Quality in Healthcare Archives

Iodine Intelligence: Should CDS Query If There’s No Impact

Key Takeaways:

Historically CDI has measured query impact primarily through financial metrics, but this has expanded over time to include quality related metrics such as severity of illness, Vizient drivers, and O:E ratio
While the administrative burden on physicians is real, not submitting a query due to lack of impact can have a variety of negative implications
A better solution to alleviating administrative fatigue is to focus on creating a consistent, streamlined workflow for physicians to review and respond to queries

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 9: Should CDI Specialists Query If There’s No Impact to learn more.

Recently Iodine Software hosted a webinar in partnership with ACDIS, and the most frequently asked question was: should CDI specialists submit a query if there won’t be any chart impact? This stems from a concern for physicians, who often complain of administrative burnout, and is an attempt to alleviate administrative fatigue.

Historically, CDI has measured the impact of queries by calculating the financial impact of the query to the DRG, either through movement to a CC/MCC or by changing family (ex. pneumonia to sepsis). Over time, as CDI scope has expanded, they’ve looked to other areas to measure their impact: severity of illness, risk of mortality, elixhauser comorbidities, patient safety indicators and hospital acquired conditions, to name a few.

Fran Jurcak, Iodine’s Chief Clinical Strategist spoke on how there are a few issues with only querying when there’s measurable impact.

First, the end goal of clinical documentation improvement is to accurately represent every patient and their clinical reality, both in the documentation and the final code set, and that cannot be accomplished if CDI specialists aren’t querying consistently and all diagnoses aren’t captured.

Second, picking and choosing when to query sends an inconsistent message to providers, and can actually hurt education efforts. As Fran Jurcak said, “What about on the physician side?…What he’s seeing is, sometimes you query me, sometimes you don’t, I’m just going to sit back and wait for when you need me to, as opposed to when I should.” Inconsistent querying can ultimately undermine CDI’s efforts overall.

Finally, there are cases where at the time of generation a query won’t have impact, but post-discharge it will. As Fran Jurack explains, “In the end, when things are final coded and the final documentation is in, and maybe the physician has ruled out some of the conditions that you thought initially were there, will that query now have a level of impact that you didn’t see on day two of your review, but now happens in the post-discharge space.”

“I think that perception is something we need to think about in the CDI space, because we are trying to capture the appropriate clinical picture for every patient and not pick and choose when something may have meaning or value.”
– FRAN JURCAK, CHIEF CLINICAL STRATEGIST

A better strategy for reducing physician administrative burden is by modifying the process and workflow for physicians. Fran Jurcak argues that the burden of documentation is not going away, and in fact may worsen in the future as additional conditions impact quality factors. Some key factors to consider when designing a query response process for physicians include:

How are physicians finding the query – Where are the queries located? Is it easy for a physician to find that there’s been a question, or does it get lost in a sea of other queries?
Do the physicians have all the information they need – Do they have the information necessary to quickly and efficiently answer the question? Are the forced to dig through the medical record for additional details?
Are queries consistent – Are queries standardized so physicians know what to expect and where to look?
Where is the answer going – Does it become part of the permanent medical record? Does the CDI specialist need to translate the physicians response into another format?

Luckily, technology is well positioned to help in all of the areas listed above and automation of tasks that don’t require clinical knowledge can remove work from over-burdened plates.

Iodine’s Interact leverages templates to both streamline the query authoring process and provide a consistent workflow. Physicians can easily find the information they need to answer a query. Interact’s mobile platform means physicians can review and respond to queries from their phone. All the clinical evidence they need is at their fingertips and their reply gets added to the medical record thanks to EMR integration. This allows health systems and hospitals achieve complete and accurate documentation and coding, capturing the full clinical picture of the patient.

