All Entries in the "Payment matters" Category
CMS issues IPPS proposed rule for FY 2013
CMS released the 2013 IPPS proposed rule Tuesday night.
Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, due to improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.
In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program.
“If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals.
Coding changes
As expected, there were few changes to the ICD-9-CM code set. CMS previously indicated that it would limit such changes to allow providers time to prepare for ICD-10 implementation previously slated for October of 2013 but now potentially delayed until October of 2014.
“Since we are proposing to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass.
For FY 2013, CMS proposes to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and a one of a list of pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179. CMS proposes to make three additional codes complications and comorbities (CCs) and change one major CC (MCC) to a CC for FY 2013. It does not plan to add any MCCs or delete any CCs.
CMS proposes adding these diagnoses to the CC list:
- 263.0, Malnutrition of moderate degree
- 263.1, Malnutrition of mild degree
- 440.4, Chronic total occlusion of artery of the extremities
It also is proposing to change the severity level of diagnosis code 584.8 (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.
“While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC,” says James S. Kennedy, M.D., C.C.S., C.D.I.P., managing director at FTI Consulting in Brentwood, Tenn.
IQR proposed changes
The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.
Participation in the IQR program is optional, although those who choose not to participate receive a 2% reduction in the annual payment update. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures to the IQR quality measures for FY 2013. In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors.
VBP proposed changes
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures.
For the FY 2014 VBP Program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line-associated bloodstream infections that can develop during inpatient hospital stays.
For the FY 2015 VBP Program, CMS proposes grouping and scoring measures in four domains—clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list.
Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions:
- acute myocardial infarction (i.e., heart attack)
- heart failure
- pneumonia
CMS also finalized its definition of readmission as:
“occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization.”
CMS also addresses these areas related to the program:
- Adjustment factor (both the ratio and floor adjustment factor)
- Aggregate payments for excess readmissions and aggregate payments for all discharges
- Applicable hospital
- Limitations on review
- Reporting of hospital-specific information, including the process for hospitals to review and submit corrections
Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013:
- surgical site infection following cardiac implantable electronic device (CIED)
- iatrogenic pneumothorax with venous catheterization
Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS plan to update the existing vascular catheter-associated infection HAC category by adding the following two codes:
- 999.32 (bloodstream infection due to central catheter)
- 999.33 (local infection due to central venous catheter)
CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says. This condition does seem to meet HAC the criteria of occurring commonly and can cause a significant increase in resource consumption in order to treat this condition, she says. It is also labeled as a complication and comorbidity. However, HACs must also be reasonably preventable, according to evidence-based research, and this has also kept other conditions, such as ventilator-associated pneumonia, off the list in the past.
The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says.
Coding and documentation adjustment
CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%.
“In good news, the documentation and coding adjustment actually works in the provider’s favor this year, increasing reimbursement by 0.2%,” Kennedy says. “That’s a substantial increase from the previous years.”
Comment on the proposed rule
CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1, 2012. Facilities can download a display copy of the proposed rule here.
The proposed rule will appear in the May 11, 2012 Federal Register.
Editor’s Note: This article first appeared as a “Breaking News Alert” and was published on HCPro.com.
To prevent VBP financial loss, think like a clinician
Experts say that for facilities to face the financial implications of value-based purchasing they'll have to start thinking like clinicians
Healthcare financial leaders and clinicians have traditionally worked in their own silos, running into each other occasionally but rarely seeing eye-to-eye. Yet they now must work together to achieve the goals set forth in the federal value-based purchasing rule.
Currently, VBP rules hold healthcare organizations accountable for 12 process of care measures and HCAHPS. Next year, however, mortality rates and hospital-acquired-conditions will be added to the mix. To meet both the medical and financial imperatives of VBP, financial leaders will need to go beyond their usual scope. Look through the eyes of the clinicians to improve patient care and prevent reimbursement losses.
“Most CFOs are concerned with the negative consequences of VBP, because if you don’t comply you get a reduction in reimbursements,” says Bruce L. Van Cleave, MD, senior vice president and chief medical officer at Aurora Health Care in Milwaukee. “But, on the medical side we need to concentrate on patient safety and high quality care. If we aren’t careful, when we [each] talk about value-based purchasing we could be having two very different conversations,” says Van Cleave, who is also the former president and CEO for Carondelet Health in Kansas City and a board-certified family practice physician.
