The Future of Clinical Documentation Integrity: Insights from Fran Jurcak (Part II)

You can read Part I of this interview here

Fran Jurcak is an accomplished senior executive with over 30 years of success in healthcare practice, education, consulting, and technology. She is currently the Chief Clinical Strategist at Iodine Software where she has worked for four years and has assisted in bringing artificial intelligence machine learning model technology to CDI and coding workflows. Jurcak currently sits on the ACDIS Advisory Board, serves on several other advisory boards, and received the 2017 ACDIS award for Professional Achievement. Prior to joining Iodine, Jurcak was a healthcare consultant, leveraging her clinical and coding knowledge to support process improvement in the mid-revenue cycle, particularly in the clinical documentation integrity space. These process improvements allowed her clients to successfully minimize mid-cycle leakage and accurately report outcomes of care. Additionally, she is the author of the CCDS Study Guide and has co-authored several papers for ACDIS and AHIMA, both organizations which recognize Jurcak as a national speaker.

Q: Some health systems have furloughed CDI staff during COVID-19. Do you think organizations can afford to have smaller CDI teams going forward?

A: In my opinion, it would be smart for programs to evaluate where they are from a staffing perspective in order to make the right decisions moving forward, and I hope they leverage strong data to make these decisions. Now is the time to identify team members’ skill sets and ensure they are aligned in the most appropriate roles. Healthcare leaders should also consider if staff can be leveraged to cross-cover the areas with lower availability or assigned to non-traditional CDI areas of review such as pediatrics, obstetrics, psychiatry, observation, and others. 

In order for CDI programs to survive in this new world where smaller teams may be the norm even as census increases, it will be key to identify the right cases that warrant review. It is more important than ever to leverage technology that creates efficiency and effectiveness in the CDI workflow. Artificial intelligence machine learning models excel at identifying cases where clinical evidence of a condition is present but documentation is lacking specificity or accuracy. Marker-based approaches, on the other hand, partition individual cases into lists based upon the rule but do not identify the likelihood that a true documentation integrity opportunity exists. This can be accomplished through use of machine learning models. It is very important that when we talk about utilizing technology we talk about leveraging the right technology to ensure the right cases are identified at the right time for CDI review.

Q: How can healthcare leaders leverage CDI as they prepare for an uncertain future?

A: There is no doubt that documentation will still be key for reimbursement and quality reporting moving forward, at least in the current world. Regardless of the EHR and the underlying case use, documentation is still vital. Whether it’s an inpatient prospective payment system or an outpatient evaluation and management system, everything is driven by what is documented in the medical record, and that relevancy is not going away, at least not in the short term. Unless there is a major change in the way we pay for healthcare in the United States, documentation of all conditions being monitored and treated is still key – whether it be capturing risk, reimbursement, or quality, it is all driven by the documentation in the medical record. How we document may change moving forward, but the importance of documentation is not going away. It will continue to be vital to identify an efficient workflow that includes technology designed to support accurate, complete and timely documentation for every patient encounter. 

Q: As a leader in the CDI space, how do you think revenue cycle leaders should be thinking about CDI given the impact COVID-19 is having on hospital revenue and reimbursement? 

A: As impactful as the past few months have been for all of us, this is the perfect time for revenue cycle leaders to re-evaluate the expected outcomes of their CDI program and ultimately identify efficiency processes for their program. I think the value of a CDI program is abundantly clear. If anything, I think its value has been heightened by this outbreak. Moving forward, there is a huge opportunity to determine the “new” workflow for CDI.  This starts with identifying the appropriate  technology, the best workflow, and the necessary staffing levels to accomplish the health system’s desired outcomes. Finances are always a key component of a health system’s goals, but I think there are additional quality metrics and concerns that need to be addressed, and this is the perfect opportunity to refocus priorities.

The current healthcare situation highlights the value of CDI programs. Now is the time for hospital executives to reassess their programs and determine which technology best creates workflow efficiency, identify the best people to utilize the technology, and realign expected program outcomes. Knowing that we are all in the midst of a financial crisis, it is truly important to ensure that we have the right tools and staff to achieve the maximum financial and quality outcomes. Now is the time!

