A Conversation with Jake Lieman, VP of Engineering at Artifact Health

*Artifact Health is proud to announce its mobile physician query platform is now available within the Cerner App Gallery, a marketplace for healthcare software products that integrate with Cerner using Cerner’s Application Programming Interface (API). The Artifact/Cerner integration gives physicians mobile technology to ensure accuracy of patient records.*

Artifact recently completed Cerner Open Developer Experience (code) Program validation. We spoke with our own Jake Lieman, Vice President of Engineering at Artifact Health, regarding the code Program, the integration of Artifact’s mobile physician query platform, and the benefits for Cerner hospitals.

### What is the Cerner Open Developer Experience (code) Program?

The code Program is about furthering interoperability of patient information. But, it’s not just about technology. The code Program also encourages developers to solve today’s complex healthcare problems by providing them with a platform to build sophisticated, more reliable systems.

Healthcare providers and technology vendors have recognized traditional HL7 integrations to be slow, complicated and lacking in modern technologies. Over the years, we’ve all become efficient at building HL7 interfaces, but these integrations remain as one of the most expensive and complicated parts of the implementation process.

The code Program was designed to make it easy for technology vendors and health systems to integrate their own platforms with Cerner’s data using modern technologies and a new interoperability standard called SMART on FHIR. The code Program is Cerner’s implementation of the SMART on FHIR paradigm.

### What is SMART on FHIR?

SMART on FHIR is the combination of two complementary standards. SMART stands for “Substitutable Medical Applications Reusable Technologies” (a name only a programmer could love!) and is a standard for launching third-party applications from EMRs. FHIR stands for “Fast Healthcare Interoperability Resources” and is a standard for electronic exchange of health information.

FHIR, in particular, is a real paradigm shift for healthcare IT. With traditional HL7 integration, every hospital system maintains a copy of the patient record. When a patient is admitted, transferred, receives a labs result, etc., the source system pushes a copy of this information to all other systems that need it. All receiving systems store a copy of the information in case needed in the future. This process is a terribly inefficient way to do things. It requires multiple systems to store significant amounts of patient information they may never need.

FHIR turns this model on its head. Instead of the source system pushing all data to receiving systems, a receiving system pulls only the data needed from the source system FHIR APIs. With this model, the receiving system is guaranteed to always have the most current information on a patient and only has information on the patients it needs, preferable from both a storage and security perspective.

### How does a vendor’s application get validated for use?

The Artifact application has undergone an exhaustive review to ensure it meets the security, functional, operational and usability standards set by Cerner. The Cerner validation and certification process attests that Artifact can be implemented safely, efficiently and reliably for Cerner clients.

We were able to update the Artifact platform for use inside of PowerChart in just a few months. One of the reasons for this quick implementation is we built Artifact from the ground up to support FHIR API integration. When we started building Artifact six years ago, FHIR was not yet even a draft standard. However, we recognized that FHIR was the future, so we structured our underlying infrastructure to support both tradition push-based HL7 integration and pull-based API integration, such as FHIR.

### Why did Artifact Health decide to join the code Program?

Artifact is already deployed at many Cerner hospitals across the country. Providing an integration option directly supported by Cerner for future Cerner customers makes sense for a number of reasons, beginning with speed of implementation. When a hospital or health system signs a contract with Artifact, we want to help them get up and running as expeditiously as possible. We’re always looking for ways to optimize the implementation process for our customers.

Secondly, the code Program allows us to achieve turn-key, plug and play integration with any Cerner hospital. This reduces overall integration time, and more importantly, reduces the hospital or health system’s FTE resource time and costs by shifting integration responsibilities on to Artifact and Cerner.

Finally, as mentioned previously, using a pull-based API model for data integration with a hospital has many advantages, including reduced infrastructure and bandwidth requirements, reduced risk and increased security.

### How will Artifact’s inclusion in the code Program benefit Cerner clients?

Artifact’s availability within the Cerner App Gallery introduces Cerner hospitals and health systems to a mobile clinical documentation improvement (CDI) solution that gives physicians an easier way to respond to requests for documentation clarification, ultimately adding greater specificity to the patient’s record and giving providers back valuable time to focus on patient care.

Traditionally, the physician query process is onerous and time-consuming for physicians, clinical documentation specialists and medical coders. Cerner hospitals often resort to delivering queries to physicians through the Message Center, which is cluttered with many other messages and requires multiple steps for the physician to respond.

With Artifact’s HIPAA-compliant, cloud-based, mobile query platform, physicians can respond to a query compliantly in seconds with as few as three taps on their smartphone. Engaging physicians with a faster, more simplified process drives improvements in hospital coding accuracy and publicly reported quality measures.

