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Insights Category: Case Study

Here you’ll find narratives detailing how Iodine’s solutions helped clients in a compelling blend of storytelling and hard data, illustrating the challenges faced, the solutions implemented, and the glorious outcomes achieved.

Triumphing with Tech: Empowering Staff and Maximizing Results 

Key Takeaways:

  • Documentation integrity is the foundation of good quality rankings
  • OhioHealth was able to expand their scope and implement new workflows even at historically low staffing levels due to efficiencies introduced by Iodine’s Concurrent
  • Improving documentation accuracy and capturing all patient conditions led to improvements in SOI, ROM, and Vizient quality rankings, including OhioHealth jumping from 112th to 14th in the nation for Trauma Care

Iodine Intelligence tackles a new challenge in healthcare’s mid-revenue cycle every month, shedding light on problems and solutions and sharing valuable insights from industry experts. Listen to Episode 14 Triumphing with Tech: Empowering Staff and Maximizing Results to learn more.

In the world of healthcare, hospital quality rankings hold immense weight, guiding consumer decisions on where to receive care, impacting hospitals’ reputations, and influencing the language healthcare providers can include in contracts with payors. Ultimately, the foundation for achieving good quality rankings lies in capturing accurate and complete documentation. Documenting patient care and medical procedures accurately and comprehensively directly impacts the assignment of codes, which, in turn, affects risk adjustment and external metrics.

As CDI programs shift their focus to quality, they must also shift their processes and workflows. Whereas in the past CDI specialists might have focused exclusively on capturing CC’s and MCC’s, it is now increasingly important to capture all conditions and treatments, regardless of whether they qualify as a CC or MCC, because many of these conditions ultimately impact risk adjustment. “It becomes important to know not only did it happen, but when did it happen?” said Fran Jurcak, Iodine’s Chief Clinical Strategist “Was it something the patient brought in with them, either from a previous encounter or something that happened to them in the outside world of the hospital? Or is it something that actually happened during the inpatient encounter? Which is what we’re really trying to capture with some of these quality metrics.”

Tonya Motsinger is the System Director of Clinical Documentation Integrity at OhioHealth, and her program has instituted a variety of workflows with the intent of completely capturing all patient conditions and improving their quality. She echoed Fran’s sentiment, relating that her CDI department found instances where HACs and PSIs were being driven by documentation, not the care being give. “If we could change the words in the chart, there wasn’t really a PSI or a HAC that happened” said Tonya, “It was just that it was documented incorrectly.” In today’s world, it’s not enough for health systems to provide good care, they also need to document the care they’re giving accurately.

OhioHealth is a nationally recognized, non-for-profit health system based out of central Ohio, composed of 14 hospitals and over 200 outpatient and physician offices, and has been recognized as one of the top five large health systems in America by IBM Watson Health six times. The CDI program at OhioHealth has 54 full-time positions, including a director, two managers, an educator, and an informaticist, although currently the program has positions open and is down ten staff. They originally invested in Iodine out of a desire to increase the efficiency in their workflow; they had found that they were performing a lot of re-work and weren’t seeing a ton of benefit from that work. Continuing, and improving upon, the success that they had seen in the financial and quality spaces was also key – around three to four years ago OhioHealth’s CDI program had ramped up their focus on quality, including instituting some new processes and workflows, and wanted to sustain that progress. OhioHealth felt that Iodine’s product Concurrent, with it’s artificial intelligence and prioritization, could help them achieve their goals without comprising their already established success.

As a quality focused program, it’s very important that Tonya’s team is not only accurately capturing the patients’ severity of illness and risk of mortality, but also ensuring the chart is explicit on what occurred with a patient so coders can accurately capture all diagnoses and treatments. As part of this effort, OhioHealth has a number of workflows in place, including an extensive second review process for expirations, DRG mismatches, and low acuity which can help ensure complete capture of how sick a patient truly was. “I believe that these practice are really essential growth avenues to drive the success of any CDI program, and I think Iodine really helped us to expand on these” said Tonya.

 We’re about ten CDS down…but we’ve been able to, even at our very lowest staffing ever in the history of our department, take on more work and meet the organization’s board goals as a result of the help that Iodine’s provided for us through the prioritization.

– Tonya Montsinger

While post implementation OhioHealth’s overall review rate has stayed the same, their query rate, especially among high priority cases, has increased. Despite spending time writing more queries, their workflow is so much more efficient they’ve been able to maintain their collaboration with coding, and took on even more work from a quality perspective, implementing additional workflows. This led to an improvement in their O:E ratio, their SOI and ROM, and their Vizient ranking. In 2019 OhioHealth was ranked 112th in the nation for trauma care, and they knew that wasn’t reflective of the care they were delivering. Today they are 14th in the nation, and number one in the state of Ohio.

