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3 rd Annual Association of Clinical Documentation Improvement Specialists Conference 3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

Data Mining and Reports: Using Data to Drive your CDI Program Provena Covenant Medical Data Mining and Reports: Using Data to Drive your CDI Program Provena Covenant Medical Center Maureen Baxley, RRT, RN, BSN, Clinical Documentation Nurse Carla Henderson, RRT, RN, BSN, Clinical Documentation Nurse Provena Health Nancy R. Ignatowicz, RN, MBA, CCDS, System Manager Clinical Documentation

Provena Health • 6 hospitals; separated by 210 miles • 12. 4 CDI FTEs Provena Health • 6 hospitals; separated by 210 miles • 12. 4 CDI FTEs (14 nurses) + System Manager Clinical Documentation + System Director Coding & Documentation • 1, 538 licensed beds • 65, 530 reviews in 2009 (7% post-discharge) • 10, 938 queries in 2009 (16% post-discharge) – – – 27% SOI/ROM/POA 27% MCC 26% PDx 19% CC 1% Procedural

How do you get from Here to Here Are you sure you want to? How do you get from Here to Here Are you sure you want to?

Compelling issue and questions • It is a waste of time to collect data Compelling issue and questions • It is a waste of time to collect data and create reports ~ and do nothing with it – How do you decide what to collect? – What do you do with the data once you collect it?

Pertinent topics • • • Productivity Financial Audits Education Profiling Pertinent topics • • • Productivity Financial Audits Education Profiling

Productivity Productivity

Measuring productivity JUN 250 JUL 295 AUG 260 SEP 240 OCT 425 NOV 400 Measuring productivity JUN 250 JUL 295 AUG 260 SEP 240 OCT 425 NOV 400 DEC 375 JAN 325 120% 450 110% 400 100% 90% 350 80% 300 70% 60% 250 50% JUN 200 JUN JUL AUG SEP OCT NOV DEC JAN

Adjusted productivity JUN 250 200 375 JUL 295 190 420 AUG 260 220 400 Adjusted productivity JUN 250 200 375 JUL 295 190 420 AUG 260 220 400 SEP 240 250 425 OCT 425 260 400 NOV 400 200 500 DEC 375 270 525 JAN 325 290 550 DEC JAN 115% 105% 95% 85% 75% 65% 55% JUN JUL AUG SEP OCT NOV

Financial data Financial data

Measuring financial impact • Reproducible • Able to correlate with census; vacations (staff and Measuring financial impact • Reproducible • Able to correlate with census; vacations (staff and provider); etc. • Ensure that without the CDI query, benefit would not have occurred • Audit to ensure consistency in data entry and post-discharge reconciliation to ensure creditable outcome data

Financial variance $300, 000 $250, 000 $200, 000 $150, 000 $100, 000 $50, 000 Financial variance $300, 000 $250, 000 $200, 000 $150, 000 $100, 000 $50, 000 $0 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

Advice from the consultant “I guess canceling all remaining vacations is a little too Advice from the consultant “I guess canceling all remaining vacations is a little too much to ask, huh? ”

DNFC A C E G I K $1, 689, 283 $1, 203, 048 $1, DNFC A C E G I K $1, 689, 283 $1, 203, 048 $1, 024, 401 $2, 531, 169 $1, 106, 886 $4, 102, 009 $2, 259, 497 $1, 789, 527 $6, 303, 134 $3, 526, 348 $2, 117, 023 $5, 859, 495 $2, 695, 518 $2, 698, 060 $6, 606, 744 $3, 963, 881 $3, 101, 549 $6, 928, 074 $2, 438, 182 $2, 010, 902 $6, 763, 622 $6, 956, 491 $3, 965, 210 $7, 140, 437 • What portion of unanswered queries contribute to DNFC? • What effect do vacations have? • Post-discharge follow-up process • 0. 5 FTEs job shared

Reconciliation audits • Systemwide staff mismatches in assigning benefit (both negative and positive mismatches) Reconciliation audits • Systemwide staff mismatches in assigning benefit (both negative and positive mismatches) • Computer issues • Isolated discrepancies; individualized mentoring • No unexplainable issues; reduce monitoring to sampling MONITER EDUCATE REPEAT THE PROCESS

Forum: Clinical documentation Show teamwork; multidisciplinary communication and collaboration has led to improved capture Forum: Clinical documentation Show teamwork; multidisciplinary communication and collaboration has led to improved capture in clarity and specificity of diagnoses This leads to more timely submissions for coding/ billing

