In the era of healthcare reform initiatives aimed at increasing transparency, accurate clinical documentation has become vital. Undoubtedly, healthcare organizations are realizing that when you can effectively tell a patient’s story, the quality of care is improved. And for that to happen, the leaders of any patient care organization must insist on clinical documentation improvement (CDI).
A few years ago in Seattle, Wash., in an effort to optimize reimbursement and prepare for the ICD-10 transition, the five-hospital Swedish Medical Center turned to the Burlington, Mass.-based Nuance to help them design and implement an in-depth clinical documentation strategy. Since partnering on the program, Swedish has achieved substantial return on investment (ROI)—attaining more than $10 million in 2013 across its five campuses, says Jennifer Woodworth, director of the clinical documentation integrity program at the medical center.
“While other organizations’ programs are focused on the revenue side of the house, we thought it was important for our program to be clinically based, with a focus on physician education,” Woodworth says. “What Swedish has found is that when our physicians are able to focus on telling their patients’ stories, the quality of care improves, and as a result, we see a boost in appropriate reimbursement.”
Telling the patient’s entire story from beginning to end, admission to discharge, allows all of the details needed for proper documentation, treatment and coding to be captured, says Woodworth. “After all, you can be an excellent physician, but when you aren’t documenting the details, no one will know and you won’t be reimbursed for the care you provided.”
Woodworth says that Swedish has taken a collaborative approach to fixing the documentation challenges that its physicians are facing, starting with meeting with specialty departments to show physicians in each group how they are stacking up in terms of documentation. “By reviewing the data and number of claims denials, we are able to find a way to tackle these documentation challenges. We have a denials group where we look at trends every month compared to the last year and we break it down by physician. Having this group of people is critical, and we’ve all become more knowledgeable and come out of our silos,” she says.
What’s more, Swedish is publically showing which of its physicians have outstanding records being denied. Since this is made public, physicians are more aware of their records and will aim towards better documentation, says Woodworth. “We are also bringing the details—whether it is documentation or coding—to the specialty groups. The time has gone where we don’t talk about finances. We have to talk about finances, because it’s important for the hospital’s bottom line,” she says.
Of course, the one-year delay to ICD-10 impacts clinical documentation significantly, given that the documentation must meet the level of coding specificity and granularity. To this end, Woodworth says that since last October, Swedish’s staff has been dual CDI coding, basically doubling cases every day. “Overall, the delay was quite a shock and disappointing for us. However, we have since shifted our focus. We know the burning platform of ICD-10 and documentation is not going to change—better documentation and quality care go hand in hand—so while ICD-10 may take a back burner with delays, we are going to continue on with our documentation message,” she says.
That said, Woodworth feels that better specificity for documentation is needed. “Because we have so few codes to fit the diagnosis, we feel that the ICD-10 coding language reflects better medical language overall. Even though vendors may say that it’s a whole new language, it’s really not. Once it’s presented by specialty, physicians will understand why it matters to them and the patient,” she says.
Woodworth adds that one of the biggest challenges Swedish has overcome was aligning its engagement strategies with what matters most to physicians, and making sure they are not bogged down with unnecessary details. After three years of identifying obstacles and working through CDI challenges, it was found that more than half of the organization’s clarifications to physicians are clinically focused and relate to documenting the severity of illness and risk of mortality, she says. “Putting this learning into action, we’ve realized that not everything is a priority to physician care, so we need to focus on the areas that are. By implementing these findings and adding clinical details in the chart, our physicians are able to provide better documentation as well as overall improved quality of care.”
For patient care organizations that are looking to document better, Woodworth first advises that implementing the right technologies—she says Swedish is still figuring out how to make technology available at the physician’s fingertips, whether it is through voice recognition or better electronic health records (EHRs)—with the right CDI program is key. This way, she says, you can glean information while your patients are still in the bed, and can provide that data easily to your physicians.
Having the right staff is also critical to success, she advises. “As part of the hiring process, we provide a test on clinical documentation to our candidates, and we only hire RNs with clinically proficient backgrounds. With a trained group of clinical staff, you avoid any potential bumps in the road that have to do with documentation.”
And lastly, Woodworth notes, you need to engage physicians and show them the trends and how data integrity makes a difference for them. “With so much at stake, transparency and collaboration are crucial,” she says. “If you don’t implement strategies, technology, and processes that support physicians and quality of patient care while meeting regulations, you won’t be successful.”