Clinical Documentation Improvement, Quality Combine for Revenue
Mar 30, 2015 | VIA BLOG | Posted 10:28 PM by Dr. Jon Elion

Community hospitals have always had their work cut out for them when it comes to providing quality care and proactive population health management for their patients, and their job has gotten even tougher in the challenging economic circumstances facing most of the healthcare industry.  As value-based purchasing and the impending implementation of ICD-10 require healthcare organizations to produce more robust, complete, and detailed documentation, hospitals of all sizes and descriptions are turning to health IT tools for clinical documentation improvement: an activity that produces downstream effects across the revenue cycle and beyond.

At Southeastern Ohio Regional Medical Center, Denise Stephens, Director of Documentation Integrity and Utilization Management, doesn’t just see clinical documentation improvement as a required part of preparations for ICD-10.  It’s a way to streamline workflow, avoid unnecessary claims denials, foster an atmosphere of transparency, and provide a foundation for quality improvement that extends past the hospital walls and into the community at large.

Stephens sat down with to describe Southeastern Ohio’s approach to clinical documentation improvement, starting with installing an EHR infrastructure that sparked a desire to move even more functionalities into the electronic realm.

“We went live on our electronic medical record in 2012, and we’re still in process of optimizing that,” Stephens said.  “We just are implementing CPOE, but our physicians are already to the part where they’re not picking up the physical chart anymore.  In recent months, they’ve started to ask, ‘Why are you putting a paper query on a chart?  I have to go back to the chart and I want to be able to look at that electronically.’”

“That came about the time we started implementing electronic CDI and concurrent chart review,” she continued.  “One of our staff members asked, “Can’t I do my queries on the computer, too?  I’m here dictating, and I don’t want to go down to the floor and look at my queries.’”

While some organizations struggle to choose a vendor and install a health IT product, Stephens and her team found the experience of implementing a CDI package to be a simple one.  “It didn’t all happen in one day,” she acknowledged, but it was close enough.  “We chose ChartWise as our vendor, and the team was phenomenal when they came in and did our training.  I think they were here on a Wednesday and Thursday.  By Friday, we were up and ready.  Even before our trainer had left that day, we were doing queries in real-time.”

Going electronic didn’t just simplify the process of creating and responding to a query.  “We’ve made the query a permanent part of the medical record now, where it wasn’t before,” Stephens explained.  “We want to provide as much transparency as we can, whether it’s with CMS or the physicians or the coders.”

“By doing concurrent documentation reviews, we’re getting into those charts and really seeing how we can make improvements to work towards our goals,” she continued.  “For example, we had a denial on a joint replacement procedure, so now we focus a little bit more on those.  Because if all the documentation is not there – specificity of the patient’s history; what medications they’ve taken; if they’ve done physical therapy before – if that’s all not documented properly, CMS will deny that right now.”

“Because we’re in there concurrently reviewing the chart, we can put a query in and ask if there’s any additional information the clinician would like to include before we submit the claim.  It’s about that transparency.  If we are audited, for whatever reason, we want that transparency there so CMS can see that.”

The push for more detailed and transparent documentation, as well the ability to have historical query records on hand in the patient’s chart, will also help Southeastern Ohio’s coders prepare for ICD-10, currently set for implementation on October 1, 2015.  Last year’s surprise delay disrupted the preparation timelines for many healthcare organizations, and Stephens hopes that won’t happen again.

“We hope ICD-10 is implemented this year,” she said.  “We were quite in favor of it last year, too.  I know that’s still up in the air, but we’d like to see it go live.  Last year, we had a countdown until go-live, and each day I’d update the countdown on my door and everybody would laugh, but this year I haven’t gotten so gung-ho about it.  We really do want ICD-10, and I was just speaking to my VP about needing to contact our senators and representatives about this, because we are ready.”

With no mention of an additional ICD-10 delay in this year’s troubled pass at fixing the Medicare sustainable growth rate (SGR), many ICD-10 advocates are hopeful that 2015 will truly be the year that ICD-9 is laid to rest. But whether or not the new codes go live in October, clinical documentation improvement is never a wasted effort.  Accurate, complete, and detailed documentation plays a critical role in accountable care arrangements, as payers closely scrutinize clinical actions for meaning and necessity instead of approving a laundry list of services that may or may not meaningfully contribute to a better patient outcome.

“I think CDI is an integral part of the revenue cycle, and it’s always really nice to see the metrics and have the metrics to support what you’re doing,” Stephens stated.  “Whether it’s a quality measure or clinical quality measure, it’s reflected in the hospital’s value-based purchasing arrangements.”

“Focusing on these aspects of the revenue cycle is so important, because remaining independent is very difficult in this economy,” she said.  “One of the things that we are very proud of here is that we’re still independent.  In 2003, Ohio had 86 independent community hospitals.  In 2013, that number dropped to fifty.  Today, there are only thirty independent community hospitals remaining in Ohio.  There are so many mergers and so many acquisitions right now, but Southeastern Medical still remains an independent community hospital. Our board wants to stay that way as long as we possibly can.  And all the measures we are taking, including our clinical documentation improvement program, are going to help us do that.”

Remaining an independent community hospital is no simple task in an era of consolidation as physicians seek shelter through employment in large, integrated health networks and smaller facilities band together just to scrape by.  Flying solo through such troubled times “is about getting the reimbursement and the documentation right,” Stephens believes.  “We focus very sharply on the patient and on providing quality.  When we go for the quality, the revenue and the reimbursements will follow.”

“There is definitely competition out there for patients,” she noted.  “And as a community hospital, we can only do what we can do.  It’s true that we might not be able to provide the same variety of services that they can at some of the bigger hospitals and health networks, but we do a lot of work with population health management in our community, and that’s really important.”

“We go to all the health fairs,” she said, to promote population health and preventative services that make patients aware of the actions they can take in order to maintain their own health – and keep costs lower for their local hospital.  “We’ve had programs that offer free breast and colon exams.  Southeastern has an inflatable colon and breast torso that is used around Ohio to educate about the importance of early detection.  The decrease we’ve seen in colon cancer in the community has been phenomenal, since we’ve provided these pre-screenings.  Our next program is going to be a lung screening with our pulmonologist. We want the public to understand the importance of early detection.”

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