Van Cleave’s clinical and administrative background helps him see VBP from both vantages. Taking a broader perspective can help financial leaders prevent VBP reimbursement losses.
“I wish the ongoing conversation we were having [with financial leaders] was, ‘How do we use this to re-look at our strategies around care delivery?’” he says. “And that we’d broaden the discussion away from, ‘How can we maximize our reimbursements?’”
Van Cleave believes that if healthcare leaders concentrate on understanding the intent of the VBP law, they will find the answers to their reimbursement concerns.
“Think about why the government wants us to do this. What outcomes are they really trying to get at? Certainly one outcome is to control cost, but it’s not all of it. … What impact will this have on how healthcare will be practiced in the U.S.? And, how can we link our outcomes and our finances so they are strategically aligned?” he asks.
Van Cleave points to length of stay as an example of how different goals for the financial and clinical staff can influence one another.
“Clinicians need to have enough time to complete the [patient] education cycle, to monitor the illness, and to get the patient tuned up to a higher level before discharge. If it’s rushed, there’s risk. What we need [from CFOs] are the right tools for an efficient process so patients get the right education and care. We need to set standards so when the patient reaches certain milestones we can help them make the transition to home,” he says.
Financial leaders have focused on LOS since 1983. That’s when Medicare introduced the prospective payment system and announced it was going to pay hospitals a flat fee to cover costs based on an expected LOS. CFOs reasoned that if their hospitals could shorten patients’ LOS, the result would be greater margins. They encouraged doctors to discharge patients as soon as they no longer required an acute level of care.
What has been the outcome of this effort? Providers have managed to shorten LOS, but at the cost of 30-day readmission rates. In 2010, Medicare released a study of heart-failure patients showing that between 1993 and 2006, mean LOS decreased from 8.81 days to 6.33 days. In-hospital mortality decreased from 8.5% to 4.3% during the same period, and 30-day mortality decreased from 12.8% to 10.7%. But 30-day readmission rates (which are not part of the VBP measures) increased from 17.2% to 20.1%.
Just as your clinicians’ actions influence patient outcomes and reimbursements, so too do the actions of financial leaders. You may know how VBP will influence your organization’s bottom line, but have you asked clinical leaders how to improve your metrics? By understanding the clinician’s perspective, CFOs may get a clearer picture on how to hit VBP measures and improve HCAHPS scores.
Complying with VBP is going to challenge organizations for the next few years. It puts 1% of Medicare payments for hospitals and health systems at risk in the first year, and that percentage will grow as the measures grow. Nevertheless, it really is possible to win with VBP.
But doing so, Van Cleave observes, requires that “everyone has to pull in the same direction and be very clear about the goal and the numbers to succeed.”
Editor’s Note: This article was written by Karen Minich-Pourshadi, Senior Editor with HealthLeaders Media, and was original posted to its website www.healthleadersmedia.com. She may be reached at kminich-pourshadi@healthleadersmedia.com.
Tips for winning support from nurses
While physician documentation drives our CDI and HIM programs, we nevertheless need the assistance of our
Don't neglect nursing notes and nursing education when looking to strengthen your CDI program efforts.
facility’s nurses and their nursing documentation. Not only are nursing notes and assessments incredibly helpful in formulating physician queries and providing supporting clinical evidence for physician diagnoses, but sharp auditors are going to notice—and question the consistency of the medical record—if physician and nursing documentation doesn’t match up.
Contributions (some obvious, some maybe not so obvious) that nursing notes can provide our CDI process include:
- Documentation of the stages of pressure ulcers. The physician has to document the ulcer, but the nurse can stage it, and, of course, stage III and IV pressure ulcers which are present on admission (POA) are considered MCCs. Educate nurses on the critical role they play in this regard. I don’t know how it is for you, but in my experience, the admitting physician isn’t always thinking about or looking for pressure ulcers. Nursing documentation of pressure ulcers at the time of admission will support a POA query, and thus help to avoid coding the pressure ulcer as a hospital-acquired condition (HAC).
