Editor’s Note: Let’s call this week’s guest post from “a ghost of ACDIS’ past.” Those who’ve worked in the profession for some time will no doubt remember with some fondness the teachings of founding ACDIS Advisory Board member Robert S. Gold, MD, who sadly passed away in the spring of 2016. The following was a note sent some years before that, encouraging ACDIS and the CDI professionals it represents to advance their efforts beyond traditional CC/MCC capture to ensure complete and accurate medical record.
It so often seems that all CDI programs have been developed based on MS-DRG maximization. Such short-term focus however defeats the goals (and challenges) of healthcare in today’s society. When CDI develops from the Medicare revenue perspective, rifts grow quickly between the coders and the CDI because so many of the teachings don’t line up. Rifts develop between the CDI folks and the docs, too, because docs feel like they are targets and are always wrong. Rifts develop between the CDI team and quality team because CDI queries seem to encourage the reporting of complications even when complications don’t exist. And massive holes exist in the patient’s database because of CC/MCC capture concentration which leaves all of the patient’s chronic conditions unsought after and unreported.
Too many instruments support the old, obsolete concepts and too few encourage people to go beyond their silos. All of the initiatives that are needed to drive us into the future will fail if we don’t expand our expectations beyond these past, financially focused, efforts.
Just because you can measure something doesn’t mean should measure it, Jon Elion, MD, founder and CEO, ChartWise Medical Systems, told ICD-10 Monitor’s Talk Ten Tuesday back in February of 2016. Specifically, he pondered why CDI programs hold onto legacy targets such as physician response rates as a measurement of program success. Instead, measures need to change as the CDI program itself matures and grows.
As CDI programs begin, managers need to track:
- physician query rates (how many queries per record reviewed)
- Physician response rates (how many of those queries receive a response either positive or negative)
- physician agree rates (how many query responses align with the intent of the CDI specialist)
Such measures help CDI programs assess the competency of its staff as well as the engagement of its physicians with program goals. Yet any assessment tool needs to be analyzed itself and the reason behind the data interrogated, Elion indicated.
For example, if the CDI team sends a query to one physician but a different physician responds should that response count towards the first or second physician’s data? What about the physician who responds to all queries, just not in a timely way? What about the physician who answers all their queries but always needs to be queried on the specificity of his or her patient’s heart failure?
Theoretically, as a CDI program matures its physician engagement and response rates should increase throughout the first year and stabilize in the second or third years. While programs may not expect 100% consistent physician response rates they should expect it to hover in the mid-90% range.
Elion doesn’t mean that CDI managers should toss out those traditional measurements altogether but to use them instead to identify potential trouble spots, educational opportunities, and to nip any provider support concerns in the bud early.
Such measures should not be used to penalize physicians, however. “Clinicians who are always on their toes would suffer from a toe walking gait which most closely maps to ICD-10 code R26.89,” he said.
What types of metrics does your CDI program measure and what items to you think should be retired?
Last year at around this time, the ACDIS Advisory Board released a white paper reviewing the role of CDI specialists in assessing information in the medical record from prior treatments.
Codes cannot be assigned based on previous conditions. However, there’s a gray area clouding whether CDI professionals can pull information forward to clarify a diagnosis being treated during the current episode of care, says Cheryl Ericson, MS, RN, CCDS, CDIP, manager of CDI services at DHG Healthcare, during an ACDIS Radio discussion on the topic.
ACDIS created the white paper as a means to help CDI programs open a dialogue about such concerns within their facilities and to help CDI managers begin to craft policies and procedures around compliant and ethical practices regarding electronic health record interrogations.
In particular, CDI specialists face the dilemma of whether to apply information from prior encounters when querying a physician in order to clarify a diagnosis documented in a current admission or episode of care. The CDI profession is divided on this topic: Some are comfortable referencing the historical information within the query when it clarifies a currently documented condition relevant to the current episode of care; however, others believe this practice violates Uniform Hospital Discharge Data Set (UHDDS) definitions regarding an episode of care, as well as coding guidelines.
