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.

Hospital Reimbursement 101: Help your docs answer every query

Hospital reimbursement starts with physician documentation. Physician documentation must be complete, accurate and precise to support optimal reimbursement and accurate quality reporting.

Increasingly, hospitals are funding clinical documentation improvement (CDI) programs and dedicated staff to educate physicians on the specificity needed for proper reimbursement and quality reporting. The primary tool used by CDI specialists and hospital coders to clarify physician documentation is the physician query. Physicians are typically queried about their documentation by email, fax, phone or in-person and asked to update the chart or respond on the query form.

Physician queries provide significant financial impact for hospitals. Artifact Health’s research found that 63% of physician query responses have a positive financial impact on the inpatient record. Each response with positive financial impact increases reimbursement by $5,000 on average. This means that every unanswered physician query reduces the hospital’s potential reimbursement by an average of $3,150. For a 1,200 bed hospital with 50,000 inpatient admissions per year querying on 15% of admissions, the difference between a physician query response rate of 60% and 100% is $9.5 million dollars.

Under enormous financial pressures already, hospitals cannot afford to leave $9.5 million dollars on the table because they fail to engage physicians in the query process. Exacerbating the situation, queries are expected to surge by year’s end with the government-mandated transition to ICD-10. The predicted 10-fold increase in query volume will account for even greater losses as hospitals tax already inefficient query processes.

There is no greater opportunity to maximize hospital reimbursement than to immediately improve physician response rates to documentation-related queries.

Pardon me, Doctor. Do you have 20 minutes to answer this query?

The physician query has become the primary tool for hospitals and practices to clarify physician documentation for proper reimbursement and accurate quality reporting. However, today the process for query creation, delivery to physicians and response tracking remains cumbersome, inefficient and difficult to measure.

By and large the greatest problem with the query process is physician responsiveness. In most hospitals, physicians respond to less than 80% of queries. The low physician response rate is the result of a burdensome administrative process.

To begin with, query processes are not yet standardized or streamlined. Typically, physicians receive queries from many different people in different ways. For example, during a patient’s hospital stay, physicians receive “concurrent” queries from Clinical Documentation Specialists (CDSs). CDSs concurrently review the physician’s documentation and query when a potential opportunity to clarify or make the documentation more specific exists. Physicians often receive these queries on paper sticky-notes in the chart, faxes to secretaries, hospital email (sometimes personal email), and verbally by phone or in-person.

At the same time, hospital coders, quality staff and second-level reviewers, retrospectively (after the patient is discharged) query the physician regarding charts that still contain unclear or missing information. Physicians are asked to respond to queries by updating the patient record or answering directly on the query form.

Responding to queries is time-consuming. For example, physicians must read the query, remember the patient, find an available computer, log in (often remotely), open a program and make about 30 clicks to review the chart and respond by updating the record. The entire process can take 15-20 minutes per query.

Other factors contribute to low physician responsiveness to queries. Many physicians remain unclear on the coding requirements that necessitate they document in specific ways and therefore do not recognize the importance of queries. For queries post-discharge, physicians often have forgotten details of the case and also feel unsettled about amending finalized documentation for legal reasons. Further, without any real skin in the hospital reimbursement game, physicians are not motivated to improve documentation beyond what is necessary for patient care but required for billing and coding.

As a result, hospitals are risking millions of dollars in annual revenue and their reputation, driven by underrepresented publicly-reported quality scores, because physicians find current query processes confusing, difficult and time-consuming.