In addition to turn-key technical integration and reduction in IT resources, Cerner hospitals can have real-time access to Cerner data within Artifact. This gives physicians everything they need to respond to a query without having to go back to the chart.

Artifact is also seamlessly available inside PowerChart so physicians have multiple ways to access Artifact and respond to documentation clarification queries.

### For more information
Contact Jake at jlieman@artifacthealth.com. View our code Program page here.

A conversation with Tammy Combs and Melissa Potts of the American Health Information Management Association (AHIMA)

*Tammy Combs, RN, MSN, CCS, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Director of HIM Practice Excellence, CDI/Nurse Planner at AHIMA

*Melissa Potts, RN, BSN, CCDS, CDIP, CDI Practitioner, HIM Practice Excellence, CDI/Nurse Planner at AHIMA

The American Health Information Management Association AHIMA represents more than 103,000 health information professionals in the United States and around the world. AHIMA is committed to promoting and advocating for high quality research and best practices in health information and to actively contributing to the development and advancement of health information professionals worldwide.

AHIMA and Artifact Health have partnered to provide hospitals with a mobile physician query platform that can utilize a library of electronic query templates developed and maintained by AHIMA experts. We spoke with AHIMA clinical documentation integrity (CDI) experts, Tammy Combs and Melissa Potts, about the importance of clinical documentation improvement during the COVID-19 pandemic.

### What is the greatest CDI and coding challenge hospitals have faced during the pandemic?

CDI programs are vital to the hospital’s financial sustainability and the accurate reporting of patient data. During this pandemic, we’ve seen hospital CDI and coding teams confronted with trying to maintain provider engagement around clarifying documentation for accurate coding purposes.

Historically, providers struggle with balancing administrative duties, such as documenting for coding purposes, and their desire to stay focused on patient care. During the last few months, hospitals dealing with COVID-19 outbreaks could not possibly expect providers to focus on anything more than patient care.

However, as hospitals are getting back to preforming elective surgeries, engaging providers around clarifying documentation for proper coding and reimbursement will be critical to their financial sustainability.

### What other CDI and coding challenges have arisen from the pandemic?

Another significant challenge was hospitals had to rapidly and unexpectedly move CDI teams to a fully remote model. This overnight transition required that hospitals procure and provide the correct technology to support productive remote work. And, all of this happening while having to furlough employees to reduce costs and stay solvent.

As the pandemic continues and spikes again in other regions, engaging providers around accurate documentation and coding is critical to our public health. CDI and coding teams ensure that the hospital reports patient disease burden accurately. Without correct documentation and coding, we as a community cannot study the true repercussions of this virus.

### During these next phases of opening up and hospitals getting back to normal operations, how critical are CDI programs?

The quality of physician documentation directly impacts hospital reimbursement. CDI programs are an extremely valuable resource to help document patient information completely and accurately so that the hospital may justify full and proper reimbursement for services.

To rebound from the pandemic losses, CDI teams must help hospitals find ways to continue and enhance engagement with providers when their documentation is unclear. Physician responses to CDI and coding queries help the hospital properly and compliantly code and bill for patient encounters. So, greater provider engagement around queries will translate into more accurate reimbursement for hospitals, at a time when they need it most.

Along with engagement around queries, CDI specialists are responsible for educating providers on new regulations and specific documentation requirements for accurate coding and quality reporting. CDI teams will be vital to delivering updated education on medical conditions not related to COVID-19, as hospitals begin performing elective procedures again.

### How is AHIMA helping hospitals deal with the pandemic?

AHIMA developed a webpage with links to numerous COVID resources. Included are two CDI query templates for COVID-19, which we added to our compliant query template library embedded within Artifact Health’s mobile query platform. The COVID-19 templates support two query opportunities brought to AHIMA’s attention by the CDI industry – diagnosis validation and diagnosis specificity of COVID-19.

Also, AHIMA’s COVID resources webpage includes other resources and information to support the healthcare industry during this pandemic, such as free educational webinars.

### What benefits does the alliance between AHIMA and Artifact Health offer hospitals and health systems?

The integration of AHIIMA’s expert, compliant query template library with Artifact Health’s innovative mobile physician query platform can help hospitals ensure accurate reimbursement and quality scores. Physicians are able to answer queries compliantly in as little as 30 seconds from their mobile device or desktop.

The ease and convenience of the Artifact mobile app is more satisfying for providers than receiving queries through email, in-person interruptions or the EMR system, and ultimately helps hospitals get queries answered as quickly as possible.

### For more information
Contact Tammy Combs and Melissa Potts at cdiexperts@ahima.org.

Accustomed to Instagram, Millennial Physicians Won’t Stand for 1980s EMR Technology

Millennials (born 1981-1996) are now a driving force in medicine. The first generation to have grown up with ubiquitous internet access, Millennials have high technology expectations. And hospital technology has to evolve as a result.