Tonya noted that job satisfaction has improved as well. By enabling CDIS to review the right case at the right time and saving them from unnecessary review, OhioHealth has freed up staff for additional workflows like using the Vizient calculator, performing mortality reviews, and collaborating with coding and other departments. Describing the impact of the increased efficiency and effectiveness of their program due to having a prioritization tool, Tonya said, “I believe it creates a higher competence level in the CDS team, a little more of a strategic lens, because they can see the impact of their work beyond just case review, and they can sometimes even connect it with patient care.”

This expansion of skillset also gives CDI specialists opportunity for career advancement. As Fran noted, “We now have clinical ladders in the CDI space where five, seven years ago, there was no such thing.” In a world where hiring new staff can be challenging, retaining the staff you already have is key, and ensuring CDI specialists are satisfied and have room to grow within your organization can entice them to stay within your program.

Interested in Being on the Show?

Iodine Software’s mission has been to change healthcare by applying our deep experience in healthcare along with the latest technologies like machine learning to improve patient care. The Iodine Intelligence podcast is always looking for leaders in the healthcare technology space to further the conversation in how technology and clinicians can work together to empower intelligent care. if that sounds like you, we want to hear from you!

Opportunities and Obstacles: A CFO Conversation on Health System Financial Resiliency

Key Takeaways:

  • Health systems need to move beyond cost cutting strategies to weather the current financial climate, they need new strategies for generating revenue, including relying on automation to scale scarce clinical resources. BJC Healthcare focuses on people, process, and technology: where can they automate where previously they relied on people to do the work manually
  • Whereas previously labor was the primary driver of economic growth in healthcare, there is real opportunity for leveraging technology to capture additional opportunity. Mueller cautions healthcare orgs to ensure they have processes in place to support new technology implemented; and Damschroder pushes the importance of standardizing work and embedding new tools into the workflow.
  • The onslaught of AI powered technologies on the market makes evaluating and selecting a tool for investment confusing. Both HFH and BJC leverage Project Management Teams to ensure they get returns on their investments

Iodine Intelligence tackles a new challenge in healthcare’s mid-revenue cycle every month, shedding light on problems and solutions and sharing valuable insights from industry experts. Listen to Episode 13 Opportunities and Obstacles: a CFO Conversation on Health System Financial Resiliency to learn more.

Financial headwinds and staffing shortages from 2022 have prevailed, carrying over into 2023, forcing healthcare leaders to re-envision their workforce, redesign processes, and rethink strategies for achieving financial stability.

This month’s episode of Iodine Intelligence brings you a conversation we had in March, Iodine’s Chief Revenue Officer Troy Wasilefsky was joined by Henry Ford Health’s Executive VP and Chief Financial and Business Development Officer Robin Damschroder and BJC Healthcare’s VP of Revenue Management Harold Mueller to discuss the challenges healthcare systems are currently facing and strategies for building financial resiliency in the face of economic uncertainty.

Leveraging Technology to Capture Opportunity

The financial challenges facing healthcare providers today has led to an uptick in the use of consultants, particularly in the revenue cycle space, to try and stabilize health system economics. Overwhelmingly, the recommendation from these consultancies is cost reduction. CFOs are looking to slash budgets, with 75% stating they were planning on decreasing operating budgets as a cost savings measure.1

However, cutting costs doesn’t generate revenue. McKinsey has mapped out impacts to profit pools if no new sources of revenue are introduced. While passing on higher costs to payors and patients lessens the impact, profit pools are eroded in all three scenarios. Hospitals and health systems need a new source of revenue, or at the very least to be effectively capturing the revenue they’ve already earned.   

This report from McKinsey is pushing the idea that cost reduction alone cannot be the answer here. We need to find a way to also generate growth and new revenue, either new revenue, or at least be capturing revenue appropriately for the work that we’re already doing.”

–Troy Wasilefsky, Chief Revenue Officer at Iodine Software

When asked how he approaches balancing efforts to manage costs with growth strategies, Mueller responded, “I think from the standpoint of things that we can’t control. So, if you think about the last 24 months, the price of some of the travel nurses…you wouldn’t have believed them five years ago, if you were to look at the balance sheet. That being said, from a revenue cycle standpoint, we are focused on the people, process, and technology. So, how do we automate things that can be automated, that are manual?” Currently BJC has a number of projects in flight looking to automate tasks which are currently done manually, and hopefully, these projects will enable BJC to ultimately redeploy staff to other areas.

Damschroder echoed these thoughts on implementing automation; noting that as the cost to procure a patient has gone up and staffing shortages persist, opening the “digital front door” is more important than ever. “Patients want to be seen faster than we can often get them through our process,” says Damschroder, “So the health system that can get that gate open in a market faster, and turns the faucet on, I think, wins there.”

