Executives at Wheeling Hospital in Wheeling, West Virginia have been involved in an initiative to improve physician documentation process and clinical support for physicians at their two-hospital system, which encompasses a 277-bed community hospital, a 90-bed community hospital, and a family practice residency. In the documentation and CS area, they went live in December 2014 with a new physician workflow technology called the 3M 360 Encompass MD System, from the Salt Lake City-based 3M Health Information Systems. That system provides automatic feedback and guidance to help physicians improve their accuracy, completeness and compliance, in their documentation work. The Wheeling Hospital executives have integrated the 3M solution with their organizations core electronic health record (EHR), from the Chicago-based Allscripts. In fact, Wheeling Hospital was the alpha development site for the 360 Enmcompass MD System, and its first live site.
HCI Editor-in-Chief Mark Hagland sat down with several senior executives from Wheeling Hospital while everyone was participating in the HIMSS Annual Conference at the McCormick Place Convention Center in Chicago in April. Wheeling Hospital executives present were Dennis R. Niess, M.D., CMIO; David A. Rapp, CIO and vice president-supply chain; and Sean D. Loy, chief technology officer. Below are excerpts from that interview.
Tell me about the strategy that all of you here and your colleagues have been pursuing in this area?
Dennis R. Niess, M.D.: We identified a long way back that every time you talk to doctors about mortality and morbidity, they say, ‘My patients are sicker.’ And we found that many of these patients were very sick but the documentation did not reflect that as well as it could have. If a fact wasn’t precisely relevant to a procedure or situation, the physicians didn’t document it. So we never believed that our morbidity or mortality rates were actually worse than average; we just hadn’t been precise in our documentation. So we brought clinical documentation specialists, nurses who understood coding, onto the floors. And initially, the errors in coding were on paper; but now as we moved to an electronic system, no one was paying attention to the [documentation] queries going to the physicians. So we needed to create electronic queries that the doctors would pay attention to; in the past, someone would have called or paged them.
Sean D. Loy: Now, they log into Allscripts Sunrise, and now they get prompts, along with other prompts in the EHR.
David A. Rapp: You’re already looking at the record of that particular patient, and the query might say, was it left side or right side? Or something similar. So the querying now takes place inside the workflow.
Niess: You can create a clarification document now. To do so, you’ll select the box acute heart failure, as a check. If you need to create a free-text document, you can. The process involves both open-ended and multiple-choice questions; with regard to the multiple-choice questions, when you as the physician click such a question, it automatically creates a document and uploads that document.
So, here’s a good example: If I write ‘congestive heart failure’ in a patient’s record, the professionals in health information management need to know whether it’s acute or chronic, acute on chronic, systolic or diastolic, and so on. Those are the types of situations where you can give us a list of questions to pick from. If the physician’s documentation is questioned—if someone needs to know whether a condition might be missing, it’s important to remember that it is not permissible to ask, for example, ‘Is this heart failure?’ That’s considered leading the physician. So the 3M folks developed an engine that can do the edits, and developed the tool to work inside our physicians’ workflow within our specific EHR.
Loy: Essentially what we did was, they put all the ‘hooks’ in there. We launch it in Sunrise, hide it in the background, and limit it to physicians.
And there are different types of queries?
Niess: Yes, there are person-generated or manual queries (open-ended) and automated queries that are multiple-choice in their format.
So if the physician simply indicates “heart failure,” the solution will trigger a query?
Loy: Yes that’s correct. Here’s what happens: a physician logs into Sunrise, and chooses to look at a patient’s record. The solution then prompts that physician with questions specific to the patient or patients. 360MD is running in the background when the doctor signs in; but it only launches if a physician signs in for whom there are queries.
Niess: We are now sending those queries to nurse practitioners and physician assistants for those doctors. So a cardiologist will get them, the NP and PA will get them also. The documentation tool requires the doctor to actually perform that task. The extender can in person ask the doctor (MD or DO) to do the coding.
How have these processes changed?
Niess: The paper queries were just ignored; most people weren’t going to the paper chart at all. And the documentation specialists were always on the phone and trying to track physicians down on the floors, and that has dramatically decreased. Conversely, our ability to reach them on the floor has dramatically increased. And for CHF, pneumonia, and sepsis—Allscripts allows you to download “favorites”—so, for example, a physician might choose pneumonia as an already-chosen favorite, and the diagnosis codes that physician might be looking for, will appear. So the physicians have automated access to lists of the diagnosis codes most often used. And the ease of use has led to a dramatic improvement in compliance.
How big is your medical staff?
Niess: It is close to 200. That number does not count residents, since we don’t query them; we query only attendings. In terms of the numbers of physicians involved here, there are on any given day, roughly 75 physicians in the building, and perhaps 30 of those will be doctors who are regularly sent queries.
How have the doctors responded to these improvements?
Niess: Their response has been very positive.
Rapp: A lot of the genesis of this was in preparation for ICD-10. And the amazing thing for me is that I asked for it to happen, and it did. And usually, when an innovation takes place, there’s a line of doctors at my door, waiting to lodge complaints. In this case, when I asked when this would go live, it already had! And there were no complaints—which shows how successful the go-live was.
Niess: And I informally polled both physicians and HIM professionals, and found that the go-live had proven to be a non-event, which was very gratifying.
What have the biggest lessons that have been learned so far in this initiative?
Niess: It’s simple, really: if you provide an easy way for physicians to provide what you need, they’ll do it.
Rapp: There are some technical details we’re still working through, but by and large, it’s been a great implementation—and the first in which we’ve had no customers complaining.