clinical documentation excellence: transforming cdi to...

Clinical Documentation Excellence: Transforming CDI to Meet Modern Challenges

Leigh Williams, MHIIM, RHIA, CPC, CPHIMS Administrator, Business Systems, UVA Health System

Today’s Agenda

• Data-Driven Documentation Maturity Model

• Clinical Documentation Excellence (CDE)

• Program Metrics and Outcomes

• Surgical Services

• Ambulatory Services

• Counterpoints

• 2015 Strategic Initiatives

• Discussion

The University of Mississippi Medical Center

• Academic medical center

• 6 hospitals including women’s, children’s, critical access, and community

• 500 physicians

• 125 specialties

• 100+ clinics

• 5 health sciences schools

CLINICAL DOCUMENTATION EXCELLENCE (CDE)

CDE Program Mission

• To guide our physicians to understanding and creating quality clinical documentation in the pay for performance era.

Data-Driven No Data Actionable Knowledge

Engagement None Engaged

CDE Program Driving Principles

Engage physicians in initiatives to improve pay-for-performance and revenue cycle metrics

Create solutions that support physicians in real-time within existing work flows

Improve inpatient and outpatient documentation accuracy, completeness, and timeliness

Drive improvement in quality outcomes measures and cash collections

CDE Program Goals

Stage 1

No data sharing

Limited queries

No education or templates

Poor delinquency

rate

Stage 2

Historical data

Queries in all settings

Some structured templates

30-50% Delinquency

Rate

Stage 3

Descriptive analytics

Education and queries

Templates and work

flows

10-30% Delinquency

Rate

Stage 4

Predictive analytics

Multi-faceted communications

Optimized work flows

< 10% Delinquency

Rate

Components

Data-Driven

Complete

Accurate

Timely

Documentation Maturity Model

Program Considerations

• Institute-wide: DRG and CPT based reimbursement

• ICD-10

• Meaningful Use and overall EHR adoption

• Hospital Value-Based Purchasing (VBP) Program

• Hospital Readmissions Reduction Program

• Hospital Acquired Conditions (HAC) Reduction Program

• Department-specific pain points

• Sustainable over years (not focused on one program)

3265 3396

3223

2035 1961

1824 1807

1624 1619 1621 1746 1750

1846

0

500

1000

1500

2000

2500

3000

3500

4000

26% 28% 27% 17% 16% 15% 15% 13% 13% 13% 14% 14% 15%

Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

Total Delinquent Deficiencies and Delinquency Rate

Early Steps: Addressing Timeliness

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

$8,000,000

$9,000,000

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Cash on Hold Due to Physician Deficiencies

Talking Impact on the Organization

$97,751 $19,570 $1,913

$3,640,312

$41,825

$657,817

$243,907

$13,595 $79,779 $26,057

$404,074

$90,227 $59,201

$1,589,537

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

Cash Holding by Attending Academic Department

Using Peer Pressure

Beginning the Program: Early Adopters

Neurosurgery

• Team includes department chairman, residency program director, CDI specialist, pro fee coder, and project manager

• Initiated November 2013

• Meets monthly

• Actively supports rounding with physicians and educational sessions

Orthopedics

• Team includes department chairman, residency program director, chief resident, surgeons, CDI specialist, pro fee coder, and project manager

• Initiated October 2013

• Meets monthly

• Actively supports rounding with physicians, educational sessions, grand rounds monthly education, intern program on business basics

Neurosurgery CDE

• Focus on inpatient documentation

• Deficiencies and delinquency rate

• Timely query responses

• Case Mix Index

• Unspecified diagnoses

Neurosurgery Query Response Activity

13.82%

13.70%

15.27%

12.52%

12.97%

14.33%

15.52%

14.26%

14.55%

14.38% 14.08%

12.93%

14.29%

12.72%

10.00%

11.00%

12.00%

13.00%

14.00%

15.00%

16.00%

% Unspecified

CDE for ICD-10: Decreasing Unspecified Codes

2.00

2.25

2.50

2.75

3.00

3.25

3.50

3.75

4.00 Ja

n-1

3

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

Dec

-13

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Two Years In: Neurosurgery CMI 2013-2015

Orthopedics CDE

• Full-blown program with inpatient and outpatient scope

• Deficiencies and delinquency rate

• Timely query responses

• Case Mix Index


• Physician business savvy / competency

Orthopedics Query Response Activity

1.00

1.25

1.50

1.75

2.00

2.25

2.50

2.75

Jan-13 Apr-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15

Two Years In: Orthopedics CMI 2013-2015

12.35%

12.18%

13.23%

13.07%

12.01%

11.80%

11.30%

11.44%

11.83%

12.03%

11.35%

7.14%

7.16%

6.22%

6.00%

7.00%

8.00%

9.00%

10.00%

11.00%

12.00%

13.00%

14.00%

% Unspecified


Family Medicine CDE

• Patient care focused: Primary care physician role, including when they’re in the hospital

• Open ambulatory encounter count

• Discharge summary deficiencies to drive timely Continuity of Care Documents

• Query response rate


Addressing Timeliness

• Open Encounters and Inpatient Deficiencies

• None more than 10 days

• 1 or 2 deficient discharge summaries, not yet delinquent

Family Medicine Query Response Activity

21.40%

20.44%

21.26%

19.28%

21.38%

20.22%

20.39%

19.69%

20.43%

19.43%

19.72%

19.27%

17.55%

16.96%

16.00%

17.00%

18.00%

19.00%

20.00%

21.00%

22.00%

% Unspecified



Diagnosis Baseline Sept. 2014 March 2015

Congestive Heart Failure 68 15

Unspecified Asthma 54 5

Unspecified Otitis Media 3 0

Total 125 20

Targeted unspecified diagnoses for Family Medicine

1.00

1.25

1.50

1.75

2.00

2.25

Jan-13 Apr-13 Jul-13 Oct-13 Feb-14 May-14 Aug-14 Dec-14 Mar-15 Jun-15

Internal Medicine CDE

UMMC Overall CMI

1.7000

1.7500

1.8000

1.8500

1.9000

1.9500

2.0000

Jan-13 Apr-13 Jul-13 Oct-13 Feb-14 May-14 Aug-14 Dec-14 Mar-15 Jun-15

CDE in 2016 and Beyond: Future Focus

• Clinical intelligence

• Real-time feedback through EHR dashboards

• Concurrent coding

• Computer assisted physician documentation

• Computer assisted coding

• ICD-10 – diagnosis and problem list support tools

• Structured template development and adoption

Leigh Williams, MHIIM, RHIA, CPC, CPHIMS

Formerly Director, Revenue Cycle / Health Information

Management, The University of Mississippi Medical Center

Currently Administrator, Business Systems,

The University of Virginia Health System

[email protected]

@leightw

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