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The Impact of a Targeted CDI Intervention on the Documentation Patterns of Surgery Residents: Can They Improve?David Jeffcoach, MD

4th Year General Surgery Resident

Trey La Charité, MD

Medical Director for Clinical Integration

Physician Advisor for Clinical Documentation and Coding

University of Tennessee Medical Center

Knoxville, Tennessee

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify the current state of CDI in resident and medical student education

– Describe how CDI training amongst residents can improve hospital performance

– Explain various strategies that have been used to improve CDI amongst residents

– Discuss a novel methodology to improve CDI in a surgical residency training program


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Case Study of a Physician in Training

• California Polytechnic State University, San Luis Obispo

– Graduate 2007

• University of California ‐ Davis

– Graduate 2011

• University of Tennessee Graduate School of Medicine

– 4th year general surgery resident

• CDI enthusiast in training

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Approach to CDI in Medical School

• First two years in the classroom

– Pathology and basic science focused

– Introduction to the H&P, progress note, and discharge summary

• Second two years on “the wards”

– Required to write notes on patients

– Focus on structure, thought process, and defending diagnoses

– Learn how to present patients to a team

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Approach to CDI in Medical School

• “Closed head injury”

– CHI was a legitimate diagnosis for me as a med student

– “Concussion,” “cerebral laceration/contusion,” “traumatic stupor,” “coma,” etc. were rarely thought of

• “Anemia”

– ICD‐9 codes 280–285

– Iron deficiency anemias, pernicious anemias, hereditary hemolytic anemias, acquired hemolytic anemias, aplastic anemias, acute post‐hemorrhagic anemia (acute blood loss anemia), anemia in chronic illness

http://upload.wikimedia.org/wikipedia/commons/5/5c/Icd9codeslogo.png


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Approach to CDI in Surgical Residency

• One‐hour training session on CDI

– Buried in three days of “one‐hour” training sessions

– Lost on the listener who was a medical student the previous month

• Day 1 you are “the doctor”– All of a sudden my notes mattered!!!

• You learn by looking at the note written by the resident the day before (Good strategy – NO!)

• Good attendings will give you pointers related to CDI (the exception rather than the norm)

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Approach to CDI in Surgical Residency

I’m not prepared for this …

There has to be a better way … right?

We are failing our patients, institution, and ourselves.

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Latest and Greatest in CDI Interventions

What are others around the country doing to address CDI at the resident level?


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Results: Using the CPEF, a significant increase in the percentage of items documented occurred for both the attending physician and physician in training groups compared with the blank form (attending physician without CPEF, n=60, CDI=36%, SD=24%; attending physician with CPEF, n=78, CDI=89%, SD=8%; physician in training without CPEF, n=186, CDI=39%, SD=23%; physician in training with CPEF, n=167, CDI=91%, SD=8%).

CPEF = Chest pain evaluation formCDI = Critical documentation itemsSD = Standard deviation

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• Summary

– Resident education community has identified the need for CDI education, but there are few examples of successful interventions

– The use of templates can improve charting

• Better for specialties with focused problems … i.e., emergency medicine

– Performance incentives … controversial

• Some attendings at our institutions when asked are supportive of incentive‐based strategies

– Problem‐oriented approaches

– Global training approach


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The Impact of a Targeted CDI Intervention on the Documentation Patterns of Surgery Residents: Can They Improve?

Our intervention …

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Our Institution …

• Tertiary academic referral center

• Servicing 26 counties in eastern Tennessee

• 536 beds + 40 beds to be added

– 75 adult ICU beds

• 7 PICU beds

• 67 NICU beds

• 36 general surgery residents (recent expansion)

– This includes preliminary interns

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Targeted CDI Intervention for Surgical Residents

• Hypothesis

– Implementation of an individualized targeted CDI intervention for surgical residents would improve documentation patterns

• Goals

– Success was defined as an increase in geometric mean length of stay, case‐mix index, and reimbursement


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• Methods– Prospective study

– Targeted individualized CDI intervention on all surgery residents

– All charts for patients discharged from four surgical services evaluated for one month pre‐intervention and one month post‐intervention

– Demographics, LOS, GMLOS, CMI, and reimbursement recorded

Trauma MIS SurgOnc Vascular

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• Resident documentation gathered

– One H&P

– Three progress notes

– One discharge summary

• Attempted to diversify notes across patients and services

• Documents evaluated by Dr. Trey La Charité

– Our UTMCK CDI specialist

• One‐on‐one 30‐minute personalized intervention with each resident

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One‐on‐One Resident Intervention

Trey La Charité, MD

Medical Director for Clinical Integration

Physician Advisor for Clinical Documentation and Coding

University of Tennessee Medical Center

Knoxville, Tennessee


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CDI Intervention Outline

• Review of why performing intervention (5 slides)– Recap of UTMC surgical service documentation trends and why they need improvement

• Review of why CDI is important (5 slides)– Emphasizing importance for future surgical practices

• Examples of increasing data transparency (5 slides)– Hospital Compare

– Physician Compare

– Private payer websites and their physician rating systems

• Review CDI best practices (3 slides)

• Review individual resident findings (6–8 slides)

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Physician writes Dxsin chart

Coder translatesDxs to

ICD‐9‐CM

Billing dept. generates

UB04 w/ Dxsnow linked to patient’s age, race, outcome, LOS, charge, complications, etc., which is sent to CMS

Data now onHealthgrades,Hospital & Physician Compare,insurancecompany websites,

etc.

