Transcription of Clinical Documentation Improvement: Reporting …
1 Clinical Documentation improvement : Reporting Opportunities Karee Burns, RN, BSN. Midas+ Solutions Consultant Waheed Baqai, MPH, CPH. Director Clinical Decision Support Loma Linda University Medical Center Objectives 1. Attendees will be able to state a process for identifying key CDI processes and stakeholders. 2. At the end of the presentation, staff will be able to identify Midas+ Reporting tools that can be used to develop reports for CDI processes and stakeholders. 3. Attendees will be able to identify how Reporting from Clinical Documentation improvement (CDI) efforts can have an impact on their National Quality Forum (NQF). scores. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 2.
2 Disclaimer: Unless otherwise stated, all patient, provider, and / or employee names in the following slides are fictitious. No HIPAA regulations were violated in the creation of this presentation. In other words: These reports are from the Midas+ demo database. That's why the dates are older and the numbers are small! The reports will work just as well using your real, live data. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 3. Adult and Pediatric Level I Service to >26%. Trauma Center of California Four campuses 4 Million People Regional CCS (California Children's Services designation). Children's Hospital LLUMC. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 4.
3 LLUMC: Who We Are 13,500 Employees 4,200 Students 700+ Residents in 26 programs & 21 fellowships Million patient visits annually 850 Physicians in 55 specialties & subspecialties 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 5. LLUMC's Clinical Documentation improvement Program Reports to Patient Safety and Reliability under Patient Safety and Quality/Chief Patient Safety Officer Five full-time CDS RNs Medicare/DRG-based Payers Only Program started in May 2008. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 6. Hospital 1. Hospital 2. Hospital 3. LLUMC. Hospital 4. Hospital 5. Hospital 6. Hospital 7. Hospital 8.
4 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona Hospital 9. Hospital 10. Hospital 11. LLUMC. Hospital 12. 7. LLUMC. LLUMC Mortality by Calendar Year Actual Expected FY 2004 FY 2005 FY 2006 FY 2007 FY 2008. CMS MedPar: Q4 2003 to Q3 2008. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 8. LLUMC. Medicare Inpatient Case Mix Index 2007 2008 2009 2010 2011. 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 9. LLUMC. Among the Best in 7 specialties: Pulmonology Cancer Diabetes & Endocrinology ENT. Gynecology Kidney Disorders 2010 Urology 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 10.
5 LLUMC. Among the Best in 10 specialties: Cancer Cardiology and Heart Disease Diabetes & Endocrinology ENT. Gastroenterology Gynecology 2011 Nephrology Orthopedics Pulmonology Urology 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 11. LLUMC. CDI Reporting Reporting has been key component in success of CDI at LLUMC. Determining what type of data and frequency of review are important steps in CDI maintenance and success Transition from previous vendor to Midas+ Care Management CDI Module required Reporting to be robust with minimal interruption 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 12. Getting Started 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 13.
6 Determining Reporting Needs Review: Program Goals Key Stakeholders Determines types of reports Process Indicators for key process points Module 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 14. Program Goals - General Identify and clarify missing, conflicting, or nonspecific physician Documentation related to diagnoses and procedures Support accurate diagnostic and procedural coding, DRG. assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement Promote health record completion during the patient s course of care Improve communication between physicians and other members of the healthcare team Provide education Improve Documentation to reflect quality and outcome scores Improve coders Clinical knowledge 2010 AHIMA - CDI Toolkit 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 15.
7 Program Goals / Metrics - Departmental Example: All DRG payers are reviewed Case Mix Index will improve Improved Documentation reflected in quality and outcome scores 80% of Major Disease populations reviewed 30-35 charts reviewed per reviewer per day 85 90% Queries with Physician response 2011 Midas+ Symposium: The Right Care, the Right Reimbursement 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 16. Stakeholders Executive Leadership Financial CDI Department CDI Specialists Medical Staff Leadership Providers 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 17. CDI Team Departmental General statistics Manager Productivity Detailed statistics CDI Specialists Individual productivity Competency 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 18.
8 Medical Staff Leadership Queries Query Response rates Providers Queries Query Response rates 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 19. About Data Entry The government are very keen on amassing statistics. They collect them, add them, raise them to the nth power, take the cube root and prepare wonderful diagrams. But you must never forget that every one of these figures comes in the first instance from the village watchman, who just puts down what he damn pleases.. Anonymous English Judge (Quoted by Sir Josiah Stamp in Some Economic Matters in Modern Life (1929). 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 20.)
9 Data Entry Lays the groundwork for Reporting Define terms Determine which fields must be completed Create Worklists to check for incomplete fields Validation Rules in User Fields 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 21. The Clinical Documentation Process - LLUMC. Retrospective Queries Physician Documentation Physician Coder Physician Specialist Documentation Response Intervention Response Intervention Concurrent Queries Final coded data that represents: Severity of Illness Services Received Case Mix Index Quality of Care Indicators for Medicare 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 22.
10 Process Create Indicators for key steps in your process 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 23. General tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 24. Queries tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 25. Outcomes tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 26. Payers tab 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 27. Other Focus Study or User Fields Staff Reviews Communication with HIM Coders Manual Indicators Case Mix Index 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 28. Episode User Fields 21st Annual Midas+ User Symposium May 20 23, 2012 Tucson, Arizona 29.
