Improving Patient Care: A Case Study

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

This article discusses how the implementation of the new ICD10 codes are costing more than originally planned. All practices are required to use 2014-certified electronic health-record technology in order to receive funding from a federal electronic health record incentive program. The new estimates for the ICD10 implantation include the cost of such things as education, IT and documentation

Let’s face it, the looming ICD-10 transition has made revenue cycle processes take more precedence. CDI shatters silos and builds bridges between coders and clinicians to help build an overall stronger revenue cycle, which is critical to stay afloat after ICD-10. CDI is one of the most effective means health systems and private practices can ensure long-term financial stability.

Casto and Forrestal (2015) state that accurate coding of diagnoses and procedures and healthcare information abstraction are important in determining the appropriate MS-DRG assignment. When invalid codes are submitted on the patient claim form, there are two MS-DRGs that can be assigned, the MS-DRG 998, listed as Principal Diagnosis Invalid as

An interview with an Assistant Professor at Duke University Health System in the Department of Medicine, Maestro Care Provider Champion and Clinical Content Architect. This physician works to incorporate clinical decision support tools into the electronic health record at Duke Health System. He manages the best practice advisory committee that may provide a way to deploy alerts to clinicians at the point of care. Alerts with order sets and recommended actions are created and updated to notify providers of current patient care guidelines or patient safety concerns.

CMS intends to work with BPCI participants to assess the effectiveness of the payment models on improvement of patient care and reduction of the healthcare costs. “All models include provider-led care redesign and enhancements, such as reengineered care pathways using evidence-based medicine, standardized operating protocols, improved care transitions, and care coordination. Awardee Agreements may also include proposals for gainsharing among provider partners.” (Center for Medicare and Medicaid Services,

Bates, D. W., M. Cohen, L. L Leape, J. M. Overhage, M. M. Shabot, and T. Sheridan.

Gawande’s (2015) article “Overkill,” suggests that physicians overprescribe drugs and tests which are ultimately unnecessary for patients. To eradicate such behavior, I would implement an electronic health record (EHR) with the following functions: Computerized provider order entry (CPOE) with a clinical decision support system (CDSS) to assist physicians/clinicians (stakeholders) in their medical practice or at hospitals. These functions will help to alleviate redundant tests and make suggestions about treatment. According to HealthIT.gov (2014), CDSS caters chiefly to drugs, laboratory testing, radiology procedures, and helpful clinical literature (HealthIT.gov, 2014).

For healthcare facilities, patient documentation is at the heart of providing quality care and maintaining financial integrity. With the trend in consolidation, unifying documentation between the inpatient and outpatient environment becomes a challenge. As IDNs acquire physician group practices, administrators struggle to get the disparate pieces aligned. Documentation needs to be standardized, compliant and controlled. In a post (Jayne, 2014) on HISTalk, a popular anonymous healthcare industry blog, Dr. Jayne detailed the distinct differences in workflows and habits — not to mention serious operational problems — her employer encountered when bringing on new physicians groups.

The healthcare industry has evolved in the technology age from medical devices and advanced surgeries to the implementation of ICD-10 and the electronic health record. Progression is not only inevitable for the healthcare industry but also for society as a whole. This drives the expectation of increased workflow to ensure continuum of care is being met. A major concern that the Health Information Management (HIM) industry facing is the wrongful clinical documentation which contributes to coding errors. This causes rejected claims and inaccurate statistics which can affect a facility’s revenue and morale. With the ICD-10 transition here, there is an expectation of high standards in processing medical records while enduring the massive amount of workload that comes along with thousands of new codes. Fortunately, with technology by our side one can now utilize resources that aid in achieving the status quo and beyond. One of those resources is Computer Assisted Coding software.

In the past three months, I have been training in our Minimum Data Set (MDS) department in my work place. As a former floor nurse, it has been an eye-opening experience for me. I had no idea of how nursing documentation reflected the facility reimbursement rate. As nurses, it is so important to take credit for everything you do, this is done by accurate documentation. Our documentation is one of the main contributing factor in The Hospital Value-Based Purchasing (VBP) Program. “The Hospital VBP Program rewards acute care hospitals with incentive payments for the quality of care they give to people with Medicare. This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care they deliver” (CMS.gov, 2017, para. 1). I chose to

Due to the Patient Protection and Affordable Care Act, reduced Medicare expenditures will occur over the next 10 years. Because inpatient facilities are one of the largest recipients of federal spending, healthcare providers will need to make sure the clinical documentation of patient’s care is complete and accurate. A clinical documentation improvement (from this point forward clinical documentation improvement will be known as CDI) system is a health information system that focuses on the improvement of the quality of clinical documentation in the patient’s health record. The three factors that influence implementation and adoption are improved documentation for the pending ICD-10-CM/PCS implementation, enhanced communication, and accurate

Although implementation of ICD-10 adoption by other countries started in the 1990s, the US was hesitant with adopting a new system, ultimately affecting many businesses’ efficiency. Cost was the biggest concern, with implementation comes training, errors and upkeep of the new system. Chute describes implementation of ICD-10 as “expensive, arduous, disruptive, and of limited clinical benefit” (Chute 2012: 839). ICD-10 includes more descriptive and specific diagnostic codes, but its ability measure clinical data is not better than its previous version (Chute 2012: 839). Pear also agrees that the new coding system requires more strenuous work for physicians. Physicians would have to be even more specific with claims, and if re-submission is an option it also requires extra effort (Pear 2015:

The electronic medical record (ehr) can help or hinder documentation if it is unorganized. This can cause a break in the communication of patient information to the physician and other clinicians which ultimately affects patient outcomes (Manojlovich, et al. 2015. ). During my practicum I helped with several projects and most of the requests were to help to organize ehr documentation and improve ehr flowsheets. The facility where I did my practicum was a level 1 stroke center and had to follow specific guidelines for nursing documentation on stroke patients. The nurses taking care of stroke patients reported that the documentation in different areas of the chart slows up their

I think that you made some extremely points regarding patient care and pain management. Patients should not be labeled as "drug-seeking," because it leads to discrimination and may cause a decline in the quality of care. Furthermore, untreated pain may lead to anxiety, depression, increased heart rate, increased blood pressure, decreased gastric motility, and decrease immune function (Wells, Pasero, and McCaffery, 2008). Therefore, accurately assessing and treating pain remains imperative to ensure quality care and patient satisfaction. I also liked that way you noted the concern of opioid overdose, but also highlighted the fact that the patient does not appear to be drug-seeking. The provider should discuss lifestyle and prophylactic changes