When Pursuing CDI, Using Risk Adjustment Is Vital

As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize the quality of care.

In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provided to the ambulatory setting and the increasing demands it places on provider organizations.

As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.

Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.

This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer-Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.

The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.

To learn about PowerSpeak+RAPID—a CAPD solution that combines powerful speech recognition technology (PowerSpeak) with real-time risk adjustment using HCCs (RAPID), please contact Saince. 

Dictation: Giving Physicians a Break While Avoiding Costly Medical Errors

Overworked professionals, regardless of industry, are far more likely to make mistakes. For medical professionals, however, particularly when it comes to documentation, those mistakes risk profound repercussions for both medical providers and their patients. They’re also notoriously difficult to correct once they’ve been made.

Earlier this year, researchers from Johns Hopkins released a report pointing to medical errors as the third leading cause of death in the United States behind heart disease and cancer. From typos to incorrect dosing to misdiagnoses, the consequences of these mistakes can range from mundane to catastrophic—blamed for 250,000 to 400,000 deaths annually. Beyond medical mistakes, documentation errors can also wreak havoc in other areas of patients’ lives, such as when applying for life insurance.

Although completely eliminating such errors would require both industry and regulatory efforts of enormous proportions, providers can leverage a simple workflow strategy to safeguard against many of these mistakes. Dictation allows doctors to spend less of their time on documentation while sharing the workload with trained specialists who can process the records—ensuring accuracy and integrity are maintained.

As we recently highlighted, the advent of electronic medical records (EMRs), which originally heralded a new age of documentation ease and efficiency, actually created more administrative work for doctors. As a result, EMRs are cited in study after study as a leading factor in the twin epidemics of physician and nurse burnout. In many of those same studies, however, dictation and transcription have been highlighted as preferred strategies to make EMRs more physician friendly.

By relying on dictation, which can be seamlessly integrated into the EMR, physicians can get back to the reason they entered medicine—to care for patients. Because, as the Johns Hopkins researchers were quick to note, these errors rarely stem from poor medical care but rather a systemic problem that places undue—and out-of-scope—burden on chronically overworked doctors and providers.

A state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes. To learn more about how these can be successfully integrated with leading EMR systems, read about Doc-U-Scribe or contact Saince.

Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement

As care is increasingly delivered in an outpatient setting, it is critical that clinical documentation improvement (CDI) programs are developed to ensure compensation for care. “Clinical documentation is at the core of every patient encounter,” says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must be accurate, timely and comprehensive of the services provided. The process should also engage physicians so that they begin to associate documentation with a higher quality of care delivery rather than an interference in care delivery.

A recent presentation from the 90th Annual AHIMA conference showcased best practices for ensuring better outpatient CDI in the areas of emergency medicine, wound care and total knee replacement procedures. The presenters outlined these key practical considerations for documentation:

Emergency Room (ER)

Better ER documentation centers around four key questions:

1.    Does documentation support the most appropriate visit level?

2.    Does documentation support the billable services?

3.    Does documentation accurately report staff present for care provided?

4.    Does documentation accurately report the amount of time staff spends with critical patients?

When it comes to supporting the most appropriate visit level, what severity is being documented?

●     Self-limited or minor

●     Low severity

●     Moderate severity

●     High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function

●     High severity, poses an immediate significant threat to life or physiologic functions

Supporting documentation is required for all elements of an ER visit, whether that means documenting the need for extra resources to deal with an intoxicated and combative patient, or the documenting the presence of a nurse in the room during a pelvic exam. The timeframe of patient time with nurses is a key element in being able to bill for critical care, with a requirement that at least 30 minutes of critical care services are provided and documented.

Wound Care

When it comes to wound care delivered in an outpatient setting, it is important to have clear and consistent documentation. Here are the key elements needed in the documentation:

●     Describe the type of wound, location, and size

●     Describe if the wound is a partial or full thickness wound

●     Describe stages of pressure ulcers

●     Describe depth of pressure ulcers

●     Any undermining/tunneling/sinus tract

●     Drainage, type, amount or odor

●     Various types of tissue in the wound bed

●     Wound edges and surrounding tissue

●     Indicators of infection and pain

●     Document interventions for healing and conditions that would affect healing

●     Current topical treatment plan, response to treatment, modifications to plan, implementations of new orders, reasons for not changing treatment plan, referrals

●     Document any education given to patient and caregiver

Total Knee Replacement

With total knee replacement procedures, it is important to note in the documentation that the procedure is appropriately offered in an outpatient setting. In order for the procedure to be taken off of the inpatient-only (IPO) list, it must meet the following criteria, all of which should be documented:

●     A low anesthesia risk

●     Few or no comorbidities

●     Family at home to support

●     A patient can tolerate rehab in an outpatient facility or at home

●     Physician expects the patient to need fewer than two nights of hospital care

For more information, contact Saince about PracticePerfect, a platform to help you address outpatient and ER CDI.

CMS Announces Release of 2018 National Impact Assessment of Quality Measures Report

Center for Medicare and Medicaid Services (CMS) conducts and publishes an assessment of the quality and efficiency impact of the use of endorsed measures in CMS programs every three years as required by statute.  The first report was published March 1, 2012, and the 2018 Impact Assessment Report is the third such report.   The data-driven results of this Report support the use of measures implemented in CMS reporting programs to drive improvement in the quality of care provided to patients in facilities and across settings nationwide.  This report is used by the measure developer community, patients and families, clinicians, providers, federal partners, and researchers.

The 2018 Impact Assessment Report demonstrates that performance on CMS measures contributed to better care and reduced expenditures, and identified critical areas of improvement across settings with respect to six CMS quality priorities:  patient safety, person, and family engagement, care coordination, effective treatment, healthy living, and affordable care.

Highlights include these main findings:

• Patient impacts estimated from improved national measure rates indicated approximately:
  • 670,000 additional patients with controlled blood pressure (2006–2015).
  • 510,000 fewer patients with poor diabetes control (2006–2015).
  • 12,000 fewer deaths following hospitalization for a heart attack (2008–2015).
  • 70,000 fewer unplanned readmissions (2011–2015).
  • 840,000 fewer pressure ulcers among nursing home residents (2011–2015).
  • 9 million more patients reporting a highly favorable experience with their hospital (2008–2015).
• Costs avoided were estimated for a subset of Key Indicators, data permitting. The highest was associated with increased medication adherence ($4.2 billion–$26.9 billion), reduced pressure ulcers ($2.8 billion–$20.0 billion), and fewer patients with poor control of diabetes ($6.5 billion–$10.4 billion).
• National performance trends are improving for 60% of the measures analyzed, including a majority of outcome measures, and are stable for about 31%.
• Overwhelmingly, hospitals (92%) and nursing homes (91%) surveyed reported they consider CMS measures clinically important. Likewise, 90% of hospitals and 83% of nursing homes agreed that performance on CMS quality measures reflects improvements in care. Respondents also described barriers to reporting, including burden; barriers to improving performance; and unintended consequences of CMS measures.

The Science Behind Clinical Documentation

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