Clinical Documentationand the

EMR

Walter Houlihan, MBA, RHIA, CCSDirectorHealth Information Management and Clinical DocumentationBaystate HealthSpringfield, MA

ObjectivesDiscuss and Share ideas/best practices..– CDI Processes...what is working– EMR Impact on CDI– Importance of Developing Metrics

– Keeping in mind …it is all about….Improving the care of each and every

Patient!

Baystate Health• Integrated academic medical center

consisting of 4 hospitals• 800+ beds, 80+ amb sites• 38,000+ discharges• 110,000+ E.D. visits• 10,000+ employees• Western MA only level 1 Trauma Center

Baystate Medical Center

• Truven® Healthcare AnalyticsBaystate Medical Center (BMC) has a proud tradition of

being recognized for its outstanding quality, patient safety and satisfaction, and innovative practices, and is honored to have been named a 2012

Top 15 Health System in the US. This distinction recognizes outstanding clinical performance and quality outcomes at Baystate Health.

• Also, Baystate Medical Center is proud to once again be named a

Truven® Healthcare Analytics Top 100 Hospital, Major Teaching Hospital in the US. Baystate Medical Center has received this designation four times.

United States Healthcare• Our system costs substantially more than every other country …with no

end in sight• We do not have satisfactory results/medical outcomes given those

expenditures• Difficult to argue this is satisfactory• Biggest problem…”physicians have little direct skin in the game” for

inpatient care…does not affect their wallet no matter what DRG is assigned

• Soon to come…office and hospital practice patterns will be aligned…targeting E&M and hospital documentation and coding

• CDI needs to grow quickly to the outpatient setting• “Our healthcare system is SICK”

– Health and Human Services Secretary, Kathleen SebeliusBUT…there is Hope…will mention at end of presentation

Documentation into the EMR• Snomed CT (clinical terms) vs. ICD 10• Snomed CT (clinical terms) is a terminology designed for input

into EMR’s• ICD 10 is a classification designed for output or reporting• Snomed should make it easier to document to the required

specificity. • The EMR system should convert that data to ICD information.• Ideally, physicians won’t need to know what revision of ICD is

being used, ie. I-9, I-10 or I-11.

• Bottom line….Physicians should just need to know…………. what needs to be documented!

Bring on CDI to assist Providers!!

EMR Management• Maximize direct entry …... minimize scanning >>>>>

– Information immediate accessible and legible– Currently approx. only 5% med rec scanned into EMR

• Copy and Paste– 90%* who use EMR routinely use copy and paste functionality– Despite 24%* indicating it led to mistakes in patient care…– 80%* wanted to continue to use copy/paste– Establish Clear Policy (BH Policy)

• to establish parameters and to minimize the use of “import”, “copy & paste” and/or “copy to new note” functionality when performing clinical documentation in CIS.

• Any copied information within a patient’s record must be reconfirmed and revised as necessary to accurately reflect the services and findings relating to a patient on a specific date (or interval) of service.

• Be Involved with EMR Form Development* O’Donnell, H.C. , R. Kaushal, Y. Barron ; J. Gen Intern Med 2009, 24:63-68

Mobile Technology• Clinical Use of Mobile Technology

– 69% View Patient Information– 42% Clinical Notifications– 39% Secure communication regarding patients

• Mobile Advantages….– “ You can’t take the time …when rolling a patient into OR to look at

the med hx or lab results….but having the 4 things most important accessible in a mobile app than a PC would be great”

– “…mobile devices should be adaptable to easily record quality metrics….they are going to be another way that we get physicians to enter data into the EMR…I rather point and touch than click”

EMR documentation enhancements

Keeping CDI and Providers on the same page

EHRo“EHR Optimization”

• The overall objective of this engagement is to develop an agreed upon roadmap for optimization of the installed Cerner clinical systems (PowerChart Office Suite), related processes and operations.

• There will be special focus on physician documentation, ambulatory computerized provider order entry (ACPOE), and immunization scheduling as part of this engagement.