The paper reviews overarching guidelines and weighs various references such as reporting additional diagnoses and the definition of the term “encounter,” to help CDI programs begin to assess their own practices.
In Arizona where Judy Schade, RN, MSN, CCM, CCDS, works as a CDI specialist at Mayo Clinic Hospital, the population includes a large
number of “snowbirds,” retirees who travel to warmer climates for the winter. For these patients, information included in the electronic medical record often represents an important link between the current encounter and conditions which may have developed in another setting since their last hospital visit.
“We might not have the most current information so we need to be careful and to ask the provider where additional information may be needed to validate a diagnosis and pull it forward,” Schade says.
“It’s not enough for the physician to say this is a complex patient,” Ericson says. “They have to document it. If someone has hypertension they’re clinically always going to have hypertension. However, we cannot automatically make that assumption in coding that’s why the physician has to document ‘history of,’ or ‘chronic,’ or something else that is affecting this episode of care and the resources directed toward treating it.”
Such information “is so much more accessible” due to extensive use of electronic health records than it was in the past, ACDIS Director Brian Murphy says. CDI specialists need to determine whether looking back in the medical record, or opting not to look back, artificially limits a CDI professional’s ability to capture diagnosis specificity or whether concerns regarding the compliance of such activities are valid.
For example, Schade cautions that CDI specialists could be pulling forward outdated or inaccurate information as well intentioned as they may be. So “partner with different departments to formulate your policies. We’re moving in a different way of looking at things so we really need to carefully examine this process and develop the best practices,” she says.
The white paper walks through some common concerns but also recommends reviewing recommendations from the Joint Commission, CMS, and your own facility’s compliance, IT, and coding policies, for example.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Pediatric efforts offer new CDI opportunities” which originally published in the October 2013 edition.
“We’re seeing more and more children’s facilities starting CDI efforts,” says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “The largest growth comes from multi-hospital systems that already have CDI programs in place. They see the potential of expanding to their affiliated children’s facility.”
With roughly 500 children’s facilities in the nation, Gold sees both the probable benefit and difficulty inherent in such CDI expansion. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.
At the Medical University of South Carolina (MUSC) in Charleston, Karen Bridgeman, MSN, RN, CCDS, CDI specialist, started building the case for expansion by examining data from the University HealthSystem Consortium and National Association of Children’s Hospitals and Related Institutions. This data allowed MUSC to compare benchmarks regarding patients’ severity, mortality, and facility case-mix index (CMI). They took the 25 top and bottom DRGs and divided them into two categories—high-volume, low reimbursement and low-volume, high reimbursement—for Medicaid, Blue Cross, and commercial payers.
The data suggested that a higher level of clinical complexity existed than was being depicted in the medical record, Bridgeman says. Asthma and bronchitis, seizures, and neonatal care fell into the high-volume, low yield bucket; that cardiothoracic conditions and Level III neonatal ICU fell into the high-yield, low volume bucket; and that chart review of pediatric patients could help with respiratory failure, cystic fibrosis, sickle cell, and chemotherapy documentation improvement.
“We found the physicians writing respiratory distress, but that just wasn’t clear enough to determine whether it was an shortness of breath or a respiratory failure,” Bridgeman says. “Sepsis and shock weren’t being documented at all.”
During a conversation regarding what basic elements CDI programs need at the onset in order to be successful, ACDIS Advisory Board member Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, Director Case Management Case Management and Clinical Social Work
University of California Irvine Health offered the following suggestions. Contact her at firstname.lastname@example.org.
- Selecting staff: Matching CDI key skills/qualification/experience to the CDI role and CDI needs of the facility (academic, community hospital, access hospital, product lines). Staff members also need to be an effective trainer and engaged learner to be able to internalize the CDI mission and explain it to physicians and ancillary staff. Having skills in communication/negotiation (vs. introverted) and knowing one’s own strengths and weaknesses goes a long way in being successful in this role.
- Assessing where to start: New program managers (or those tasked with starting CDI reviews) need to understand administrators’ top priorities and focus area for the program. The first task is to meet (or exceed) those expectations in order to move the program forward and meet some of the larger programmatic targets suggested by industry leaders. (Advancing beyond CC/MCC capture and straight Medicare record reviews.)
