Janury 22, 2007

RHITs Take the Helm of Documentation Improvement
By Elizabeth S. Roop
For The Record
Vol. 19 No. 2 P. 18

With its clinical documentation program teetering, the University of Michigan Health System turned to its HIM staff to right the ship.

Prompted by an ineffective postdischarge query process and the desire to more accurately capture inpatient reimbursement for services rendered and reflect case complexity and severity, the University of Michigan Health System (UMHS) broke with tradition and turned its clinical documentation improvement program over to its HIM department.

“A lot of programs use RNs, but we were fortunate in that we were able to use the [RHIT] staff we already have,” says Gwen Blackford, BS, RHIA, coding and health information manager at UMHS. “The RHITs know what needs to be documented in the medical record … we really feel that the RHITs are experts in the documentation, and they’re going to know what the diagnoses are that move DRGs [diagnosis-related groups] into the more severe DRGs.”

It was that expertise that the organization asked its registered health information technicians (RHITs) to apply to identifying how to best collect the clinical documentation necessary to improve patient care, reimbursement denial rates and case mix, clinical communications, and research data.

It turned out to be a smart move. Since implementing the program in 2004, UMHS has seen its physician query response rate increase to 86% and has identified approximately $8 million in potential reimbursements calculated from the working DRG to the final DRG that might otherwise have been lost due to undercoding.

Identifying the Weak Spots
UMHS consists of three hospitals with 865 licensed beds, annual admissions of approximately 49,000, 1,693 attending physicians, and 970 residents. Part of the University of Michigan Medical School, it also includes five major health centers, 30 community-based health centers, and two ambulatory surgery centers.

The organization uses a hybrid medical record system that is 60% online, including discharge summaries, pathology/radiology, history & physicals, consults, and some progress notes. Utilizing 3M and SMART (Systematic Monitoring and Review Technique, a product from PriceWaterhouseCoopers that allows coding compliance and education coordinators to perform secondary reviews on cases that have been flagged for an edit prior to billing), the department codes from both electronic and paper records. Codes only inpatient and observation and averages 14 charts per eight-hour day and a 95% accuracy rate.

As happens at many facilities, UMHS coders were querying physicians one week or more after discharge, with most requests going to the attending physicians. The problem, however, was that most documentation was handled by house officers, physician assistants, nurse practitioners, etc, and not the attendings. Thus, if a response was received, it was often just as vague as the discharge information that led to the query in the first place—such as referring to the diagnosis of “burn” without providing more comprehensive details on site, degree, or percentage.

“We were communicating with the wrong audience, and when we did get an answer, it wasn’t always the answer we needed because we are not able to lead the physicians,” says Blackford. “The postdischarge process was just not working.… We would also hold our cases open anywhere from two to four weeks waiting for physicians to respond, so our accounts receivable was getting older, which is another reason it was just not effective.”

Exacerbating the problem is that approximately 900 new residents flow into the UMHS system each July. With their medical education focused on patient care, most new residents have little training in, or understanding of, the documentation process. Also, residents rotate from department to department, making it difficult for them to become proficient in the documentation needs of any given specialty.

“Because we are a teaching institution and there are so many new clinicians, there are always opportunities for teaching documentation specifics and many are very open to learning,” says Debbie Slater, RHIT, UMHS’ clinical documentation specialist. “We were missing those opportunities. “

Refining the Process
The desire to implement a clinical documentation improvement program at UMHS came from the top. The organizational leadership was concerned that not all pertinent data was being captured to reflect appropriate DRG and the severity of patients treated at UMHS.

“Leadership felt there may be opportunities within our current process to capture more appropriate DRGs. A work group was formed to identify a consultant for process improvement,” says Blackford, adding that the program would not have been possible without the support and strategic leadership of the HIM department’s chief administrator, Rosanne Whitehouse, MPH.

UMHS’ Clinical Information Decision Support Services group provided data identifying clinical services that presented an opportunity for improved complications and comorbidities (CCs) capture rates, while the consultants reviewed HIM’s complete coding process to determine where improvements could be made.

After familiarizing themselves with the various workflow processes, rounding with residents, working closely with clinicians, and analyzing documentation problems, the consultants identified specific problems, including the following:

• incomplete and/or contradictory clinical documentation;

• incomplete documentation for facility reimbursement, severity, and complexity of the UMHS patient mix; and

• incomplete specificity of documentation to support treatment rendered.

The consultants also identified the root causes, including a lack of clinician education regarding documentation; a clinician query process that took place postdischarge; and missed opportunities for clinician interaction and education.

Armed with this knowledge, the consultants and HIM set out to establish the framework for the clinical documentation improvement program, the goals of which were to:

• capture clinical documentation at the point of care;

• improve facility reimbursement and case mix;

• improve clinician communication; and

• decrease reimbursement denials.

To achieve these goals, four coders were repositioned as clinical documentation specialists (CDSs) and three coding compliance and education coordinator positions were created. Coding operations were then reconfigured into three teams, each assigned to designated clinical service areas.

