WHITE PAPER QualityAnalytics Bridging Clinical Documentation and Quality of Care
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EXECUTIVE SUMMARY The US Healthcare system is undergoing a gradual, but steady transformation. At the center of this transformation is an increased focus on patient outcomes, rapidly becoming the linchpin of revenue cycles, cost and quality control and other key functions in centers of care, small and large. Highly specific and comprehensive patient information is becoming the currency on which the financial health of these organizations will depend. Accurate and detailed aggregation of these data and their timely reporting is now the key function on which administrators, Healthcare Information Management (HIM) and medical informatics leaders are focusing, to ensure sustainability and growth in this new, quality driven, healthcare landscape. With the emergence of Accountable Care Organizations and value-based purchasing, facility stakeholders must deliver and document high quality healthcare services to protect reimbursement. Clinical indicators are hard to gather and difficult to manage, despite the now long established use of structured documentation templates to capture discrete data within specialized clinical information systems and Electronic Medical Records (EMRs). Despite early expectations, these systems actually have impeded the workflow of documenting a patient encounter, introducing obstacles that limit the ability to capture the updated, detailed and rich clinical data required to document clinical outcomes. In addition, physicians prefer to document patient visits with narrative text dictated, typed or transcribed because this documentation method respects the articulate and multifaceted nature of actual clinical presentations, their evolution over time, and the impressions they make on doctors memories. Optimal clinical reasoning requires all these dimensions of clinical information, so it is not surprising that most providers resist the fragmented documentation flow EMRs impose. The challenge: Collecting the discrete data needed for outcomes analysis while retaining the clinical narrative needed for physician decision-making. Clinical Language Understanding (CLU) now makes it possible to capture key patient data that supports outcomes reporting, quality of care analysis and compliance risks assessment directly from dictated notes. CLU is the bridge between the ideal narrative clinical documentation and the requisite structured patient data. This paper describes a new system for quality and compliance analysis that leverages the combined power of dictation technologies, CLU, data mining and visualization tools, to provide an analytic solution that identifies areas of criticality and potential quality improvement in a hospital. From quality, financial and compliance standpoints, organizations can track patients down to single data points within the context of the hospital population, both concurrently and retrospectively. The ability to understand the content of a dictated note in real time, combined with predefined analytical dashboards and the ability to define customized, provider specific, metrics and parameters, allows HIM staff, case managers, quality officers and physicians to study and intervene on areas of exposure, identify where improvements may be needed (for example, to reduce readmission rates or proactively manage other preventable adverse events. Similarly, actual physicians notes can be retrieved, to support documentation review during audits based on diagnoses specified in them. 3
The system will allow clinicians to: Identify and delineate any subset of the patient population based on clinical and demographic data, across multiple facilities, both concurrently and retrospectively, in a matter of seconds View and search all clinical documents for each patient in the population and identify key clinical findings in each document Track such key indicators as Core Measures or rate of readmissions, over the entire hospital population, in real time Gather pertinent clinical notes instantaneously in case of an unplanned audit Develop customized, provider-specific, clinical indicators driven by the hospital s strategic initiatives, local policies, patients and providers profiles and risk index. QUALITY INDICATORS AND CLINICAL DOCUMENTATION EMR systems have served providers well for decades, being deployed in clinical care environments where the most important data collected were diagnostic and procedural codes, needed for billing. ICD-9, CPT and other coding systems have supported a relatively standardized information environment, favorable to IT systems and software applications built with a focus on administrative functions. Actual clinical information expressed as narrative has been typically left at the margins of these systems, if included at all. On the other side the resistance physicians exerted against structured data entry systems has left EMRs in a state of scarcity for actual patient data that reflects the patient s story. Healthcare Reform, Pay-for-Performance initiatives, Meaningful Use and the proposed transition to widespread capitated reimbursement models, widens the gap despite attempts to develop new data entry functions to meet the new requirements. Until healthcare organizations find cost effective ways to collect, gather and abstract patient data, they won t be able to sustain ongoing transformation, nor will they realize the full value of their investments in Electronic Medical Records. Although intelligent data-mining tools are essential to quality and clinical process improvement, these tools cannot focus on discrete data already captured in EMRs, which cover only a fraction of the spectrum of documented care. While computer order entry systems typically capture medications, for instance, diagnoses, smoking status, comorbidities, stated reasons for noncompliance and much more are in the assessment or history sections of admission or progress notes and discharge summaries. Serious complications are documented in operative notes, while key parameters like the cardiac ejection fraction resides in radiology and other dictated diagnostic reports. Much of the clinical data still resides in narratives, inaccessible by the EMR for quality and outcomes analysis. 4