According to Pew Research, 93 percent of Millennials own a smartphone (versus 90 percent for Gen X, and just 68 for Baby Boomers). Of the average 242 minutes Millennials spend on the Internet each day, 211 minutes of it – or 87 percent – is on a mobile device. They are accustomed to being constantly connected.

 A millennial nurse practitioner recently told me of her hospital’s EMR system, “It’s so time consuming to do something so simple – the opposite of my experience using Facebook and Instagram.”

And then they start working in a hospital setting, where the most commonly used EMR software was originally developed before many of them were born.

In a Wall Street Journal article, one physician leader shared that millennial physicians on staff at her hospital questioned why EMRs and clinical documentation couldn’t be more like using an iPhone. Anyone who uses Instagram on a regular basis and then uses an EMR would be shocked – the experiences could not be any more different.

A millennial nurse practitioner recently told me of her hospital’s EMR system, “It’s so time consuming to do something so simple – the opposite of my experience using Facebook and Instagram.” She feels most of her time is taken up by documentation, yet the EMR doesn’t provide the means for her to add notes in her own voice – it’s all drop down, predefined selections. This is probably why mobile apps for the major EMRs have between a 2.5 – 2.6 rating on the app store. The bar has been set very low.

In a mobile-first era, we are asking our physicians and other medical staff to use software interfaces that were originally designed well before the advent of mobile devices. One anonymous millennial physician, writing for MedSpace, said that for every one hour of patient care, s/he spends two hours entering data into an EMR. Another, writing for Medical Economics, pleaded for new user interfaces, saying, “I have yet to meet a young physician colleague or trainee who has displayed any emotion greater than lackluster contentment with their medical record system.”

The frustrating user experience associated with EMR technology is a chief contributor to physician burnout – a very troubling issue in the healthcare industry. Even before the COVID-19 pandemic struck, the numbers of physicians reporting burnout, fatigue and depression were on the rise. In fact, in a Jan 2020 Medscape report, 42 percent of physicians reported feeling burned out, and one in five reported that they are depressed. The most common reason physicians cited for their burnout (55 percent): increasing administrative burdens, like charting.

Bringing back the “Joy in Medicine” is something hospitals all over the country are prioritizing so they can attract and retain the best staff. Reducing administrative tasks so physicians can spend more time on patient care has been identified as a key to addressing burnout, so hospitals are researching tech solutions to automate things like physician queries on documentation.

Physician queries are designed to make sure physician notes are accurate and complete in the medical record, and they play an important part in hospital reimbursements, quality metrics and patient care – especially during the current COVID-19 pandemic, when hospitals need to capture full reimbursement for the complex and expensive care they are providing. Higher query response rates and completion of more queries can translate into millions of dollars in additional reimbursement and higher quality scores for a hospital. It is, however, a very time-consuming process for physicians, and one that reduces time available for patient care.

Artifact Health has automated this task so it can be done on a physician’s smartphone in a matter of seconds, easily and compliantly. Hundreds of hospitals such as Johns Hopkins Medicine, Children’s National Hospital and UPMC Western Maryland have already put this mobile technology to work to ease the administrative burden for physicians, clinical documentation specialists and coding staff.

Healthcare mobile apps are especially needed right now, during the pandemic, because they allow physicians and other hospital staff to more quickly and easily access and triage information while at the hospital or from home – where many non-essential staff are currently working.

Within a few years, millennial (and then, Gen Z) physicians will become the majority, and these younger physicians will be making the purchasing decisions at hospitals and health systems. They will demand technology that has the same ease of use they are used to, and without a doubt, will select modernized solutions that give them more time for patient care.

A conversation with Brian Sanderson, National Healthcare Leader at Crowe LLP

*Crowe LLPis a public accounting, consulting and technology firm with offices around the world. Crowe uses its deep industry expertise to provide audit services to public and private entities. The firm and its subsidiaries also help clients make smart decisions that lead to lasting value with its tax, advisory and consulting services. Crowe is recognized by many organizations as one of the best places to work. As an independent member of Crowe Global, one of the largest global accounting networks in the world, Crowe serves clients worldwide. The network consists of more than 200 independent accounting and advisory services firms in more than 130 countries around the world.*

We spoke with Brian Sanderson, National Healthcare Leader at Crowe, regarding the financial impact of the COVID-19 pandemic on hospitals and health systems and the steps they may consider taking to recover quickly.

### How has COVID-19 impacted hospitals’ revenue cycle?

We’ve calculated that most hospitals will need to operate at 110 percent of their previous volumes for six straight months to offset the volume declines we saw from mid-March through April. For most organizations, this will be a significant throughput challenge combined with the need to prioritize the pent-up demand of elective surgeries.

