How to improve patient care and physician engagement with the right AI technology

In 2018, 34 percent of Medicare beneficiaries — more than 20 million people — were enrolled in Medicare Advantage plans, according to an analysis conducted by the Kaiser Family Foundation. By 2028, the Congressional Budget Office projects the percentage of Medicare beneficiaries enrolled in Medicare Advantage plans to increase to 42 percent. For these patients, Risk Adjustment Factor, or RAF, scores determine how much Medicare pays for their medical services. Healthcare providers that aren't billing for chronic conditions may be leaving money on the table, since chronic conditions affect RAF scores.

In October, at Becker's Hospital Review 5th Annual Health IT + Revenue Cycle Conference in Chicago, 3M and M*Modal, now one company, hosted an executive roundtable to explore how hierarchical condition category (HCC) management and speech recognition systems with computer-assisted physician documentation (CAPD) technology can help address these challenges.

Clinical documentation is complex and critical

Clinical documentation is complex because it impacts patient care, compliance, quality measures and billing integrity – and clinician wellbeing. Newer models of risk-adjustment documentation and care management of patient populations require HCCs, which are primarily chronic conditions. Around 10,000 ICD codes represent HCCs. RAF scores are based on demographic factors, as well as diagnoses that are billed each calendar year. CMS aggregates this information and feeds it into a calculator that generates patients' RAF scores.

Dan Engel, product manager at 3M, explained, "Documentation is both mission critical and complex. We must capture the complete patient story without it being an onerous task for the physician to support patient care and billing claims with relevant clinical information and diagnoses. It is necessary to ensure that chronic conditions are billed and to demonstrate that these chronic conditions have been monitored, evaluated, assessed and treated in the calendar year."

For instance, consider a 76-year-old woman visiting her physician with a urinary tract infection, and, although she has diabetes and heart failure, this is her only visit to the physician during the calendar year. If the physician simply diagnoses the UTI and writes her a prescription for the infection, the physician has missed the opportunity to review her chronic conditions and capture the true severity of illness. By under-representing a patient’s severity of illness, RAF scores and related risk-based payment rates are reduced.

Clinical documentation improvement: Physician engagement and scalability are challenging

To address documentation challenges in the outpatient care setting, clinical documentation improvements (CDI) teams have started using EHR tools, Excel spreadsheets and other manual processes due to a lack of better options. These approaches unfortunately have many limitations such as scalability, timeliness and consistency. With more and more care being provided in the outpatient setting, it's not possible for CDI teams to keep up with the demand with spreadsheets alone.

Mr. Engel noted, "Structured data alone isn't useful. There's no context to it. You don't just want a registry or list of patients. You must be able to contextualize the information and make sure it describes your patients' illnesses, so you know where to spend your time for maximum impact. For this, the system must consider all the data available, both structured and narrative."

EHRs don't have enough context around data to determine which alerts will be useful for physicians. As a result, physicians often receive huge volumes of EHR alerts, which can contribute to burnout. In contrast, 3M only delivers high-value, context-specific, unobtrusive and proactive nudges to clinicians at the point of care and within the EHR documentation workflow through its CAPD functionality. CAPD is designed to close care gaps and create time to care for physicians and reduce runaway burnout rates.

Using technology to transform the clinical documentation experience

With the mission of creating time to care, 3M is committed to unifying workflows and delivering proactive insights at the right time and to the right person so that physicians can focus on patients and not on their computers.

The 3M system is built on a single cloud-based conversational AI platform. The 3M platform uses speech recognition with embedded CAPD functionality to help clinicians capture the complete patient story. The underlining natural language understanding engine abstracts, aggregates and contextualizes clinical insights from both structured and narrative data and then presents it to the user in an actionable manner.

Mr. Engel said, "With the help of our advanced AI technology, we build a complete clinical picture of the patient. If the physician hasn't identified the patient's acuity, we provide a reminder for them to do so. If there is a gap in patient care, we gently nudge the physician on it. This actionable feedback is delivered to clinicians within their electronic health record workflows.”

For example, when opening a patient record, a physician can be nudged proactively to fully specify the patient's diabetes with diabetic neuropathy, thereby preventing under-billing as "diabetes without complication." Alternatively, if a patient mentions being depressed, the 3M system will nudge the physician to document for this diagnosis as it will significantly contribute to the RAF score and increase the patient's bundled payment. More importantly, this drives a more accurate and complete patient record.

In addition to such physician-assistive solutions, 3M offers a web-based system so CDI staff can work ahead of the physician, conduct pre-visit reviews and decide how to prioritize patients for maximum revenue impact. According to Mr. Engel, "Prioritization is critical for programs to scale and ensure CDI teams spend time on more complex cases for the greatest impact. The key is to be able to proactively prep doctors with pre-visit insights, engage them in real time, and then measure the results to identify opportunities for further improvement."

Measuring and improving continuously throughout the year are essential components of this program. 3M’s month-by-month data shows progress and highlights both new opportunities and risks.

Conclusion

Physicians need to focus on treating patients, rather than being distracted or overwhelmed by administrative tasks and desk work. They need technology that is unremarkable in that it is unobtrusive and helps them do the right things easily and within their normal workflows. 

3MTM M*Modal CDI Engage OneTM and 3MTM M*Modal HCC Management are comprehensive solutions that deliver differentiating value to several stakeholders within the clinical documentation lifecycle and across the care continuum. Mr. Engel explained, "Among other things, our solutions give users insights into what was not visible or accessible to them before, allowing them to then prioritize and take early action. When we design our technologies, we make sure they fit the individual needs of, physicians, clinicians, nurses, coders, the CDI team and auditors alike."

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