Prior to the COVID-19 pandemic, Henry Ford Health decreased their revenue cycle costs while improving their yield by tipping their revenue cycle on its side and inserting automation to cluster homogeneous work (ex. grouping denials by demographics, regardless of payor), enabling staff to complete work faster and more efficiently. Henry Ford Health implemented Iodine with the same idea: increasing the productivity of the staff they currently do have. Damschroder noted that they have a lot of openings in the revenue cycle, and they’re holding out on those openings in the hopes that Iodine’s product will enable them to cover their current workload without the need for additional hires. 

Healthcare Providers Need a New Driver of Economic Growth

These strategies of implementing automation to reduce workloads, improve processes and scale staffing aligns with McKinsey studies. Historically, labor has been a heavy driver of performance and growth in the healthcare industry, dramatically so when compared to other sectors of the US economy.

Research from the Bureau of Labor Statistics shows that 90% of the economic growth in the healthcare space comes from labor, with more than two-thirds of labor’s contribution coming from workforce expansion (4M net jobs were added) whereas other sectors’ growth was primarily driven by capital or innovation.2 However, McKinsey would argue that there is a $1T opportunity in healthcare stemming from accelerating and scaling innovation in four key areas: care delivery transformation, administrative simplification, clinical productivity, and technology enablement.3 

However, it’s not enough for healthcare providers to merely find and acquire the right technologies, they must also be mindful of how they’re implementing them. As Wasilefsky explained, “Innovation, technologies powered by AI and machine learning…they can bring a tremendous amount of opportunity to organizations, and yet, if you don’t use them, or build your processes around using them, and manage that change management, you’re not necessarily going to get all the results.”

Mueller was quick to point out that ensuring processes are in place to support the actual technology implementation is key. As an example, before 2019 the mid-revenue cycle at BJC was decentralized, many departments including CDI, HIM operations, and coding were not part of a shared service, and different hospitals deployed technology in different ways. BJC centralized services right after the start of the COVID-19 pandemic, and this enabled them to deploy Iodine, which BJC used as an opportunity to educate staff consistently, query physicians in a consistent manner, and gave them a tremendous lift in query volume. BJC facilities that deployed Iodine saw a 15%-20% lift in query rates, with physician response and agree rates staying the same. Although CDI specialists were reviewing the same volume of charts, Iodine’s prioritization ensured they reviewed the right charts at the right time, resulting in improved query volume.

“You want to make sure that your technology supports your actual administrative processes, and the processes that you have in place… From an Iodine standpoint, when we had facilities that we had centralized (and we centralized them in waves) we saw a 15%-20% increase in query rates, with physician response rates staying the same and agree rates staying the same. And these folks were reviewing the same volume of charts, but they were actually in the in the right charts, “

-Harold Mueller, VP of Revenue at BJC Healthcare

Damschroder touched on change management; while some may interpret “standardization” to mean “you don’t trust me to do my work,” she was quick to push back that standardization is not about lack of trust, but rather about elevating staff to their top of license and focusing them on where they can make the biggest impact. 

Damschroder also talked about the importance of ensuring new tools are embedded in the workflow and that the new workflow has buy-in. Henry Ford’s Health trick is robust monitoring and transparency: ensuring everyone can see how everybody is performing. “When you can barely find the other workflow or the workaround somewhere else, it’s been fully adopted.” said Damschroder, “And when new people come into the organization, they don’t even recognize that there was an old workflow out there.”

Realizing the Promise of AI

While there may be a lot of promise surrounding AI powered technology, and the majority of healthcare executives recognize they need it if they hope to weather the current financial challenges, there remains some skepticism, largely stemming from lack of literacy surrounding artificial intelligence.

In fact, 60% of healthcare leaders report being confused by the range of automation and AI solutions.4 In the words of Wasilefsky, “AI is the new shiny bauble, and everybody uses that term, probably to an exhaustive level.” The confusion surrounding AI can make selecting an AI powered tool, and ensuring that investment will have a financial return, challenging. 

These feelings were reflected in the webinar attendees. In an Iodine survey of those attending the webinar, only 19% felt very confident in their ability to effectively evaluate and select the best AI tech needed to improve their financial performance, and only 28% of respondents felt they were getting quantifiable ROI from their current mid-revenue cycle solution. In fact, 80% of respondents felt they are missing out on earned revenue in the mid-rev cycle.

“This is something we hear in the market a lot. There’s an inherent skepticism of: have we seen the ROI prove out on some of these AI applications?” 

– Troy Wasilefsky, Chief Revenue Office at Iodine Software

The confusion surrounding AI is exacerbated by the glut of AI-powered solutions on the market. Between buzzword inflation, AI’s nebulous definition, and the vast range in AI technologies, their capabilities, and results, it can be difficult for healthcare leaders to truly wrap their arms around: what am I buying, what is it doing, and what outcomes can I truly expect? 

“As a representative of the vendor community I think a lot of this falls on us to not obfuscate the terminology of AI, and what AI is being utilized.” said Wasilefsky, “But instead, be far more transparent about what these technologies are, and how they work, and how they’re different from others, and also the impact piece.”

