- 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.”
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.”
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.
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.
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.”
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