Janury 22, 2007

A Virtual Success
By Elizabeth S. Roop
For The Record
Vol. 19 No. 1 P. 12

A city edict to put a curb on traffic congestion served as the impetus behind a Houston hospital’s decision to send its coders home.

When Stacie Ellis, RHIA, CCS, clocks in for her job as a coder with St. Luke’s Episcopal Health System in Houston, she isn’t stressed from a long commute in rush hour traffic. When she clocks out, no traffic jam gets in the way of a personal life filled with family, hobbies, and volunteering.

She never has to waste a personal day on a broken-down car, and she’s saving a bundle on gas and parking. While on the job, her concentration is never interrupted with nagging concerns about running late, missing her children’s school bus, or getting her daughter to dance lessons on time. Her productivity has skyrocketed along with her job satisfaction.

It may sound like utopia, but for Ellis and her fellow coders, it is the world they’ve lived in for the past year when St. Luke’s took its coding department virtual and sent them all home.

“My kids don’t miss out on anything because I’m a working parent,” she says. “I love it. It’s a great balance between work and family. I feel like I have a lot more free time to do things with my kids, and it’s a lot less stressful. St. Luke’s is very good to its employees and they understand how important it is to have a good balance between work and family.”

The coders’ satisfaction pales in comparison to that of the managers and administrators. Since sending its coders home, the hospital has reaped the rewards of higher productivity—up 12% for inpatient coding and 16% for outpatient—increased quality, and lower overhead.

“We are thrilled; the administration is thrilled. We are working a lot more efficiently,” says Sarah Glass, MA, RHIA, CCS, assistant director of HIM at St. Luke’s.

A Team Approach
St. Luke’s Episcopal Health System is comprised of St. Luke’s Episcopal Hospital in the Texas Medical Center, a 946-bed nonprofit tertiary teaching facility; St. Luke’s Episcopal Health Charities, the city’s largest charity devoted to healthcare; St. Luke’s Community Medical Center-The Woodlands, an 84-bed primary and secondary care facility; and Kelsey-Seybold Management LLP, which operates 21 clinics and 11 pharmacies.

In late 2004, its administration decided to explore the viability of operating several of its departments virtually in response to the city’s initiative to encourage employers to implement flexible scheduling and teleworking programs to alleviate traffic congestion.

The centralized coding department was the natural choice to pilot the program, in part because the department already had an effective productivity and monitoring system in place to measure the initiatives’ success. The caliber of the coding staff and its experience in working with remote employees also factored in.

“We have a lot of experienced coders, and we wanted to retain them,” says Glass, adding that “we knew it would work because we were already remotely coding for our community medical center hospital, and it was working very efficiently.”

It was also a natural transition because the facility’s HIM department was preparing to relocate to office space outside the hospital, making it the ideal time to reduce space requirements by sending coders home.

However, managing a handful of remote employees was a far cry from managing an entire virtual department that includes 18 coders and two coding quality coordinators. Plus, as the first department to make the transition, they knew that whatever the staff did would set a precedent for the rest of the hospital.

That’s why their first move was to establish a multidisciplinary team to oversee implementation of the virtual operations. Joining Glass on the project team were Senior Vice President and Chief Information Officer Kay Carr; HIM Director Peggy Reed Stasky, RHIA; Coding Supervisor Gloria Polk, RHIT, CCS; and representatives from human resources, risk management, and IT, including hardware, software, and help desk.

“One of the main concerns we had was that we would be setting a facilitywide precedent, so any decisions we made would have an impact beyond our department,” says Glass. “There wasn’t any one way to address this concern, except to be continuously cognizant of our role in changing the future of our workplace. That’s part of the reason we had that interdisciplinary team.”

By including representatives from each area that would be affected by the transition, the project team was able to address numerous key issues. For example, at the time, the help desk did not have anyone dedicated to remote issues, raising concerns about what may happen if multiple coders had problems with their remote connections simultaneously.

The solution was to implement the program slowly, sending coders home one at a time every other week starting with the part-time outpatient emergency department coders. This allowed testing and troubleshooting to be handled on a manageable scale. IT also developed a troubleshooting guide for coders and a set of processes for the help desk. (By May 2005, the entire coding staff was operating remotely.)

Other issues addressed by the team included risk management’s concerns over workspace safety and security, and human resource issues such as changes in benefits or taxes should a coder move out of state.

The team also reached out to the AHIMA as well as other facilities that had undertaken similar projects using the same software (ChartMaxx for electronic patient records; 3M for coding; and SoftMed for abstracting). That resulted in the determination that they could handle the implementation internally.

“IT worked diligently to ensure the software worked as well remotely as it did in house,” says Glass. “They made everything work the same way. Although we get into [the system] a different way through a certification process, all the software is the same.”

Getting on the Same Page
The one area where St. Luke’s did bring in outside consultants for assistance was developing the policies, procedures, and communication structures to help coders make a successful transition from on-site to remote employment. It also tapped a number of resources on teleworking available from the state and federal governments and Commute Solutions’ Telework Resource Center, a program of the Houston-Galveston Area Council.