Mueller touched on the onslaught of AI-powered tech in the market, saying “Every vendor that we deal with that has a computer is “AI” now.” When it comes to evaluating AI powered solutions and measuring their impact, BJC has implemented Project Management teams, including some specifically in the revenue cycle space with revenue management experience, who evaluate business cases for new technology investments, and post implementation do a look-back to ensure they are seeing a return on their investment.

Damschroder echoed this, discussing HFH’s rigorous due diligence process regarding implementing new solutions. Regarding ensuring you see return on your investment, Damschroder emphasized the importance of ensuring adoption and that the new tool is embedded in the workflow. Whenever Henry Ford Health evaluates a new solution, they pay particular attention to: what is the lift to get this embedded in the workflow. For healthcare leaders out there who believe they’re not seeing the promised return on a technology investment, Damschroder’s advice was look at the workflow and ensure it’s embedded in the process, and then look at your adoption rates, because staff may not be using the tool or may only be using parts of it.

  1. Academy IQ, CFO Forum Debrief, December 2022
  2. The Productivity Imperative for Healthcare Delivering in the United States. McKinsey & Company. February, 2019.
  3. Claiming the $1 Trillion Prize in US Health Care. McKinsey & Company, September, 2013.
  4. The Academy Research and Analysis

Interested in Being on the Show?

Iodine Software’s mission has been to change healthcare by applying our deep experience in healthcare along with the latest technologies like machine learning to improve patient care. The Iodine Intelligence podcast is always looking for leaders in the healthcare technology space to further the conversation in how technology and clinicians can work together to empower intelligent care. if that sounds like you, we want to hear from you!

Iodine Toolkit in the Mid-Revenue Cycle

Key Takeaways:

  • Despite costly investments in the mid-revenue cycle, leakage continues to occur and opportunities continue to be missed
  • Healthcare providers interested in keeping their cost to collect down must leverage technology to scale their workforce and introduce new efficiencies
  • Implementing Concurrent allowed Integris Health to more than double their query rate, capturing more opportunity

Iodine Intelligence tackles a new challenge in healthcare’s mid-revenue cycle every month, shedding light on problems and solutions and sharing valuable insights from industry experts. Listen to Episode 7: Iodine Toolkit in the Mid-Revenue Cycle to learn more.

Clinical Documentation Improvement and stemming leakage have long been priorities for health systems, but studies have shown that despite investment in this area, leakage continues to occur and opportunity continues to remain un-captured. One such study from 2016 by the Advisory Board found that the average 250 bed hospital continues to lose around $4.7 million in the mid-revenue cycle each year, even after costly investments into halting leakage. Part of the problem is the mid-revenue cycle is a multi-step process with each step presenting its own unique problems and opportunities for leakage.

The impacts of revenue leakage can be many and far reaching. As hospitals margins continue to shrink, they can’t afford to leave dollars on the table, especially if they hope to continue to re-invest in their facilities, physicians and nurses, and clinical technology. Inaccurate documentation can also lead to inaccurate quality scores and rankings. In a time of workforce shortages, healthcare providers need to be able to attract applicants, and the top talent wants to work for the top organizations. Additionally, healthcare consumers have never had more freedom of choice and are selecting their providers based off publicly available rankings and ratings.

Kati Beisel, Director of Health Information at Integris Health, implemented Iodine Software’s artificial-intelligence powered tools at three key stages of the mid-revenue cycle to tackle documentation leakage.

Review and Query Concurrently to Capture Documentation Leakage

From a patient’s perspective, things are changing every day. So in a manual environment you need to review every medical record every day to ensure accuracy, which is impossible with the current staffing levels and admission volumes. Healthcare providers interested in keeping their cost to collect down must leverage technology to scale their workforce and serve patients efficiently and effectively.

Concurrent leverages Iodine’s proprietary machine-learning engine, CognitiveML, to perform live gap analysis between the clinical evidence and existing documentation, simultaneously de-prioritizing cases with no apparent opportunity and prioritizing for review cases with errors, inaccuracies, or omissions in real time. 

“Our query rate before we had a prioritization tool, and then after, our query rates more than doubled. So we know that we started getting to the right cases at the right time, because we just weren’t seeing that kind of opportunity before” says Kati Beisel.

“One of the biggest things that we’ve done is implemented prioritization software through Iodine Concurrent. That was a game changer for us because it uses artificial intelligence to help prioritize cases that we need to see…it surfaces those cases to us when we need to see them, and that helps take some of the pressure off”

– Kati Beisel, Director of Health Information at Integris Health

To combat the physician pushback that can accompany increased query volumes, Kati and her team took a proactive approach: educating physicians on why they were implementing Concurrent, what to expect, what the top query reasons were, and what questions they would be asking. As a result, physicians know the goal of the program and the entire organization, and in Kati’s words, their participation has been “outstanding.”

