We Start an Outpatient CDI Program, Now What Do We Do? This is … · –Late 2016, picked up another payer and added more clinics –Wake Forest Baptist Medical Center purchased

1

This is the Full Title of a Session

We Start an Outpatient CDI Program, Now What Do We Do?

David Reece, BSN, RN, CCDSOutpatient Clinical Documentation SpecialistWake Forest Baptist Medical CenterWinston‐Salem, NC

Sara Atwater, MD, MPHAssistant Professor Internal MedicineWake Forest Baptist Medical CenterWinston‐Salem, NC

2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

2

Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Demonstrate EMR (Epic) integration as a CDI tool for documentation and queries

– Define ROI impact and identify tracking methods– Discuss program metrics– Identify and discuss ambulatory provider program engagement and integration


3

Agenda

• Overview of Wake Forest Baptist Medical Center Outpatient Clinical Documentation Excellence Department

• The role of the EMR as a CDI documentation tool• Defining program ROI and tracking impact• Establishing a CDS workflow• Defining productivity metrics• Physician champions in the ambulatory setting• Promoting provider engagement


4

Overview of the Wake Forest Baptist Medical Center Outpatient Clinical Documentation Excellence Department


5

Wake Forest Baptist Medical Center


6

Wake Forest Baptist Medical Center Outpatient Clinical Documentation Excellence Department

• The outpatient CDE team was born out of an ICD‐10 educational group in the summer of 2015– Value‐based contracts needing Hierarchical Condition Categories (HCC) follow‐up

– Clinovations HCC tool initiative

• Initial focus– Prospective reviews and education– Started with three clinics in a stair‐step fashion based on largest volume of contracted lives

– Covered one payer for 3‐month pilot with two CDSs


7


• Expansion timeline– 2 additional CDSs hired by end of 2015– 2 additional CDSs hired in 2016– Began prospective reviews and querying providers in March 2016

– Late 2016, picked up another payer and added more clinics– Wake Forest Baptist Medical Center purchased Cornerstone Health Care in 2017 and hired 2 additional CDSs

– Transitioned from data cube to Wake One (Epic) platform in June 2017

– Incorporated electronic queries and CDE documentation into Wake One


8


• Current status– Coverage includes 4 payers under 6 separate contracts– 20 clinics are currently covered– 8 CDSs– 40%–45% of Medicare Advantage patient population covered

– CDE Analyst Pilot began in March with focus on back‐end query reconciliation between coding and billing

– CDE workflow completed in Wake One– Wake One reports for key performance indicators in use, although accuracy is monitored through spreadsheets at this time


9

Department Performance


10

“Raise Your Hand” Questions

• How many of you have incorporated a software program as a CDI tool in the outpatient setting?

• How many of your outpatient CDI programs have defined metrics?

• How many of your outpatient CDI programs have dedicated physician champions?


11

The Role of an Electronic Medical Record as a CDE Documentation Tool in the Outpatient Setting


12

Getting By

• Limited resources available to initiate or launch an outpatient CDI program or define the focus of outpatient CDI

• Most CDI software companies are still in the developmental stage of outpatient CDI platforms, resulting in many new programs trying to adapt current software to fit their needs or resorting to time‐consuming manual tracking


13

So What Did We Do?

• Initially, the CDE outpatient department at Wake Forest Baptist Medical Center was in the same boat as everyone else

• After establishing a solid workflow with the 3 pilot clinics, CDS starting writing queries on paper to pass along to the providers– Each clinic had a slightly different process based upon provider preference and workflows

• In early 2017, a trial was started using the Wake One provider In Basket to send queries electronically, although CDE documentation and query tracking was done manually


14

The Real Breakthrough

• After a very long development and build time, CDE documentation, tracking, and queries were transitioned to Wake One in June of 2017

• CDE daily reviews and outstanding queries are now reports generated in Wake One that are produced as workbenches

• CDE queries are generated as a master Best Practice Advisory alerting the provider as they start the encounter

• CDSs can now see and follow each other’s documentation• Integrating with the Epic platform allowed our program to

utilize the strengths of resources already available


15

Our Tools, Our Process


16

Wake One CDE Tools

• CDE new review workbench• Review of previous CDE encounters• Problem list• HCC Left• Electronic queries• Best Practice Advisory• CDE open query workbench


17

The Workbench: Where It All Begins

• Each workbench or worklist is generated from reports in Wake One– Report criteria include

• Department and provider• Patient scheduled status• Registry ID

– Medicare Advantage, ACO, MSSP• Patient living status• Date range

– Plus or minus 7 days– Primary individual CDS‐adjustable filters include

• CDS of record• Date ranges• Primary payer• Appointment department


18

CDE Review WorkbenchRisk Score: This is based on multiple factors including disease registries for CHF, CAD, CKD stage 4, behavioral health, and substance abuse.


