta’s Stroud and AHN’s Strickland, Fortunato and other AHN staff executed the implementation of care plans and IQ Scripts resulted in a problem-free roll-out and relatively infrequent issues over the last 12 months.
“It’s pretty smooth sailing now,” Fortunato says. “In the first few months, we would get suggestions or requests to modify an IQ Script to, for instance, launch in a different way, but for the most part our Quality Assurance and Quality Control Trigger [QCT] meetings are about whether to add new care plans and IQ Scripts. Frequently at these periodic meetings, an IQ Script can address a quality issue.”
She cites a recent meeting in which a network employee submitted a QCT that the departments needed a reminder to check the pacemaker policy because a patient had made it to simulation without a notification being sent out.
“Having a pacemaker and getting radiation is a big deal,” she says. “So, we created a new IQ Script so that when the doctor orders a pacemaker it’ll send out notices to the staff the patient has this device.”
Care plans have simplified the duties of the radiation oncologists, Strickland adds. “Orders can be accomplished in two or three clicks versus the 10 clicks they had to do before. It makes life easier for the doctors.”
Stroud, who spent countless days working with AHN to help them establish care plans and IQ Scripts, now has only occasional contact.
“I had three initial follow-ups and after that, I would get calls asking for help to solve an issue. But after the first couple of months, things started going more smoothly. These days I don’t hear from them very often,” she says. “They’re very self-sufficient because they were trained well and they took it upon themselves to learn how to make changes. Allegheny Health Network is an example for any site to follow. They really took ownership and worked with us like a partner.”