The final policies and procedures established everything from training (the first three months are spent working on-site); whether St. Luke’s would provide the equipment, including computers and Internet connections for remote employees (no, because working remotely is not mandatory); what coders would do if they had computer problems unable to be corrected in a timely fashion (work on-site until the problem was fixed); and what coders would do if the entire system was temporarily down (work on mandatory education modules until they could resume coding).

Also addressed were security issues, including how to handle the coding files and communications with physicians. Coders, who access the hospital’s coding system through a secure Internet connection, are not able to save records to their computers, nor can they print any part of the records. And while coding queries can still be sent directly to physicians, additional documentation is faxed to the main facility and scanned into the electronic record for coders to access.

Another concern the policies addressed was what would happen if all the coding employees needed to work on-site at any given time, since the relocated HIM department could not accommodate the full staff. If the unlikely event occurs, coders can either work at the facility closest to them or use the IT classroom space, according to Glass.

Work hours were also addressed—a particularly critical issue in the early days when success would be measured by productivity.

“When we started, we asked coders to work the same hours they did at the hospital,” says Glass. “We were trying to measure the success of the program, and we didn’t want to have any variables like working odd hours, so we could do an apples-to-apples comparison.

“It worked out well because we did show an increase in productivity. Since then we have gone to more flexible scheduling. They can’t just work anytime they want—we don’t want them working 20 hours on Sunday and 20 hours on Monday, then taking the rest of the week off—but we do allow some flexibility.”

Finally, St. Luke’s developed a Teleworking Agreement the coders signed before they went home. The agreement covered everything, including time and attendance, salary and benefits, standards of conduct, and even the explanation that teleworking was not an alternative to child or older adult care.

“The Teleworking Agreement was a critical thing,” says Glass. “If you want to avoid having issues and concerns, address them in a Teleworking Agreement to make sure everyone is working on the same page.”

Satisfaction at Every Level
In the year that’s passed since St. Luke’s went virtual, the coding department has adjusted nicely to the new structure. It has not been without some challenges, however.

“Our communications initially were a challenge because it’s a lot easier to manage people when you can just go out the door and talk to them,” says Glass. “Now we have to think about how to get them the information.”

The department relies more heavily on e-mail communications, with the management team copying each other on all e-mails and comments sections in the software programs to ensure clarity and avoid duplication. It also established a shared directory where much of the information that used to be distributed on paper is now saved for easy access by everyone in the department. Coders also have personal folders in the directory.

To maintain a sense of community among the coding staff, quarterly meetings are held on-site, as are special appreciation events such as HIM and hospital week. This opportunity to catch up with colleagues is something the coders particularly appreciate, according to Ellis, who says the biggest adjustment for her was losing the ability to interact with coworkers.

“One of the great aspects of my job is that I have wonderful people to work with. Once you go home, that all changes,” she says. The quarterly meetings “are very exciting because we get to see each other. We have our business meetings, but we still have time to catch up.

“Good communication and support from management [were] a tremendous help,” she adds. “We have all the right tools and our policies and procedures are set, so we know what’s expected of us.”

Polk adds, “We are really proud of our staff. They’ve done so well since they’ve been remote.”

The coding department and the health system as a whole share in the coding staff’s satisfaction with the virtual organization, particularly given the scope of benefits that have been realized as a result of the transition, including the following:

• filling two openings that had been vacant for years, with a steady stream of qualified applications coming in to fill any future vacancies;

• a 100% retention rate since the department went virtual;

• reduced costs from a reduction in overhead and the elimination of contract help;

• no interruption of services, even during hurricanes Katrina and Rita;

• increased productivity and quality;

• lower absenteeism rates; and

• increased job satisfaction for both coders and managers.

“It’s working better than we expected. The coders are happy. We filled our open positions, and we eliminated [the need for] contract coders,” says Glass, adding that the result of the virtual coding department paved the way for parts of IT and human resources to follow suit. “We’ve been very fortunate here because we had everyone’s support from the beginning.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.

The Secrets to Virtual Success
St. Luke’s Assistant Director of HIM Sarah Glass, MA, RHIA, CCS, and Coding Supervisor Gloria Polk, RHIT, CCS, had the following advice for others who may be considering transitioning to a virtual coding department:

• Form an interdisciplinary team “because you’re going to need everyone’s support,” says Glass.

• An electronic record system and means for scanning paper records are absolute musts. Coders need a high-speed Internet connection to maintain productivity.

• Make sure the electronic patient record (EPR) area (prep/scan/quality control) is staffed appropriately. Bar code as much of the record as possible. “This will enable the prep area to stay current because if they get behind, the tendency is to want the coders to code from paper, and you lose all the benefit of having an EPR,” according to Glass.

• Equipment-wise, a large monitor is beneficial because it eliminates the need for coders to waste time maximizing and minimizing screens. “If you want this program to be successful, then you need to give the coders the tools they need to be as efficient as they can be,” Glass says.

• Keep up-to-date contact information for each coder and give coders a list of manager and help desk contacts.

• Develop a comprehensive Teleworking Agreement.

• Start looking at everything you have in paper form and figure out a way to automate it.

“If something is on paper, there’s usually a way to convert it. We have found that for just about anything we are doing in paper, there is some way to do it online,” Glass says.

— ESR