Structured Physician Order Entry for Trauma CT: Value in Improving Clinical Information Transfer and Billing Efficiency

OBJECTIVE. The purpose of this study was to measure the effects of use of a structured physician order entry system for trauma CT on the communication of clinical information and on coding practices and reimbursement efficiency. MATERIALS AND METHODS. This study was conducted between April 1, 2011, and January 14, 2013, at a level I trauma center with 59,000 annual emergency department visits. On March 29, 2012, a structured order entry system was implemented for head through pelvis trauma CT, so-called pan-scan CT. This study compared the following factors before and after implementation: communication of clinical signs and symptoms and mechanism of injury, primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code category, success of reimbursement, and time required for successful reimbursement for the examination. Chi-square statistics were used to compare all categoric variables before and after the intervention, and the Wilcoxon rank sum test was used to co...