The Impact of COVID-19 on Clinical Documentation Integrity: Insights from Fran Jurcak (Part I)

Fran Jurcak is an accomplished senior executive with over 30 years of success in healthcare practice, education, consulting, and technology. She is currently the Chief Clinical Strategist at Iodine Software where she has worked for four years and has assisted in bringing artificial intelligence machine learning model technology to CDI and coding workflows. Jurcak currently sits on the ACDIS Advisory Board, serves on several other advisory boards, and received the 2017 ACDIS award for Professional Achievement. Prior to joining Iodine, Jurcak was a healthcare consultant, leveraging her clinical and coding knowledge to support process improvement in the mid-revenue cycle, particularly in the clinical documentation integrity space. These process improvements allowed her clients to successfully minimize mid-cycle leakage and accurately report outcomes of care. Additionally, she is the author of the CCDS Study Guide and has co-authored several papers for ACDIS and AHIMA, both organizations which recognize Jurcak as a national speaker.

Fran Jurcak,
Iodine’s Chief Clinical Strategist

Q: What are the greatest challenges faced by CDI teams during the COVID-19 outbreak?

A: Perhaps the biggest challenge has been census fluctuation, and in most cases, a decline in census, which means there are fewer cases for CDI teams to concurrently review. This decrease in census has often resulted in reassignment or furloughing of staff. I also believe the second greatest challenge, specifically for facilities in COVID hotspots, is the limited availability of providers to answer queries. These challenges have caused many CDI teams to change workflow processes to identify the right cases for review, identify appropriate queries, and truly get the answers they need from providers. As a result, many programs are holding records longer than usual before final coding in order to ensure accurate and complete documentation before billing. Increased time to billing increases DNFB and ultimately time before payment is received.

Q: Given the decline in patient volumes, some CDI teams are expanding and adapting their programs. What initiatives do you think should be prioritized?

A: COVID-19 is not just impacting Medicare patients. It is impacting all patients from all payer types, even self pay. Financial reimbursement and quality reporting will continue to depend on the specificity of all conditions requiring accurate and complete documentation in all medical records. This creates a huge opportunity for CDI programs to expand to all payers and ensure that all conditions being monitored and treated during a patient’s encounter are clearly and consistently documented.

Health systems also have the opportunity to expand beyond financially motivated queries to ensure documentation integrity in the entire medical record. To truly capture patient acuity and support the research needed to identify patient patterns that identify at risk populations for COVID-19 and other diseases, CDI teams need to ensure that documentation appropriately captures all of the comorbid conditions that are being monitored and treated during the patient encounter. This means that simply documenting COVID-19 or respiratory failure will not be sufficient; capturing all other comorbidities as well as the specificity of all conditions will be crucial.

At Iodine, we are seeing a mixed bag of initiatives among our clients. For example, some have pulled back on physician-based education because physicians just don’t have additional time as they are busy caring for the influx of COVID-19 patients. Others have spent more time training and educating about COVID-19 and comorbid conditions to ensure they may not have to query as frequently. Census declines have definitely opened the door for CDI programs to reallocate time for additional education and training of their staff – whether it is cross-training to review records in a specialty they are less familiar with, or opening up to other types of inpatient admissions such as pediatrics or obstetrics. Additionally, expanding, supporting, and reinforcing the knowledge base of CDI professionals keeps staff up-to-date during a time of heightened complexity and uncertainty.

Q: In your opinion, can CDI teams stay remote full-time? What do you think the impact will be if remote work continues?

A: There are portions of what has traditionally been seen as CDI workload that I think can be done remotely. Obviously, electronic health records (EHRs) and most of the technology that CDI specialists are using in their workflow can be accessed remotely. However, engaging providers and ensuring accurate, appropriate, and timely responses requires some level of face-to-face interaction. I’ve seen teams accomplish this a variety of ways. Some programs have a portion of their staff conduct record review remotely while additional staff members interact with providers onsite. Other programs have their entire staff working a few days at home and a few days onsite so they can interact with providers themselves. In person communication is important for maintaining not only interpersonal relationships with providers but also to remind them of the relevance of documentation integrity.

I think remote work will increase moving forward, but the need to monitor quality of work will also increase. The challenge is that quality of work often suffers when teams work remotely. Social distancing makes it easier to stay focused on work, but there will be many more distractions once restrictions are lifted. Leveraging additional staff for internal auditing can help ensure query opportunities are not missed, queries remain compliant, and final codes related to queries are accurately captured. Peer audits also promote shared learning and accountability.

Part II will be published later this week. 

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.

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.

