Research Work
Characterizing the role of a high-volume cancer resection ecosystem on low-volume, high-quality surgical care.
Kothari AN, Blanco BA, Brownlee SA, Evans AE, Chang VA, Abood GJ, Settimi R, Raicu DS, Kuo PC.
Abstract
BACKGROUND:
Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers.
METHODS:
Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models.
RESULTS:
A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection (P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy (P = .421) or pancreatectomy (P = .413) at low-volume centers.
CONCLUSION:
Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem.
Inpatient Rehabilitation after Liver Transplantation Decreases Risk and Severity of 30-Day Readmissions.
Kothari AN, Yau RM, Blackwell RH, Schaidle-Blackburn C, Markossian T, Zapf MA, Lu AD, Kuo PC.
Abstract
BACKGROUND:
Discharge location is associated with short-term readmission rates after hospitalization for several medical and surgical diagnoses. We hypothesized that discharge location: home, home health, skilled nursing facility (SNF), long-term acute care (LTAC), or inpatient rehabilitation, independently predicted the risk of 30-day readmission and severity of first readmission after orthotopic liver transplantation.
STUDY DESIGN:
We performed a retrospective cohort review using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases for Florida and California. Patients who underwent orthotopic liver transplantation from 2009 to 2011 were included and followed for 1 year. Mixed-effects logistic regression was used to model the effect of discharge location on 30-day readmission controlling for demographic, socioeconomic, and clinical factors. Total cost of first readmission was used as a surrogate measure for readmission severity and resource use.
RESULTS:
A total of 3,072 patients met our inclusion criteria. The overall 30-day readmission rate was 29.6%. Discharge to inpatient rehabilitation (adjusted odds ratio [aOR] 0.43, p = 0.013) or LTAC/SNF (aOR 0.63, p = 0.014) were associated with decreased odds of 30-day readmission when compared with home. The severity of 30-day readmissions for patients discharged to inpatient rehabilitation were the same as those discharged home or home with home health. Severity was increased for those discharged to LTAC/SNF. The time to first readmission was longest for patients discharged to inpatient rehabilitation (17 days vs 8 days, p < 0.001).
CONCLUSIONS:
When compared with other locations of discharge, inpatient rehabilitation reduces the risk of 30-day readmission and increases the time to first readmission. These benefits come without increasing the severity of readmission. Increased use of inpatient rehabilitation after orthotopic liver transplantation is a strategy to improve 30-day readmission rates.
Transient postoperative atrial fibrillation after abdominal aortic aneurysm repair increases mortality risk.
Kothari AN, Halandras PM, Drescher M, Blackwell RH, Graunke DM, Kliethermes S, Kuo PC, Cho JS.
Abstract
OBJECTIVE:
The purpose of this study was to determine whether new-onset transient postoperative atrial fibrillation (TPAF) affects mortality rates after abdominal aortic aneurysm (AAA) repair and to identify predictors for the development of TPAF.
METHODS:
Patients who underwent open aortic repair or endovascular aortic repair for a principal diagnosis AAA were retrospectively identified using the Healthcare Cost and Utilization Project-State Inpatient Database (Florida) for 2007 to 2011 and monitored longitudinally for 1 year. Inpatient and 1-year mortality rates were compared between those with and without TPAF. TPAF was defined as new-onset atrial fibrillation that developed in the postoperative period and subsequently resolved in patients without a history of atrial fibrillation. Cox proportional hazards models, adjusted for age, gender, comorbidities, rupture status, and repair method, were used to assess 1-year survival. Predictive models were built with preoperative patient factors using Chi-squared Automatic Interaction Detector decision trees and externally validated on patients from California.
RESULTS:
A 3.7% incidence of TPAF was identified among 15,148 patients who underwent AAA repair. The overall mortality rate was 4.3%. The inpatient mortality rate was 12.3% in patients with TPAF vs 4.0% in those without TPAF. In the ruptured setting, the difference in mortality was similar between groups (33.7% vs 39.9%, P = .3). After controlling for age, gender, comorbid disease severity, urgency (ruptured vs nonruptured), and repair method, TPAF was associated with increased 1-year postoperative mortality (hazard ratio, 1.48; P < .001) and postdischarge mortality (hazard ratio, 1.56; P = .028). Chi-squared Automatic Interaction Detector-based models (C statistic = 0.70) were integrated into a Web-based application to predict an individual's probability of developing TPAF at the point of care.
CONCLUSIONS:
The development of TPAF is associated with an increased risk of mortality in patients undergoing repair of nonruptured AAA. Predictive modeling can be used to identify those patients at highest risk for developing TPAF and guide interventions to improve outcomes.