We’ve seen revenue cycle metrics actually improve over the course of April, primarily because of the lower volume – less accounts, more focus on collections. But, we’re concerned that late May and all of June will show very volatile performance.

### What steps are you recommending hospitals take to limit the negative impact of the pandemic?

We’re recommending hospitals focus on three main priorities:
1. Institute an “acceleration mindset” by condensing schedules and increasing hours of operation.
2. Focus on coding and capture precision – capture every procedure, CC, etc. that they are entitled to. It’s not time to be sloppy with documentation.
3. Introduce more automation to their business models. Labor has become severely impacted by flexing and furloughing of staff and is an inhibitor to differential success. Hospitals should use the chaos of the crisis to reinvent how they operate.

### How can clinical documentation improvement and coding teams help hospitals rebound?

The spotlight on coding documentation has intensified as the country attempts to understand and quantify the impact of the pandemic. Securing additional federal reimbursement will depend on a hospital’s ability to document and code COVID-19 cases accurately.

Organizations that have the tools, methodologies and sufficient focus on coding and documentation are in a much better position to respond and will be quicker to capture the pent-up demand for the remainder of the year. This skillset will be the differentiator for hospitals when it comes to achieving margin, and in many cases, bond covenants and cash flow metrics.

### What programs and initiatives should hospitals be implementing now to maximize cash flow?

We see five key elements of revenue recovery for hospitals:
1. Recapture patient demand in a strategic way using three levers:
* Assure patients that they will come back to a facility free from contamination.
* Reconfigure operations for more throughput.
* Assist physicians with the acceleration of the consult/schedule/operate process.
2. Segment operations distinctively between contagious and non-contagious areas – e.g. inpatient wards, outpatient tracks, etc. Part of the issue with the cancellation of electives was the government looking negatively at co-mingling all patients, and therefore more space was procured (at the expense of other services).
3. Become experts at revenue cycle operations – revenue projection, service mix analysis, capturing, processing, billing and collecting.
4. Challenge the clinical operating model. Now is the time for hospitals to move aggressively towards telehealth and the digital gatekeeping it can provide. Included in this shift are dispersed sites of care, touchless patient access, risk tolerance for value-based contracts, etc. The business of “one foot on the canoe, one foot on the dock” straddling of old and new models should be abandoned and hospitals should use this pandemic experience to charge solidly ahead in one clear direction.
5. After mastering the first four elements, hospitals must focus on the patient experience. Many hospitals will not be able to rapidly pivot and capture pent-up demand, and patients will seek care elsewhere. To the degree that other hospitals can provide a better experience, patients and their families could become their new market share.

### How is Crowe helping your hospital partners?

Crowe simplifies the business of healthcare through revenue and risk lenses. We help hospitals capture and account for revenue to keep them solvent. Crowe’s Revenue Recovery Program focuses on the elements hospitals need to accelerate and achieve to return to financial stability while improving their risk profile. Our key solutions include: revenue cycle operations, outpatient charge capture, finance and reimbursement services, as well as internal audit.

### Would you like more information?
Connect with Brian at Brian.Sanderson@crowe.com.

A conversation with Laurie Prescott, CDI Education Director for HCPro

*Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O is CDI Education Director at HCPro.

As an acknowledged industry authority in healthcare compliance for over 30 years, HCPro delivers information, education, training and consulting products and services that meet the specialized needs of the healthcare industry. Its team of renowned CDI educators, led by Laurie Prescott, have applied their substantial clinical and coding experience to the design of an electronic query template library for Artifact Health. The library provides compliant templates and process guidance so healthcare facilities can better capture the true complexity of their patient population.

HCPro and Artifact Health have partnered to provide hospitals with a mobile physician query platform that utilizes a library of electronic query templates developed and maintained by HCPro/ACDIS experts. We spoke with Laurie about the impact of COVID-19 on U.S. hospitals and the importance of clinical documentation improvement efforts at this time.

### COVID-19 has caused unprecedented turmoil for hospitals in major cities across the U.S. at capacity with healthcare providers working overtime to triage and treat patients. Why is proper coding of patient hospital stays important right now?
Many people associate proper coding with hospital reimbursement. However, during a pandemic coding actually plays a much more significant role in understanding how deadly diseases quickly spread from country to country, like Ebola, SARS and now COVID-19.

So yes, proper coding of COVID-19 will be important for hospitals to stay afloat financially – to get reimbursed for all of the services they are performing and to apply for funding from the government to keep them in business. But, the coding of COVID-19 will be more critical for statistical reasons and advancing the study of the disease to hopefully prevent similar outbreaks in the future.

### How does the coding of patient data inform public health decisions?
The fact is, ICD-10 codes were designed for epidemiological purposes – to track, report and better understand public health diseases.