Where’s Your Data Come From?

Mistakenly, most docs believe data generated here

Only place where provider has input!

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Problem list:PADHypertensionSepsisUTIA‐fibLactic acidosis

Resident X Example


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Problem list:PADHypertensionSepsisUTIA‐fibLactic acidosis

Resident Y Example

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Where’s the problem list?

D/C summary considered“final diagnostic statement.”First place auditors look

when trying to deny payment.

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Where’s the problem list?

D/C summary considered“final diagnostic statement.”First place auditors look

when trying to deny payment.


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CDI Review of Dr. UTMC Resident Q

• Total number of diagnoses clinically or historically present but not documented = 20– Number of CCs not documented = 0

– Number of MCCs not documented = 1

• Number of potential DRG changes = 0

• Number of extra days missed (GMLOS) = 0

• Total potential RW increase missed = 0

• Total amount of money potentially left on the table = 0

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CDI Review of Dr. UTMC Resident X

• Total number of diagnoses clinically or historically present but not documented = 25– Number of CCs not documented = 3

– Number of MCCs not documented = 2


• Number of extra days missed (GMLOS) = 1.4

• Total potential RW increase missed = 1.1843

• Total amount of money potentially left on the table = $5,316.00

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CDI Review of Dr. UTMC Resident Y

• Total number of diagnoses not called = 36– Number of CCs not called = 10

– Number of MCCs not called = 3


• Number of extra days missed (GMLOS) = 6.6

• Total potential RW increase missed = 2.8153

• Total amount of money potentially left on the table = $13,819.00


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Examples of Resident‐Specific Recs

• Daily problem list (and complete list on D/C summary)• Don’t forget “SIRS/sepsis” as presentations of surgical

issues like appendicitis, IAAs, perforated viscous, or diverticulitis

• Don’t forget “malnutrition” and its grades (mild, moderate, severe)

• Don’t forget “acute respiratory failure” for patients on vents due to trauma, ICH, etc.

• Don’t forget “acute blood loss anemia” when losing blood for reasons other than elective procedures (GI bleed, trauma, hematoma, AUB, etc.)

• Don’t forget to ask yourself what kind of CHF the patient might have

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Kia vs. Honda

What you say ...

• K• I• A

Yet reality is ...

indngratiatingged

• H• O• N• D• A

Why would you want to make yourHonda look like a Kia?

ypertensivebeseoncompliantiabeticlcoholic

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Our Results of the Resident Intervention


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Results

• All surgery residents participated (n = 29)

• Pre‐intervention group of 396 patients

• Post‐intervention group of 328 patients

– These are different numbers than those notes taken for instructional purposes

• Actual LOS remained constant!

– 4.0, IQR 5.0 vs. 4.0, IQR 5.0; p = 0.970(IQR = Interquartile range)

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Results

Table 1: Baseline comparisons for study groups

VariableFrequency (%) or Median (IQR)1

p‐value2Pre‐intervention Post‐intervention

Sex

Female 162 (54.0%) 138 (46.0%) —

Male234 (55.2%) 190 (44.8%)

OR = 0.95 (95% CI =

0.71 – 1.28), p = 0.752

Age 55.00 (33.00) 56.00 (32.50) 0.909

LoS 4.00 (5.00) 4.00 (5.00) 0.970

Service

Orange 270 (56.4%) 209 (43.6%) —

Vascular79 (52.7%) 71 (47.3%)

OR = 0.86 (95% CI =

0.60 – 1.24), p = 0.426

White36 (50.7%) 35 (49.3%)

OR = 0.80 (95% CI =

0.48 – 1.31), p = 0.371

Red11 (45.8%) 13 (54.2%)

OR = 0.66 (95% CI =

0.29 – 1.49), p = 0.3141IQR = Interquartile range2Comparisons made using Mann‐Whitney U and chi‐square tests of independence, as appropriate.

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Results

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Pre‐Intervention Post‐Intervention

Difference in GMLOS compared to ALOS

GMLOS1.09

1.90


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Results

2.1

2.15

2.2

2.25

2.3

2.35

2.4

2.45

2.5


CMI

CMI

2.25

2.47

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Results

$11,200

$11,400

$11,600

$11,800

$12,000

$12,200

$12,400

$12,600

$12,800

$13,000


Reimbursement

$11,834

$12,790

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Results

Pre‐intervention Post‐intervention p‐value

GMLOS M = 1.90, SD 6.69 M = 1.09, SD 8.17 0.134

CMI 2.25, SD 1.94 2.47, SD 2.32 0.165

Reimbursement $11,834, SD $12,744 $12,790, SD $14,108 0.333


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CDI Intervention for Surgical Residents: Can They Improve? YES!

• Limitations: Use of advanced practitioners, running diagnosis lists, cross cover of surgery residents

• Scientific significance does not equal real‐world business

• Future goals:

– Focused surgery intern training during second month

– Repeat study to evaluate skill maintenance

– Repeat study with larger patient sample

– Export our model to other residency departments

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Take‐Home Points …

• Surgical residents are an untapped resource

– We CAN learn and we WANT to learn

• Targeted resident education can increase hospital revenue

• Be creative, think about durable solutions


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Thank you. Questions?

[email protected]@mc.utmck.edu

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