• To maximize the value of an Electronic Health Record, it is essential to assess the current status of the implemented system (both positives and challenges), and then to develop a plan that addresses people, process, and technology to assure we achieve established goals…• improved patient experience• improved quality of care and • cost efficiency across the BH population.

CDI• Clinical Documentation…..– Improvement

– Importance» Innovation

• All leads to the same end goal..…– Improved Patient Outcomes….• For you, me, your family member etc…

– Improved and Appropriate Revenue will follow

Why is clinical documentation Important?

• Revenue…revenue…revenue….• Yes, external data reporting is also important……….

SOI, ROM, Mortality rates, PSI’s, HACs• What about the Patient!!!– Continuity of Optimal Quality Care!– Patient Safety– Demonstrating Medical Necessity

• Complete and Specific documentation for the benefit of the patient ..… this action will bring the appropriate revenue for the services provided

Let’s get the credit for the quality of care we provide and for the services we deliver!

The Impact of Great Documentation

Primary Diagnosis: MRSA PneumoniaSecondary Diagnosis: CHF

Specify type of CHF to Capture Complication/Co-morbidity or Major Complication Co-morbidity. It has an

impact on reimbursement and expected LOS.

CHF Chronic Systolic CHF (clinical evidence: Systolic dysfunction on recent echo, EF<40-50%, LV dilation)

Acute on Chronic Diastolic CHF(lasix IV, decompensation from baseline)

$7,516.23 $10.767.78 $15,381.21

MSDRG 179LOS 3.7RW. .9741

MSDRG 178LOS 5.1RW. 1.3955

MSDRG 177LOS 6.4RW. 1.9934

The Impact of Great Documentation

Primary Diagnosis: Renal Failure Secondary Diagnosis?: Nutritional concern – dietary

consult Specify nutrition status to Capture Complication/Co-morbidity or Major Complication Co-morbidity. It also

has an impact on reimbursement and GLOS

Weight loss Mild to moderate malnutrition

Severe Malnutrition

$4,793.99 $7,449.86 $11,883.53

MSDRG 684LOS 2.5RW .6213

MSDRG 683LOS 3.7RW. .9655

MSDRG 682LOS 4.7 RW. 1.5401

Strategies for Successful CDI Program

1. Enlist Senior Leadership Support2. Enlist Physician Champion(s)3. Cultivate CDI Talent4. Monitor Documentation Concurrently in addition to

Post Discharge5. Continually Measure Success…use benchmarking

tools as available * “If you cannot measure it, how can you improve it”

6. Leverage Technology (NLP etc)

BMC Inpts

Patients w/ CDI Review

Reviews done on Patients

Queries Req Resp

MD Responses

Response Rate

Year /Month Total Pts

Total # of Pts

ReviewedTotal # of Reviews

# Comm w/MD Req Response

# of MD Responses

% MD Response

Rate

2014 Apr 2,489 585 1,092 73 66 902014 Mar 3,393 684 1,435 114 109 962014 Feb 2,989 794 1,577 97 86 892014 Jan 3,326 719 1,464 113 105 932013 Dec 3,140 602 1,176 100 94 942013 Nov 3,165 636 1,279 108 92 852013 Oct 3,273 640 1,286 133 109 822013 Sep 3,183 590 1,112 91 79 872013 Aug 3,380 612 1,226 97 89 922013 Jul 3,359 779 1,270 147 110 752013 Jun 3,269 752 1,213 146 114 782013 May 3,421 713 1,296 147 92 632013 Apr 3,208 679 1,203 155 104 672013 Mar 3,270 276 406 66 44 67

Total 44,865 9,061 17,035 1,587 1,293 81%

Best Practices - Benchmarks

• Continually reviewing our performance against other entities…– ACDIS, AHIMA and all available surveys– MedPar– Premier– Etc….

NLP Technology• NLP…natural language processing• Beyond CAC …computer assisted coding• Customizable queries on multiple data points with

documentation and diagnostic results, ie. if “this” is documented along with “this” and the lab value of “X” is “this” then put on CDS work list

• Using the latest technology a user can query vast amounts of data and generate results rapidly, without affecting the performance of other users.