The Impact of COVID-19 on Inpatient Admissions

Overview

Iodine Software is a healthcare AI company that has pioneered a new machine learning approach—Cognitive Emulation—to help healthcare finance leaders build resilient organizations. Using Iodine’s CognitiveML™ engine, we reviewed inpatient admission data from 350+ facilities and 6M+ admissions. This analysis is a comparison of data from 2019, with data from the January 1 through May 19, 2020 timeframe.

Prior to the COVID-19 pandemic, hospitals were experiencing similar year-over-year levels of inpatient admissions for both elective and non-elective procedures. However, medical and surgical admissions began to decline in early March with admission counts dropping to their lowest point in early April. Following this sharp decline, both medical and surgical admissions began to recover but have still not reached their respective 2019 volumes.

Figure 1: Year-over-year Weekly Admissions

This figure shows that both elective and non-elective inpatient admissions began a significant decline around the week of March 4, 2020. After hitting their lowest volumes during the week of April 1, admissions began to steadily increase but are still below 2019 volumes. Elective admissions are trending to be close to pre-COVID levels.

Figure 2: 2020 Elective Surgery Inpatient Admissions

This figure shows that elective surgery inpatient admissions experienced a precipitous decline around the week of March 11 and dropped to a significantly low volume of 23% of 2019 admissions during the week of April 1. However, that low was short lived and beginning the week of April 22, admissions began to increase almost as quickly as they declined. Currently, elective surgery admission volume is at 76% of 2019 admissions.

Figure 3: Year-over-year Weekly Admissions: Selected Elective Admission Types

This figure analyzes selected elective admission types, omitting those with insufficient data, including palliative, pediatrics, and psychiatry. Maternity admissions, which are typically stable, remained relatively consistent with 2019 admissions. However, medical and surgical admissions began to decline around the week of March 4 and arrived at the lowest admission volume the week of April 8. Following this sharp decline, both medical and surgical admissions began to recover but have not reached their respective 2019 volumes.

Closing

As Iodine showed in previous analyses, hospitals are experiencing a significant drop in expected overall reimbursement this year because of COVID-19. As hospitals exit the pandemic, medical dollars are expected to go down as COVID admissions decrease. Unless surgical volumes appreciably recover, we expect overall reimbursement to sink once more. In reviewing this information, it will be important for CFOs and Revenue Cycle departments to look at new strategies for operating in this “new normal”, both short- and long-term.

Redefining Reconciliation with Iodine Retrospect

Prior to COVID-19, health systems were already operating on generally thin margins, with many finance leaders acknowledging that a significant root cause was leakage from their mid-revenue cycle and that “average performance” was still well below optimal results. Given the unforeseen impact of COVID-19 on hospital revenue, healthcare finance leaders must now be even more protective of margins.

Retrospective reviews are the last opportunity to resolve documentation and coding issues for billing and quality reporting purposes. However, traditional reconciliation is inefficient and often ineffective for a number of reasons, including:

  • Chart selection criteria that do not specifically identify all correction opportunities
  • Manual processes, which force unnecessary chart reviews
  • Complex, frequently changing documentation and coding guidelines
  • Over- and under-documentation by physicians
  • Understaffed CDI teams
  • Strict productivity requirements for coders

Traditional approaches force clinical documentation integrity (CDI) specialists to unnecessarily review a significant number of charts in search of these opportunities, which extends DNFB to no benefit. Additionally, most CDI teams are unable to review every chart, leaving many documentation and coding issues unidentified prior to billing.

The broad scope of factors impacting CDI efficiency and accuracy require creative solutions beyond hiring more CDI specialists. Only technology can automatically review each record during the retrospective review process and direct CDI teams to the charts that are most likely to require their attention, allowing them to eliminate a significant, unproductive portion of their workload and focus on improving documentation integrity.

Iodine Software is redefining reconciliation through its Retrospect module, which eases the burden on CDI and coding teams by automatically reviewing every chart prior to billing. Iodine Retrospect combines the prioritization technology of Iodine’s SmartList with an integrated CDI review workflow for post-discharge records. Narrative documentation, clinical evidence, and patient demographics are all taken into consideration, allowing Retrospect to make accurate predictions and automatically identify both cases that do and do not require a review. Discharged patients are therefore prioritized based on their statistical likelihood of containing documentation opportunities.

Retrospect also helps quality-audit CDI staff. Residual documentation concerns are detected in records already reviewed by CDI teams, allowing CDI program leaders to isolate knowledge deficits and identify workflow and process opportunities to support continued CDI program growth and success.

To learn more about the Iodine Retrospect Module, contact: info@iodinesoftware.com.