With ICD-10 still looming and value-based payments and penalties on the horizon, U.S. hospitals need strategies to tackle the “triple threat” of financial, operational and clinical challenges these transitions present. Summit Health implemented an end-to-end clinical documentation improvement process to address all three main challenges holistically.
In healthcare, we know it’s better to be proactive. Reducing stress, watching your diet and exercising to prevent a heart attack is a proactive approach instead of undergoing a triple bypass after the attack hits. Doctors see warning signs, like high cholesterol and blood pressure, take proactive measures and put patients on a care plan to prevent a cardiac event. For Summit Health, the ICD-10 requirement was our warning sign and the reason we took proactive measures early on. We knew we had to take dramatic steps to not just meet ICD-10 requirements, but to also prepare for the inevitable and much-needed transition to a value-based system that could significantly impact our bottom line. To stay ahead of the game, we charged forward with a vigorous, preemptive strike to ensure our clinical documentation process set up to succeed in any payment model and any number of coding changes.
We identified three areas as our primary concerns:
- Financial: Estimates said health systems our size were at risk of losing between $2.5 million and $7.1 million over the course of three years if coding was inaccurate or insufficient – a likelihood, considering the fivefold increase in codes.
- Operational: Productivity could drop by as much as 60 percent initially for our coders and up to 20 percent for our physicians, costing us time and money.
- Clinical: Our clinicians make critical care decisions based on documentation, so accuracy is key. But we worried about recent studies that showed only 63 percent of current documentation is accurate enough to support more rigorous ICD-10 regulatory requirements.
We knew taking a piecemeal approach would not adequately address these issues. Instead, we took a broad and holistic approach to ensure teams across functional areas were focused on clinical documentation improvement (CDI) from end-to-end – beginning with physicians at the bedside, connecting with clinical documentation specialists, coders and HIM staff, and continuing to quality professionals focused on outcomes and reporting. By integrating CDI into our approach to ICD-10 readiness, the information flowing through our health system would be accurate enough to prove we are delivering good care, supporting appropriate payment and complying with federal regulations.
As key part of our pre-emptive strategy, we signed up as a beta site for Nuance’s Clintegrity 360 solution, consulted with Nuance clinical, operational and financial experts, and began implementing our CDI program as early as February 2012. Through this process, we discovered the prescription for improving clinical documentation and tackling financial, operations and clinical challenges:
- External teams are invaluable for scrutinizing charts for coding errors to assess risk. The Nuance team found that our physicians were frequently failing to include some of the necessary details in their documentation. Without the detailed, clinical specific documentation, the encounter coding was incomplete and did not reflect the true acuity and resource consumption the patient during required during their stay. The outside-in approach also helped us better predict potential impacts that ICD-10 would have to our overall productivity from documentation, codes used to order tests and exams to individual coding staff productivity. We learned that with the transition to ICD-10 we were at risk for a $400,000 loss due to diagnosis-related group shifts.
- Hospitals need to educate and engage their employees in the process. The change to ICD-10 is a major transition for everyone, and it was important to us that our staff became educated on proper documentation procedures. Our team started by training our coders, and worked hand-in-hand with each of our coders to pinpoint areas for improvement and tailor educational programs to meet each person’s specific areas of concern. From there, our ICD-10 implementation team developed a staff-specific training plan for any area impacted by the change to ICD-10. Our physician training plan was specific to specialty. The plan also included an analysis of their current documentation against what, if any, additional documentation or level of specificity would be required to code the same encounter with ICD-10.
- Workflow needs to be at the heart of all CDI to prevent massive productivity losses. We learned that clinical documentation becomes a better process when the workflow of HIM staff and clinicians are integrated. Implementing technologies like Clintegrity 360 that puts critical information, such as documentation procedures and reference materials right at the coders’ fingertips, which not only increased productivity by as much as 35 percent, but also resulted in fewer missed codes, boosting case mix index (CMI) by more than 15 percent.
ICD-10 is a big change, but for us, it served to put a spotlight on how well we were positioned for the future of healthcare. For more details on how we prepared for the transition, download the CHIME Best Practices Institute white paper, “How Clinically-Focused Closed-Loop Best Practice Improves Outcomes, Productivity and Patient Care.” This describes how preemptively digging into and refining our clinical documentation strategy enabled Summit Health to reap the financial, operational and clinical benefits of our strategic clinical documentation overhaul.
Michele Ziegler is Vice President of Information Services & CIO, Summit Health