New onset postoperative atrial fibrillation predicts long-term cardiovascular events after gastrectomy.
Nassoiy SP, Blackwell RH, Kothari AN, Besser S, Gupta GN, Kuo PC, Abood GJ.
Abstract
BACKGROUND:
Recent evidence suggests transient postoperative atrial fibrillation leads to future cardiovascular events, even in noncardiac surgery. The long-term effects of postoperative atrial fibrillation in gastrectomy patients are unknown.
METHODS:
The Healthcare Cost and Utilization Project State Inpatient Databases identified patients undergoing gastrectomy for malignancy between 2007 and 2010. Patients were matched by propensity scores based on various factors. Adjusted Kaplan-Meier and Cox proportional hazards models assessed the effect of postoperative atrial fibrillation on cardiovascular events.
RESULTS:
A higher incidence of cardiovascular events occurred over the 1st year in patients who developed postoperative atrial fibrillation. Cox proportional hazards regression confirmed an increased risk of cardiovascular events in postoperative atrial fibrillation patients.
CONCLUSIONS:
Our results demonstrate that patients undergoing gastrectomy for malignancy who develop postoperative atrial fibrillation are at increased risk of cardiovascular events within 1 year. Physicians should be vigilant in assessing postoperative atrial fibrillation, given the increased risk of cardiovascular morbidity.
KEYWORDS:
Atrial fibrillation; Gastrectomy; Myocardial infarction; Postoperative complications; Stroke
Early Intervention during Acute Stone Admissions: Revealing "The Weekend Effect" in Urological Practice.
Blackwell RH, Barton GJ, Kothari AN, Zapf MA, Flanigan RC, Kuo PC, Gupta GN.
Abstract
PURPOSE:
Obstructing nephrolithiasis is a common condition that can require urgent intervention. In this study we analyze patient factors that contribute to delayed intervention during acute stone admission.
MATERIALS AND METHODS:
We retrospectively reviewed the HCUP SID (Healthcare Cost and Utilization Project State Inpatient Database) for Florida and California from 2007 to 2011. Patients who were admitted urgently with nephrolithiasis and an indication for decompression (urinary tract infection, acute renal insufficiency and/or sepsis) were included in the study. Intervention was timely or delayed, defined as a procedure that occurred within or after 48 hours, respectively. Adjusted multivariate models were fit to assess factors that predicted a delayed procedure as well as mortality.
RESULTS:
Overall 10,301 patients were admitted urgently for nephrolithiasis with indications for decompression. Early intervention occurred in 6,689 patients (65%) and was associated with a decrease in mortality (11, 0.16%), compared to delayed intervention (17 of 3,612, 0.47%, p=0.002). On multivariate analysis timely intervention significantly decreased the odds of inpatient mortality (OR 0.43, p=0.044). Weekend day admission significantly influenced time to intervention, decreasing patient odds of timely intervention by 26% (p <0.001). Other factors decreasing patient odds of timely intervention included nonCaucasian race and nonprivate insurance. Presenting medical diagnoses of urinary tract infection, sepsis and acute renal failure did not appear to influence time to intervention.
CONCLUSIONS:
Delayed operative intervention for acute nephrolithiasis admissions with indications for decompression results in increased patient mortality. Nonmedical factors such as the "weekend effect," race and insurance provider exerted the greatest influence on the timing of intervention.
Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
outcome assessment (health care); socioeconomic factors; urinary calculi; urologic surgical procedures
Components of Hospital Perioperative Infrastructure Can Overcome the Weekend Effect in Urgent General Surgery Procedures.
Kothari AN, Zapf MA, Blackwell RH, Markossian T, Chang V, Mi Z, Gupta GN, Kuo PC.
Abstract
OBJECTIVE:
We hypothesized that perioperative hospital resources could overcome the "weekend effect" (WE) in patients undergoing emergent/urgent surgeries.
SUMMARY BACKGROUND DATA:
The WE is the observation that surgeon-independent patient outcomes are worse on the weekend compared with weekdays. The WE is often explained by differences in staffing and resources resulting in variation in care between the week and weekend.
METHODS:
Emergent/urgent surgeries were identified using the Healthcare Cost and Utilization Project State Inpatient Database (Florida) from 2007 to 2011 and linked to the American Hospital Association (AHA) Annual Survey Database to determine hospital level characteristics. Extended median length of stay (LOS) on the weekend compared with the weekdays (after controlling for hospital, year, and procedure type) was selected as a surrogate for WE.