- Creating the return on investment (ROI): Regardless of whether your program is a single CDI staff shop or led by a manager and team of coworkers, those involved need to understand the mission and the metrics used to measure the program’s efforts toward its goals. Providing those metrics to the team and keeping that information sharing going through administrative outcome reports (showing quality progress and revenue/CMI capture) not only ensures transparency but effectiveness as well.
- Standardizing queries: As this is the CDI program’s most essential tool, spend some time studying the evolution of physician query practice guidance from AHIMA and ACDIS. Queries do need not be scripted. In fact, each must contain the critical clinical information related to that particular patient encounter. Yet, the program needs comprehensive policies and procedures in place as to how to draft a compliant query, how to follow up with physicians, how to track queries, and how to escalate matters if necessary.
- Building critical relationships: As CDI professionals essentially work as intermediaries between physicians and coders as translators between the clinical and coding languages establishing effective relationships with these core groups can’t be understated. CDI teams should meet regularly with HIM/coding staff to share documentation integrity concepts. They should feel enabled to ask coders questions about new guidelines and coding conventions. CDI staff also need to obtain input from other departments such as wound care, pharmacist, respiratory therapist, nursing, ICP, etc.)
These are just a few of the essential ingredients, to be sure. If you’re just starting out and want some additional information, feel free to reach out to Wendy or any of the members of the ACDIS Advisory Board. Learn more about them at our website.
by Amber Sterling, RN, BSN, CCDS
Getting CDI specialists involved at the point of entry in the emergency department (ED) provides numerous benefits to downstream documentation and coding accuracy:
- The entire CDI effort for each case becomes more effective.
- Electronic health record (EHR) documentation begins with an accurate report—important when ED documentation captures the severity of the patient at presentation, which often differs from the documentation of the admitting physician, who sees the patient after he or she has been stabilized.
- Cohesive documentation helps to improve CC/MCC capture rates, and solidifies medical necessity for admission.
Consider these five tactical guidelines to help spur ED CDI efforts.
1. Start Early: The best starting point is early evaluation of patient admission status. Knowing which trajectory the patient encounter will take informs your CDI workflow. Admission status can go one of two ways:
Inpatient admission: For cases where the inpatient admission appears medically justified based on clinical findings and screening criteria, the CDI specialist’s role is simple. The goal is to confirm ED documentation accuracy, since emergency documentation often differs from admitting documentation, which is done after the patient has been stabilized. Incorporating ED documentation in the codeable record will help capture diagnoses and present a clearer picture of the patient’s condition.
Maybe, possible admission: In this case, additional steps should be taken. More documentation is needed in the ED record to support inpatient status. The CDI specialist should work closely with the ED case manager and ED physician to discuss specifically what documentation is required to meet inpatient medical necessity.
Involve the CDI specialist right away, and engage the emergency services physician to clarify exactly what is required to support the admission determination.
2. Use technology to trigger action: The most successful CDI programs take advantage of technology. CDI in the ED is no exception. Use technology alerts, such as a “bed request” or “transfer from ED to inpatient status” as a trigger point for the CDI specialists to review the case prior to patient transfer.
CDI specialist can achieve great success, speaking with attending physicians between the ED and the nursing unit. Signs and symptoms that warranted a visit to the ED often stabilize after several hours of emergency treatment, therapies, and tests. CDI specialists bridge the gap between clinical findings in the ED and patient condition hours later in the nursing unit. If attending physicians aren’t available, rely on your organization’s hospitalists to meet with you, case management, and the patient prior to nursing transfer.
Start in locations that already have a hospitalist program in place who see patients in the ED prior to admission. This gives the CDI specialist the best opportunity to work with both the attending and the ED physician to capture necessary information in the record.
3. Collaborate with case management: From a screening practice standpoint, patients typically must meet a combination of criteria to justify medical necessity for inpatient admission. This gap represents a proactive query opportunity for CDI to make sure all diagnoses are addressed, DRGs are assigned appropriately, and principal diagnoses are identified correctly.