Retrospective Reviews as the Last Line of Defense

The more accurate documentation has flowed downstream and positively impacted coding as well. Kati explained that prior to Concurrent, they were doing a lot of retrospective queries, which is time consuming for the coder. Coding is now able to pick up all the diagnoses appropriate for the patient stay, which cuts down on discrepancies between the clinical perspective and the coding guidelines.

Her team is also using Iodine’s Retrospect to comb through patient records and identify cases at risk of denial.

Focus CDI on documentation by removing final DRG prediction from their plate

The COVID-19 pandemic has given Integris Health, and many hospitals, the additional strain of needing patient beds. It’s more important than ever to get the patients in, get them treated at the right level of care, and then get them discharged.

Forecast is key to helping Integris Health’s multi-disciplinary teams including physicians, case management, nurses, and nurse managers anticipate what a patient’s length of stay may be, and what needs to be done to get a patient ready for discharge and the next level of care. As Kati explained, “Instead of my team being responsible for making sure every single case has a working DRG every single day – and we’re not going to get yelled at by case management and UM – we have Forecast for that and then my team gets to focus on where are the biggest opportunities in documentation and how can we affect the outcomes of what is reported.”

Interested in Being on the Show?

Iodine Software’s mission has been to change healthcare by applying our deep experience in healthcare along with the latest technologies like machine learning to improve patient care. The Iodine Intelligence podcast is always looking for leaders in the healthcare technology space to further the conversation in how technology and clinicians can work together to empower intelligent care. if that sounds like you, we want to hear from you!

Achieving ROI at Speed

Key Takeaways:

  • The CDI profession has evolved and is no longer about capturing a single CC or MCC, but rather the true clinical picture of the patient
  • West Tennessee Healthcare saw an increase in query volume after implementing Iodine accompanied by a financial return 3x more than expected
  • Leveraging Interact allowed West Tennessee to improve physician response times and rates even while simultaneously increasing query volume

Iodine Intelligence tackles a new challenge in healthcare’s mid-revenue cycle every month, shedding light on problems and solutions and sharing valuable insights from industry experts. Listen to Episode 6: Achieving ROI at Speed to learn more.

The Clinical Documentation Integrity (CDI) profession has evolved along with documentation requirements, and it’s no longer about capturing a single CC or MCC, but rather an accurate and complete record of everything that happened during an inpatient encounter. Technology provides a unique opportunity to enhance the CDI workflow. Rather than CDI specialists aiming to review all cases (and wasting an inordinate amount of time reviewing cases with no opportunity) the technology reviews 100% of cases, and prioritizes those with the greatest likelihood of opportunity for specialists to review to validate the clinical information and confirm the query opportunity.

 

 

Historically, one of the biggest challenges within CDI is knowing when to review a cases. “So, I looked at it [a case] today, but how soon will something change? Whether it be additional clinical information for a condition I looked at today, or a whole new condition that develops during the patient encounter. The only way, historically, that CDI had an opportunity to identify that, was to review every case every day, which is impossible” Fran Jurcak explained, “At Iodine, we allow ourselves, through technology, to identify when something has changed of significant value that then requires a re-review.”

 

“So for us, the new metric is not how many reviews do you actually get to, it’s how many of the priority reviews are you getting to, because with technology you’re getting at 100% reviews of all cases, so it’s really about which are the cases that CDI needed to look at, and then comparing that from the pre-Iodine performance to post-Iodine performance.“
– Fran Jurcak, Chief Clinical Strategist

West Tennessee Healthcare has six facilities in the West Tennessee area, the largest being Jackson-Madison County General with 740 beds. Their CDI team encompasses 11 CDI reviewers (some of whom are general, some of whom are specialized), a CDI manager and educator, and CDI director.

Several years ago their program shifted to focus on quality and improving their CMS star rating which led to West Tennessee implementing a variety of products in Iodine’s AwareCDI suite: Forecast which automatically predicts final DRG and GMLOS, Concurrent which prioritizes cases in CDI specialist’s workflow for review, Interact (formerly Artifact) which is a physician engagement tool that eases the query response process, and Retrospect which prioritizes post-discharge, post-code, pre-bill review. In the words of Denise Humphreys, their Director of CDI, “I think this product, in total, has helped us evolve as just a day to day CDI program to something that really specializes in: can we help our facility, our whole system, in attaining the goals that we have.”

Industry recommendation for a seasoned CDI team is a query rate of 20%-25% if you’re reviewing all charts; after implementation Denise’s team reviewed only prioritized cases and their query rate went up to 35%-38%. This resulted in increases in their case mix index, CC and MCC capture rates, and a financial return on investment that was 3x more than expected, allowing West Tennessee to pay off the full cost of Iodine within 3 months.