RESULTS:
Included were 126,666 patients at 166 hospitals. A total of 17 hospitals overcame the WE during the study period. Logistic regression, controlling for patient characteristics, identified full adoption of electronic medical records (OR 4.74), home health program (OR 2.37), pain management program [odds ratio (OR) 1.48)], increased registered nurse-to-bed ratio (OR 1.44), and inpatient physical rehabilitation (OR 1.03) as resources that were predictors for overcoming the WE. The prevalence of these factors in hospitals exhibiting the WE for all 5 years of the study period were compared with those hospitals that overcame the WE (P < 0.001).
CONCLUSIONS:
Specific hospital resources can overcome the WE seen in urgent general surgery procedures. Improved hospital perioperative infrastructure represents an important target for overcoming disparities in surgical care.
"Right place at the right time" impacts outcomes for acute intestinal obstruction.
Kothari AN, Liles JL, Holmes CJ, Zapf MA, Blackwell RH, Kliethermes S, Kuo PC, Luchette FA.
Abstract
BACKGROUND:
The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention.
METHODS:
The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions.
RESULTS:
A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91]).
CONCLUSION:
Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.
Copyright © 2015 Elsevier Inc. All rights reserved.
The "weekend effect" in urgent general operative procedures.
Zapf MA, Kothari AN, Markossian T, Gupta GN, Blackwell RH, Wai PY, Weber CE, Driver J, Kuo PC.
Abstract
BACKGROUND:
There is growing concern that the quality of inpatient care may differ on weekends versus weekdays. We assessed the "weekend effect" in common urgent general operative procedures.
METHODS:
The Healthcare Cost and Utilization Project Florida State Inpatient Database (2007-2010) was queried to identify inpatient stays with urgent or emergent admissions and surgery on the same day. Included were patients undergoing appendectomy, cholecystectomy for acute cholecystitis, and hernia repair for obstructed/gangrenous hernia. Outcomes included duration of stay, inpatient mortality, hospital-adjusted charges, and postoperative complications. Controlling for hospital and patient characteristics and type of surgery, we used multilevel mixed-effects regression modeling to examine associations between patient outcomes and admissions day (weekend vs weekday).
RESULTS:
A total of 80,861 same-day surgeries were identified, of which 19,078 (23.6%) occurred during the weekend. Patients operated on during the weekend had greater charges by $185 (P < .05), rates of wound complications (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.05-1.58; P < .05), and urinary tract infection (OR 1.39, 95% CI 1.05-1.85; P < .05). Patients undergoing appendectomy had greater rates of transfusion (OR 1.43, 95% CI 1.09-1.87; P = .01), wound complications (OR 1.32, 95% CI 1.04-1.68; P < .05), urinary tract infection (OR 1.76, 95% CI 1.17-2.67; P < .01), and pneumonia (OR 1.41, 95% CI 1.05-1.88; P < .05). Patients undergoing cholecystectomy had a greater duration of stay (P = .001) and greater charges (P = .003).
CONCLUSION:
Patients undergoing weekend surgery for common, urgent general operations are at risk for increased postoperative complications, duration of stay, and hospital charges. Because the cause of the "weekend effect" is still unknown, future studies should focus on elucidating the characteristics that may overcome this disparity.
Copyright © 2015 Elsevier Inc. All rights reserved.
Postoperative Atrial Fibrillation Predicts Long-Term Cardiovascular Events after Radical Cystectomy.
Blackwell RH, Ellimoottil C, Bajic P, Kothari A, Zapf M, Kliethermes S, Flanigan RC, Quek ML, Kuo PC, Gupta GN.
Abstract
PURPOSE:
Postoperative atrial fibrillation after radical cystectomy occurs in 2% to 8% of cases. Recent evidence suggests that transient postoperative atrial fibrillation leads to future cardiovascular events. The long-term cardiovascular implications of postoperative atrial fibrillation in patients undergoing radical cystectomy are largely unknown.
MATERIALS AND METHODS:
The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify patients who underwent radical cystectomy between 2007 and 2010. After excluding patients with a history of atrial fibrillation, coronary artery disease and/or stroke, patients were matched using propensity scoring on age, race, insurance status and preexisting comorbidities. Adjusted Kaplan-Meier time-to-event analysis and Cox proportional hazards models were used to assess the effect of postoperative atrial fibrillation on cardiovascular events (acute myocardial infarction and stroke) during postoperative year 1.
