Elizabeth Bonetti, RN, MA, MS
Using Data to Recharge Your CDI Program
HISTORY
• Community hospital
• Member NYPHCS
• ADC 300-325
• Urban setting
HISTORY
• Shared resource model
– Case managers assumed CDI function
– Physician and hospital staff education
• Coding opportunities
– Department development
HISTORY
• Physician education
• Audits and re-bills
• Multiple false starts!!!!
WHY NOW?
REALITY: PAYMENT RESTRUCTURING MS-DRGS
• Pay for performance: Direct– Coding/outcomes (P4P)
• Pay for performance: Indirect– Consumer choice– Selective contracting
• No pay for poor performance: – Adverse events not POA
• Recovery Audit Contractors (RAC) 2010:– Readmissions– Bundled $
American Journal of Medical Quality: “Medicare’s Value-Based Payment Initiatives: Impact on and Implications for Improving Physician Documentation and Coding,” by Alan H. Rosenstein, MD, MBA, Michelle O’Daniel, MSG, MBA,Susan White, PhD,Ken Taylor
HOSPITAL DATA REPORTS
• MS-DRG coding impact – Coding complexity– Financial impact projections
• NYS DRG severity impact • Severity-adjusted LOS report
– Opportunity assessment
• Adverse event incidence and impact • CMS/JC quality indicator report• HealthGrades report
– Actual to expected mortality/complication rates– Patient safety ratings
WHAT IS IMPACTED?
• Revenue
• ALOS
• Patient flow
• Medical necessity and DRG denials
• Quality data reporting
• Risk management
ADMINISTRATIVE SUPPORT
• CEO
• CMO
• CFO
• Finance
• Clinical chairmen
• Nursing leadership
• Clinical pharmacy
• IT
• Compliance
• Case management
• HIM
PHYSICIAN INCENTIVES
• Improves patient outcomes• Emotional: Loyalty/pride/respect• Competitive: Peer pressure• Awareness/accountability:
– Reputation– Contracting– OPPE
• Financial:– Billing– P4P incentives– Market share
American Journal of Medical Quality: “Hospital Report Cards: Intent, Impact, and Illusion,” by Alan H. Rosenstein, MD, MBA
Medical Economics: “When Health Plans Don’t Want You Anymore”
PROGRAM PLACEMENT
Assistant vice president
Clinical documentation improvement
Coding Patient
placement Social work
Senior vice president, chief financial officer Executive vice president, chief medical officer
Denials management Case management
Health information management
DEVELOPMENT
• Opportunity for improvement – Assessment
– DRG benchmark report
• Business plan
• Vendor selection
• Physician buy-in
• Staffing—type of workers
• Collaboration with HIM
• Tools
• Reporting—monthly benchmarks
PHYSICIAN BUY-IN—WHAT’S IN IT FOR ME?
• Salaried vs. voluntary physicians
• Education at routine meetings
• Tied to professional billing
• Meet the physician for 1:1 reviews
• Achievement certificates
• OPPE reporting
This certificate is awarded to
DateSignature
DateSignature
Jennifer Smith, MD
in recognition of excellent clinical documentation:
“CHF, acute on chronic with systolic dysfunction; respiratory failure
secondary to pulmonary edema”
CERTIFICATE OF EXCELLENCE
METHODOLOGY/TOOLS
• Work environment
• Laptops—concurrent entries– 3M coding software and Sunrise Record
Manager
– CDI database
– EMR
• Pocket guides—physician billing guidelines
METHODOLOGY/TOOLS
• Physician query sheets/electronic query
• Policies/processes
• Weekly coding/CDS leadership meetings
• Strategic postings
• Verbal rewarding and candy
• Physician achievement certificates
• Validation of $$ reported
A NEW START
A branding all its own!
