Better physician documentation with more patient face time? It can happen

Patient notes are critical to quality patient care, but for physicians, medical documentation may at times feel at odds with this goal.

Physicians, and hospitals more broadly, often struggle with inefficient work practices when it comes to documentation and may have trouble expanding clinical documentation improvement programs to meet enterprise-wide goals. Add constantly evolving documentation rules and short appointment times with patients, and it's easy to see why providers want to run when they hear "CDI." 

It doesn't have to be this way, according to Robert Budman, MD, chief medical information officer of Nuance Communication's Healthcare Division.

Dr. Budman joined Nuance in March 2019 from Atlanta-based Piedmont Healthcare, where he served as CMIO. Speaking in an executive roundtable at Becker's Hospital Review 2nd Health IT + Clinical Leadership + Pharmacy in May, Dr. Budman said, "One of the key elements of patient notes is telling that patient story, extracting the most important pieces of information out of it, not just for coding and billing, but to share that information across care teams."

The secret to getting higher quality notes and engaging physicians? Using artificial intelligence to create useful, detailed notes with the right information — and to get it right the first time, not retrospectively. "If I can do it right the first time using AI, that's going to help everybody across the team. In real time, at the point of care, how do I get that advice and assistance right in the hands of your providers," Dr. Budman said.

Accomplish more with AI

During the roundtable, Dr. Budman discussed Nuance's in-workflow computer-assisted physician documentation solution, Dragon Medical Advisor. This AI-driven, cloud-based solution gives physicians evidence-based guidance and suggestions at the point of care to improve and speed documentation without disrupting workflow. It interfaces with Nuance's Dragon Medical One, the industry’s most widely trusted cloud solution for documenting patient notes and interacting with the EHR.

"Most critical at the point of care is a really solid assessment of what's going on with the patient," Dr. Budman said.

Dragon Medical Advisor runs in the background, constantly scanning notes in real time to identify and suggest clarification opportunities — based on patient symptoms, vital signs, diagnostics and other information — that could ultimately change a patient's treatment plan and outcomes.

Dragon Medical Advisor prompts physicians to be more specific in their documentation of certain diagnoses to improve accuracy of diagnoses, capture major complications and comorbidities, and code for appropriate reimbursement. This results in fewer retrospective and time-consuming queries. For CDI teams, this means they can home in on more complex cases. For physicians, this means they have more time to dedicate to patient care and interactions, which improves physician engagement and satisfaction.

Dragon Medical Advisor was designed with the provider's workflow in mind. To begin, a physician can type or dictate a patient assessment into Dragon Medical One. Take pneumonia and respiratory distress, as example. While typing, a red notification might pop up, similar to a smartphone notification. If the physician clicks on it or verbally cues to open Advisor, it may prompt them to add specificity for respiratory distress or add clinically relevant details defining the type of pneumonia.

With these details added, a patient's note may now read Methicillin-resistant Staphylococcus aureus pneumonia present on admission with acute respiratory failure. Any evidence-based changes to the predicted mortality and length of stay will be automatically updated, as will the Medicare Severity Diagnosis Related Group for billing.

The tool's immediate feedback prompts physicians to write more specific notes over time without even putting a formal documentation improvement program in place, according to Dr. Budman. "Instead of saying congestive heart failure and diabetes, they will start saying acute systolic heart failure, right side, and Type 1 diabetes mellitus poorly controlled with XYZ complications and no DKA (diabetic ketoacidosis)," he said.

Proven results  

Dr. Budman spoke from experience about the solution. Before joining Nuance's team, Dr. Budman used it from the provider side at Piedmont Healthcare. "Piedmont has been live with Dragon Medical Advisor for eight months. They are still using it, believe it or not," Dr. Budman joked. "As you are typing the letters, hitting return and going to the next line, the notification is popping up. If I say 'Run Advisor,' it pops up a window on the side of my screen."

The benefits to physicians are immediate. They are able to document more efficiently and make more informed decisions at the point of care, giving them more time to spend with patients. However, the benefits continue downstream. "Physicians aren't getting manual queries as often from the CDI team," he said. "They don't have to go back and review the chart and say is it respiratory failure or not. The CDI team is unburdened from giant massive new admissions on Monday because a lot of the work has already been done and they can focus on the most complex cases."

More accurate documentation results in clean claims and greater support for medical necessity, both of which help improve reimbursement from payers. For example, a health system in Mississippi using Dragon Medical Advisor has seen $30,000 more per month in reimbursement from just a single provider’s use of the Advisor, according to Dr. Budman.

Nuance can demonstrate improved reimbursement, risk adjustment and denials management. Now the 17-year-old tech firm is working to document answers to the big question: Does Dragon Medical Advisor measurably improve patient outcomes?

"That's the first question I asked when I came to Nuance. We are looking for partners to pilot and run those studies. That's the holy grail," Dr. Budman said.

Intelligent documentation

Clinical documentation is essential to coordinating patient care, and ultimately to reimbursement. However, sustaining a CDI program across a large medical staff is difficult to achieve with consistency. AI can help with that.

"Weak documentation misrepresents the efficacy of the quality of care provided and underserves patients, providers and payers," Dr. Budman said.

Guidance baked into the workflow improves care delivery at the point of care and avoids reworking documentation down the line. This allows CDI teams to focus on the most complex patients, so hospitals can get paid sooner and use their resources more efficiently. Most importantly, it helps reduce physician time spent on documentation, giving them more time to deliver what AI cannot — high-quality, patient-facing care.

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