RESULTS:
Radical cystectomy was performed in 4,345 patients who met the study inclusion criteria, of whom 210 (4.8%) had postoperative atrial fibrillation. There was a significantly higher cumulative incidence of cardiovascular events during the first postoperative year in patients in whom postoperative atrial fibrillation developed (24.8% vs 10.9%, adjusted log rank p=0.007). Cox proportional hazards regression demonstrated an increased risk of cardiovascular events in patients with postoperative atrial fibrillation (HR 10, p=0.02).
CONCLUSIONS:
Our results demonstrate that patients undergoing radical cystectomy in whom transient postoperative atrial fibrillation develops are at significantly increased risk for cardiovascular events in the first postoperative year. Physicians should be vigilant in assessing postoperative atrial fibrillation, even when transient, and establish appropriate followup given the increased risk of cardiovascular morbidity.
Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Abstract
BACKGROUND:
We hypothesize that medical centers that prioritize altruism can also deliver superior quality care.
METHODS:
Data were obtained from California's Office of Statewide Health Planning and Development, Medicare Hospital Compare, and the Joint Commission US Census Bureau's American Community Survey. Outcomes were measured using summary statistics, regression analysis, and quality indices. Total discounted revenue/total revenue (TDR/TR) served as a proxy for altruistic care.
RESULTS:
In nonprofit hospitals, TDR/TR positively correlated with 5 quality indices including pneumonia (P < .001), heart failure (P = .05), and overall surgical process of care (P = .009). Hospital size predicted higher quality surgical process (P = .06, 201 to 300 beds; P = .01, >301 beds), hospital teaching status demonstrated positive correlation (β = .048, P = .69), and poverty was negatively correlated (β = -.00072, P = .89). Positive TDR/TR did not adversely affect mortality or readmission rates (P = .52).
CONCLUSIONS:
TDR/TR predicts quality in nonprofit hospitals without increasing mortality and readmission. Altruistic motivation may be associated with the delivery of higher quality surgical care.
Copyright © 2015 Elsevier Inc. All rights reserved.
KEYWORDS:
Access; Altruism; Outcomes; Quality; Surgery
Abstract
BACKGROUND:
The increasing prevalence of obesity has altered the practice of medicine and surgery, with the emergence of new operations and medications. We hypothesized that the landscape of medical malpractice claims has also changed.
METHODS:
We queried the Physician Insurers Association of American database for 1990 through 1999 and 2000 through 2009 for cases corresponding to International Classification of Diseases, 9th edition, codes for obesity. We extracted adjudicatory outcome, closed and paid claims data, indemnity payments, primary alleged error codes, National Association of Insurance Commissioners severity of injury class, procedural codes, and medical specialty data.
RESULTS:
A total of 411 obesity claims were filed from 1990 to 1999 and 1,591 obesity claims were filed from 2000 to 2009. General surgery was the specialty with the greatest number of obesity claims from 1990 to 1999 and was second to family practice for 2000 to 2009. Although the percentage of paid general surgery obesity claims has decreased significantly from 69% in 1990-1999 to 36% in 2000-2009, the mean indemnity payments have increased substantially ($94,000 to $368,000).
CONCLUSION:
Recently, the percentage of paid general surgery obesity claims has significantly decreased; however, individual and total indemnity payments have increased. Obesity continues to impact general surgery malpractice substantially. Efforts to manage this component of physician and hospital practices must continue.
An analytic decision support tool for resident allocation.
Talay-Değirmenci I, Holmes CJ, Kuo PC, Jennings OB.
Author information
Abstract
BACKGROUND:
Moving residents through an academic residency program is complicated by a number of factors. Across all residency programs the percentage of residents that leave for any reason is between 3.4% and 3.8%.(1) There are a number of residents that participate in research. To avoid discrepancies in the number of residents at the all levels, programs must either limit the number of residents that go into the lab, the number that return to clinical duties, or the number of interns to hire. Traditionally this process consists of random selection and trial and error with names on magnetic strips moved around a board. With the matrix that we have developed this process is optimized and aided by a Microsoft Excel macro (Microsoft Corp, Redmond, Washington).
METHODS:
We suggest that a residency program would have the same number of residents at each residency stage of clinical practice, as well as a steady number of residents at each research stage. The program consists of 2 phases, in the first phase, an Excel sheet called the "Brain Sheet," there are simple formulas that we have prepared to determine the number of interns to recruit, residents in the research phase, and residents that advance to the next stage of training. The second phase of the program, the macro, then takes the list of current resident names along with the residency level they are in, and according to the formulas allocates them to the relevant stages for future years, creating a resident matrix.
RESULTS:
Our macro for resident allocation would maximize the time of residency program administrators by simplifying the movement of residents through the program. It would also provide a tool for planning the number of new interns to recruit and program expansion.