Teams are responsible for staying in touch with their primary clinical services provider contacts and communicating daily with clinicians by e-mailing, paging, or talking in person. They also round with clinicians once per week, which increases their visibility with the clinical staff and proficiency within their service area.

“While on rounds, we listen to different cases and learn more about the treatment modality for the patients on that specific service. It’s also a chance for the CDS to ask questions … and the CDS gets recognized as part of that documentation team,” says Slater.

With the framework of the new program in place, the next, and perhaps most critical, step was to introduce the point-of-care documentation process to the medical staff leadership and gain its support. Leadership quickly realized the new program’s value and proceeded to notify all the organization’s physicians about its expectations that they fully adopt it and support its implementation. As a result, clinicians realized the importance of the documentation being requested during implementation of the program by HIM.

Working with the various clinical departments, the implementation team identified who performs documentation and the contact for rotation schedules, established rounding times, developed documentation “tip cards” for clinicians, and provided documentation follow-up presentations with specific DRG scenarios.

CDSs were also outfitted with wireless laptops, providing access to coding software and online clinical information systems to manage admissions, establish baseline DRGs, initiate clinician communications, and track working DRGs.

Finally, an online rounding tool was developed to allow residents to make notes on each patient and hand them off to the next intern or resident. Creating the online tool and providing the CDS teams with access to those notes, along with rounding, played a significant role in the program’s success by giving CDSs extra clues to what the appropriate DRG might be and giving them more information to take back to the physician when necessary.

“Occasionally, documentation is in the rounding tool but not in the actual progress note. [Now] we are able to discuss missing documentation,” says Slater, adding that “because we are rounding and more visible, the clinicians are more receptive when we approach them with a question and we feel like a part of the team.”

In fact, physicians are now approaching the CDS teams when they have questions of their own and are working with them to develop discharge templates that make it easy for physicians to include the appropriate CCs. For instance, they have already developed a newborn discharge template that includes capturing the presence of meconium.

“We plan to work with house officers to create templates to improve clinical documentation. In our electronic rounding tool, we are exploring the possibility of creating pull-down boxes that list the degree and/or extent of burn so the information can be pulled into a progress note,” says Blackford. “Electronically, there is so much information out there and we have a lot of opportunities to ensure all data is being captured.”

Improvements at Every Level
According to Blackford and Slater, the clinical documentation improvement program has had an impact beyond improved physician response and recouped reimbursements. It has brought a new level of awareness to clinicians and organizational leadership of the impact of proper documentation.

The postdischarge query process has been drastically reduced because of increased complete and accurate documentation at the time of coding. In recent third-party audits, there were no denials on cases involving CDSs.

“We have seen an increase in case mix and our clinicians are learning,” says Blackford. “We’re finding that [residents] are documenting the same way they did on other services. They’re listing the comorbidities; they’re identifying the principal diagnosis. We see their documentation as they move from service to service. If they move to another service, we’re still seeing improved documentation because they’re learning and taking that with them.”

Coders are also seeing much better documentation and greater specificity. The burn unit, for example, now includes extent and body surface area in their discharge documentation, which is necessary to drive the DRGs.

“Communication between the coders and the CDS is also important,” says Slater. “We meet with coders and discuss the type of documentation challenges they’re encountering. We keep their issues in mind while pursuing improved documentation.”

Keys to Success
Along with ongoing education, a successful clinical documentation improvement program utilizing RHITs requires buy-in from physician champions and organizational leadership as well as high CDS visibility among the clinical staff.

For example, the UMHS CDS teams proactively seek out new residents each year to begin their documentation education. They send an e-mail on a monthly basis explaining who they are, what they are doing, and why they may be contacting them.

They also seek out innovative ways to continue educating the staff on the importance of documentation to support the appropriate DRG.

“We don’t necessarily have to be in a higher DRG; we need to be in the correct DRG,” says Slater. “We need the documentation to support clinical findings. We’ll code it according to coding guidelines and go from there.”

The most important factor to success, however, is gaining and maintaining the support of physician champions and organizational leadership. At UMHS, this is accomplished through regular presentations to clinical departments and by providing data that demonstrates the program’s effectiveness.

For example, UMHS’ coding manager provides data that shows each clinical service their rate of DRGs without CCs and proactively demonstrates the impact of lack of documentation.

“Provide them with data on their current CC rates and give them case examples,” says Blackford. “Go in and say, ‘This is what we’re seeing. You’ve got five cases here and you wrote that the patient was on Bactrim and was growing E. coli, but you didn’t document UTI [urinary tract infection] in any of these. Each case is worth $5,000, and here you’ve got $30,000 we’re going to lose.’ Really hit it that way with case examples and show them the opportunities, and at the same time, show them the opportunities just for patient care.

“Help them understand how important coding documentation is and how it impacts not only reimbursement but is used to evaluate the quality of healthcare facilities across the country,” she adds. “And with the pay-for-performance initiatives that are coming down the wire, it’s only going to be more important.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.