19

Where Do We Look for Opportunities?

• HCC Left– Incorporated into the Wake One patient header– Identifies HCC diagnoses

• Populated by HCCs that are on the problem list but have not been billed for the calendar year

• Works in tandem with a third‐party tool within Wake One that prompts providers to document HCC diagnoses based on above criteria– Tool also identifies GFRs that meet stage 4 and 5 CKD, BMI of 40 or greater, potential diagnoses related to amputations


20

HCC Left


21

The “Problem List”

• The Wake One problem list identifies HCCs by ICD‐10‐CM codes– The good

• Common and not‐so‐common HCC diagnoses are identified• Any provider can see which diagnoses are HCCs

– The not‐so‐good• HCC values must be updated via Intelligent Medical Objects (IMO) vocabulary– Not always a priority for IT

• HCC diagnoses need to be updated as CMS makes changes• Wake One providers can change the diagnosis wording, which doesn’t always match the ICD‐10 code that should be used


22

Problem List Identifying HCC Diagnoses

© 2018 Epic Systems Corporation. Used with permission.

Diagnoses with HCC value are identified


23

Reviewing Previous Encounters

• Each encounter in Wake One is identified per encounter type and by provider

• Individual CDSs can filter the notes in various ways– Chief complaint– Diagnoses/impressions– Department – Admissions – Office visits– Phone/email– Previous CDE notes


24

Review of CDE Notes

Chart Review: Encounter notes filtered on Clinical Documentation Excellence


25

CDE Review Only

By double‐clicking on the specific encounter, it opens the CDE note up for reading


26

The Encounter Tab: Where the Real Magic Starts

• Each CDS review begins by opening an encounter as a provider– Limited provider access allows the CDS to complete certain

functions and see additional patient information• Encounter tab options

– Medications– Problem list– Previous query– Query 1– Query 2– CDE review only– Quality measures– Sign visit


27

CDE Previous Query and Review Flowsheet

Allows a CDS to see all previous queries, query status, and provider response through opening up the “Review Flowsheet” selection


28

Writing a Query in Wake One

• Queries are written to ensure accurate, complete, and compliant documentation within the medical record

• Queries are based on clinical indicators and diagnoses already in the medical record and must meet current standards for compliance– Guidelines for Achieving a Compliant Query Practice, AHIMA Practice Brief, 2013 (updated for ICD‐10 in 2016)

– Queries in Outpatient CDI: Developing a Compliant, Effective Process, ACDIS Paper, January 8, 2018

• A CDS may leave 2 queries per scheduled encounter for the provider

• Queries will stay “active” for 30 days unless resolved


29

CDE Query Development

© 2018 Epic Systems Corporation. Used with permission.

All queries must contain clinical indicators unless the query is for problem list “cleanup” and no current documentation is found (which should be noted in the reference notes field).


30

CDE Query Development


31

Master BPA: What Do the Providers See?

• All queries fire as a “master” best practice advisory (BPA) when the provider opens a patient encounter

• Other notices populate with the CDE query on the master BPA– Immunizations– Transitional care – Quality measures

• Provider’s options for CDE BPA– Dismiss the master BPA– Select acknowledge with prompting for documentation

• Recommended that provider document reason if not going to address query during the encounter

– Select link to problem list for updating– No option to go directly to the note or respond to query here


32

Provider View of Master BPA With CDE Query

Providers may dismiss the BPA or select acknowledge and add documentation or go directly to the problem list


33

Provider View of CDE Query

• If the provider dismisses the query or wishes to look at it again, the query may be viewed from the Quality Measures or MU tabs (depending on provider view settings)

• Four options for query acknowledgement– Yes, I will update the documentation– No, I will not update the documentation– I will add alternate documentation– I am not the provider responsible for this patient