Public health officials and scientists look at coded patient data to better understand and tell the story of exactly how diseases are spread, the symptoms and complications, the underlying conditions that influenced outcomes, the impact on age groups and gender, how many people died and how the outbreak compares country to country.

The rapid spread and high mortality associated with COVID-19 is further underscoring the importance of capturing codes correctly.

### How important are Clinical Documentation Improvement (CDI) initiatives during COVID?
During a crisis or a pandemic like COVID-19 the hospital’s CDI team becomes even more essential. Increased patient encounters and disease information must be captured and coded correctly to keep the hospital solvent and provide accurate data for research studies and pandemic modeling.

Healthcare providers must have guidance around properly documenting COVID-19 patients and the complications that arise from the disease which can have broad or vague symptoms, such as respiratory issues. CDI teams are the educators. We ensure that providers have the information they need to document accurately for proper coding.

### How is HCPro/ACDIS helping hospitals right now?
We are supporting hospitals with guidance on documenting COVID-19. We have developed a compliant COVID-19 physician query template which helps increase the specificity and accuracy of the symptoms and complications resulting from the disease. This new COVID-19 template is available to the hospitals we work with, and we are grateful this type of information can be used by physicians, public health officials and researchers to more accurately map the disease and its widespread impact.

Through our partnership with Artifact Health hospitals can utilize our full library of compliant CDI physician query templates. Our library is kept compliant and updated for our hospitals to incorporate new coding guidelines as well as new diseases, like COVID-19.

### Need more information?
Connect with Laurie at lprescott@hcpro.com. For information regarding HCPro’s CDI Boot Camps, click here.

Elements of Consideration During CDI Review of COVID-19 Patients

Bridging the gap between the clinical transcript and coded data

COVID-19 may be the headline but, as a seasoned clinical documentation improvement (CDI) professional, I always ponder what’s the rest of the story? As we learn more about the disease and its effects on the body systems, CDI is challenged to look through the documented words and identify gaps between the written story and the data that will eventually be used to tell that story.

CDI’s challenge has always been to bridge the gap between the clinical transcript and the coded data. With a goal to make sure the coded translation agrees with the provider’s clinical determinations, CDI identifies and clarifies areas not in alignment (e.g., urosepsis versus sepsis associated with a urinary tract infection).

Another element of consideration during a CDI documentation review is to determine why patients with the same diagnoses receive different levels of care. For example, let’s say a patient with a urinary tract infection presented with altered mental status and fever with orders to admit to medical floor. Another patient with a urinary tract infection presented with altered mental status and fever with orders to admit to critical care. CDI looks to answer questions, such as:
* What is the difference between these two patients?
* Are both patients receiving the same antimicrobial management?
* Do comorbidities account for the difference in the intensity of service?
* Is there evidence of acute organ dysfunction or failure associated with the infection?
* Is there an undocumented diagnosis that requires critical care management?

Healthcare is now confronted with a disease that no one has ever had before. Coronavirus disease (COVID-19) is caused by the virus identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 clinical presentation is similar to, but not a direct match with, other disease processes. Treatment is different and changing as new data and new intervention results are analyzed. In unprecedented moves, Coding Guidelines published a temporary new code specifically for COVID-19 accompanied by interim Coding Clinic information for technical guidance. DRG groupers were also revised to accommodate these changes midway through Federal Fiscal Year 2020.

Against the backdrop of these changes, CDI evaluation of clinical documentation, through the lens of clinical and technical translations, did not change. What changed, however, was documentation describing COVID-19 and SARS-CoV-2 related illness, diagnostic results, and treatment. Let’s begin the CDI review with provider documentation and associated CDI considerations.

