How to work with physicians to improve data quality and funding
Physician documentation quality directly impacts hospital funding in Ontario. This article explores the MRDx paradox, physician education strategies, and what Ontario hospitals can learn from performance-based funding models in the United States.
April 9, 2018
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How to work with physicians to improve data quality and funding
Physicians learn many things during their years of training. Unfortunately for the people who work in hospital Health Records and Decision Support departments, clinical documentation is generally not one of them.
High quality physician documentation matters more than ever
Since the launch of Health System Funding Reform (HSFR) in 2012, up to 70% of a hospital's annual funding is based on their performance relative to other hospitals in Ontario. Efficiency is measured in terms of cost per weighted case, with the denominator directly coming from the output of Health Information Management (HIM) professionals coding and abstracting from physician documentation of discharged patients.
In the years since the introduction of HSFR, hospitals across Ontario have realized the critical impact that high quality documentation and coding has on their revenue cycle. Hospitals have adopted lean process improvements to streamline the Health Records function. They have hired data quality staff to focus on educating their HIM team and conducting audits and data quality checks. Many hospitals have also invested in Data Quality Assist, a software solution to help guide data quality efforts.
The MRDx paradox
Improving physician documentation is much more challenging than the coding element. CIHI coding standards and both ICD-10 (diagnosis) and CCI (intervention/procedure) codes often do not align with how physicians describe patients, their diagnoses, and the care they provide. This can create a problematic 'language barrier' between physicians and coders.
CIHI defines MRDx as the one diagnosis most responsible for the longest component of the patient's stay and/or most resources used. With Ontario's aging population and increased prevalence of people living longer with multiple chronic conditions, most patients have more than one diagnosis associated with an inpatient admission. It is not uncommon for long-stay patients to have over 10 diagnoses.
In my 7 years of working with physicians on data quality projects I have never met a physician who initially understood what CIHI is looking for with MRDx.
Is it tougher in teaching hospitals?
In most teaching hospitals it is the residents and fellows that document care, with staff physicians having varying levels of engagement in the process. Health Records departments in teaching hospitals need to understand their current state in terms of who does what (trainees vs. staff physicians) and tailor their education and engagement strategies accordingly.
Physician education — an uphill battle?
Hospitals have designed initiatives to educate physicians on the importance of high-quality documentation. When considering this approach, Health Records teams should ask themselves if "the juice is worth the squeeze?" For example, in-person education for specific physician teams is the most comprehensive approach. It is also the most time-consuming and difficult to spread and sustain.
One best practice is to focus any in-person education on physician teams and services where you have evidence of the most room for improvement in terms of documentation and data quality.
Are we becoming more like the Americans?
In the United States, where CMS has had performance and quality-based funding for decades, clinical documentation improvement is a major focus for hospitals. While the business case for concurrent coding does not exist in Ontario yet, we should look south to understand the importance of high quality data.
True value-based care is on the horizon, bringing with it more bundled payments, a population health focus, and potentially shared risk models with more hospital accountability.
Where to start
Understanding the current state of your physician documentation, from a wide-ranging quality perspective (accuracy, comprehensiveness, timeliness, etc.) is a critical first step. 3terra has helped hospitals determine how much room for improvement they have using DQA and through detailed benchmarking with peer organizations for specific populations.