The Documentation and Coding Adjustment (DCA): A CDI Specialist’s Perspective

This week on Excellence in Health Information, I am pleased to present Donna Wright, MSN, RN, CCDS, currently a medical coding data analyst at M*Modal, formerly a Clinical Documentation Improvement Specialist for a health system here in Pittsburgh. Donna has a 28-year-long nursing career and has worked in a variety of fields including critical care, OR, clinical research, and supervisory/management in long term care. She is a graduate of Lehigh University, St. Luke’s School of Nursing, with a BSN from Slippery Rock University and MSN in Informatics from Walden University.  Donna is married to a structural engineer and has two grown children.

Donna brings up some interesting points in her post about clinical documentation improvement and the stance CMS has taken with respect to changes in reimbursement levels resulting from documentation improvement.  I visited a provider two weeks ago who told me, “we are only asking to be paid for what we are actually doing – no more and no less.” What does everyone think? Do you have a story to tell about CDI in your organization?

See what Donna has to say here

Health Information – the Exciting Road Ahead!

Dr. Schreiber of San Augustine giving a typhoi...

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Hello everyone:

I have been privileged over the past couple of weeks to visit some of the most prestigious health care providers in the country and to hear their thoughts about the state of health information today.  I can tell you that we in the health information field are in for some exciting times ahead!  Whether we work for HIT or HIM companies or for health care providers, the changes occurring in health care mean that our roles in serving health care are changing too.  So there could be no better time to pick up our conversations again on Excellence in Health Information.

See the rest here…Health Information – the Exciting Road Ahead!

Til next time!
Lynn
M*Modal

Speech Recognition as the Accelerator of Meaningful Clinical Documentation

Hello everyone: Over the last couple of weeks I had the opportunity to attend several conferences. One was the national conference of the Case Management Society of America (CMSA) (more about this visit later) which was held in San Antonio, Texas, (home of the Alamo). Then I had the privilege of presenting to two state HIMA conferences; New Jersey (NJHIMA) in Atlantic City, and then back to Texas (TxHIMA) for their state conference in Dallas.

As always, I really enjoyed meeting with state HIMA members. It is so satisfying to know that wherever you are in the country, HIM professionals have the same passion for safe, high-quality, useful health information. It is also interesting to see that everyone seems to be facing the same challenges with respect to adoption and use of electronic health records. Everywhere I go, I hear the same stories about point-and-click, template-driven EHR systems that are time-intensive and cumbersome for the physician, that don’t provide the necessary information for the HIM, and which cause concerns for the health care enterprise because of costs and questionable ROI.

Needless to say, there is always interest in discussing narrative documentation including how to produce it cost-effectively and efficiently, and how it can be used to generate the discrete data needed for the interoperable exchange of information, to provide data for reporting and analysis, to drive clinical decision support and other automated care protocols, and in general, to realize the benefits that we all expect as we make use of electronic health information.

Some of you have seen these before, but just in case, here are my slides:  NarrativeDocumentation_HIMA_20110629.

In a nutshell:

1. Today’s changing health care environment is setting higher standards for documentation while seemingly making it more difficult for physicians to document patient care. The need for documentation to support Meaningful Use, to drive the communications and reporting necessary for Accountable Care and the Patient-Centered Medical home, to enable the conversion to ICD-10 from ICD-9, and to support the reporting required to monitor quality and outcomes is increasing. It is more apparent than ever that comprehensive, complete, and accurate health information is integral to the functioning of any health care facility. And yet newer methods of documenting patient care are often inefficient and time consuming for the physician and are not intuitive for other consumers of health information.
2. Dictation is still a viable, economical, and effective means of capturing clinical information.
3. In order to be cost- and time-effective, options for clinical documentation must be made available based on the type of encounter being documented and the needs of the user. For some encounters, templated, structured forms are likely sufficient. For others, physicians may do very well with speech recognition and self-editing. For more complex encounters, physician dictation supported by skilled medical transcription might still be the best way to go. The point is – health care providers must have flexibility and options for capturing the complete, comprehensive level of information required to support patient care, coding for billing and reimbursement, research and population health reporting, and all of the other uses for health information.
4. Speech recognition and other technologies, when combined with efficient management practices, can be a cost-effective way to produce high-quality narrative documentation.
5. We cannot continue to look to the best practices that many services and providers have historically followed when implementing speech recognition. In the past the goal might have been to “create cheap documentation fast” – now the goal for clinical documentation MUST be, “create useful documentation efficiently.’
6. Quality is key. We are all hearing a great deal about natural language processing, computer assisted coding, and other technologies that will help us to process and make use of our health information – but if the documentation at the foundation of these technologies is poor – the technology can’t do its job.
7. Efficient management practices are another key component. The percentage of productivity gained does not necessarily reflect the increase in output! Again, technology is no replacement for effective management practices.
8. It is not, as many believe, necessary to eliminate narrative documentation in order to have semantically interoperable electronic information. The Health Story, HL7, IHE Consolidation project is making great strides towards the creation of interoperable standards for the exchange and use of health information which will allow us to have the structured and encoded clinical data that we need to support automated processes, while at the same time retaining the human-readable narrative information that is required for communication and understanding. I personally have always been a big believer in having my cake… and eating it too. 

If you have any questions about the slides or the presentation please let me know. I’d love to hear your thoughts and experiences!

Till next time,
Lynn
M*Modal

Too Expensive to Fix

I recently came across a 2003 issue of Journal of Healthcare Information Management that is almost entirely devoted to measuring the ROI of HIT investments and I was struck by this quote from Richard Lang, EdD in his Editor’s Introduction.

“Although an ROI may predict how long it will take a capital investment to return anticipated savings via cost reductions or new revenue, it lacks a suitable measurement for the “qualitative” aspects that can contribute heavily to the realization of strategic objectives” (Lang, 2003)

I have worked with or talked to so many providers over the last year who realized they made a mistake in the way they planned to realize, or in how they measured, the ROI of their EMR systems.  One health system executive said he knows his organization made a mistake in their plans for EMR implementation and he admits they made incorrect assumptions about where they would see the return on their investment.  But he asked – how do you get an entire organization to admit that that it made a mistake? Even if it does, what can they do about it after spending many millions of dollars? Start all over? Not likely. And they are not alone.  Currently several of these providers are coming to my employer, M*Modal, looking to augment the capabilities of their EMR in hope of achieving the strategic objectives they expected to see upon EMR implementation.

One of the most common mistakes seems to come from the assumption that point-and-click data entry and structured EMR forms are a better way to capture health information than narrative dictation.  Many in fact incorrectly believe that direct-data entry into structured reporting is the only way an organization can get the discrete data they need to drive automated clinical decision support, to enable population reporting, and to attain the holy grail of electronic health information – semantic interoperability.

One of the primary contributors to ROI that these providers expected to see was the elimination of dictation and medical transcription costs.  After all, since the doctors can point-and-click their way through a structured form, why should they need to dictate?  Since many of these facilities spend millions of dollars every year on dictation and transcription, the cost benefit seems like a no-brainer.  And let’s face it; many of the decision-makers aren’t accustomed to looking at the aspects of health information which can only be measured qualitatively.  They are accustomed to looking at FTE expense and productivity units.

However, they found several things:

  • Point-and-click methods of information capture can be time-consuming, cumbersome, non-intuitive, and significantly add to the physician’s documentation time, even sometimes causing a decrease in the number of patients physicians see in a day.
  • The information captured is not as usable for clinical care and some HIM functions as narrative forms of documentation.  As one physician told me, “I like that I have access to all the patient vitals, but I can’t tell how the patient feels today compared to how he felt yesterday.”
  • The quality of the documentation is often degraded as well.  Physicians copy and paste in order to save time and end up with duplicate, extraneous, or contradictory information.  They enter information into the miscellaneous text boxes because they can’t find a place for the information they wanted to capture in the drop-down menus and structured fields.  And in the traditional EMR world, information captured in the plain text boxes = no structured data = information that is lost in the computer and can’t be reused by the EMR.  As one IT manager said, “we have several thousand physicians using it, but that doesn’t mean they are using it correctly.”

So getting back to the quote at the top of this post, in counting on the elimination of narrative documentation, and thus dictation and transcription, as an expense that can be eliminated, providers often forget about the cost of the physician’s time and about the cost of degraded quality of information.  In the organization’s quest for structured data, they forget about the clinician’s need to use health information as a means of communication. They forget that one of the benefits to be gained as a result of the implementation and use of electronic health information is the improved health of the patient. That is, some of the benefits will not be realized by the provider but rather will be felt by the recipients of the improved, more efficient care.  This type of return on a technology investment is not as easily measured as number of FTEs or productivity units per hour.

At M*Modal, we’re working with several providers now who have realized that they can give physicians the option to document patient care using narrative dictation AND still get the structured data they need. They’ve realized that their objectives for truly useful and cost-effective documentation can only be achieved if the system offers options and flexibility for capturing health information.  Is the solution always optimal? No – because EMRs with their proprietary data formats aren’t eager to open up to accept readily-exchangeable data standards.  Some organizations are beginning to look to capabilities available outside of their EMRs as the solution to their problems.  But what happens to the providers who cannot afford to look to complementary solutions that will help them to realize the benefits they expected to get from their EMRs?

Though the government-driven efforts to encourage the adoption and use of electronic health information through the ARRA, HITECH, and Meaningful Use certainly have increased interest in HIT, one negative result is that providers might place so much emphasis on the financial incentives that they don’t look at the benefits of health information that can’t be measured in cost per FTE or in CMS incentive payments.  I hope that providers who are only now in the decision-making process take note of the lessons-learned by others before they too end up with a problem too expensive to fix.

Food for thought,

Lynn

Originally appeared at Excellence in Health Information

Reference:

Lang, R. (2003).  ROI and IT:  Strategic alignment and selection objectivity.  Journal of Healthcare Information Management.  Volume 17, number 4. Fall 2003.

Throw Away Everything you Thought you Knew About Speech Recognition and Medical Transcription

Fort Lauderdale, Florida

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Hello everyone:  What better way to roll into National Medical Transcriptionist Week than with a trip to lovely Fort Lauderdale to meet with the even lovelier folks of AHDI – Florida!

As always, a visit to this lively, engaged group of dedicated professionals resulted in more discussion than there was time!  And to cap it all off, I had the pleasure of meeting two luminaries in the health information domain, Pat Forbis and Claudia Tessier.  I was greatly humbled to have been part of a speaking schedule that included two women who have been such leaders in our field. I even got to share a bench with Claudia, both of us “iPadding” away.  Very cool to “ipad” sitting next to the leader of the mHealth Initiative!

The theme for AHDI-Florida’s annual meeting was the “Winds of Change”, so what better topics to discuss than the emerging technologies which are having such an impact on our industry, on health information, and on how health care itself is delivered.

The point I most wanted to make in my presentation is that changing technologies do not mean the end of medical transcription.  In fact, if we keep sight of the fact that medical transcription is about the accurate and high-quality creation of meaningful, useful clinical documentation – not the “cheap” creation of something someone only uses to check off requirements on a chart completion list, then transcription can actually be an important enabler for electronic health information.

Unfortunately, the focus in recent years has sometimes been on the wrong things.  We’ve focused so much on cost, on print formats, and on providing customized requirements, that we’ve lost sight of the real value we provide to the health care provider.  Worse, we’ve allowed them to lose sight of our value too.

So let’s throw away everything we thought we knew about transcription, slides here –  Florida_AHDI_20110514 , and look at it in an entirely new light.  Let’s look at it as a way to provide high-quality, comprehensive documentation to support increasing demands for information….produced in a way that happens to be cost-effective.

What can we do?

  1. Make sure everyone knows about the Health Story project, particularly the Health Story, IHE, HL7 Consolidation project.  Learn about it, and share your knowledge with your employer, your customers, your vendors, and your representatives in the U.S. Congress.
  2. Remember how important your highly skilled, highly productive, career-MTs are if you are to be a provider of information that can be used to support Meaningful Use, computer assisted coding, the coming ICD-10 conversion, and the other increased demands for health information that are coming our way.  Feel free to refer here for links to other articles about this topic.
  3. Focus on quality.  Without quality, the rest can’t happen.

Thank you as always to AHDI-Florida for being such gracious hosts and such passionate supporters of high-quality clinical documentation.

And don’t forget to visit Misty and Bethany at M*Modal’s Always Understanding blog for activities all week in honor of National Medical Transcriptionist Week!

All my best as always,

Lynn

M*Modal

Health, Information, and the American Way!

US Congress on Capitol Hill, Washington DC

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Good morning everyone!  I am very excited to be heading to Washington, DC to attend the AHIMA Team Talks and Hill day events!

Why?

Well, first there is the fact that I’ve always been a little bit of an “advocate” at heart. From the ecology club I started in the 7th grade (sigh – only 4 people joined including me), to the letters I used to write on behalf of multiple causes, to the daughter I raised who once failed a history test because she refused to give the desired answers to questions about Christopher Columbus (because he was a usurper of the indigenous people) and who only a couple of weeks ago kindly rearranged books in Barnes and Noble because books written by and about Frederick Douglass were only shelved under “Cultural Studies” and not under American History where  they belonged, I am appreciative of being allowed to be a part of the democratic process that is the United States of America. After all, we’re only here because of a little effort conducted by a band of “advocates” known as The American Revolution, right?

Second, it is important. Health care in our country is in bad shape and health information and technology can play a big part in helping to improve care and to decrease costs.

What is advocacy? According to Princeton University’s WordNet, (2011) advocacy is the, “active support of an idea or cause etc.; especially the act of pleading or arguing for something.”

Yep, that sounds about right.

But what does that have to do with health information?

I’ve referred to HIM previously as the “keeper of the keys” for quality health information, and AHIMA is the keystone of HIM. According to the paper About the American Health Information Management Association (AHIMA) made available on the AHIMA Communities of Practice Hill Day community, “AHIMA members believe you achieve quality health through quality information” (2011).

Yep, that sounds about right too.

But with so much change happening in the HIM realm including health care reform and its associated Meaningful Use requirements, advances in technology, the coming conversion from ICD-9 to ICD-10, it is easy to lose sight of what “quality information” really means, and what we, as a profession, must do to preserve and maintain it.

AHIMA, as an organization 60,000 people strong, has a big voice in advocating for health information. AHIMA organizes its Hill Day as a means to provide members with opportunities to meet to discuss relevant topics, and then to talk about these topics with our elected officials. In short, AHIMA provides us with a wonderful opportunity for advocacy.

On Tuesday during our meetings with our representatives in the 112th Congress, AHIMA members will focus on the following (AHIMA, 2011):

  • The HIM profession and the AHIMA association – who are we and what do we do? Our strategic focus on key points such as the adoption and implementation of the EHR, health information exchange, guidelines for interoperability including attention to standard terminologies and classification systems, privacy and security of health information, ICD-10, and more.
  • Support for the “Health Information Professions Advancement Act” which will address the need for the HIM profession and shortages of knowledgeable, trained professionals.
  • Protection for HIT and HIM initiatives established as part of ARRA-HITECH including Meaningful Use.
  • A solution for the patient identity challenges encountered as HIT evolves.

I will be blogging and tweeting from DC – so stay tuned as Lynn goes to Washington!

You can find more detailed information about AHIMA’s Hill Day on the AHIMA website.

Of note, AHDI/CDIA has its Advocacy Summit scheduled in DC for May 3-4.

See you on The Hill!!

Lynn

Director of Health Information Services

M*Modal

References:

Asmonga, D. (2011) About the American Health Information Management Association (AHIMA). Retrieved March 26, 2011 from http://cop.ahima.org/Community/Topics/tabid/66/ctl/Detail/mid/409/community/63/topic/43217/Default.aspx

Princeton University WordNet. (2011). http://wordnetweb.princeton.edu/perl/webwn?s=advocacy

AHDI Florida Technology Workshop

Florida AHDI

In Florida? Join us at the AHDI Florida Technology Workshop as M*Modal and AHDI continue the Management for the Modern MTSO series.

From 9:30 to 11:30 we’ll be discussing Innovative Transcription…

Folks, the more doctors I talk to, the more I’m convinced – without my natural bias for transcription – that transcription is integral to the creation of comprehensive health information.

But can we  compete? Can we stay relevant? How do we add the value that providers will be willing to pay for?

Let’s talk!  See you in Orlando!

-Lynn

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