“It’s about workflow, it’s about consistency, it’s about creating efficiency and templates that make this process easy, so it’s less of a burden. The burden is not going to go away…So there are two options for physicians: get it right in their documentation, which is where our educational programs come in, or when you happen to miss it, find a quick and easy way to get that answer into the medical record.”
FRAN JURCAK, CHIEF CLINICAL STRATEGIST

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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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Kona Community Hospital Chooses AHIMA Physician Query Templates to Improve Quality of Health Records

The American Health Information Management Association (AHIMA) announced today that Kona Community Hospital in Kealakekua, Hawai’i, has chosen to use the AHIMA library of physician query templates available in the mobile query platform from Artifact Health, an Iodine solution.

Do I Really Need to Query for that Third (or Fourth or Fifth) MCC?

Written By: Rachel Mack, RN, MSN, CCDS, CDIP, CCS
Clinical Program Manager

We all tend to have a number of “firsts” we never forget when it comes to our CDI careers:

First positive interaction with a physician
First educational session with a physician group – and it goes well
First coder interaction where you have a light-bulb Coding Clinic moment
First time you felt as though you truly impacted patient care

My first example of impacting patient care is when I saw a patient with a slew of clinical indicators for malnutrition diagnosis (including significant weight loss, decreased PO intake, a pressure ulcer, and a BMI of 12). I did not yet see an order for a dietitian evaluation, and the patient had been in the hospital for several days. I took a risk and sent the query anyway; the next day the physician I sent the query to put in an RD order. That dietitian went on to document that the patient met criteria for severe protein-calorie malnutrition. I thought, “wow, I helped do that.”

But another instance I’ll never forget is opening a denial email from Coding and seeing that an insurance company was denying all three MCCs for one case.

….three MCCs. No wonder the Coding department had reached out for CDI help!

It’s commonplace for insurance companies to deny whatever they can, whether clinically sound or not. But all three MCCs? I had to dive in and take a look. After review, I discovered that they were partially correct: one diagnosis was incorrectly coded (acute respiratory failure final coded, but was part of a previous visit only), and in our defense letter I acknowledged that yes, we should remove it from the final bill. However, the other two diagnoses – metabolic encephalopathy and septic shock – were above and beyond clinically sound. The patient was confused with a GCS score of 11 that improved to 15 by discharge and was treated with a head CT, sitter, and safety restraints. And the patient was clearly in septic shock and required Levophed s/p aggressive fluid resuscitation to improve their blood pressure.

So what can CDI specialists do to make sure records are as safe as possible from denials?

Here at Iodine Software we have a few best-practice suggestions:

Query consistently for clarification of conditions when the clinical indicators are present but there is no associated documentation (or vice versa when it comes to clinical validation). When we do this consistently, we help teach our providers to consistently document with a higher level of specificity.
Query consistently regardless of the financial impact to the record. Only querying for a first CC or MCC is no longer acceptable practice in CDI. If we only query for conditions when they impact the DRG, we are doing our physicians and providers a disservice. This behavior has potential positive downstream effects on quality metrics beyond the scope of typical CDI programs.
Query consistently to determine present-on-admission (POA) status of conditions. It’s very easy for us (as clinicians reading the record concurrently) to make assumptions and assume that the coder will realize something is POA.
Query consistently if a condition or conditions are documented in such a way that they are unclear, inconsistent, vague, or non-specific. If a condition is not clear for us reviewing a record concurrently, it will likely not be clear for the coder and is at risk for not final coding or requiring a retro query.

I don’t think we should query simply out of fear of denials. That’s no way to live or to work. But we do have to be aware of the healthcare climate of today. Hospitals are depending on us to prevent denials as much as possible – and confirming accurate documentation of diagnoses irrespective of impact is our responsibility.

I hope this spurs some critical thinking for CDI specialists. At the least, I hope next time you hear someone say “Yeah, I’m not going to query, this record is maxed out,” you might encourage them to think again.

Industry professionals weigh in on CDI practices that present ethical concerns

From the article in For The Record magazine:

Clinical documentation improvement (CDI) processes have made significant inroads in recent years. Now a mainstream strategy within any forward-looking hospital, CDI teams are critical players in the greater quality management picture as it relates to successfully positioning for value-based care. Click here to read full article

Iodine Software

Insights Category: Quality in Healthcare

Iodine Intelligence: Should CDS Query If There’s No Impact

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