Structured physician order entry for trauma CT: value in improving clinical information transfer and billing...

Area of Science:

• Radiology and Imaging
• Health Informatics
• Healthcare Administration

Background:

• Effective communication of clinical information is crucial for accurate trauma CT interpretation.
• Current practices may lead to incomplete or inaccurate coding, impacting reimbursement.
• Trauma CT (pan-scan CT) is vital for diagnosing injuries in critically ill patients.

Purpose of the Study:

• To evaluate the impact of a structured physician order entry system on trauma CT.
• To assess changes in clinical information communication, coding practices, and reimbursement efficiency.

Main Methods:

• A quasi-experimental study was conducted at a level I trauma center before and after system implementation.
• Data collected included clinical signs/symptoms, mechanism of injury, ICD-9-CM codes, and reimbursement metrics.
• Statistical analysis used chi-square and Wilcoxon rank sum tests.

Main Results:

• Significant increases in documented clinical signs/symptoms (62%) and mechanism of injury (99%) were observed.
• Primary ICD-9-CM codes representing clinical information increased by 19%.
• Reimbursement success rose by 7%, and billing cycle time decreased by 14.7 days.

Conclusions:

• Structured physician order entry for trauma CT enhances clinical history communication to radiologists.
• The system positively influences coding accuracy and improves billing efficiency and reimbursement success.
• This intervention offers a valuable tool for optimizing trauma imaging workflows.