- BMI. Nursing (or dietary) documentation of a patient’s body mass index (BMI) can be linked to a related diagnosis, such as morbid obesity, which allows for either a low or high BMI to be coded as a CC. Severely underweight and overweight patients require a disproportionate amount of hospital resources. Heavier patients may need special equipment and additional staff to meet their physical needs. Very underweight patients may have low functional reserves and intensified dietary requirements. Both of these patient populations may be more likely to experience a longer healing process after surgery and a corresponding longer hospital stay.
- Atelectasis. This is another CC that increases length of stay and is often under documented by physicians. Look for nursing documentation of weak cough effort, poor performance on incentive spirometry, resistance to ambulation, diminished breath sounds, or an unexpected temperature spike.
- Functional quadriplegia. Encourage nurses to document in their assessment the patient’s mental status and a description of the patient’s ability to use their extremities; that documentation can provide a supporting basis for your physician queries.
- Catheter-related UTI. Appropriate documentation may help the facility to avoid another HAC, but possibly even improve the patient’s DRG assignment. Remind nurses to document the presence of any indwelling catheter (not just Foleys, but also suprapubic and nephrostomy tubes) in their admission assessment, as well as an evaluation of the urine quality and the patient’s urinary symptoms at the time of admission.
- Vascular catheter infections. Again, nurses may find the infected insertion site before the physician does. Encourage them to document what they see.
- Acute blood loss anemia (ABLA). Encourage nurses to be precise in their documentation of chest tube or surgical drain output, as well as hemoptysis/hematemesis or saturated wound dressings, so you can include that clinical information with the low hemoglobin and hematocrit (H/H) when you decide to query for ABLA.
- Mechanical ventilator duration. Recovery Audit Contractors (RAC) are catching facilities that bill into DRG 207 or 870 (continuous invasive mechanical ventilation for 96 consecutive hours or more with a respiratory or sepsis principal diagnosis) for not calculating the hours correctly. It’s not always clear from physician or respiratory therapy records when the patient goes on or off a ventilator, especially when there are extended weaning trials. ICU nurses should be diligent about documenting the time of intubation, extubation, and the exact times when the patient is on the vent or being weaned. They should also understand the importance of noting the use of T-pieces for trached patients.
As a CDI specialist, when I push the computer cart from nursing station to nursing station, I can pick up a lot of information just by listening to the nurses, or by asking them questions about a particular patient. They are invaluable resources to the CDI specialist, because they are with the patient 24/7, unlike the snapshot moments the patient has with the physician. When nurses understand how they can help the CDI program, most are very willing and eager to participate. So, don’t forget them!
VBP discussion offers new initiatives for CDI programs
Join us next week for a discussion of the implications of Value Based Purchasing.
Most facilities are already familiar with the Value-Based Purchasing (VBP) measures since CMS has collected data on them for some time. The Hospital Inpatient Quality Reporting Program is now known as QualityNet, but some know it better as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). Many CDI programs incorporate RHQDAPU items on physician documentation improvement tip sheets. (See the Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP.)
Until now CMS hadn’t tied payment to a facility’s performance. Instead, hospitals were paid to participate in the program and simply reported the requested conditions. Since 2005, CMS has published each RHQDAPU participating hospital’s measure rates on the Hospital Compare website. Starting October 2012, Medicare will begin paying hospitals for quality measures, according to a CMS fact sheet released April 29.
Editor’s Note: This article is an excerpt from the July edition of the CDI Journal. Join Deborah K. Hale, CCS, CCDS, and Susan Wallace, MEd, RHIA, CCS, CCDS, of Administrative Consultant Service, LLC, in Shawnee, OK, on Tuesday, November 8, for an audio conference discussion regarding the implications of VBP for documentation and coding accuracy.
The Problem List Project: Managing Post Acute Care Transfer DRGs
Michele D. Johnson, RN, BSN
by Michele D. Johnson RN, BSN
The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record review from October 2007 through December 2008. So the hospital administration formed a work team to identify why YH LOS differed so much from the transfer Medicare DRG GMLOS.