Using these economic times to illustrate CDI to all disciplines • Patient care techs Using these economic times to illustrate CDI to all disciplines • Patient care techs – Height and weight • Dietitian – BMI Inpatient: Vascular Procedure Height & Weight NOT Documented Ht. & Wt. documented and BMI >40 or <19; and treatment ordered $8, 800 (MS-DRG 254) $12, 900 (MS-DRG 253) • Physicians – Order diet or supplements • Nurses – Document supplement intake (actual dollar amounts will vary by hospital)

Don’t take your data at face value, get down to the details Don’t take your data at face value, get down to the details

Identify improvement opportunities • Audit – Charts – Data entry into tracking tool – Identify improvement opportunities • Audit – Charts – Data entry into tracking tool – Tracking tool data reconciliation • Factor in your variables • Analyze your results • Analyze outcomes pre- and post-intervention Remember, it is not just about the financial opportunity.

Inter-rater reliability; consistency and credibility • Charts – Each hospital’s audit may have a Inter-rater reliability; consistency and credibility • Charts – Each hospital’s audit may have a unique target • Queries – Were they needed – Were they non-leading • Tracking tool – Currently using Midas 7. 2. 4 with PH developed focus note screens to track our data within the Midas CM module

Audit: ‘My doctors document well’ • Productivity measures below target • Pattern: case reviewed Audit: ‘My doctors document well’ • Productivity measures below target • Pattern: case reviewed only once, no follow-up review • Finding: – Documentation changed after initial review; if case would have had follow-up reviews, it was likely that 64% would have been asked a query for clarification • Conclusion: – Mentor staff to continue to follow cases rather than try to see all cases – Findings used to write for an increased staffing proposal

Audit: ‘Our doctors document poorly’ • Cost per case higher than Medicare base rate Audit: ‘Our doctors document poorly’ • Cost per case higher than Medicare base rate • Average LOS greater than GM-LOS • Finding: Queries were written and answered in H&P (Get down to the details: H&P dictated days after query was written) • Conclusion: Seek administrative assistance

Audit: Performance • Productivity measures below target • Finding: Get down to the details, Audit: Performance • Productivity measures below target • Finding: Get down to the details, don’t just look at productivity number as the census was low • Incidental finding: patient expired; few diagnoses documented; SOI~2; ROM~2 • Conclusions: collaborate with quality to perform review of death charts for documentation opportunities; expand target to all payer, all ages

Justify increasing your FTEs • Audit to verify opportunity is being missed (remember to Justify increasing your FTEs • Audit to verify opportunity is being missed (remember to include SOI/ROM cases) – Use audits from other ministries to support calculation justifications • Project increased caseload volume that would be seen with increased FTE • Mentor current staff to optimize productivity measures before requesting increase in FTEs Remember T~3

Discover the hidden benefit Discover the hidden benefit

CDI staff education • Reconciliation is a teaching tool • CDI education/HIM education – CDI staff education • Reconciliation is a teaching tool • CDI education/HIM education – Is education/mentoring needed • Is it isolated or systemwide – Is it a process improvement opportunity • Is it one ministry or a system opportunity – Agree to disagree

MIDAS Reconciliation as a teaching tool • CDI nurse performs own reconciliation • Manager MIDAS Reconciliation as a teaching tool • CDI nurse performs own reconciliation • Manager initially performed 100% reviews of queries then decreased to sampling Conclusions: Able to gain objective data; opportunity to learn mentoring opportunities for individuals and for systemwide; opportunity to identify concurrent versus post-discharge interventions; opportunity to identify provider opportunities; opportunity to identify best practices and share with others and improve performance …

Don’t just analyze, do something Don’t just analyze, do something

Data-driven education • What are your most frequent queries? • Physicians: Do they not Data-driven education • What are your most frequent queries? • Physicians: Do they not answer any query or just certain queries? • Evaluation: What is the pre- and posteffect of your physician documentation CME?

Query frequency Renal failure 7 9 11 11 7 6 AMS 6 2 4 Query frequency Renal failure 7 9 11 11 7 6 AMS 6 2 4 1 0 0 Anemia 5 16 4 9 6 3 Debridement 0 0 1 1 2 2 Heart failure 13 44 10 12 17 2 Malnutrition 5 7 20 5 3 11 Pneumonia 19 0 5 11 7 8 Pressure ulcers 2 5 10 8 0 1 Respiratory failure 4 0 4 7 9 10 Sepsis 6 5 6 7 16 17 UTI 2 2 2 4 2 5