NETPRESENTER
• Clinical documentation program– Accurate provider and hospital profiling is now
possible
– Instant feedback on practitioner documentation to reflect severity of illness
– Coming events: Physician/staff education seminars
– Documentation team is now in place; contact Jennifer at Ext. xxxx or Brenda at Ext. xxxx for more information
Physician query
• Bright color
• Inserted in progress notes
• CDI contacts
• Compliant
METHODOLOGY/TOOLS
• Rollout
– Physician rounds
– Disease based vs. unit based
– Emergency department
• Coder identified opportunity (retro)
• Electronic query solution
COMPLIANCE
• Policy review
• Process review
• Query review
• Reports
CD TEAM EDUCATION
• Team-building methodology – All attended coding review/
updates
– Graduation
– Celebrations
– New staff orientation
– Bimonthly education/sharing
EDUCATION
– Across all disciplines
– Grand rounds
– Resident lectures
– Strategic postings
– 1:1
– Unit-based small conferences
– Physician rounds
– Discharge summary review
– EMR utilization
Reports drive success and improvement
MONTHLY FINANCIAL DASHBOARD
Month/year Reviews
MD queries
(+) DRG changes Variance
Type of reviews # % # % # %
Concurrent opportunities
Retrospective opportunities
Re-bill records
Severity of illness (SOI)
No opportunity
TOTAL
• Senior finance leadership dashboard—monthly and annual tracking
• Case-specific validation
• Annual budgeted revenue expectation
• Tracked for attaining annual target
ANNUAL FINANCIAL DASHBOARD
Type of Reviews
# Reviews
% DRG change
Variance #
Reviews % DRG change
Variance #
Reviews % DRG change
Variance #
Reviews % DRG change
Variance
Concurrent Opportunities
108 63% $184,206 26 65% $68,762 35 97% $186,721 313 76% $1,063,587
Retrospective Opportunities
41 44% $83,196 33 45% $54,622 37 51% $119,249 193 46% $443,922
Rebill Records
2 100% ($7,756) 0 0% $ - 2 0% ($13,956) 11 67% $22,739
Severity of Illness
10 na na 25 na na 47 na na 107 na na
No Opportunity
17 na na 34 na na 54 na na 177 na na
TOTAL 178 69% $259,646 118 37% $123,384 175 49% $292,014 801 63% $1,530,248
Apr May June YTD
CDI CLINICAL DEPARTMENT DASHBOARD
Apr May June 2nd Q
Clinical department
# reviews
% DRGchange
Variance #
reviews % DRGchange
Variance #
reviews % DRGchange
Variance #
reviews % DRGchange
Variance
Family medicine
27 82% $39,940 24 50% $14,657 29 100% $ 38,316 80 77% $92,913
Internal medicine
137 68% $192,698 91 57% $96,846 140 94% $ 245,572 368 73% $535,116
OB/GYN 3 100% $10,887 0 0% $0 3 0% $ - 6 33% $10,887
Pediatrics 3 100% $6,072 1 100% $7,911 0 0% $ - 4 67% $13,983
Surgery 8 62% $10,049 2 100% $3,970 3 100% $ 8,126 13 87% $22,145
TOTAL 178 69% $259,646 118 55% $123,384 175 83% $ 292,014 471 69% $675,044
• Clinical department leadership dashboard—monthly and annual tracking • Departmental CMI and revenue impact • Specific physician monitoring included
PHYSICIAN-SPECIFIC DASHBOARD
September 2010
Family medicineattending MD
Cases reviewed
Queries MD response MD agreement $$ variance
Yes No Yes No
John McParland 10 22 0 1 1 ($4,277)
Mary Eagan 12 2 2 0 2 0 $8,524
Steve Seifried 22 4 3 1 3 0 $24,123
Andrew Smith 15 1 1 0 1 0 $2,100
Total 59 9 8 1 7 1 $30,470
• OPPE indicator
• Physician response and agreement rate
• Case-specific data available on request
CDI STAFF DASHBOARD
October 2010
Family medicineattending MD
Cases reviewed
Queries MD response MD agreement $$ variance
Yes No Yes No
Jennifer Smith, RN 325 45 42 3 40 2 $77,240
Annaliza Gonzales, RN 375 66 60 6 59 1 $107,830
Elizabeth Jones, RN 280 42 40 2 38 2 $52,231
Sally Jones, RN 288 38 35 3 32 3 $45,455
Total 1268 191 177 14 169 8 $282,756
• Staff productivity monitoring
• Staff QA monitoring
• Staff feedback
DASHBOARD—IN DEVELOPMENT
• By DRG– Education opportunity by service line
– Opportunity for hospital improvement
THE ULTIMATE GOAL
• Balance cost and quality
COSTQUALITY