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by Angie Curry | Jeff Hurst
Published on September 26, 2016

CoxHealth, recognized for its commitment to quality and patient safety, eliminated a two system workflow for clinical documentation specialists (CDS) in 2015, by piloting Nuance® Embedded CDI™ within Cerner Acute Case Management. With physician documentation and clinical documentation improvement (CDI) reviews in the same patient record, CoxHealth saw increases in physician response, acceptance rates and revenue.

Angie Curry, Corporate CDI Manager at CoxHealth, tackled a unique staffing model in an effort to retain an in-demand certified team of CDS nurses and maintain the productivity gains its highly engaged medical staff is accustomed to seeing across service lines.

During CDI Week, September 19-23, Curry and Jeff Hurst, senior vice president of Cerner Revenue Cycle Management and president of Cerner RevWorks, discuss key considerations for a successful CDI program, as health care moves to value-based care.

Highly engaged medical staff

Curry: With new health care payment reform, medical record accuracy is more important than ever. Physicians must show how complex—how sick—their  patients are, because future payments are dependent on what chronic conditions are being seen today. It’s a big change for physicians at CoxHealth, especially surgeons. Surgeons are now looking beyond the joint replacement and factoring in the holistic health of the patient.

Hurst: In my experience, the biggest key to success is having a very highly engaged and aligned medical staff. At the end of the day, CDI is all about physician documentation.

Cerner, and the industry in general, will talk about the concept of a clinically-driven revenue cycle, which in simple terms means every clinical action results in a financial transaction. So we’re moving toward a world where providers are paid for services documented, rather than services provided. This has a financial impact for providers as it relates to payments on the episode of care they’re delivering. It also has a broader impact on things like pay-for-performance, value-based purchasing, and the Medicare Access and CHIP Reauthorization Act (MACRA), all reliant on the accuracy, timeliness, and thoroughness of documentation.

The successful collaboration with providers really comes down to two points: A vested interest in ensuring there is comprehensive documentation and aligned incentives, which haven’t always been readily available in health care.

Seasoned, experienced, well-resourced CDS staff

Curry: Hiring and retaining a highly skilled team of Certified Clinical Documentation Specialists (CCDS) is important to building a good CDI program. Our hybrid approach at CoxHealth gives CDI nurses the ability to work two days in the office and two days from home. It’s a huge satisfier with the nurses, who are highly recruited by other national agencies. Some say it was like getting a raise because of the gas mileage saved. Others appreciate the work/life balance it gives them. This work flexibility gives us an edge over other organizations.

Additionally, our CDI nurses are now assigned to a unit of the hospital. One nurse reviews all cardiology patient documentation and goes to all monthly cardiologist physician group meetings. This puts a face to the service and we can help increase quality scores. In this era of physician transparency with publically reported data, our physicians are very competitive, so if we show that their quality scores aren’t the best, we have immediate buy-in and they will answer queries to help enhance the accuracy of the documentation.

Hurst: It comes down to the simple concept of value. In most cases, whether you’re a hospital provider or physician provider, you’re likely delivering high-quality care, but you’re probably not getting credit for it because of poor documentation.

The implementation of ICD-10 put the industry in a position to have a broader conversation around quality documentation. There are still opportunities for clinical documentation improvement, influenced by a combination of hospital administration, medical staff leadership and physician champions who really advocate for an aligned CDI strategy that produces value.

Sophisticated technology partner

Curry: Electronic communications have enhanced the relationship between the physician, CDI nurse, and coders. They no longer have to be in the office to communicate.

Many CDI programs are not electronic. Some physicians see a query as a Post-it note in the chart and they crumple it up and toss it out. Cerner provides the quality proof we need to document the queries and show physician response and acceptance rates with the tight reporting functionality.

We’ve used our hybrid CDI approach for six months and I have four months’ worth of data. Our nurses have the same amount of reviews as before, but the queries are more appropriate because they are able to concentrate better at home with less distractions. More accurate queries lead to more accurate reimbursement.

Hurst: In considering a technology partner, think of current and future state of technology—the better the technology that’s available, the more providers can leverage that technology and the more productive you can make your physicians and staff.

Advancements in areas like Document Quality Review (DQR)—concurrent, computer-assisted physician documentation that uses natural language processing to drive CDI queries versus manual review and post-documentation queries—can impact a broader population and create more success across the organization due to the timeliness and accuracy of the technology.

Patient experience and a healthier bottom line

Curry: Why do you become a nurse? To make a difference. But the medical accuracy of a patient record is worth more than the person even knows. If a patient moves to another city, or if something in the record was misrepresented or not accounted for or in error, it’s hard to remove it; that error follows you. CDI is the transparency of the medical record to the entire care team, including the patient. They deserve the clarity of their own personal medical record.

Hurst: It’s important to focus on the value proposition from both clinical and financial perspectives. Health care is working on figuring out how to drive waste and inefficiency out of the cost structure and oftentimes people translate that into reducing costs. CDI is actually one of those programs where you may have to make additional investments in your organization, whether in the area of staff or technology, but that investment will produce an ROI both in terms of your financial outcomes and your quality clinical outcomes.

Broader reach across populations, payers and care venues

Curry: CoxHealth participates in four bundled payments for care improvement (BPCI) initiatives, and in the last four months of data, two months—April and June—have shown 100 percent of traditional Medicare patient reviews. I had a goal of 98 percent and we blew that out of the water during those two months.

With these benefits, I can expand review to all payers. We’re reviewing Medicare and Medicare HMOs, but not looking at Medicaid or self-pay. In Missouri we have Managed Medicaid that requires an accurate list of chronic conditions and acute conditions. With a new budget year, I’ve requested that we add two full-time equivalents.

Hurst: Think of the next. Don’t limit yourself to the Medicare population and to the acute setting. When an organization is at risk from a financial standpoint across payers, there’s an opportunity to leverage a CDI program. Additionally, with MACRA, there’s an opportunity to expand beyond the acute setting and into the ambulatory and physician practice setting.

Curry will speak on hybrid CDI with service line responsibility at the Missouri State ACDIS Chapter Conference on Saturday, October 15. 

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