 

“We have a query escalation policy here where if the query is not answered after 14 days, it goes on a suspension list…The number one offender that was on the suspension list every week was one of the first to use Interact…the first to answer a query, and he did within 40 seconds of us sending it. And he’s not been anywhere near the suspension list for the query process since.”
– Denise Humphreys, Director of CDI West Tennessee Healthcare

While increased query volume could be cause for concern in some physician circles where administrative burden is already high, Denise stated that the largest impact she saw to her program after implementation was physician satisfaction. Pre-Iodine, they regularly had physicians on suspension lists for taking more than 14 days to respond to queries. After implementing Interact, their biggest offender responded to a query within 40 seconds of receiving it – and he hasn’t been on the suspension list since.

Interact creates a quick and easy workflow that is intuitive, doesn’t interrupt physicians during their standard patient process and allows them to communicate in a fashion that works best for them – within the EMR or via a mobile app. Discussing the advantages of Interact, Denise stated, “One of the main things we’re looking for, and we have experienced already, is an excess of additional time during our day. We’re not chasing queries like we were before.” The additional time during the day enables Denise’s team to expand their scope, and focus on impacting their O:E ratio, improving their star rating, physician engagement and education, increasing SOI and ROM and more.

West Tennessee is going live with Iodine’s Retrospect this July. Retrospect – a post-charge, post-code, pre-bill tool that helps CDI and coders identify discrepancies between the clinical evidence documented and the final code and capture additional leakage – will help West Tennessee monitor their backend and make sure their coding and documenting correctly. Having Iodine products end-to-end will help West Tennessee ensure documentation accuracy across all medical records.

Interested in Being on the Show?

Iodine Software’s mission has been to change healthcare by applying our deep experience in healthcare along with the latest technologies like machine learning to improve patient care. The Iodine Intelligence podcast is always looking for leaders in the healthcare technology space to further the conversation in how technology and clinicians can work together to empower intelligent care. if that sounds like you, we want to hear from you!

Documentation Accuracy: Quality as an Outcome or a Process

Key Takeaways:

  • Documentation translates into publicly available information that drives hospital reputation and accreditation
  • Consumers today have more freedom of choice than ever before, and are able to decide where they want to receive their care based on hospital scores, rankings, and other publicly available information
  • A Documentation Accuracy Index measures if the clinical evidence equates to the documentation, so organizational leaders don’t make the assumption that a quality metric doesn’t look as good as it should due to a documentation problem
  • Through the use of Iodine’s Concurrent prioritization tool, Brigham Health was able to review less cases while simultaneously increasing query volume and improving financial impact

Iodine Intelligence tackles a new challenge in healthcare’s mid-revenue cycle every month, shedding light on problems and solutions and sharing valuable insights from industry experts. Listen to Episode 4: Documentation Accuracy: Quality as an Outcome or a Process to learn more.

The Institute of Medicine (IOM) introduced the six domains of quality care in 2001 with the goal of improving healthcare overall, and since then the business of evaluating hospital quality has only grown. In addition to CMS’s homegrown system of star ratings, a variety of private organizations including US News and World Health, Vizient, Leapfrog, and more, have popped up all with the same goal: objectively evaluating healthcare providers and their quality of care.

These scoring and ranking systems are leveraged by healthcare consumers, who have more freedom of choice than ever before, when choosing where they’d like to receive their care. Every patient, and every patient’s family, wants the best quality care possible.

In addition to swaying public opinion and driving consumer behavior, these quality rankings are increasingly tied to reimbursements and hospitals face being penalized with fines or having payments withheld if they do not meet minimum benchmarks. 

While the methodologies powering these quality rankings may vary, one thing they all share in common is that they’re based off of claims data. In fact, the humble hospital bill has grown into a mighty metrics driver with far reaching effects for hospitals. To name a few:

  • The documented acuity of a patient effects hospital accreditations and risk and severity adjustment, which cascades to influence quality scores and reimbursements
  • Documentation of present on admission (POA) conditions can impact Hospital Acquired Conditions rates (HACs) and Patient Safety Indicators (PSIs), which are tied to reimbursements and fines 
  • Quality scores and hospital rankings are based on the documented care given and patient outcomes; they also inform hospital reputation, both within the community and at large

Claims data’s large sphere of influence makes documentation accuracy imperative. The same claims data that drives hospital scores, accreditations, community reputation, and consumer decisions passes through Clinical Documentation Specialists (CDS’s) hands, which means CDS’s have more to monitor than ever. In the words of Fran Jurcak, Chief Clinical Strategist at Iodine Software, “There are conditions that are now very important to these methodologies in terms of identifying risk that, historically in the documentation world, we didn’t worry about…so today it’s really about capturing the true clinical picture of what’s happening to patients today, so you can best reflect yourself as an organization to the outside world.”

“Our rankings and scoring are based off of claims data, and that claims data is dependent upon accuracy of the documentation. And if you have bad documentation, or inaccurate, inconsistent, unspecified documentation, you are not going to reflect the type of patients you’re taking care of. ”
– Fran Jurcak, Chief Clinical Strategist, Iodine Software

While the connection between CDI and quality metrics is undeniable, there remains debate about the best way for CDI to influence quality metrics. The impulse can be to have CDI teams focus on improving specific metrics. Unfortunately, while the individual metric under the spotlight may improve, it’s often at the detriment of others, which slip under the neglect. 

