Physicians today face increasing pressure to produce more accurate, complete and compliant clinical documentation while trying to maintain a focus on patient care and satisfaction.
Under ICD-10, government and commercial payers require significantly greater clinical detail to show medical necessity and clinical quality. This means a note that appears accurate and complete from a clinical standpoint may lack the level of specificity coders require to accurately document medical care under ICD-10.
This content is sponsored by Nuance
Hospitals that do not actively work to reconcile this disconnect in their workflow risk losing critical aspects of patient care — acuity, severity and risk of mortality — in the translation between medical treatment and insurance billing. This puts a hospital at a significant disadvantage under value-based care, where outcome and quality measurements affect payer reimbursement levels.
"Hospitals historically used clinical documentation improvement programs to optimize revenue capture, not to improve the quality of their clinical notes," Anthony Oliva, MD, vice president and CMO at Nuance, said during a roundtable discussion at Becker's Hospital Review's CEO + CFO Roundtable in Chicago Nov. 8.
But as providers prepare to take on risk under alternative payment models, more hospitals are turning to clinical documentation technology for clinical performance improvement.
Clinical Documentation Improvement (CDI) feedback in real-time
Hospitals are increasingly realizing the value of partnering with health IT vendors that offer front-end speech recognition solutions to accurately translate physician dictation into a rich, detailed clinical narrative, which is fed directly into an EHR. "Once enabled, a program like this can analyze clinician notes in real time and suggest ways to make the medical narrative stronger and more specific to justify medical decisions and improve ICD-10 coding compliance," said Reid Coleman, CMIO of evidence-based medicine at Nuance.
This type of responsive CDI interface can improve the quality of documentation, eliminate transcription costs, increase administrative efficiency and improve physician satisfaction — all strategic priorities for hospitals in the transition to value-based care.
Clinically driven CDI in the transition to value-based care
Value-based healthcare delivery means hospitals must demonstrate a strong correlation between patient outcomes, cost and measured value. A key component and strong indication of value in the inpatient hospital setting is medical necessity — namely, did the physician devise a thoughtful treatment plan in line with the patient's medical acuity? This means a physician's clinical documentation should include context that accurately reflects physician clinical judgment and medical decision making.
"A CDI program that focuses exclusively on improving fiscal gain may fail to demonstrate clinical value in the medical record," Dr. Oliva says. For instance, clinicians and coders can enhance revenue capture under fee-for-service models by specifying additional DRG codes during billing. In value-based care, however, clinical documentation and coding should reflect severity, acuity and risk of mortality in addition to diagnoses.
"The only way your [hospital's] clinical performance is adjudicated by those outside of your medical facility is through billing data," Dr. Oliva says. Therefore it's crucial a coder selects CPT codes that maximize reimbursement and signify a high level of patient care and quality treatment. By helping clinicians document according to ICD-10 standards, CDI technology can help hospitals build robust, descriptive and complete documentation for more accurate communication of patient care.
Public reporting organizations like CareChex, Healthgrades and Thomson Reuters use billing data in part to determine quality rankings among top healthcare organizations. "Comprehensive, clear clinical documentation of patient care can actually improve hospitals' baseline performance, which helps hospitals more accurately stack up against their peers and regional competitors on quality comparison sites," Dr. Oliva says. As more informed consumers increasingly rely on quality rating sites to decide between healthcare facilities, hospitals have a vested business interest in achieving high scores.
For instance, a hospital's mortality ratio — the ratio of the total number of patient deaths observed to the total number of patient deaths expected — is a key performance indicator often used to compare quality of care between hospitals. "Hospitals with a clinically focused CDI program outperform their peers in overall mortality ratings," says Dr. Oliva. This suggests documentation methodologies that more accurately capture severity can reduce variability in a hospital's observed mortality metrics.
Reactive versus proactive
Clinical documentation improvement technology shifts the onus of process improvement from the back to the front of the documentation lifecycle.
Typically, documentation improvement occurs retroactively, when coders or clinical documentation specialists identify a need to query the responsible physician for context during coding. Because clinicians are typically absorbed in the demands of day-to-day patient care, few have the capacity to quickly respond to administrative requests.
This makes completing query and documentation improvement processes from the back office both resource and time intensive. Some physicians may even interpret CDI queries as punitive or degrading, which can negatively impact employee collaboration.
Technology deployed in the clinical setting can empower physicians to proactively improve documentation in real time. Speech recognition software responds in real-time, so physicians can improve specificity, accuracy and medical context before saving it to the medical record. "Right there at the point of care, in real time, a physician is getting advice on how to make the notation easier for the coder," Dr. Coleman says. This can reduce time-intensive administrative processes downstream.
Improved patient care
By improving the quality of clinical documentation, clinicians can improve the quality of care they deliver. Speech recognition technology gives physicians relevant, actionable information about their clinical documentation in real time, allowing clinicians to adjust patients' care management plans to better match medical necessity.
Clinically integrated CDI technology also lends itself to quality improvement initiatives by streamlining communication between clinicians, nurses and ancillary staff. Speech recognition software enables physicians to create a narrative document that outlines medical decision making and defines the nuances of the episode of care. The output is composed in a readable note — important not only for the medical record and coding team, but also for communication with other physicians and patients.
Nurses often see gaps in the clinical documentation from providers and ancillary staff, the COO of a Chicago-based hospital system said during the roundtable discussion. "I see CDI technology as a vehicle to improve channels of communication between caregivers to make sure everyone is on the same page," she said. The shared understanding helps ensure continuity of care in the transition between on-duty nursing staff or care settings.
Improved clinician experience
An intuitive CDI solution that seamlessly integrates with clinical workflow can markedly improve physician satisfaction. More than 80 percent of physicians said it is disruptive and time consuming when queries for information occur after they entered the note or after the patient is discharged, according to a 2014 survey from Nuance.
"[Real time speech recognition technology] would help our physicians tremendously because currently we have coders trailing behind physicians, looking over their shoulder, trying to improve [physicians'] documentation," said Paul Mihalakakos, MD, an anesthesiologist and president of medical staff at Aurora Medical Center in Twin Rivers, Wis.
Technology and process improvements can help reduce physician frustration and support quality patient care by ensuring clinical information is complete and compliant from the start to eliminate rework.
Conclusion
Natural language processing programs infused with clinically-based guidance engage physicians and reinforce CDI specialists and coders while easing the administrative burden on clinicians in the transition to value-based care. Advancements in areas like computer assisted physician documentation (CAPD) — either front-end solutions or those or integrated with a hospital's electronic health record (EHR) — provide physicians and hospitals with powerful tools to drive timeliness, accuracy and clinical quality across an enterprise.
"Technology should be simple and do work for physicians — not the other way around," Dr. Coleman says. "Through a more natural approach to creating clinically -accurate information, everyone wins — the physician, the institution and most importantly, the patient."