In early 2009, the work team observed that post acute care transfer (PACT) DRGs resulted in a decrease of $4 million in our expected Medicare reimbursement in fiscal year (FY) 2008. After investigation, the work group determined that YH had an unexplained higher-than-expected distribution of cases in the cardiovascular service line with complications or comorbidity (CC) rates that affected DRG assignment.
The group reviewed a sample of 102 cases and determined that 32 of those cases had evidence of acute respiratory failure that were appropriately documented and coded. The YH physicians documented acute respiratory failure as the reason for a post operative pulmonary consult which increased in LOS as determined by the DRG formula; however, the assigned DRG and its associated GMLOS differed from YH clinical care standards.
After researching and reviewing the medical records, the documentation team found acute respiratory failure did not always, or even most of the time, actually increase patients’ LOS or use of resources. The majority of the patients did not experience unexpected significant respiratory issues that required extended post cardiovascular surgery LOS. In fact, many of our patients had shorter LOS than indicated by the Medicare GMLOS.
The documentation improvement team met with the pulmonary medical director to establish a better definition of acute respiratory failure that acknowledged DRG requirements. The CDI team helped the director understand how Medicare guidelines determine what diagnoses lead to increased LOS and emphasized the importance of documenting well-supported diagnoses.
The CDI team realized that the hospital staff lacked a common understanding of which co-morbidities affect the patients’ expected LOS. To help facilitate awareness, the team developed a tool (available on the ACDIS Forms & Tools Library) to help identify and track pertinent medial issues with the patient’s working LOS. The team also developed a problem list tool to help identify DRG diagnoses with LOS timetables. A pilot program for the new problem list was implemented and incorporated into clinical rounds and medical record documentation.
The team tried to identify a probable discharge date for each patient ± 1 day. The expected DRG and LOS also were incorporated into care management activities and staff communication during patient rounds. We use the problem list to help us better manage the LOS and better understand the transfer DRGs.
Currently YH is working to incorporate the problem list into patients’ electronic health records. When the PACT DRG list was expanded in 2007, Medicare stated that the financial impact of the transfer DRG formula was neutral on hospital DRG reimbursement if DRG assignment is accurate. Our study suggests that this premise is valid and hospitals should assess documentation practices to ensure accurate final billing and coding.
Editor’s Note: Johnson is the documentation specialist supervisor at Wellspan Health in York, PA. Contact her at mjohnson3@wellspan.org.
CMS releases Medicaid HCACs final rule
CMS announced Medicaid HCACs
States to implement payment reductions for provider-preventable conditions
Provider-preventable conditions (PPC), including health care-acquired conditions (HCAC), are now subject to payment adjustments under the Medicaid program, according to the final rule released by CMS June 1.
The rule, “Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions,” implements provisions in the Patient Protection and Affordable Care Act requiring HHS to prohibit federal payment to states for specified HCACs, as well as additional conditions determined on a state-by-state basis.
“We found that 29 states do not have existing HCAC-related nonpayment policies,” according to the final rule. “Most of the 21 states that currently have HCAC-related nonpayment policies identify at least Medicare’s HACs [hospital-acquired conditions] for nonpayment in hospitals.
“However, it is important to note that at least half of the existing policies we reviewed exceeded Medicare’s current HAC requirements and policies, either in the conditions identified, the systems used to indicate the conditions, or the settings to which the nonpayment policies applied.”
CMS introduces the term PPCs in the rule, which consists of two categories: HCACs and other provider preventable conditions (OPPC). OPPCs would be those additional conditions identified and approved by states that are not found on the list of HCACs, which are included on pages 20 and 21 of the final rule. This also allows states to expand beyond the inpatient hospital setting HCACs.
“We believe, and confirmed through public comment, that incorporating Medicare’s HACs in Medicaid’s policy is inherently complex because of population differences across programs,” according to the rule. “We fully understand that the HACs developed for Medicare’s population will not directly apply to various subsets of Medicaid’s population. While we have established Medicare as a baseline, we understand that states will, through their payment policies, appropriately address these differences.”
As with the Medicare HAC program, there will be no payment reductions for those conditions that existed prior to treatment by the provider, according to the rule.
In addition, payment reductions are limited to only those PPCs that would otherwise result in a payment increase and those that the state can “reasonably isolate for nonpayment the portion of the payment directly related to treatment for the PPC.”