CONCLUSIONS:
The application of our macro illustrates that analytical techniques can be used to minimize the time spent and avoid the trial and error while planning resident movement in a program.
Abstract
BACKGROUND:
We hypothesized that the increasing body mass index of the population has affected general surgery malpractice claims.
METHODS:
We queried the Physician Insurers Association of America database from 1990 to 1999 (ie, period 1) and 2000 to 2009 (ie, period 2) for claims associated with obesity and morbid obesity. We analyzed the error involved, injury severity, procedure, and outcome.
RESULTS:
Five hundred seventy-five claims were identified. The percentage of paid claims did not differ by body mass index. Improper performance was the most common alleged error, gastric bypass was the most common procedure, and death was the most common injury. For obesity claims, the case was more likely to be settled in period 1 and withdrawn/dismissed in period 2 (P < .001). The number of morbid obesity claims rose from 9 in period 1 to 249 in period 2.
CONCLUSIONS:
The significant rise in morbid obesity claims between periods is likely caused by the substantial increase in the number of bariatric procedures performed.
Impact of business infrastructure on financial metrics in departments of surgery.
Wai PY, O'Hern T, Andersen DO, Kuo MC, Weber CE, Talbot LJ, Kuo PC.
Author information
Abstract
BACKGROUND:
In the current environment, pressure is ever increasing to maximize financial performance in surgery departments. Factors such as physician extenders, billing and collection, payor mix, contracting, incentives from the Centers for Medicare and Medicaid Services, and administrative incentives may greatly influence financial performance. However, despite a plethora of information from the University HealthSystem Consortium and the Association of American Medical Colleges, best-practice information for business infrastructure is lacking. To obtain a sampling of current practices, we conducted a survey of departments of surgery.
METHODS:
An anonymous 30-question survey addressing demographics, productivity, revenue and expense profile, payor mix, physician extender and staff personnel, billing and collections methodology, and financial performance was distributed among members of the Society of Surgical Chairs via SurveyMonkey. This was approved by the Loyola Institutional Research Board. Multivariate linear regression analyses and t tests/rank-sum tests were performed, as appropriate. Data are presented as mean ± SEM.
RESULTS:
A total of 25 (19%) departments responded; 14 were integrated with the hospital/health system, and 11 were integrated with the medical school. In 60% (n = 15), the main hospital had 500 to 1,000 beds; 48% (n = 12) had >4 hospitals in their system. For FY10, MD clinical full-time equivalents (FTEs) were 49 ± 10; total work relative value units (wRVUs) were 320 ± 8 k; and total billed cases were 43 ± 16 k. A total of 23 of 25 used physician-extenders with an average of 18 ± 5 per department and in 22 of 23, the physician extenders billed. On average, there were 18 ± 6 clinical-support staff, 25 ± 11 front-office staff, and 13 ± 3 back-office support staff FTEs. Among these FTEs, there were 16 ± 5 devoted to business operations (billing, coding, denial/claims management, financial oversight). Collections/wRVUs were $60 ± 3 (range, 39-80). Regression modeling demonstrated that total wRVUs were determined by the number of MD FTEs (P = .01), number of physician extenders (P = .01), number of front-office staff (P = .01), number of back-office staff (P = .02), and number of total business staff (P = .01). Collections/wRVUs were predicted by number of hospitals (P = .04), number of MD FTEs (P = .03), number of physician extenders (P = .01), and number of cases/total business staff (P = .02). Interestingly, wRVUs/MD was predicted by number of MD FTEs (P = .01) but were not greatly impacted by numbers of clinical or business support staff. In 4 of 25, the billing and coding staff were incentivized and had a Collections/wRVU = 64 ± 5 whereas nonincentivized staff had collections/wRVU = 59 ± 3. (P = NS) Also, %Accounts receivable >90 days (15% vs 25%) were not substantially different. Only 48% (12/25) have departments have recouped Centers for Medicare and Medicaid dollars for Physician Quality Reporting Initiative, Meaningful Use, Patient-Centered Medical Homes, or other Accountable Care-like programs. One-half (13) of the departments had both an inpatient and outpatient electronic medical record. Finally, on a scale of 1-10 (10 = highest), the average level of satisfaction with billing and collections processes was 6.
CONCLUSION:
Our results indicate that the physician extender, clinical support staff, and business staff environment can impact surgeon productivity, and there is opportunity for improvement. Determining best practices for ratios of support staff/MD and optimizing the role of electronic medical record in workflow and billing/collections are critical in the current environment. Our pilot study requires extension across more institutions for validation.