Healthcare's Second Curve: Is Your Clinical Documentation Ready?

Healthcare and economics have always been entwined. Analogous principles are at play in both disciplines, and the two have cross-pollinated for centuries. But not all economic ideals have played out in the healthcare world — yet.

This content is sponsored by Nuance Healthcare.

In 1996, economist and futurist Ian Morrison outlined a theory called "the second curve" in a book of the same name. The second curve refers to the point in a market or industry where technology and consumerism meet to generate a big leap forward that most stakeholders never saw coming. In computing, the second curve was the laptop and tablet. For telecommunications, it was the smartphone.

"The vital part of this whole concept is, how do you prepare for and make that transition?" says Tony Oliva, DO, vice president and CMO of Nuance. "If you make it too late, competitors will capitalize on what you've missed, but if you make it too early, you may not be prepared to meet the needs of the consumers."

Healthcare's second curve is more complex than a single piece of technology. Dr. Oliva says this industry's second curve may ultimately be the shift to a value-based system of care, driven by technology and consumerism. For almost the entire span of medicine's history, physicians and hospitals held the power of knowledge over patients — their consumers. In medicine, knowledge plays a large part in driving both sides of the supply-demand equation.

"But consumers today have the tools to ask more questions and understand their medical conditions better than they ever have before," Dr. Oliva says. "We've let in a little light through our armor and we no longer have control of the grail — our consumers can challenge us now."

Technology has also spurred transparency, which counters previously held assumptions of care quality. Transparency has shifted power from providers to consumers, driving the volume-to-value shift and requiring hospitals to become more efficient and agile to maintain revenue, while demonstrating the quality performance that increasingly determines reimbursement levels.

What does this have to do with clinical documentation improvement? A lot. When care teams do not have effective clinical documentation tools, they are more likely to inconsistently chart information about patients. Inconsistent charting of patients' illness severity can result in incomplete coding, greater predicted mortality rates and a financial loss of millions in one year alone.

Over the last 20 years, Nuance has honed its approach to clinical documentation improvement, with services and technology to support clinician efforts across organizations for complete and compliant documentation that puts the patient first.

"Every patient deserves an accurate clinical picture of their story," adds Dr. Oliva, "By enabling CDI teams and physicians to engage in a clinical dialogue about all the patient's conditions and treatments, we develop a much richer patient record." This clinically focused approach coupled with technology creates a truly Advanced Practice CDI program.

Through voice-enabled technology and advanced clinical language understanding capabilities, the Nuance approach to CDI maximizes physician adoption and avoids the lack of specificity in clinical documentation that compromises clinical, quality care and financial outcomes. With documentation that reflects the complexity and severity of each patient's illness and risk of mortality — and the resources used to address them — Nuance's approach helps organizations enhance quality patient care, achieve reimbursement appropriate to the level of treatment provided and improve hospital quality ratings.

"It fits between the first and the second curve," Dr. Oliva says. "There's almost nothing we do in healthcare that's a pure win-win, but this is one of them."

The Connection Between CDI and Quality

Clinical documentation is notoriously vexing for many clinicians, but the problem doesn't stem from poor coding, Dr. Oliva says. Nor does the fault lie with the provider.

"We as physicians live in an isolated world that is very clinically focused," Dr. Oliva says. "We use clinical terminology — we don't speak in ICD-10 codes, and if we did we'd look at each other with blank faces, because codes don't convey the clinical picture."

Outside of the clinical sphere, however, code is the prime language. Under value- or performance-based contracts, most matters are measured by analytics and technical language, Dr. Oliva says. Physicians commonly find themselves in situations where they don't know the "magic words" that coding systems require to properly synchronize a diagnosis, treatment or other element of care with a bill or electronic health record (EHR). Clinicians may think they are doing an excellent job with clinical documentation by writing thorough notes, but they face a number of setbacks if they don't work within the confines of what the coding system will recognize.

Nuance believes technology should work in service of people: instead of forcing people to adapt to machines, technology should adapt to the way people communicate. Through advancements in speech recognition and Clinical Language Understanding technology (CLU), the Nuance approach to accurate documentation enables physicians to document care through narrative dictation. These solutions capture the unique nature of each patient encounter and document physicians' decision-making processes without the rigidity and limitations of templates. CLU technology enables CDI Specialist efficiency by automating the review of physician documentation, which allows greater case coverage and more in depth chart analysis. EHR companies are realizing the benefit of embedding such tools into their solutions to further improve the physician and CDI Specialist experience.

Dr. Oliva says he always had a hunch that clinical documentation improvement programs could affect care quality, but there were no tools to draw a line between the two — until now. Running numbers produced by tools that give a granular picture of hospital performance, such as ProPublica's Surgeon Scorecard, CareChex® and Healthgrades, against severity adjusted mortality — whether patients die or are discharged — demonstrates the impact on quality.

"If you look at hospitals that used our program from 2011 to 2014, 37 percent of our hospitals are in the top 10 percent for severity adjusted mortality," Dr. Oliva says. "About 70 percent of them are in the top 25 percent, and about 90 percent are in the top 50 percent."

It is very difficult to move the needle on quality without robust clinical acumen. Fortunately, Nuance's solution is rooted in clinical expertise, which is a large determinant of its effectiveness. The approach and supporting technology is developed by clinicians and continually updated to include the latest guidelines and strategies to support clinical decision-making. Tailored education programs and peer-to-peer training reinforce the continuing education and real-world clinical training often overlooked in clinical documentation.

Now is the Time to Address Clinical Documentation

If healthcare's second curve is the shift to a value-based system of care, healthcare providers must ensure their care teams have the proper tools and support for exemplary patient care, correct coding and accurate quality reporting. It is imperative for physicians to accurately describe patients and patient interactions so they get credit for all that they are doing, and that will in turn accurately reflect the hospital's financial and quality performance, Dr. Oliva says.

"I call it the clinical revenue cycle, because we've so often lived in two worlds, but they're inextricably merging as we move forward," Dr. Oliva says. "Understanding that is vital, because every dollar you leave on the table today, you never get back. Are you capturing dollars and moving quality at the same time?"

Reimbursement is quickly moving toward value- and outcomes-based payment, and commercial payers are following suit. An increasing percentage of healthcare claims will be measured in relation to performance, with reimbursement based on outcomes achieved. The way in which episodes of care are coded becomes more critical when there is a direct correlation to payment based on performance. This scenario will become increasingly problematic for those organizations who don't get it right over the coming years.

Clinical Documentation Improvement with the appropriate methodology to engage physicians, CDI Specialists and coders with an emphasis on measuring outcomes and quality commensurately is at the center of a successful transition. 

"Sometimes we think just having the program is enough, but coding and documentation is a very complicated world," Dr. Oliva says. "You can't just give it lip service."


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