In the rule, CMS notes that while the point of the Medicaid PPC payment adjustments is to improve quality of care, it does expect to realize cost savings on a state and federal level.
The federal government expects to save approximately $4–5 million annually between 2012–2015, with states experiencing an additional savings of $3–4 million each fiscal year, leading to a total savings of $35 million through 2015.
“These steps will encourage health professionals and hospitals to reduce preventable infections, and eliminate serious medical errors. As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time,” CMS Administrator Donald M. Berwick, MD, said in a June 1 press release.
Due to the fact that the majority of hospitals already have programs in place to reduce the occurrence of Medicare HACs, CMS does not believe the cost of implementing a similar program for Medicaid HCACs will be significant.
The effective date of the rule is July 1, 2011; however, CMS is delaying compliance action until July 1, 2012.
Editor’s note: Access the display copy of the final rule here. The proposed rule was published in the Federal Register February 17. This article was published as an HCPro Inc., breaking news alert on Thursday, June 2.
Training video on healthcare acquired infections offered
Don't ignore documentation improvement efforts related to hospital acquired infections or conditions. There's always room for CDI programs to grow.
HHS recently released this cool collection of training videos under the auspices of “Partnering to Heal.” The videos slow-walk the viewer through various elements of different care provider perspectives in order to better illustrate how healthcare acquired infections (HAIs) can collaboratively (it is hoped) be eliminated. The training is designed to increase knowledge, alter attitudes, and shift the behaviors of clinicians and patients by focusing on the principles of teamwork, communication, hand washing, flu vaccination, and the appropriate use of antibiotics and medical devices, a press release regarding the videos states.
The videos allow you to role play as one of five characters—a family caregiver, a unit director, an infection control specialist, a medical student, or a nurse. I watched a few sections of each of the characters. The videos do a nice job of highlighting simple “right” actions that are easy to overlook, easy to ignore, and easy to simply pass over in the course of our busy day and general larger concerns.
As I watched I wondered why CDI specialists were not among the cast of characters playing their part in these instructional videos. Sure, the HHS team that no doubt put the training together probably had an unwieldy selection of healthcare professionals they could have included, from phlebotomists to dieticians, so I understand why they chose the limited cast as they did.
Nevertheless, the training reminded me of ACDIS Director Brian Murphy’s note in the January 2011 edition of the CDI Journal and the efforts he describes there of CDI specialists at Provena Health in Frankfort, IL.
We’ve all heard how hospital stays can lead to infections, Murphy writes, but often the reporting of such infections suffers from the same “lost in translation” troubles as many of other elements of clinical documentation. In essence the problem is that “[i]nfection control departments report infections based on their definitions. CDI and coding departments use coding guidelines. Often, these two departments’ regulations don’t line up. And when the data don’t match, fingers are often pointed…” he writes.
Provena decided to use a multidisciplinary approach and asked CDI managers to connect with the infection control staff to resolve clinical/coding clashes and different reporting requirements.
For example, HAIs are not the same as hospital acquired conditions (HACs). HACs were created by the Deficit Reduction Act of 2005 (DRA), which required a quality adjustment in MS-DRG payments and were implemented under the Inpatient Prospective Payment System (IPPS) effective October 2008. Eight HACs that took effect on October 1 2009 are: [more]
CMS methodology to calculate IPPS coding adjustment “flawed,” reports AHANewsNow
AHANewsNow, the highly recommended daily publication of the American Hospital Association, published a very interesting news item yesterday regarding the documentation and coding adjustment (DCA).
The report states that CMS’ methodology for calculating the DCA is flawed as it ”fails to separate documentation and coding effects from true case mix change.” This is according to an assessment prepared by Joseph Newhouse, a healthcare payment expert who serves on the Congressional Budget Office Board of Health Advisors and co-chairs the 2010 Technical Review Panel on the Medicare Trustee Report. The AHA sent the assessment in a letter to CMS yesterday.
The AHA, the Federation of American Hospitals, and the Association of American Medical Colleges urges CMS in the letter to use a different methodology that “adequately separates true case mix change from documentation and coding, or decrease its estimate of documentation and coding change to account for real case mix change.”