Documentation may include diagnostic statements such as “SARS-CoV-2 Pneumonia”, “SIRS due to COVID-19”, “COVID-19 Cytokine Response Syndrome”, “Acute Hypoxic Respiratory Failure due to SARS-CoV-2 Pneumonia”, and “Cytokine Storm due to COVID-19.” Before sorting through these or similar COVID-19 documentation findings, it may be necessary for CDI to consider:
* Cytokine Release Syndrome
* Refer to Coding Clinic First Quarter 2020 for a clarification of previously published coding guidance.
* As a “syndrome,” refer to the Official Coding Guidelines Section I.B.15 Syndromes.
* Cytokine Storm: An overwhelmingly dysregulated inflammatory response resulting in high levels of cytokines (immune system proteins).
* Section I.B.15 of the Official Coding Guidelines, Syndromes: *Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations **that are not an integral part of the disease process** may also be assigned when the condition does not have a unique code.* Although there is no ICD-10-CM code for systemic inflammatory response syndrome (SIRS) due to infection, SIRS is a “syndrome” and, as such, would be coded according to these Official Coding Guidelines.
* Definition of sepsis
* Sepsis-3 Definition: *In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.*
* CDC Sepsis Definition: *Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency.*
* CMS Sepsis Core Measure (SEP-1: the Early Management Bundle, Severe Sepsis/Septic Shock Measure is a CMS National Inpatient Quality Measure, which went into effect October 1, 2015) defines sepsis as:
* SIRS Criteria, 2 or more of the following:
* Heart Rate >90
* Respiratory Rate >20
* Temperature >100.9F or <96.8F * White Blood Cell Count >12K, <4K, or bands >10%
* AND known or suspected source of infection
* Severe Sepsis and Septic Shock are defined as:
* Severe Sepsis:
* Two SIRS criteria, AND
* Known or suspected source of infection, AND
* End-organ dysfunction which includes any one of the following and excludes evidence that is considered chronic or secondary to medication (e.g., ESRD with creatinine >2, Coumadin with INR >1.5):
* Prior lab values used to determine end-organ dysfunction must have been reported within 6 hours preceding the onset of severe sepsis.
* Hypotension defined as
* Systolic blood pressure <90, OR
* MAP <65, OR * Drop in systolic blood pressure of >40 mmHg from the last previously recorded systolic blood pressure considered normal for that patient
* Creatinine >2, OR Urine output <0.5ml/kg/hr for >2 hours
* Total Bilirubin >2
* Platelets <100K * Coagulopathy: INR >1.5, OR aPTT > 60 seconds
* Lactate >2 mmol/L
* Acute respiratory failure as evidenced by new need for invasive or non-invasive mechanical ventilation
* Septic Shock is severe sepsis with
* Hypoperfusion despite adequate fluid resuscitation, OR
* Lactate > 4

Keeping CDI Teams Productive and Patient Data Accurate During the COVID-19 Pandemic

COVID-19 has caused unprecedented upheaval for hospitals across the globe. Hospitals in hotspots face overcapacity. Providers are risking their lives, and the lives of their family members, working round-the-clock to treat patients who need critical care.

Over the last month, we’ve been checking-in with our customers. We ask them how we can help – whether by creating a specific report, adding a COVID-19 template to their library, or simply giving moral support at this difficult time.

Our hospital colleagues have shared stories about ever-increasing COVID-19 admissions, decreasing overall admissions, providers who’ve been exposed and quarantined, employees furloughed, and more personally, the stress they feel every day.

We’ve taken to heart that each person has expressed gratitude for the ability to continue to do their jobs remotely using our technology. Here’s what we’ve learned from our hospital colleagues as it pertains to our business of supporting accurate patient documentation.

### CDI will become even more critical for hospitals’ financial survival
Hospitals in hard hit areas have become overwhelmed with COVID-19 admissions that require complex and expensive care. To minimize the spread of the virus, all hospitals across the country have been forced to suspend high-margin elective surgeries and refocus resources on potentially rapid increases in critical care patients.

As a result, hospitals expect to lose significant revenue this year. They have responded with immediate cost-cutting measures, such as flexing and furloughing staff, halting IT projects, and even closing or filing for bankruptcy.

> Clearly, hospitals have an immediate and paramount public health responsibility to document and report COVID-19 patient data as accurately and comprehensively as possible.

Across the board, our hospital colleagues say they need to lean on CDI review even more, otherwise their hospitals risk losing additional reimbursement.

One CDI professional commented, “Proper coding of COVID-19 will be important for hospitals to stay afloat financially – to get reimbursed for all of the services they are performing and to apply for funding from the government to keep them in business.”

### Public health decisions are informed by hospital data – it must be accurate and comprehensive
Government and public health officials are analyzing hospital-reported patient data daily to inform life-saving decisions regarding flattening the curve, securing medical supplies, and determining when it’s safe to reopen schools and businesses.

The importance of ensuring accurately reported COVID-19 patient data cannot be overstated. A CDI professional explained, “CDI review and clarification of patient data plays a critical role in our ability to study and understand COVID-19 – how it spreads, the risk factors, associated deaths, and how we can avoid future outbreaks.”

Clearly, hospitals have an immediate and paramount public health responsibility to document and report COVID-19 patient data as accurately and comprehensively as possible. Our safety and the development of effective therapeutics and vaccines depend on it.

### Given the right technology, CDI staff can work from home effectively
During routine times, CDI staff typically round with providers on the floors to ensure patient information is accurate in the chart. Last month, non-essential hospital staff were asked to begin working from home. CDI teams fall into the category of “non-essential” to in-person patient care.

One CDI manager remarked, “CDI teams often work on top of each other, sometimes with three members in a 10×10-foot room! Keeping your social six-foot-distance just doesn’t work.”