A more effective strategy is striving for truly accurate documentation. Documentation that completely captures all patient conditions, is accurate, and consistent, allows quality metrics to accurately reflect the type of patients a healthcare provider is caring for, and the outcomes they’re experiencing. Jurcak says, “It’s really about ensuring that the world can see the level of care that you provide, and what level of acuity your patients are experiencing, and whether or not they have positive outcomes.” 

It can be a struggle for organizations to truly gauge where they stand in the documentation improvement process; oftentimes, if a quality metric doesn’t look as good as expected deep dives in the medical record are required to determine if the root cause is a documentation issue, a quality of care issue, or a patient acuity issue. In response to this conundrum, Iodine has created a Documentation Accuracy Index which reviews the clinical evidence in a patient record and compares that against its data warehouse of millions of historic patient records to determine if there is a discrepancy between the evidence and the documentation. The likelihood that the documentation is complete and reflective of the clinical evidence is then measured in a ratio.  

The Documentation Accuracy Index is designed to allow CDI managers and healthcare leaders to determine at a glance both if the clinical evidence equates to the existing documentation, and how effective a CDI program is at capturing leakage.  Jurcak explains, “I think it’s been very easy in the healthcare industry to point the finger at documentation and coding, as opposed to the problems you would need to potentially solve from a clinical perspective…yes, we do have documentation problems, I’m not going to deny that….but at what point do you know you’re there? And I think that’s a component we haven’t really explored in our industry, that we are excited to be looking forward to at Iodine.”

“Reviewing less cases, we’re finding more cases with opportunity”
– DEB JONES, DIRECTOR OF CLINICAL DOCUMENTATION IMPROVEMENT, BRIGHAM HEALTH

Brigham Health is a 1000 inpatient bed hospital located in Boston, Massachusetts that serves around 60,000 inpatient stays annually. Brigham and Women’s, a member of Brigham Health, is a large medical academic center consistently ranked among the top 20 hospitals in the nation by US News and World Health Report. Deb Jones, who has been their Director of Clinical Documentation Improvement since 2015, describes her team, “We felt like we were doing a really good job. We have a very seasoned CDI team. Eighteen CDI nurses…most of them have over 10 years of CDI experience. This is pre-2019, pre-2020, and then things started to shift.“

In 2020 Brigham Health was given a new goal of improving expected mortality, through which they could influence the hospital’s O/E ratio, US News & World ranking, and have peripheral effects on LOS and readmissions.  According to Jones, “All of this new work we’re charged with, but we’re not given any more staff. So we have 18 CDS’s and we were staffed at probably 1 for every 1500 discharges. So the big question was, how do we incorporate this new work without losing sight of the work we were doing that we were really good at and maintaining that performance as well.” 

Rather than focusing solely on this new metric to meet their goal of improved expected mortality, Jones and her team instead concentrated on achieving “true north” in documentation accuracy, and took a three-pronged approach to implementing effective, quality processes: new technology, new processes, and new metrics.

New Technology

To optimize their workforce, Brigham Health implemented Iodine’s Concurrent, which prioritizes cases for review based on the greatest likelihood of opportunity. Prior to implementation, the team was reviewing 95% of encounters, but querying on less than 40% of the cases they reviewed. This large volume of non-productive work was neither the most efficient use of their resources nor the best way to reach their goals. In the first month after rolling-out Concurrent, their review rate dropped to 75%, but their query rate rose. Even though the team was reviewing less cases, they were finding more opportunities and querying more.

By removing all the unnecessary reviews of cases without opportunity, the CDS’s were able to broaden their scope and spend more time in patient records, review for complex conditions that affect severity and risk adjustment, and investigate complex cases. 

New Processes

Concurrent allowed Brigham Health to scale their workforce, so much so that even though their workload had expanded, the new efficiencies in their process allowed them to free up a CDS for a Special Assignment role. 

The CDS in this rotating role is able to focus on mortality reviews, applying risk-adjustment methodology, and reviewing prioritized discharged cases, which the team had not always had time for previously. Jones stated, “In addition to that, they’re also having the ability to go out and do some education that we didn’t really have time for before and aligning the CDS’s with the service lines, they’re building relationships, and all of this has really led to a lot of satisfaction for the nurses.”

New Metrics

Whereas originally Brigham Health tracked individual CDS review rates, after implementation they started measuring their total chart impact in comparison to total discharges. Jones found that prior to implementation on average, they had 925 encounters with clarification a month, after implementation, this rate rose to around 1400 a month, stating, “​​That’s again reviewing less cases, we’re finding more cases with opportunity. It’s been exciting all these quality initiatives have really invigorated CDI, at least at our organization, with its new lifeblood and purpose, it’s an exciting time.” Her team has also seen movement on their expected mortality metric – the same metric which initially prompted them to seek improvements to their workflow. They started with a baseline of 2.5% expected mortality and are currently at 3%, well on their way to their goal of 4%. 

