Reduction in Use of Executive Health Resources (EHR)

The utilization review staff at HSHS St. Elizabeth's Hospital examines medical records for inpatient and outpatient orders and statuses to ensure patient records are accurate. The redesign aims to increase internal reviews and decrease external reviews, which aligns with safe patient care practices. This is achieved by doing concurrent reviews and reviewing the appropriateness of statuses and orders for care. The effectiveness of internal reviews is bolstered through using the InterQual screening tool, appying the 75 percent rule with documentation of severity of illness and intensity of service, and collaboratimg with internal staff.

In fiscal year 2011, 1,236 cases that did not meet InterQual criteria were sent to Executive Health Resources (EHR) for a second-level review. This second-level review increased operating costs and delayed appropriate application of patient Medicare benefits by 24 to 48 hours.

The goals of the redesign were to reduce secondary EHR reviews by 50 percent and ensure internal, skilled reviews for inpatient and outpatient cases by applying the knowledge of the utilization review staff, the InterQual screening tool and the 75 percent rule with documentation of severity of illness and intensity of service.

This case study is part of the Illinois Health and Hospital Association's annual Quality Excellence Achievement Awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals and health systems in continually improving and transforming health care in the state. These organizations are improving health by striving to achieve the Triple Aim—improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care—and the Institute of Medicine's six aims for improvement—safe, effective, patient centered, timely, efficient, and equitable. To learn more, visit https://www.ihaqualityawards.org/javascript-ui/IHAQualityAward/