At hospitals across the country, CDI teams have setup at home. Some report having sufficient technology to do their jobs, while others are restricted and frustrated by basic IT issues – slow Internet, inability to connect to VPNs, and limited access to hardware provided by the hospital.

> Giving providers faster, more convenient mobile solutions will be imperative as we redesign healthcare workflows with post-pandemic learnings.

For hospitals with cloud-based technologies such as Artifact, CDI productivity and engagement with physicians have continued without interruption. One CDI manager commented, “Our workflow hasn’t changed from home. Physicians are responding to our queries in Artifact. It’s business as usual for us, and we don’t know how we would have kept up without our mobile query platform during this time.”

Each hospital colleague we spoke with agreed that, while it’s helpful for CDI teams to be onsite for education, their jobs can be done from home. A physician asserted, “One of the lessons we will learn during this pandemic is that CDI teams can work efficiently remotely because of the technology now at their disposal.”

### Mobile technology for providers is faster to use and less distracting to patient care
Prior to the COVID-19 outbreak, physician burnout had become a major focus of concern for hospitals. The pandemic has taken physician well-being challenges to a heightened and truly incomprehensible level.

A CDI manager described the atmosphere at her hospital saying, “With the onset of COVID-19, physicians are solely focused on patient care and it’s nearly impossible to get their attention. They are completely overwhelmed and not accessible to answer emails, phone calls or talk in person to someone about responding to a query. They are maximally stressed.”

During normal times, the most valuable asset to providers was having more time in their day. Administrative burden and cumbersome EMR workflows were often to blame for taking time away from patient care. With this pandemic, an already bad situation turned much worse overnight.

A Director of Emergency Management at a state medical center pointed out, “Right now everyone is asking physicians for all types of information. Crises like pandemics illuminate why mobile technology tools like Artifact are critical – it’s all about access and control over the flow of information.”

We can only hope COVID-19 teaches our healthcare system new lessons that bring safer, more efficient care for the next generation. Giving providers faster, more convenient mobile solutions will be imperative as we redesign healthcare workflows with post-pandemic learnings.

4 emerging CDI trends and how they will impact the industry in 2020

The Clinical Documentation Improvement (CDI) industry has been transformed by new technologies since its inception in the mid 2000s. Today, CDI nurses act like air-traffic controllers with sophisticated software systems at their fingertips, quickly scanning, identifying and resolving opportunities for clinical documentation improvement within thousands of patient charts. The days of walking the floors with a stack of paper sticky-notes and chocolate bars are pretty much gone.

With new technologies available, hospitals are expanding CDI coverage, as they struggle to accurately and consistently translate care provided into diagnostic coding terms necessary for proper payment and publicly reported quality outcomes. Hospitals lose significant reimbursement dollars when physician documentation is not consistency and quickly clarified for coding purposes.

Along with having to earn their due twice over, hospitals are reacting to new and intense marketing pressure. Patients are demanding greater transparency in healthcare. Armed with physician report cards and hospital quality scores, they make decisions based on hospital and physician rankings, rather than their primary care doctor’s referral.

In 2020, CDI will become even more responsible for the hospital’s sustainability. As a result, hospitals will continue to invest in CDI technology to capture full reimbursement for services and ensure publicly reported coded data tells a story of excellent care. As the leader in mobile query platforms, we see the following trends propelling the CDI industry forward:

#### 1. CDI prioritization
At Artifact Health, we are seeing hospitals and health systems combine our mobile physician query solution with CDI prioritization tools. Together, these tools become powerful success drivers for CDI programs by guiding record review selection, identifying high-value query opportunities and ensuring queries are answered quickly and 100% of the time. CDI prioritization will continue to grow in 2020 helping drive greater efficiencies at hospitals and health systems.

#### 2. Outsourcing of physician query templates
Increasingly, health systems are moving away from developing and maintaining their own physician query templates. Instead, they are opting to outsource standardized template libraries that can be shared electronically across CDI and coding staff. Artifact Health formed the first alliances to provide expert-reviewed and maintained template libraries for mobile query delivery with the American Health Information Management Association (AHIMA) and HCPro. AHIMA and HCPro’s Association of Clinical Documentation Integrity Specialists (ACDIS) together set industry guidelines for compliant clinical documentation querying and have developed extensive template libraries formatted for mobile query delivery.

#### 3. Outpatient CDI
CDI will continue to expand into outpatient areas in 2020. With mobile physician query delivery, we’ve noticed more CDI specialists working remotely and spending less time on patient floors. This workflow shift in itself is a growing trend. Now, hospitals can more easily scale CDI into outpatient areas. Further, as hospitals and health systems learn to succeed under risk-based population health models, they must expand CDI programs into outpatient to optimize reimbursement.