By expanding their scope from “improve expected mortality” to “achieve true documentation accuracy” Brigham Health was able to achieve a multitude of goals. 

  • Team efficiency improved, allowing less CDS’s to do more work: increasing query volumes and chart impact rate. 
  • CDS’s role expanded to include a Special Assignment role, allowing for further training and growth for the CDS’s
  • They achieved their initial goal by improving expected mortality from 2.5% to 3%, and continue to strive for additional improvement

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OU Medicine Chooses AHIMA’s Compliant Template Library Within Artifact Health’s Mobile Physician Query Platform

The American Health Information Management Association (AHIMA) announced today that OU Medicine has chosen to use the AHIMA library of physician query templates available in Artifact Health’s mobile physician query platform.

As the leading source of health information management (HIM) education, training and policy making, AHIMA updated in 2019 its Guidelines for Achieving a Compliant Query Practice to establish and support industry-wide best practices for the function of clinical documentation querying. Through its partnership with Artifact Health, AHIMA is able to provide standardized, electronic query templates and educational guidance for physicians, CDI professionals and HIM professionals. These templates help clarify clinical documentation and ultimately improve the quality of patient records.

>”…[W]e have been able to completely transform our query process.”
– Jennifer Dhooge, RHIA, CCS, CDIP, CRC, OU Medicine director of HIM

“We are thrilled to work with AHIMA and Artifact to be able to standardize physician queries across our system while ensuring compliance and improving the quality of our patient records,” said Jennifer Dhooge, RHIA, CCS, CDIP, CRC, OU Medicine director of HIM, coding and CDI. “Coupled with the innovative mobile query platform provided by Artifact, we have been able to completely transform our query process.”

“AHIMA is pleased that OU Medicine is taking advantage of our library of physician query templates,” said AHIMA CEO Wylecia Wiggs Harris, PhD, CAE. “Our alliance with Artifact Health continues to decrease administrative burdens for hospitals and health systems, while boosting the accuracy of patient records. I’m proud our strategic vision is helping to improve patient outcomes and save resources.”

Artifact Health provides the first and only mobile platform that streamlines the physician query process. Traditionally, the query process can be onerous and time-consuming for physicians, clinical documentation specialists and medical coders. With Artifact Health’s HIPAA-compliant, cloud-based, mobile query platform, physicians respond to a query compliantly in seconds with as few as three taps on their smartphone.

“We are excited to provide OU Medicine with an opportunity to work with AHIMA experts to standardize compliant query workflow,” said Marisa MacClary, co-founder and CEO of Artifact Health. “Artifact customers are committed and passionate about reducing query burden on their busy providers. By adding AHIMA’s world-class knowledge and best practices to query workflow, our customers ensure queries and educational guidance are accurate, compliant, and current.”

**About Artifact Health**
Artifact Health provides the first and only mobile platform that streamlines the physician query process so hospitals can improve the quality of patient records and ensure full reimbursement for services. Already in use by thousands of physicians, Artifact simplifies a traditionally time-consuming, multi-step process allowing physicians to respond to queries anytime, anywhere in seconds. By shortening average physician response time to queries by 20x, Artifact helps CDI specialists and coders receive more accurate responses faster, which can translate into capturing missed reimbursement for hospitals and ensuring more accurate medical records for patients. Visit www.artifacthealth.com to learn more.

**About AHIMA**
The American Health Information Management Association (AHIMA) is a global nonprofit association of health information (HI) professionals. AHIMA represents professionals who work with health data for more than one billion patient visits each year. AHIMA’s mission of empowering people to impact health drives our members and credentialed HI professionals to ensure health information is accurate, complete, and available to patients and providers. Our leaders work at the intersection of healthcare, technology, and business, and are found in data integrity and information privacy job functions worldwide. Visit www.ahima.org for more information.

**About OU Medicine**
OU Medicine — along with its academic partner, the University of Oklahoma Health Sciences Center — is the state’s only comprehensive academic health system of hospitals, clinics and centers of excellence. With 11,000 employees and more than 1,300 physicians and advanced practice providers, OU Medicine is home to Oklahoma’s largest physician network with a complete range of specialty care. OU Medicine serves Oklahoma and the region with the state’s only freestanding children’s hospital, the only National Cancer Institute-Designated Stephenson Cancer Center and Oklahoma’s flagship hospital, which serves as the state’s only Level 1 trauma center. OU Medicine is the No. 1 ranked hospital system in Oklahoma, and its oncology program at Stephenson Cancer Center and OU Medical Center ranked in the Top 50 in the nation, in the 2019-2020 rankings released by U.S. News & World Report. OU Medicine’s mission is to lead healthcare in patient care, education and research. To learn more, visit www.oumedicine.com.

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