Column: The myth of ‘meaningful use’
The search for 'meaningful use' in electronic health records continues.
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have been a myriad of interim steps, from models which simply scan the handwritten documents into a computer system to those which begin with an electronic template complete with check boxes and drop down menus.
Some programs use dictated and transcribed elements for physician or mid-level provider entries. Some programs take the electronic record and utilize fuzzy logic to search for key words, phrases, and abnormal lab results in an attempt to assign ICD diagnosis codes.
But what is the purpose of this transition? What is the stated goal? What is the real goal to be achieved with an EHR? There are two major reasons for the development and adoption of the EHR. One we are close to achieving, the other, in my opinion, just doesn’t exist.
The desire to ensure that an electronic model of a patient’s encounters contains all of the elements needed for somebody’s perception of a “complete” record has led to the currently marketed and sold models. To know that a patient’s problem list is present, that his or her medication list and reconciliation is there, to know that the history and physical (H&P), progress notes, discharge summary, nursing notes, and all the rest of the elements that make up a traditional patient’s chart are present is a great reason to have an electronic record. It forces people to remember to make these entries. Also important is the electronic records ability to:
- Keep the patient’s inpatient and outpatient encounters available in one compendium
- Track crossover treatments provided by different specialists
- Monitor for drug interactions
- Track scheduling and follow-up visit dates
The potential to facilitate practice guidelines and order sets based on best practice is great—if the physician knows how to set them up and use them or, in specific cases, elect not to use them for the benefit of the outlier patient. So, for these reasons, I say good for the companies who have put such an important functionality together.
But, there are still problems with implementation of the so-called complete EHR. In the January 2011 edition of the Journal of AHIMA, Genna Rollins writes about the experience of Barbara Drury, president of Pricare Consulting. According to the article, Drury experienced difficulties with the EHR recording inappropriate dates at inappropriate times. She also expressed frustration with the inability of tracking patient data when someone does not have access to the electronic record and worried about those who would then develop alternative, manual, work-arounds.
Yes, there are still process issues.
Clinical Integration: Active engagement with the patient’s experience
On, Friday, January 7th, Centers for Medicare & Medicaid Services (CMS) issued the following press release:
“ ..the proposed rule that would establish a hospital value-based purchasing program for acute care hospitals
Don't let CMS value-based purchasing proposal catch your CDI program off guard.
that are paid under the Medicare Inpatient Prospective Payment System (IPPS) for inpatient services furnished to Medicare beneficiaries. The new program, which was required by the Affordable Care Act of 2010, would provide value-based incentive payments to hospitals beginning in FY 2013, based on their achievement or improvement on a set of clinical and patient experience of care quality measures. The transition to value-based purchasing is intended to transform Medicare from a passive payer of claims based on volume of care to an active purchaser of care based on the quality of services its beneficiaries receive.”
Why is the Value-Based Purchasing Program (VBP) important to CDI programs? The following statement from CMS bears repeating: “The transition to value-based purchasing is intended to transform Medicare from a passive payer of claims based on volume of care to an active purchaser of care based on the quality of services its beneficiaries receive.”
CDI programs must follow CMS’s lead by transitioning from a passive participant in the patient experience to a more active role. Two important factors are needed to allow this transition to take place. The first is that CDI professionals must evolve and recognize the unique skill sets and knowledge that members of the CDI team offers. The second factor is that hospitals have the right and ethical responsibility to bring a team together that optimizes patient outcomes using sound clinical documentation.
CDI programs can improve patient care and be an instrumental force in the adoption of VBP. In order to take advantage of this opportunity, hospitals need to support the integration of the CDI specialist into the clinical care team, advocating for their involvement in multidisciplinary rounds, providing real-time documentation improvement education, and identifying opportunities to capture and clarify under-documented co-morbidities. The CDI specialist facilitates the observations from all members of the clinical care team resulting in improved communication and sound clinical documentation, optimizing patient outcomes and improving the patient’s experience.
The clinical care team looks to and expects active engagement from the CDI program. This is the year for CDI to actively engage through clinical integration, your clinical care team is waiting for you.
To view the hospital value-based purchasing proposed rule, please see: www.ofr.gov/inspection.aspx.
