7th AnnualAssociation for Clinical Documentation

Improvement SpecialistsConference

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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.

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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

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A Look at Current CDI Programs

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• Impact of documentation improvement– Compliance– Revenue cycle

The Documentation Gap

Hospital inpatient

carePhysicia

n documen

-tation

Coding process

Revenue cycle

processes

CDI program

s

Gap

Error recovery

Fraud

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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

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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

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• Focus of documentation improvement– Compliance– Revenue cycle– Quality

A New Source of Physician Engagement

Hospital inpatient

carePhysicia

n documen

-tation

Coding process

Revenue cycle

processes

Quality/outcome measure

-ment

Evolving quality- based

payment

CDI program

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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

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“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

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So What Will Happen Under ICD-10?

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Uninformed Physician ICD-10 Documentation

Inaccurate

physician documen-

tationCoding process

Revenue cycle

CDI program

s

CAC

Compliance

Inaccurate medical

record

Quality

Rework

Rework

Rework

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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

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Leveraging Technology

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Current Clinical Documentation and Coding Processes

Little operational integration of workflow

The physician world The HIM/revenue/compliance world

EHR AnalyticsQuality reportingComplianceCodingDocumentation

Patient encounter

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17Article: http://www.nationaljournal.com/healthcare/obama-administration-warns-hospitals-on-fraud-20120924Photo: http://en.wikipedia.org/wiki/File:Health_Care_Fraud_Press_Conference.jpg

Obama Administration Warns Hospitals on FraudBy Meghan McCarthySeptember 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.”

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Leveraging the EHR for Value

CLU

EHR

CAPD/CA CDI

AnalyticsQuality reportingComplianceCodingDocumentationPatient

encounter

ICD-10 knowledge

CA compliance

CA quality reporting

CA data analyticsCAC

Voice/direct text

entry

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Current Technology

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CHIEF COMPLAINT

PAST MEDICAL HISTORY

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PAST MEDICAL HISTORY

CHIEF COMPLAINT

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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 FailureConcurrent medical record

corrected: “acute on chronic respiratory failure”

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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”

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Addressing Other Challenges

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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?

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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 …

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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

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Summary

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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

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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.