Advancing CDI Through Leveraging Technology

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Discuss challenges of EMR content awareness and analysis, and current disconnected documentation clarification processes;
Explain methodologies to engage physicians in the CDI process
Describe how technology can assist with documentation improvement and acceptance
Identify status of current advanced CDI programs and the opportunity for integration of evolving technological innovations

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Advancing CDI Through Leveraging Technology

  1. 1. 7th Annual Association for Clinical Documentation Improvement Specialists Conference
  2. 2. 2 Advancing CDI Through Leveraging Technology Paul L. Weygandt, MD, JD, MPH, MBA, CCS, FACPE Vice President Physician Services Nuance Communications, Inc. Nick van Terheyden, MD Chief Medical Information Office – CLU Nuance Communications, Inc.
  3. 3. 3 Learning Objectives • At the completion of this educational activity, the learner will be able to: – Discuss challenges of EMR content awareness and analysis, and current disconnected documentation clarification processes; – Explain methodologies to engage physicians in the CDI process – Describe how technology can assist with documentation improvement and acceptance – Identify status of current advanced CDI programs and the opportunity for integration of evolving technological innovations
  4. 4. 4 A Look at Current CDI Programs
  5. 5. 5 • Impact of documentation improvement – Compliance – Revenue cycle The Documentation Gap Hospital inpatient care Physician documen- tation Coding process Revenue cycle processes CDI programs Gap Error recovery Fraud
  6. 6. 6 Typical CDI Programs • Early successes – Typical hospital revenue cycle impact 2%–4% – Compliance • A revenue cycle initiative – Managed by HIM under a strong coding influence – Little communication with quality • Focus: DRG “optimization” – Specific focus only on those areas of documentation impacting hospital reimbursement
  7. 7. 7 Typical CDI Programs • Result: – Cynicism from medical leadership/medical staff – No fit with other physician/clinical initiatives – 1–2 year success cycle – Documentation specialists progressively disappeared into cubicles
  8. 8. 8 • Focus of documentation improvement – Compliance – Revenue cycle – Quality A New Source of Physician Engagement Hospital inpatient care Physician documen- tation Coding process Revenue cycle processes Quality/o utcome measure- ment Evolving quality- based payment CDI program
  9. 9. 9 Physician Engagement: The “Game Changer” Typical CDI programs • Success metrics – Typical hospital revenue cycle impact 2%–4% – Compliance • A revenue cycle initiative – Managed by HIM under a strong coding influence – Little communication with quality • Focus: DRG “optimization” – Specific focus only on those areas of documentation impacting hospital reimbursement • Result – Cynicism from medical leadership/staff – No fit with other physician/clinical initiatives – 1–2 year success cycle – Documentation specialists progressively disappeared into cubicles “Physician-engaged” CDI • Success metrics – CMI improvement a metric of quality and revenue – Improved compliance – Typical CMI improvement 4%–8% • A clinical initiative – Integrated with clinical quality – Clinical management, CMO accountability • Focus: clinical accuracy – Accurate severity capture for every admission impacting reimbursement, clinical care, and quality metrics • Result – “Ownership by the medical staff” – Response rates approaching 100% – Integrated with other physician/clinical initiatives – Sustained results – CDSs part of the clinical team
  10. 10. 10 “Physician-Engaged CDI” • Current impact of advanced CDI – Quality metrics ─ POA/HAC – Core measures ─ Medical necessity – Compliance ─ Patient safety • Impact during ICD-10 implementation – Fully functional computer-assisted coding – Decreased fraud/abuse risk – Physician engagement and satisfaction • Evolving reimbursement methodologies – Risk assumption, ACOs/derivatives, CMS-HCC system
  11. 11. 11 So What Will Happen Under ICD-10?
  12. 12. 12 Uninformed Physician ICD-10 Documentation Inaccurate physician documen- tation Coding process Revenue cycle CDI programs CAC Compliance Inaccurate medical record Quality Rework Rework Rework
  13. 13. 13 Basic Concepts • Inadequate physician documentation has been a challenge for accurate coding under ICD-9 • If uncorrected, that challenge will increase dramatically under ICD-10 • Coding solutions, alone, cannot resolve the issue of inadequate physician documentation • Physician leaders must be able to engage their colleagues in a proactive manner, establishing the appropriate motivation and sharing necessary knowledge to achieve success under ICD-10
  14. 14. 14 Leveraging Technology
  15. 15. 15 Current Clinical Documentation and Coding Processes Little operational integration of workflow The physician world The HIM/revenue/compliance world EHR Analytics Quality reporting ComplianceCodingDocumentation Patient encounter
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  17. 17. 17Article: http://www.nationaljournal.com/healthcare/obama-administration-warns-hospitals-on-fraud-20120924 Photo: http://en.wikipedia.org/wiki/File:Health_Care_Fraud_Press_Conference.jpg Obama Administration Warns Hospitals on Fraud By Meghan McCarthy September 24, 2012 “The Obama administration warned hospitals on Monday that the government would vigorously pursue cases of fraud involving the using of electronic medical records to inflate bills and generate extra revenue. In a sternly worded letter to several major hospital groups, Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder vowed to prosecute any abuses.”
  18. 18. 18 Leveraging the EHR for Value CLU EHR CAPD/ CA CDI Analytics Quality reporting ComplianceCodingDocumentation Patient encounter ICD-10 knowledge CA compliance CA quality reporting CA data analytics CAC Voice/ direct text entry
  19. 19. 19 Current Technology
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  23. 23. 23 CHIEF COMPLAINT PAST MEDICAL HISTORY
  24. 24. 24 PAST MEDICAL HISTORY CHIEF COMPLAINT
  25. 25. 25 CAPD: A Revolutionary New Solution Voice input: “the patient has acute respiratory failure” CAPD response: Multiple correlates of acute on chronic respiratory failure identified within narrative documents Physician determines and documents additional specificity “acute on chronic respiratory failure” Acute Respiratory Failure Concurrent medical record corrected: “acute on chronic respiratory failure”
  26. 26. 26 Fits Physician Workflow • Interactive clarifications while physician is documenting “Patient has altered mental status, abnormal liver function, and treatment with lactulose” CAPD identifies clinical correlates of hepatic encephalopathy and presents documentation alternatives in a compliant manner Physician reviews clinical finding and documents clinical opinion “hepatic encephalopathy” Hepatic encephalopathy Accurate diagnosis for: • Severity • Quality • Outcomes • Payment Altered Mental Status Concurrent medical record indicates specific diagnosis of “hepatic encephalopathy”
  27. 27. 27 Addressing Other Challenges
  28. 28. 28 On the Horizon • Progress notes – Meaningful expression of a physician’s “clinical impression” – Should systems be designed for E/M coding? – How can we avoid error/fraud?
  29. 29. 29 On the Horizon • Problem lists – When should they be created (the ED)? – When should they be available? – Only definitive diagnoses? – Where do they reside? – Who owns them? – Resolved conditions …
  30. 30. 30 On the Horizon • Discharge summary – Inclusion of diagnoses managed during the admission (resolved conditions) – Inclusion of diagnoses provided by consultants (which may conflict with attending) – Availability on day of discharge – Physician workflow/support
  31. 31. 31 Summary
  32. 32. 32 Summary • ICD-10 will impact every medical record interaction – All physician documentation should be viewed through the ICD-10 lens – The transition to ICD-10 will require advanced, clinically integrated CDI programs • Watch out for technologies that could impact fraud, abuse, and error – Copy and paste, point and click, etc. – We need to capture the physician’s “clinical impression” • Physician engagement and satisfaction is critical – We must positively impact physician workflow – We must avoid rework – We must leverage technology at the point of care
  33. 33. 33 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook.

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