How hospitals can use CDI to navigate the value-based care transition: 5 insights

A successful clinical documentation program can help healthcare organizations achieve better financial performance and patient outcomes, which are both crucial improvements for hospitals navigating the shift to value-based care.

"What we document drives what we receive financially. What we drive on the revenue side is directly related to how we show performance on the outcomes side," said Anthony F. Oliva, DO, vice president and CMO of Nuance Communication's healthcare division. "There are very few things in healthcare that can affect both sides of the [value-based care] transition, and this is one of them."

Dr. Oliva offered his thoughts on the importance of clinical documentation improvement to 22 healthcare leaders during a Sept. 21 executive roundtable at the Becker's Hospital Review 4th Annual Health IT + Revenue Cycle Conference in Chicago.

During the presentation, Dr. Oliva made the case that hospitals need to tap technology to make documentation initiatives more efficient and effective, especially on the inpatient side.

Here are five takeaways from the discussion:

1. Consumerism and technology are driving the shift to value-based care. The transition away from fee-for-service is not policy-driven, but rather a consumerism-driven aspect of a normal economic cycle, according to Dr. Oliva. He cited the book "The Second Curve" by economist Ian Morrison, PhD, which outlines a business model consisting of two curves. The first curve represents a company — or healthcare organization — comfortably operating a traditional business model. The second curve occurs once factors like technology, consumerism and increased competition start to put pressure on the business model.

"This is an absolute vital transition. If a business doesn't make that transition to the second curve, they will get left behind," Dr. Oliva said. "It can be a difficult process knowing when to make the transition and [knowing] what competitors will look like in that world."

To understand how this curve will affect the healthcare industry, leaders must consider how the original healthcare business was designed.

"The American healthcare model was built around the provider," Dr. Oliva said. "They drive everything, because those with knowledge control. I think we can all agree, physicians have always been the driver in a fee-for-service world."

However, the rise of the internet and other technological advancements have made knowledge more ubiquitous — patients can Google their own symptoms, shop around for healthcare and view quality ratings online. These capabilities put pressure on hospitals to offer patients a convenient, low-cost and high-quality healthcare experience to remain financially viable in a value-based care environment. 

2. Inpatient revenue loss will be a major challenge. Technology and the push toward the second curve will drive more healthcare to outpatient settings without equal transfer of revenue, which will pose a major financial challenge for hospitals, according to Dr. Oliva.

"We built these beautiful massive buildings for medicine with lots of beds and lots of cost that we developed our healthcare structure around," he said. "Now technology is saying we don't need to do everything in there."

To prepare for this transition toward outpatient care, hospitals must optimize revenue under the current fee-for-service infrastructure while also working to accurately define the healthcare needs of the population they will be responsible to care for in a value-based environment.

3. Focus on expected patient outcomes. To maximize financial performance, Dr. Oliva said healthcare leaders should first spend time and energy to optimize processes, such as clinical documentation, that affect their facility's expected outcomes.

A hospital's outcomes performance is calculated by dividing actual patient outcomes over expected outcomes. Many different factors can influence actual outcomes. For example, a patient who presents with early sepsis will likely have a much greater chance at survival than someone with severe sepsis, but this type of information is not represented on a billing statement, according to Dr. Oliva. "From a billing standpoint, sepsis and severe sepsis are the same, even though they really make a big difference," he said.

In contrast, expected outcomes comprise only a patient's age, principal diagnosis and all secondary diagnoses, which are much easier for healthcare organizations to control.

"At the end of the day, the equation is still observed over expected," Dr. Oliva said. "We focus all our activity to improve quality. But you can't talk to physicians about their outcomes until you they know the denominator is right."

4. CDI can move the needle on outcomes. After serving as a CMO for 15 years, Dr. Oliva joined Nuance in 2013 with a burning question: Can CDI really make a difference in patient outcomes?

To answer this question, Nuance looked at multiple years of inpatient mortality data from CareChex, pinpointing hospitals using Nuance's clinical documentation program. Ninety percent of about 400 hospitals using the CDI program placed in the 90th percentile among all hospitals in the U.S. for overall inpatient mortality ratings. Before implementing the program, Nuance's client hospitals fell in the 54th percentile for mortality. When broken up by hospital type, CDI hospitals still demonstrated better mortality ratings, according to Dr. Oliva.

"This is important because as we start to think about where we go with CDI improvement, if we're going to start using technology, we better be sure whatever we're doing is working," he said.

5. Let technology do the work for you. Technology solutions that use artificial intelligence and natural language processing capabilities to "understand" human language can help create more efficient workflows for physicians and CDI teams, according to Dr. Oliva.

An AI-driven CDI program can run 24/7, freeing up clinicians to spend more time with patients, instead of completing arduous documentation tasks that can cause burnout.

"If we can bring speech and physician-directed solutions to the physician at the time they're documenting, we can avoid bothering them later," he said. "For the CDI teams, there needs to be solutions to triage their work and flag the highest risk charts first for their review."

These types of programs offer a much more efficient and cost-effective process for clinical documentation that allows clinicians to stay at the bedside while still capturing a patient's entire care journey, ultimately supporting both the healthcare organization's financial and clinical performance.

To learn more about Nuance's clinical and revenue integrity solutions, click here.

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