BMJ Qual Improv Report 6: doi:10.1136/bmjquality.u217231.w6746
  • BMJ Quality Improvement Programme

Proper Electronic Order Linkage of Electrocardiograms at a Large Children's Hospital Improves Reporting and Revenue

  1. Jeffrey B Anderson
  1. Cincinnati Children's Hospital, United States of America
  1. Correspondence to David Spar david.spar{at}
  • Received 19 November 2016
  • Revision requested 2 February 2017
  • Revised 16 March 2017
  • Published 12 May 2017


Electrocardiograms (ECGs) are performed to determine an individual's cardiac rhythm. Approximately 25,000 ECGs are performed yearly throughout our hospital system. Historically only 68% of all ECGs were performed with the proper order linked to the electronic ECG reading system (MUSE). Failure to link the orders to the electronic reading system leads to problems in patient safety, reporting and hospital revenue.

Our aim was to increase the percentage of linked ECG orders in MUSE compared to total ECGs performed from 68% to 95%.

We created a detailed process map of ECG order linking to the MUSE electronic system. FMEA and Pareto chart creation were used to determine etiology of process failures. Multiple interventions (LOR1 to LOR3) were implemented utilizing the PDSA technique. Process control charts were used to evaluate change.

FMEA and Pareto chart determined most common failures were related to: 1) ECG order not electronically acquired properly, 2) duplicate ECGs and 3) ECG order was not electronically placed. We performed multiple interventions including: 1) ECG performance education, 2) created reminders on the ECG machines, 3) specialized electronic linking system for physician readers and 4) bar-code scanners for all ECG machines. These changes improved ECG order linking to MUSE from 68% to 95% over 6-months. In direct comparison between fiscal year (FY) FY2014 to FY2015, the number of ECGs performed increased 2% while billing increased by 23%.

Utilization of quality improvement methodology allowed us to identify failures for ECG order linking. We established multiple successful interventions amongst different hospital locations and improved our compliance, billing and reporting of ECGs.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: