3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. Finding the Key to Success:Adapting to the EHR Katie Miller, RHIA, MA Michelle Callahan, RN, BSN, CCDS Hennepin County Medical Center Minneapolis, MN

3. Finding the Key to Success:Adapting to the EHR • Defining the team • Managing and delivering expectations • Managing change and fostering interpersonal relationships • Physician • CDS • Organizational • Defining success • Avoiding the common pitfalls

4. Finding the Key to Success:Adapting to the EHR • Composed of the following entities: • Hennepin County Medical Center (HCMC) • Hennepin Faculty Associates (HFA)

5. Finding the Key to Success:Adapting to the EHR • Recognition: • HCMC: comprehensive, public teaching hospital in downtown Minneapolis • Minnesota’s premier Level 1 Trauma Center with many nationally recognized programs and specialties • 13 straight years on U.S. News & World Report list of top hospitals • Minnesota’s true safety-net hospital, with 62.6% of our inpatient charges being submitted to Medicaid or Medicare payers

6. 2005 2006 2007 1 2 3 4 1 2 3 4 1 2 3 4 Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Pre-Imp Plan Implementation Timeline EHR Rollout Pre-Imp Plan EMPI Clean Up First Design Session Doc Imaging, CDR +, HIM, Go-Live May 2006 Wave 1 Wave 2 Ambulatory Registration & Schedule, Pro Fee Billing for HFA Go-Live June 2006 Wave 3 Ambulatory EMR Pilot Go-Live Nov 2006 ADT, Hospital Billing, Radiology, CPOE, Pharmacy, ED, Limited Nursing Documentation Go-Live February 2007 Wave 4 Wave 5 Non-Physician Clinical Documentation, EMAR, Patient Education, Care Plans Go-Live May 2007 Wave 6 OpTime & Physician Documentation Go-Live Aug 2007 Implementation Phase Testing Phase Training Phase Post Live Phase

7. In the Beginning2005–2008

8. In the Beginning … • Program implemented in 2005 • Program focus • Capturing CCs for surgical DRGs, and other specifically identified DRGs that are below the 80th percentile for capture • To facilitate the documentation in the medical record as an accurate reflection of the: • Severity of illness • Intensity of services/resource consumption • Length of stay • Treatment complexity • ICD-9-CM (International Classification of Diseases, Clinical Modification) coding • DRG (diagnosis-related group) assignment • Expectations • Financial capture goal of Medicare patients in the first year of the program was $1,162,406 • Review rate: 85%–95% of all Medicare patients • Query rate: 25%–35% of reviewed patients • Response rate: 80%

9. In the Beginning … • Scope • Medicare-only payer coverage • All services except moms/babies, pediatrics, rehab, psych • Staffing • 4 FTE, valid nursing license required • Established leadership structure • 5 executive sponsors (including 2 physicians) • 3 additional “formal” physician champions • 6 additional “informal” physician champions

10. In the Beginning … • Training • Contracted with vendor • Included reviewers and coders • 120 hours of classroom training • 40 hours of field training

11. In the Beginning … • Review process • Reviewed patients 24–48 hours of admission for Medicare patients • Reviewed paper charts • Divided patients out by hospital units • Query process • Paper query forms • Unclear procedure for unanswered queries • Provider process • Sign and date query form • Indicate location of documentation or check disagree

12. In the Beginning … • Tools • Paper worksheet • Paper query forms • Paper provider tip cards

13. In the Beginning … • Reporting • Application/System • Communication • Steering Committee established with physician champions • Reviewers did not sit on the committee • Reviewers’ only contact was with attending physician • No escalation process • “Square peg in round hole” • Required standard work flow for entire organization

14. Gap Between Paper and Electronic • Program scope • Turnover • CDS turnover • Metrics • Communication

15. Today

16. Program Revitalization • Program revitalization started in Q4 2008 • Scope • All payers • All services except moms/babies, rehab, psych • Staffing • 7 FTE focused CDI • Credentials • Nursing license • RHIA w/ 3 years experience • RHIT w/ 6 years experience required • 1 FTE clinical documentation supervisor • 0.5 FTE assistant medical director of documentation quality

17. Program Revitalization • Leadership structure • Collaborated hospital and physician group leaders • Created assistant medical director of documentation quality position • Areas of collaboration

18. Program Revitalization • Training • Vendor retraining fall ’08 • Included reviewers and coders • Internally developed training • Individualized to each person’s needs

19. Program Revitalization • Review process • Reviewed patients within 24–48 hours of admission • Review all data entered into EHR • Patients divided by terminal digit • Coders and CDS now work in identified teams • Query process • Electronic query field • Defined and specific escalation methods for unanswered queries • Service specific (determined by providers and CDS) • Provider process • Indicate location of documentation or respond to any disagreement within the electronic query field

20. Program Revitalization • Program focus is to facilitate the documentation in the medical record as an accurate reflection of the: • Severity of illness • Intensity of services/resource consumption • Length of stay • Treatment complexity • ICD-9-CM (International Classification of Diseases, Clinical Modification) coding • DRG (diagnosis-related group) assignment

21. Program Revitalization • Expectations • Financial capture goal of $2,700,000 in ’09 and $4,300,000 in ’10 • Review rate: 85%–95% of all patients within the scope • Query rate: 35%–45% of reviewed patients • Response rate: 85%–95% • Objective to create a program that has determined processes that allow for the continuous movement that is required to ensure success in a data-driven program

22. Program Revitalization • Tools • Daily, weekly, monthly performance monitoring • Paper and electronic worksheets • Electronic query templates • Paper provider tip cards • Electronic tip sheets embedded in our EHR and online provider resources • Electronic encoder and analyzer

23. Program Revitalization • Reporting • Application/System • Communication • Identified key contact CDS for each involved clinical service

24. Managing Change and Fostering Interpersonal Relationships

25. Change Management: Provider Engagement • Developed an assistant medical director of documentation quality position • Monthly provider status reports (report cards) • Documentation Tip Sheet Library • Increased education about program and benefits • Increased collaboration with providers • Building trust

26. Change Management: CDS Engagement • Career advancement opportunities • Involvement in program processes/decisions • Communication of organization and program services • Created and communicated expectations • Creating coder-CDS teams • Leveling workload

27. Change Management: Organizational Engagement • Using data to drive focus of program • Expansion to include PEDS/PICU • Expansion to include “intake” and “no payer” • Expansion to include weekend coverage • Expansion to include all payer coverage • Using data to demonstrate success of the program and return on investment • CMI • MCC/CC capture rate • Types of MS-DRGs • Building trust • Data • Case examples • Accountability

28. Avoiding the Common Pitfalls

29. Avoid the Pitfalls (general) • You can never overcommunicate • Sell your skills! Market yourself within the hospital. • Need to measure! • Demonstrate progress • Create your vision • Defining the “team” • Accountability and integrity

30. Avoid the Pitfalls (general) • Documentation • Procedures • Accountability • Escalation • Embrace change • Monitor data to adjust work flow • Empower end users • Mentor users on how to analyze the data to drive decisions and outcomes • Blending clinical, coding, and financial lingo

31. Avoiding the Pitfalls (EHR specific) • Build strong relationships prior to implementation • Be involved with the development of your electronic program tools • Prepare for learning curves for providers and CDS • Providers will need extensive EHR training • Prepare for the CDS to become an informal educator about the EHR • Chart access issues • Prepare for adjustments/changes • Require time and resources from EHR

32. Note bloat Copy/paste functionality Pick-list nightmares Diagnostic terms do not match CMS requirements Difficulty tracking attending provider In-basket overload CDS and provider frustration! Documentation Challenges/Hurdles

33. Defining Success

34. Measuring Success • Department • CDS dashboards • Provider tip sheets • Organization • Case-mix index • Severity of illness • Risk of mortality • CC/MCC capture rate • Financial impact on gross revenue • Provider report cards

35. Department Examples: Tip Sheets Documentation tip sheets available on the HCMC intranet Also integrated as links in the queries in EHR …

36. Standard Query Templates: Electronic Query Field Anemia Asthma/COPD BMI CHF Debridement Skin ulcers Malnutrition Pneumonia Sepsis Renal failure Radiology POA/HAC General Department Examples: Queries

37. Department Examples: Census

38. Department Examples: Dashboards

39. Baseline performance (Q4 05) Overall CMI: 1.30 Medical CMI: 0.89 Surgical CMI: 2.67 (Q1 08) Overall CMI: 1.33 Medical CMI: 0.961 Surgical CMI: 2.58 2009 Performance (Q3 09) Overall CMI: 1.47 Medical CMI: 1.04 Surgical CMI: 2.86 Organizational Metrics: Overall Impact

40. Query and Response Rate EHR Implementation

41. Organizational Metrics: Overall Impact

42. Organizational Metrics: Overall Impact

43. Financial Benefit No data collection

44. Example Monthly Provider Status Report: Executive Summary

45. Example Provider Status Report: Service Summary

46. Vision for the Future • 2010 goals • No signs/symptoms working DRG assignments/final DRGs • All final/working DRGs match or complete the identified reconciliation process • Focus on coder-CDS collaboration • Expectations • No sign/symptom MS-DRGs sent out without CDIP reconciliation • CDS peer audits • Increased frequency of CDS-provider interaction • Completely internalized financial and quality CDIP program results reporting • Online worksheet housed within the EHR • Collaboration with case management regarding expected length of stay and readmissions • Utilizing RAC results to guide documentation clarification

47. Vision for the Future • Collaboration with case management regarding expected length of stay and readmissions • Utilizing RAC results to guide documentation clarification

48. Questions?