• Provider may leave documentation under Acknowledge Reason to clarify response


34

Provider View of CDE Query


35

CDE Open Query Workbench

• The open query workbench is viewed each day to address outstanding queries

• Query follow‐up is outlined in our CDE review process• Queries will populate on the workbench as long as the query resolve response is set to “NO” and the query is less than 31 days old

• Each CDS may filter the report based on their queries


36

CDE Open Query Workbench


37

Payer Reports

• Provides a 2‐year “lookback” of HCC diagnoses that were billed but may not have been documented in the current calendar year

• The report is updated each month to remove patients that have already been accounted for

• The report is utilized for each patient review• If a diagnosis does not apply to the patient anymore, it is noted

as invalid on the report• Valid diagnoses are marked as such and remain on the report• Pros

– Highlights diagnoses that may have been documented at an outside facility

• Cons– Often includes acute diagnoses or diagnoses entered in error


38

Department Metrics and CDE ResponsibilitiesAn evolving process as the program matures


39

Key Performance Indicators

• Monthly average of daily initial reviews– Optimal ≥ 17– Target 14–16– Threshold 11–14

• Monthly query average ≥ 30%• Monthly audit score ≥ 90%• Provider response rate goal > 80%• Monthly provider education time goal is 4 hours• Remote work metric criteria• Total monthly RAF potential


40

CDE Responsibilities

• Medical record review– Initial review– Query follow‐up and escalation

• Education– Weekly and PRN clinic visits – In‐time and formal education sessions with assigned clinics– Assist with provider compliance training– Assist with provider/clinic annual quality training

• Communication– Promote and maintain open dialogue with providers and clinic/support staff


41

The Physician Champion and Provider Engagement


42

Physician Champion in the Outpatient Setting: Finding the Right Fit

• Time and willingness• Institutional support of the role• Compensation• Accessibility• Outpatient setting experience• Significant clinical responsibilities• Balancing time: patient care versus physician champion responsibilities


43

Promoting Provider Engagement

• Where is the biggest bang for the buck– Face‐to‐face time

• Challenges with multiple provider/clinic schedules– Consistent reinforcement of program goals

• Supporting CDE efforts• Proper documentation and billing to capture acuity of patient population

• Institution policies and initiatives– Streamlining/simplifying CDE queries for provider understanding


44

Promoting Provider Engagement

• How are providers impacted by quality and safety– Provider reimbursement

• How do you get providers on board with risk adjustment and HCCs if it doesn’t impact their pocket directly (yet)

• Current state versus future state– Relative value units (RVUs)

• What they are and how they impact provider payment– Evaluation and management coding– Value‐based care

• Accountable care organizations• Bundled payments• Patient‐centered medical homes• MACRA, MIPS, APMs


45

Provider Engagement: What Matters to Them?

• Does the documentation reflect statements that you take care of the sickest patients

• Public profiles: What do their patient outcomes and acuity look like to outsiders

• Financial stability • Practice improvement

– Staffing– Equipment

• Provider and practice competition• Making the job of actually taking care of patients a priority


46

Challenges Facing Providers

• Paperwork and red tape burnout– HCCs are just one more thing

• Problem lists – Nationwide problem– Who owns it – Why is the primary care provider responsible

• Electronic medical records– Retrofitting to fit provider’s needs– Click overload– Copy and paste


47

Summary


48

So Where Does That Leave Us?

• “Outpatient or ambulatory” CDI settings are still being explored and are loosely defined compared to inpatient CDI

• Outpatient CDI software or prebuilt tools are mostly in the development stage or do not fit across all ambulatory settings

• New resources available to initiate outpatient CDI programs• Multiple consulting firms now have outpatient CDI divisions• Metrics are dependent on program focus, workflow, and setting• Institutional support is critical• Provider engagement and buy‐in is very different than inpatient• Physician champions are key to program acceptance by

providers• Bonus – did anyone recognize a theme in the patient names or

their assigned provider?


49

Thank you. Questions?

[email protected]@wakehealth.edu

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


Documents

We Start an Outpatient CDI Program, Now What Do We Do? This is … · –Late 2016, picked up another payer and added more clinics –Wake Forest Baptist Medical Center purchased