Heart failure documentation Heart failure documentation

Physician responses This can be hospital- or physician-specific. We can also stratify by query Physician responses This can be hospital- or physician-specific. We can also stratify by query topic. # of Queries 124 44 250 101 127 193 # of Q answered in agreement 69 26 143 32 45 62 # of Q ans. in disagreement 7 2 16 4 16 10 # of Q not pursued 2 1 9 18 2 1 # of Q ans. physician uncertain 0 0 0 1 1 0 62. 9 65. 9 67. 2 54. 5 50. 4 37. 8 Preliminary Physician Response Rate 2009 CUMMULATIVE Physician Response Rate 90% 76% 94% 75% 82% 59%

Physician CME PRE CME data 1. 1971 POST CME data All-payer Overall CMI less Physician CME PRE CME data 1. 1971 POST CME data All-payer Overall CMI less trachs 1. 2548 MEDICARE 1. 4698 CMI less trachs 1. 4817 1. 0876 Medical CMI less trachs 1. 0906 2. 7593 Surgical CMI less trachs 2. 8011 55. 1 MCC capture rate 57. 0 69. 6 CC capture rate 67. 1 4. 58 HF LOS ~ all payer 3 months before versus 3 months after CME 4. 29

HOLY COW: Someone is looking • Is cost per case higher than expected? • HOLY COW: Someone is looking • Is cost per case higher than expected? • Is LOS higher than expected? • Is SOI and ROM low?

Why profile? • • Credentialing (quality and economic) Excluded from insurance network Marketing/competition Medicare Why profile? • • Credentialing (quality and economic) Excluded from insurance network Marketing/competition Medicare P 4 P and VBP Patient insurance copays Personal salary Profiles/report cards Third-party contractual

Physician profiles • • Average Avoidable days CMI Cost LOS SOI ROM Physician profiles • • Average Avoidable days CMI Cost LOS SOI ROM

Physician-specific example Cases Days LOS GM LOS Variance CMI Cost/ CMI SI ROM Age Physician-specific example Cases Days LOS GM LOS Variance CMI Cost/ CMI SI ROM Age Dr. 123456 10 77 7. 70 4. 77 29. 30 1. 4963 16974 11, 344 2. 90 2. 60 74 Dr. 678912 3 12 4. 00 2. 57 4. 30 1. 0354 8, 596 8, 302 2. 00 1. 33 56 Dr. 345678 121 598 4. 94 4. 82 14. 60 1. 4387 8, 237 5, 725 2. 87 2. 60 75 INTERNAL MEDACINE 618 2, 655 4. 30 4. 49 (117. 10) 1. 3264 7, 878 5, 939 3. 00 2. 89 75 Ministry A 806 3, 616 4. 49 4. 51 (16. 00) 1. 3605 8, 552 6, 285 2. 59 2. 36 75 Ministry B 2131 8, 306 3. 90 4. 37 (1005) 1. 3109 7, 970 6, 080 2. 10 1. 72 74 Ministry C 2135 9, 028 4. 23 4. 45 (479) 1. 3802 8, 565 6, 206 2. 15 1. 75 56 National avg. Medicare payment for FY 2010 is $5, 223. 14 37

The epiphany Oh my ____ What are we going to do? The epiphany Oh my ____ What are we going to do?

Physicians in private practice • Clinic physician serving as CDI physician • • liaison Physicians in private practice • Clinic physician serving as CDI physician • • liaison for own group Clinic partnering with hospital to work on documentation Requesting CME at their offices Utilizing profiling data in peer evaluations Utilizing query response rate in annual physician appraisals

Wrap-up Wrap-up

You too can be data-driven with your limited resources • Audit to identify opportunities You too can be data-driven with your limited resources • Audit to identify opportunities – Create automated data reports that measure and promote accountability – Apply the lessons learned (across the system) – Physicians want data – Use data to direct physician CME education COMMUNICATE and EDUCATE

Managing your resources: Being data-driven NOT data rich • Partner with IT/DS: Automate reports Managing your resources: Being data-driven NOT data rich • Partner with IT/DS: Automate reports • Partner with your multidisciplinary steering committee: Limit data collection to what you are going to use ~ actionable data • Make sure your data is objective and reproducible • Educate: – Deliver key points – Bullet-point it

Using data to promote change in your organization • Doing more without increasing staffing Using data to promote change in your organization • Doing more without increasing staffing or changing productivity or financial targets – Learn from others; make knowledge transferable: extrapolate what you learn where applicable • Address shortages of time and staff

Using data to drive your CDI Program Using data to drive your CDI Program

Questions ? ? ? ? ? Thank You Questions ? ? ? ? ? Thank You