Cross-training in medical necessity screening criteria is essential for CDI specialists assigned to the ED. CDI specialists should also develop a strong collaboration with case management. Knowing case management’s role in the care process prepares CDI to fully understand the workflows, timelines, and criteria that drive clinical documentation. When you better understand decision points, and how your work affects what follows, it is easier to determine what and when to query.
4. Define Your Reporting Structure
The reporting structure is key to how communications are handled within the ED. Roles, responsibilities and communication channels should be clearly defined at the director level. Collaboration should be purposeful and direct to achieve the full benefits of CDI in the ED.
5. Be Prepared for Push-back
Based on my experience launching a program for emergency services, physicians may resist—at first. But once the downstream benefits are realized, your efforts become best practice. A concerted effort to educate the ED physicians on the “why” of a CDI program is needed in the ED, and should be made to help the physicians understand the crucial link their documentation makes in a more accurate and thorough record. As with other CDI efforts, ED physicians are more cooperative once they are aware of how their documentation impacts the quality of care for the patient.
CDI programs in emergency settings carry a unique set of challenges for everyone involved, including CDI specialists, case managers and physicians. These five strategies will position CDI specialists to help streamline documentation workflow in the ED and on the nursing unit.
Editor’s note: Amber Sterling, RN, BSN, CCDS is the director of CDI services at TrustHCS. Sterling has experience in the cardiac ICU, PACU, general ICU, case management, and utilization review. Most recently, she worked as the director of CDI for a five-hospital network, where she developed a CDI quality audit program, trained physician advisors in reconciling cases, creating a retrospective DRG denial review process, and developed and implemented a physician engagement program. Contact her at amber.sterling@TrustHCS.com.
As the healthcare industry shifts from traditional fee-for-service to a value-based and quality-driven model, CDI specialists should be aware of the principles that drive risk adjustment payments. “I describe it as traveling down parallel to that which we travel to establish the DRG,” says Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, CDI Educational Director for ACDIS and BLR Healthcare in Middleton, Massachusetts, during theAugust 10 ACDIS Radio program.
Patients bring their own medical complexity, and CDI specialists must make sure that the documentation captures those complexities. Each patient has their own level of risk, Prescott says, which includes the severity of illness and expected cost to manage their care needs.
For example, take an 85-year-old woman who lives at home, participates in aerobic dance and yoga twice a week, is a non-smoker, and her only comorbidity is osteoporosis. This patient will have a very different rating in risk adjustment than an 87-year-old who lives in a skilled nursing facility, is diabetic, has a history of stage 4 chronic kidney disease, and chronic obstructive pulmonary disease with a history of smoking. This higher risk adjustment score reflects the higher cost of care we are expected to expend due to the higher severity of illness.
Many quality measures included in CMS’ hospital value-based purchasing program are risk-adjusted, including 30-day mortality and 30-day readmissions, says Prescott. “We want to make sure that we’re capturing [documentation] for risk adjustment, which is very different methodology.”
The most common methodology used in risk-adjustment is the CMS Hierarchical Condition Categories (HCCs), says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, CRC, director of HIM/Coding for BLR Healthcare. HCCs share many similarities to the DRG system CDI specialists are used to working with. Both are prospective systems, meaning there are pre-determined payments for different diagnoses, and both use diagnostic information to drive either the overall assigned DRG or HCC. However, HCCs are cumulative in nature—all you need is one heavily-weighted diagnosis to boost the DRG for a singular inpatient admission, but, with HCCs, diagnoses are extrapolated for many encounters for that beneficiary for a time period (e.g. year) that contribute to the total patient risk score. Procedures don’t affect HCCs like they can for DRGs, says McCall. HCCs are solely diagnosis-driven, an ideal fit for CDI specialists who typically focus on diagnoses for documentation improvement.
Chronic conditions for risk-adjustment have a much bigger role in HCCs than DRGs, where most chronic conditions have little impact on reimbursement, says McCall. Take heart failure, for example. In the MS-DRG system, the CDI specialist may find an opportunity to query for added specificity for systolic or diastolic, as well as acuity to optimize the DRG. However, for risk adjustment, the documentation of heart failure in the record yields a HCC even without the additional specificity.
