Collaborative Intelligence: Unlocking the Power of Narrative Documentation

Transcription

1 M*Modal White Paper WP CI Collaborative Intelligence: Unlocking the Power of Narrative Documentation See us at HIMSS booth 5725

2 WP CI Page 2 Current Situation The healthcare industry is currently undergoing tremendous change caused by a myriad of issues which have been building over decades. These include: Rising healthcare costs that are not correlated with healthcare outcomes, Increasing ranks of the uninsured, Unsustainable Medicare and Medicaid programs, and Government efforts to transform healthcare. Fundamentally, everyone from providers to patients to payors seeks a system that delivers quality care and avoids medical errors. It has been the focus of many Institute of Medicine treatises 1, and careful implementation and deployment of Electronic Health Records (EHRs) is one way to achieve this. The impact on hospital CIOs and CMOs is clear. Healthcare organizations are driving their staff to rapidly adopt certified EHR systems and demonstrate that providers are using them in a meaningful way. Unfortunately, today s EHR systems cause a number of challenges when it comes to clinical documentation. EHRs only solve half of the data dilemma: They mostly structure data input into EHR templates for access and mining with only limited capturing of the physician s narrative commentary about the patient encounter. This issue of data integrity or the complete patient story is the missing link required for documentation improvement, proper reimbursement, and more. EHRs decrease physician productivity: They replace easy-to-use dictation interfaces that fit naturally into a physician s workflow with point-and-click computer templates that require a keyboard and mouse. Because it takes clinicians more time to document a patient encounter and opportunities to describe the complete patient s story are limited, the adoption of these systems by the physician community is a slow and strained process. Plus, the end result is less expressive documentation. Physician productivity losses in a healthcare delivery system lead to a variety of problems, including: 1) Physician dissatisfaction. 2) Poor documentation quality. In particular, poor quality clinical documentation significantly impacts the acute care setting. It can affect the quality of care, the revenue cycle, and ultimately the bottom line as insurers deny claims that are based on insufficient or poor documentation.

3 WP CI Page 3 To add to the challenge, acute care physicians are bracing for the transition from ICD-9 to ICD-10 the core medical code classification system used for billing. The new system will quadruple the number of codes which must be recognized and assigned by coders now 68,000 versus 14,000 diagnosis codes for ICD-9. In a recent article in Health Affairs 2, a GE Healthcare executive describes the transition as, It s like you spoke English on Friday, and now you must speak Chinese on Monday. Preparation for this mandated transition in October 2013 is extremely daunting given the complexity of the new alpha-numeric format, the industry-wide Coder shortage, and the current revenue cycle challenges facing the industry today. But that is not all. Meaningful Use and the associated government incentives (and soon penalties) are strong drivers toward the adoption of EHR systems, despite the known impact on care quality and physician productivity. Stage 2 Meaningful Use standards go into effect in 2014, and Stage 3 guidelines are not far behind. With each new stage, the government aggressively raises the bar in the hopes of improving quality and reducing costs through healthcare information technology. The Crux of the Problem As the industry races to adopt EHR technology driven by mandates and reimbursements, the crux of the problem is that clinical documentation fundamentals are being forgotten. Narrative dictation has played a dominant role in clinical documentation for decades for two important reasons: 1) Narrative dictation is the efficient method providers prefer. 2) Narrative dictation is the most effective way to capture the complete patient story. Narrative documentation captures the full health story of the patient and as such, is critical for providing safe care, for communicating to the care team, and for downstream needs such as coding, billing and revenue cycle management. Physicians are at the center of the clinical documentation universe. A productive physician implies better patient care, better and more complete documentation, and better reimbursement. In today s world of electronic documentation, physicians receive automated alerts about a patient s condition based on EHR data. The idea to generate alerts is a good one; however, it is only valuable to the physician if the information is appropriate based on a comprehensive, accurate patient story. Because these alerts are currently based only on the structured data entered discretely into an EHR system and not the complete patient story they often become meaningless and intrusive to the point where providers suffer from alert fatigue. The only way to address the issue of alert fatigue is to incorporate narrative documentation into the alert data and process it as caregivers do.