#### 4. Importance of physician engagement in CDI
Hospitals will continue to place physician burnout high on their priority list, especially around technology and EMR usage. Physicians typically find responding to documentation clarification queries burdensome, taking on average 10-15 minutes to answer one query. Making it fast and easy for physicians to respond to queries is a logical step toward addressing burnout and engaging physicians in CDI initiatives. Artifact Health customers report increased physician satisfaction with the speed and ease of mobile query delivery.

In 2020, we predict the CDI industry will continue to grow with advanced technologies as hospitals and health systems close the gap on missed opportunities for full reimbursement and accurately reported quality outcomes. Further, provider organizations will rely more heavily on CDI expertise as they adopt value-based programs that require them to tell the patient story correctly to justify quality care and reimbursement.

Physician Advisors: Applying peer-pressure to stop the bleeding

Over the years, I’ve interviewed and attended countless presentations by hospital coders and clinical documentation improvement (CDI) specialists to study physician query workflow and its challenges. I’m always struck by the use of the Physician Advisor as the last resort, the big brother who steps-in to kick butt and get queries answered. They call it *leveraging a physician engagement strategy to maximize physician response.* It seems more like band-aiding a poor process.

Physician Advisors play an important role in CDI and coding. They serve as a clinical resource and educator to physicians on the importance of documentation. They are active in revenue cycle management and utilization review. They encourage physician buy-in, intervene when problems arise, and manage audits and denials.

Using Physician Advisors to chase-down colleagues for query responses wastes MD time and perpetuates the misconception that answering a query is done as a favor rather than an obligation. Then again, what choice do CDI and Coding Managers have? Physicians have limited time and incentive to answer documentation-related queries with no real skin in the hospital reimbursement game.

At a recent meeting, a Coder Manager described her query escalation process like this:

*”Our coders are often two-weeks out after discharge, so the response rate to queries is not great. We escalate unanswered queries after seven days to our Physician Advisor. He sends an email to the doctor. Sometimes this works, and the Physician Advisor gets a response. If not, at least he knows who the bad guys are.”*

Knowing “who the bad guys are” does not address inaccurate documentation or the loss of full reimbursement for a case. The root of the problem lies with the process.

Six Sigma and Lean Management techniques and tools have been around as long as the DRG. We know that successful process improvement requires decision-making based upon verifiable data. However, tracking physician query activity and its impact on quality and reimbursement remains largely a manual process notoriously difficult to measure.

Another Coder Manager once imparted, “Even one unanswered query is not acceptable.” Some hospitals employ extreme measures, such as tying physician bonuses to query responses or suspending physicians when queries go unanswered.

A better way to improve the physician query process – make it easier and faster for physicians to respond to queries and create clear visibility and accountability with all query activity tracked and transparent.

CDI’s uphill battle to boost query response rates

At a recent CDI conference, a presenter proudly announced, “Our hospital achieved a 100% physician query response rate in surgery.”

The audience of seasoned CDI specialists seemed impressed but skeptical.

Hospital CDI programs rarely achieve high physician query response rates. Physicians find query workflow burdensome and time-consuming. A physician friend summed it up succinctly, “Queries are time away from making people better.”

Back in the day, CDI specialists stuck paper queries in the paper chart for physicians to answer the next time they documented on the patient. These queries were not easily tracked, reported or discoverable. Today, some hospitals have replaced paper queries with email-type queries in the EMR, ironically with the same lack of tracking and reporting.

Yet, these email queries in the EMR have not eased the burden on providers. Response rates of 60% or lower are common, leaving significant opportunities for hospitals to achieve full reimbursement and accurate quality scores on the table.

Also, without the ability to easily track and report on provider query activity, hospital CDI programs still cannot effectively manage the process or motivate greater physician response rates. Some CDI specialists argue that paper queries were more successful.

To boost query response rates, CDI specialists and coders allocate significant bandwidth to manual follow-up efforts. A CDI Manager in the audience whispered to me, “Our response rate to queries in the in-basket is 40%, so we resort to verbal querying where we get a 70% response rate, but it’s killing us.”

The presenter echoed this statement when she detailed the keys to her 100% response rate in surgery. “We employ top-down leadership, physician advisor support and an electronic query process… with follow-up.”

How much follow-up, I wondered? I asked her after the presentation, and she described the following CDI query follow-up activities:

* Searching patient charts to determine if physicians have responded to their queries
* Documenting query information and updating the status in multiple systems for tracking and reporting
* Emailing, calling and approaching physicians multiple times with query reminders
* Creating lists of physicians with unanswered queries for the physician advisor to chase-down

Attaining a 100% physician response rate to queries is a clear measure of success for any hospital CDI program. However, poor query workflows force a trade-off. CDI specialists appear to be devoting significant effort to query follow-up activities taking time away from reviewing additional charts and educating providers.