UNLOCKING DATA, IMPLEMENTING QUALITY One component of QualityAnalytics is Clinical Language Understanding (CLU), a sophisticated software technology able to parse clinical notes and capture relevant clinical findings in them, such as diagnoses, medications, allergies, vital signs or social habits, like smoking or alcohol consumption. Extracted data are then standardized from their narrative expression into SNOMED-CT and ICD-9-CM codes (and eventually in ICD-10-CM) in a fully reliable and consistent way by the software. The data is then presented in a web-based user application, where they are aggregated in summaries, dashboards, working lists and visual displays, to control the whole spectrum of quality indicators across multiple facilities. Users also can develop indicators and clinical profiles, based on their needs and their institution s focus. Highly detailed patient populations can be defined, identified and isolated for further analysis and for tracking any kind of clinical presentation or trend, from clinical research to the understanding of specific risk profiles. These custom queries can be stored and executed at any time, and modified as needed. 5
Patients at risk for falls while hospitalized, or community acquired conditions such as pneumonia, urinary tract infections, or pressure sores, can be identified and managed aggressively during the stay, controlling their complications, the associated cost to the hospital and increasing reimbursements. Using the same technology, coding and safety teams can address proactively areas targeted by Recovery Audit Contractors (RAC), such as patients admitted for syncope and dehydration, while the patient is still admitted. Documents containing description of relevant diagnoses can be fetched instantaneously to support associated codes and to demonstrate compliance. Textual descriptions of diagnoses are highlighted for immediate identification. FROM MANUAL CHART ABSTRACTION TO CLINICAL INTELLIGENCE Nuance Healthcare QualityAnalytics is designed for quality and safety officers, case managers and HIM teams, and supports their work from the workstation to the ward. After analyses have been conducted and relevant cases identified, lists of target patients, with all the relevant data, can be uploaded and distributed to track each patient in the hospital and execute the required tasks. The focus for these professionals shifts from manual chart extraction and review to identification and deep analyses and understanding of clinical and financial areas of criticality and opportunity. Armed with detailed information, they then can focus on planning and carrying out the appropriate resolution. Case managers use queries to detect cases of possible readmission and trigger actions such as patient education, controlling compliance with prescriptions and work with home support staff. Patients with critical clinical parameters such as low ejection fraction, can be identified before a final diagnosis is established, triggering execution of aggressive care protocols. Similarly, serious complications such as postoperative bleeding can be brought to the attention of quality officers for further investigation. Each of these instances is identified concurrently using the CLU technology to parse the dictated notes for any written evidence, regardless of admitting symptoms and diagnosis. A retrospective analysis is also possible by using reimbursement codes associated with conditions identified in clinical documentation. Robust linguistic analysis allows users to identify indirect, even vague references to relevant findings and conditions, in any part of the note, or, in determined sections. Documents can be filtered by type, date, facility or patient identifier. At the same time, numeric indicators such as lab values can be constrained by specific values, so that, as an example, only abnormal cases are retrieved. This type of automated review scales far beyond the capabilities of manual chart abstraction, allowing staff to view, and drill down into the entire patient population. Nuance QualityAnalytics enables a new focus, aimed at the high value parts of the hospital information flow, reducing the background noise and thus, the amount of clerical work needed to find valuable data. Automated review frees time and resources for expanded quality control and cost reduction initiatives. Searches are executed over the entire patient documentation at a given point of time. Meanwhile, the current, dictation-driven workflow can be preserved, allowing physicians to document patient care using their preferred documentation tool and free-flowing, narrative text that conveys the patient s story more accurately. As more regulations and quality measures are introduced, it will be imperative for organizations to move from manual, review to automated, concurrent review. 6
Earlier identification, earlier intervention better care for those at risk, results in mitgated cost associated with events acquired during a patient admission. ZERO FOOTPRINT, FULLY INTEGRATED SOLUTION Nuance QualityAnalytics gathers clinical notes seamlessly from Nuance dictation platforms, and extracts from these clinical indicators, with no installation, interfacing or integration. Users can access the web-based analytics platform anywhere, inside or outside the hospital, with a secure login. Nuance hosts and maintains the entire hardware and software infrastructure, guaranteeing access 24 hours a day, seven days a week. In addition to standard training and support, Nuance clinical, quality and IT experts will help extend the system on additional data sources if needed, develop new data queries and support users in complex analytical work. Nuance is the right partner to help physicians and organizations transition from structured data entry to structured data creation, while enhancing the quality of clinical documentation, adoption, and utilization of the EHR system. Nuance Healthcare leverages its considerable speech and CLU technology assets the industry s largest portfolio of solutions, extensive knowledge and experience, and integration of cutting-edge communication and mobile devices to create the right solutions for each physician. Moreover, Nuance Healthcare s partnerships with the major EHR vendors ensure clinicians direct access to their choice of clinical documentation workflow, while data flows seamlessly into the EHR system. Nuance Healthcare s portfolio of medical intelligence solutions empowers healthcare provider organizations, payers, and individual physicians worldwide to deliver higher-quality care, improve financial performance, and enhance compliance efforts. To learn more about how Nuance Healthcare can help you improve financial performance, raise the quality of care, and increase clinician satisfaction, please contact us at 888-350-4836, 800 350-4836, or visit www.nuance.com/healthcare. Nuance, the Nuance logo, and QualityAnalytics are trademarks and/or registered trademarks of Nuance Communications, Inc., and/or its subsidiaries in the United States and/or other countries. All other trademarks are properties of their respective owners. 7
10/11 DTM QP The experience speaks for itself NUANCE COMMUNICATIONS, INC. ONE WAYSIDE ROAD 888 350 4836 BURLINGTON, MA 01803 NUANCE.COM