• Helps find that needle in the haystack, ie. what record contains incomplete documentation

• Resulting in queries to physicians within minutes or just a few hours after documentation occurs

EMR and CDI workflow• CDI

– Reviews approx 20% of patients concurrently• Coders

– Reviews 100%(with ext assistance) with alerts to send to HIM compliance specific types of records…

– Does it (Codes, DRG, LOS, Age, SOI, ROM, etc) ALL make sense?

• HIM Compliance– Seasoned coders review HACs, PSI’s, etc and perform any

post disch queries• Dept of Healthcare Quality (RN’s, MD’s)

– Collaborates with HIM on documentation clarification with HACs and PSIs to assure an accurate portrayal of patient before bill is generated and administrative data is available

CDI Staff• Remote vs. Onsite– Benefits of Remote…need 100% EMR• Increased employee satisfaction, thereby…

– Productivity– Quality– Retention– Recruitment– Live anywhere

– Still have CDS onsite, as needed• education, collaboration, meetings etc

What Should CDI Specialist Do?

• Constantly promote idea that providers and hospital are in this mess together

• Show how your CDI program and principles will help providers and hospitals survive– Reductions in complication and PSI rates– Improved quality outcomes, patient safety,

mortality rates, LOS goals, reimbursements

Engaging Physicians• Critical to Success• Senior Clinical Leadership Support• Multiple Educational Options– Face to face individually and groups, web

based etc• Share actual current documentation examples• Explain importance to quality/mortality scores,

not just revenue!!

Relationship Building• How does CDI reach out?– Utilization of technology and tools to

ensure timely connections….• Email• Webpage• Telephone

– Last but not least…face to face!

Positive Feedback• Provide standards and structure – – The 3 C’s… Consistent, Clear and Concise

messages• Query monitoring – Note improvements!• Not all emails are bad news…we celebrate good

work with our MDs and their directors.

CDI Challenges• MD Query Challenge:– Queries are not “attached” to the record• Doctor Specific… MD must review his email• Impacts timeliness of communication and

response

• Goal:– Attach queries to the specific acct/record• All MD’s will have access to query and improve

response time

MD Feedback/Requests• Challenge:– Delays in reviewing emails• Using multiple systems, ie. EMR and email or

fax, office messages, paging

• Goals:– Queries need to be brief and to the point– Optimal to have one stop shopping to

review, reply and update EMR, if needed

EMR/CDI/ICD 10• Premier survey

– 60% of members have not done the necessary physician education to prepare for implementation

• HFMA Survey of 126 hospitals– 87% rated CDI as high or very high priority – 72% indicated will decrease denials– 62% indicated will increase CMI– 62% indicated will add greater protection against RAC

EMR/CDI/ICD 10• Barriers/Hurdles

– Most frequent cited is “disruption of clinical workflow” due to more time on documenting

– Physicians needing to deal with EMR’s…”too hassled by technology”– Experienced CDI nurses are hard to find..

• Good clinical knowledge• IT savviness• Appreciation for financial advantage of detailed documentation• Need for strong communication skills

• Overcome Barriers/Hurdles– Develop staff internally rather than finding the optimal external candidates

ACDIS CDI Survey• 350+ responded from across the country • Only 69% indicated that their CDI staff will be trained on I-10

– They need to understand the documentation details ..not I-10 codes…while keeping focused on the overarching goal of delivering optimal patient care

• Unfortunately, 38% do not provide CDI training to new providers• Good news is that about 30% of respondents reported 81% - 90%

physician query response rate• 44% indicated a complete EMR• 35% indicated they have a hybrid EMR• 52% indicated that electronic querying results in greater provider

response rate(47% vs. 16%)

CDI Collaboration

• Pursuing Collaboration between….– New York– Massachusetts– Connecticut– and any other state

• Goals: – Improve CDI processes– Share metrics– Share best practices

Remember

Always try and be a better person TODAY

than you were yesterday….cause we aren’t guaranteed

TOMORROW!

Questions/DiscussionNYHIMA

Thank You for the

Privilege and Opportunity to be join you at your

79th Annual Conferencewalter.houlihan@baystatehealth.org413-322-430921:3