As Medical Director of Clinical Document Improvement at St. Joseph Health, it is my department’s responsibility to facilitate an accurate representation of a patient’s clinical status, which can be translated into useable, coded data. This data is then processed into quality reporting, physician report cards, public health data, disease tracking, and ultimately reimbursement. As a multi-specialty 380-bed hospital in Orange, CA, with one of the busiest Emergency Departments west of the Mississippi, getting our physicians to document has been an important responsibility.
Over the past few years at St. Joe’s, we’ve made it our goal to get our physicians to adopt best practices for documentation. Our IT staff cannot code from nurses’ notes, or from reports from the lab, radiology, EKG, or pathology. So in terms of useable data, if the physician didn’t personally document something, it didn’t happen.
This documentation determines a provider’s pay-for-performance by Medicare with a simple equation, where observed mortality is divided by expected mortality. If this number is less than one, the physician receives a very favorable rating. If the number is one, the physician is doing just fine. However, if the number is greater than one, it is regarded as “excessive mortality,” and no one wants that. These ratings are very important, and can make or break a practice.
So you can see why ensuring specificity in diagnosis and procedure documentation is important, and we do this by generating physician queries in our MEDITECH system. Queries are a combination of concurrent clinical documentation specialists’ and retrospective coders’ chart review. Queries are triggered at admission if there is unclear or conflicting documentation, among other situations.
Clinical documentation specialists concurrently review medical records within two or three days of a patient’s admission. Queries are created and placed in the EHR, and the provider typically answers within 48 hours. If needed, the medical record is updated, and final coding usually takes place a few days after the patient’s discharge.
Making the switch from paper to this electronic query process in MEDITECH bumped our query response rate from 76% to 87% between 2013 and 2014, which was remarkable. And it didn’t stop there. In 2015, we hit a 96% response rate, and to cap it off this past year, a staggering 99%. We couldn’t be prouder of this change.
From these changes, it is obvious that the clinical documentation impact is very real. Since 2012, St. Joseph has increased its Clinical Documentation Improvement (or CDI) financial impact by a net of $14 million. And since implementing nutrition queries, we have seen an increase in reimbursements for three of our southern California facilities, producing a total of $431,000 over a three month period of time.
Like I said, if a physician doesn’t document it, it didn’t happen, so this has been an incredibly powerful clinical and financial undertaking for St. Joseph Health.
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