The common misconception is that HCCs apply to the outpatient setting only. This is not the case, according to McCall. Documentation to support a condition assigned to an HCC can come from outpatient, inpatient, and professional service documentation. Payers look at documentation from every setting for the reporting period for each beneficiary to determine whether a diagnosis should have been reported and is supported in the documentation.
“CDI specialists have to get used to looking at the record as a whole,” says McCall.
While conditions count toward a patient’s HCCs regardless of treatment setting, documentation and coding specialists need to follow the coding rules applicable to the setting in which the patient was treated and services were provided. Depending on the setting (outpatient or inpatient), documentation requirements for certain diagnoses in the HCC methodology will differ.
“From a rules standpoint, coding guidelines differ depending on setting and services,” says McCall. “CDI specialists need to be familiar with what diagnoses were documented, what setting they were provided in, and then apply the coding and documentation rules for that setting.”
For facilities looking to expand into risk-adjustment, Prescott says first identify which diagnoses “will map” to HCCs. Go to the CMS.gov website to find comprehensive HCC information, including lists of codes and how each maps to which HCC and its value. While self-study may seem intimidating, it is a great first step, Prescott said.
“Traditionally, the main focus of CDI is principal diagnoses and sequencing correctly,” says Prescott. “In HCCs, sequencing isn’t something we worry about. We want to capture all of the appropriate diagnoses, and review records for missing or vague diagnoses. This is what CDI has been doing all along.”
I am often asked by CDI managers and directors about how can they hire and retain a successful CDI specialist. These comments identify two issues: one, finding a person with the right skills, and, two, keeping them in this highly competitive environment.
If you visit the ACDIS Job Posting page, LinkedIn, or other professional networking sites, you are likely aware that you could probably find a new position by the close of the work day today if you wished. The demand for CDI skills and years of experience is high. This has created a very competitive environment with high turnover for many organizations. I usually have one specific piece of advice when asked this question, that I believe touches both the issues of who to hire and how to retain staff.
“Shop” for your new staff member close to home—even within your facility. I know it is tempting to offer large sign-on bonuses and look for the most qualified person nationwide, but you gamble in that process. I learned this lesson many years ago. I managed an intensive care unit in small rural hospital. Staffing was a challenge, as my nurses had to be strong, experienced, and independent. They had little support, often working alone on the night shift. The issue was when I found that rare experienced nurse who could hit the ground running on day one, they usually did not stay in the position for long. I learned that if I “shopped” close to home, found the right person with the right personality, I could teach the skills and build a loyal employee who was invested both in the organization and the community. In other words, an employee who would stay.
So, as you look for new CDI staff, scope out your intensive care unit, emergency department, med/surg units, and coding departments. You may find that new employee right in front of you.
I also was hiring a “known entity.” By looking for new staff members from within my own facility, I got to know the person’s work ethic, personality, and I saw them interact with co-workers, physicians etc.
You can’t teach personality skills. They have to come naturally. When I started my journey in CDI, the consultant designing our program said to the HIM manager during my interview, “hire her, she has the right personality.” She later shared with me that she knew she could teach me CDI, but there was so much more to this job than that. She understood that personality, work ethic, and willingness to learn were important.
So, when you have that position to fill, sit down and list the personality traits, as well as the experience and skills you need in your department. Then, go shopping close to home. You might just find that employee that will shine under your mentorship and stick around for the long haul.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at email@example.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.
Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we looked at an article from our July 2012 CDI Journal, “Four tips to tackle multi-facility CDI management.”
CDI specialists working within a single facility often meet weekly to talk about any difficult records or problems with reviews. They also often sit near each other when not out on the hospital floors and may have team meetings or face-to-face interaction with each other daily.
At Robert Packer Hospital in Sayer, Pa., “it is easy to walk down the hall and talk to my staff,” says Susan Tiffany, RN, CCDS, CDI program supervisor for Guthrie Healthcare System in Sayre, Pa., “but I have to remember that what I say to one group of individuals also needs to be communicated to the rest of my staff.”