4 WP CI Page 4 Collaborative Intelligence Collaborative Intelligence seamlessly captures and combines narrative (unstructured) documentation with structured EHR data, structures the complete dataset in a standard format, and makes resulting information easily accessible. This complete, accurate output is critical for downstream uses across the healthcare continuum such as Computer-Assisted Coding, abstracting for Core Measures and other regulatory reporting, and Clinical Documentation Improvement (CDI) initiatives. Results for healthcare providers include increasing physician productivity, improving the quality of documentation, and accelerating the revenue cycle. Powered by industry-leading Speech and Natural Language Understanding technology, Collaborative Intelligence combines a variety of solutions: 1) Search & Discovery based on semantic indexing and ontological reasoning. 2) Real-time Clinical Documentation Improvement. 3 3) Computer-Assisted Coding workflow. 4 4) Front-end and back-end Speech Understanding based documentation workflows. 5 5) Meaningful Use abstraction workflows to enable reporting on quality measures. 6 6) Meaningful Use list management including medication reconciliation. 7

5 WP CI Page 5 The Solution Framework In essence, various sources of structured and Physician Nurse Coder/CDS Abstractor unstructured documentation are analyzed, structured, tagged, and then fed into a Content Server. The Content Server is populated with structured and encoded HL7 CDA (Clinical Document Architecture) CDI Alerts Concurrent Review Concurrent Coding Concurrent Abstraction documents. All of the workflow solutions listed in the previous section are built on this framework. Our approach assures interoperability with all EHRs by leveraging the same standards that EHRs are expected to support. An overview of how the Collaborative Intelligence solution suite is structured: Signed Clinical Notes Nurses Notes Medication Admission Records Lab Results Content Tagging Content Server Benefits & Value Proposition We presented a variety of vexing problems faced by hospital CIOs and CMIOs. Through the use of Collaborative Intelligence these problems can be addressed in a cost-effective way, yielding a variety of benefits: 1) Physician Productivity: Physicians can continue to dictate, using a variety of front-end (real-time) or traditional back-end solutions, thus providing the full patient story. Speech and Natural Language Understanding technology automatically abstracts and codifies all relevant content. 2) Meaningful Use: Patient problem and current medication or allergy lists can be identified from unstructured documentation, tremendously increasing physician productivity in the process. 3) Revenue Cycle Management: Capturing appropriate and complete physician documentation at the time of documentation via real-time feedback avoiding physician queries at a later time. 4) Coder Productivity: Improved coder productivity via a Natural Language Understanding-driven Computer Assisted Coding (CAC) solution. 5) ICD-10 Readiness: Clinical coding of dictated content via SNOMED-CT with subsequent rules for deriving appropriate billing codes allows for generation of both ICD-9 and ICD-10 codes for comparison and training purposes. 6) Quality of Care: Abstracting and reporting on Meaningful Use quality measures ultimately drives quality of care. By adopting Collaborative Intelligence, CIOs and CMIOs can improve the quality of physician documentation, increase physician productivity, and drive the adoption and meaningful use of electronic health record systems.

6 WP CI Page 6 References: 1. IOM reports that are relevant: To Err is Human (1998); Crossing the Quality Chasm (2001); Patient Safety (2004). 2. Harris Meyer, Health Affairs, 30, no.5 (2011): Coding Complexity: US Health Care Gets Ready For The Coming Of ICD See also: Data mining framework whitepaper. 4. See also: CAC whitepaper. 5. See also: Clinical Documentation Improvement (CDI) whitepaper. 6. See also: Quality Measures whitepaper. 7. See also: On-ramp to EHR white paper. World Headquarters: 9009 Carothers Parkway, Suite C-2 Franklin, TN solutions@mmodal.com MModal IP LLC. All rights reserved.