To keep CDI staff on the same page, Meg McGill, RHIA, corporate director for HIM at Methodist Le Bonheur Healthcare in Memphis holds monthly meetings for all CDI staff with the coding director and two lead coders who also attend. CDI specialists also meet monthly by facility with their immediate directors to discuss productivity, statistics, and facility concerns.
“Communication is definitely one of the big challenges,” says McGill. “You need to be sure you say the same thing individually that you say to the entire group. You have to have open communication and you have to get to know your staff. When concerns come up, they can talk to you one-onone, pick up the phone and call you, schedule an appointment, or send you an email. Be sure to make time for that. But otherwise I really rely on email.”
So does Bonnie Epps, MSN, RN, manager of CDI at Emory Healthcare in Atlanta. “It is not often I get to meet face-to-face with each staff member,” she says. “We all work pretty independently. I trust them to do their best and we mostly communicate by email.”
Staff members do meet monthly at individual facilities and quarterly for training and other meetings, with those from smaller facilities traveling to Emory’s main campus.
At Methodist Healthcare, however, McGill plans to have her new manager spend at least some time in every facility on a monthly or bimonthly basis. “The better you know someone, the easier it is to communicate,” she says.
Four years ago, in these very pages, during CDI Week, I wrote about the art of CDI, comparing what we do to creating a fine painting. I wrote about seeing the patient in my mind and trying to create the fullest possible portrait of who they are and what they represent. At the time, I had been a CDI specialist for a few years and had progressed beyond the overwhelming challenge of learning and absorbing this role to being on the cusp of taking a leadership role in our profession. A lot has changed in the past four years, not only for me, but for our profession. I think it’s time to consider a little touching up of our portrait.
Back then, most of us looked at DRGs. Most of us looked at CCs and MCCs. Most of us looked at reimbursement. Many of us focused on Medicare.
Some CDI specialists grabbed for the low hanging fruit and called it a day. We might have talked about severity of illness and risk of mortality. We might have talked about quality and patient safety indicators and hospital acquired conditions and value based purchasing. We might have talked about reviewing all payors. We might have talked about what seemed at the time to be right on the horizon, ICD-10.
Some of our paintings were Rembrandts and some of our paintings were Elvis on black velvet. When we paint our portrait, are we painting from the heart, or we painting by number? Are we taking what we see and looking for every nuance, making the shading just right, or simply filling in the spaces that someone else drew for us?
I think many, many CDI programs have done their darnedest to be the former, and not the latter. I’m very proud of CDI teams that have moved beyond the low hanging fruit and have aspired to, and achieved, greatness. Do we still want to capture those CCs and MCCs? Of course we do. But what we really want to do is paint a masterpiece. Or more exactly, to help the physicians paint that masterpiece so that anyone can recognize what they’ve done as a great work of art. Because healthcare, just like CDI, is an art as well as a science. People are not just a collection of body parts and organ systems. After all the blood tests and radiology exams and other diagnostics, it’s the art and the skill of the physician that makes the difference between diagnosis and symptom, between recovery and illness. And we are here to capture the essence of that art and skill, carefully documented in our medical record. We’ve moved beyond clinical documentation improvement to a world of clinical documentation integrity.
We’ve grown so much as a profession. Thousands of highly skilled nurses and coders have transitioned into our world, and many more are coming. Certification in CDI as a CCDS or CDIP has validated the expertise of many experienced CDI professionals. CDI teams, under dynamic leadership that understands the value we add to our institutions, have gone far beyond the easy pickings of the CC and the MCC. They have carefully evaluated the needs of their facilities and trained their focus on severity and mortality and quality and readmissions and medical necessity and clinical indicators and observation cases and developing tools to help their physicians document and a thousand other areas that meet their organization’s current needs and will meet their future needs. They paint a picture with colors so vibrant, so real, so intense, you won’t know if it’s a photograph or a portrait.
Appreciate the skill of the artists, both healthcare provider and clinical documentation expert. Because they’re grand masters.