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Thousands of consumers’ files in the Federally Facilitated Exchanges (FFE’s) Direct Enrollment pathway may have been compromised. The Centers for Medicare & Medicaid Services (CMS) said “anomalous activity” was detected in the portal on Oct. 13 and a breach was declared on Oct. 16. CMS issued a press release on Oct. 19. “At this time,” […]
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Can I code from the data reviewed / MRI/XRAY interp? and make the code DDD with radiculopathy even though he isn’t saying DDD in his final
Challenges and opportunities in data analytics
Healthcare organizations have become mass gatherers of data. But without sophisticated analytics, integrated IT tools, and processes to mine that data, they may not be able to take advantage of it.
The 33 leaders who gathered for the HealthLeaders Media Revenue Cycle Exchange, held March 23?25 at the Fairmont Grand Del Mar in San Diego, discussed some of the challenges and opportunities they’ve identified within their organizations around data analytics, as well as the tools that help them maintain an effective revenue cycle.
Let the data do the talking
Popular wisdom says culture starts at the top?but data is another important catalyst for change. The ongoing managed Medicaid expansion is requiring organizations to collect more prior authorizations and precertifications, presenting a challenge for revenue cycle leaders. Changing the culture of the organization is often key to handling that challenge, and one way to make the change is through data, says Jane Berkebile, MA, CPAM, system vice president of revenue cycle for OhioHealth in Columbus.
One significant challenge for OhioHealth is educating physicians about the increased need for preauthorizations under managed Medicaid. In the past, many of these patient accounts were written off as charity care. However, Berkebile’s organization now needs to focus on the administrative requirements around Medicaid.
Educating OhioHealth’s 343 physician practices, as well as the employed specialists and primary care physicians, by showing them the importance of preauthorizations, has represented a change in culture.
"For communication with our physicians, clinicians, and administration, the best tool we have is to show them in the data what’s really happening," says Berkebile. Her organization’s data analytics team drills down to the information that impacts each department. Departments usually see the gross charge number and think they are doing well, she says.
However, if a department is not getting appropriate authorizations, it may not actually be getting paid that amount. Berkebile finds physicians in particular react positively to seeing data.
"If you show them the data and don’t preach to them, and let them discover the problem, you can get more positive reactions from the physician community," she says. Following the data trail can also help you avoid pitfalls, such as relying on anecdotes that may hide the actual problem.
"The tyranny of the anecdote will not be allowed in this organization," says Doug Robison, performance improvement leader for John Muir Health in Walnut Creek, California. "You have to back it up with data."
Turn data into information
Even data only goes so far?it needs to be turned into information, says Russ Weaver, vice president of revenue cycle/finance for Adventist Health System in Burleson, Texas, relating advice he once received.
"You will be more successful if you figure out how to turn data into information. When you’re given something, ask, ‘What does this tell me?’ "
It is important to get back to the root cause and have a sufficient level of detail to address change. As part of the transition to the Cerner Patient Accounting product, Adventist has taken the opportunity to review its processes and reporting. As part of this, Weaver is careful to avoid relying on anecdotal information.
"You can’t go to the director of patient accounts and say you think his or her department is doing something wrong without having meaningful data to back it up," he says.
Sometimes what seems like a data problem is really something else, so it’s important not to lose sight of the basics, such as whether your organization is collecting required data on the front end, according to Doug Brandt, CPA, associate chief financial officer for Truman Medical Centers in Kansas City, Missouri.
"We’re focused on capturing the data items that need to be captured. There is always some low-hanging fruit, so identify and fix that first, then move to the harder-to-fix items," he says.
For example, it is important for revenue cycle leaders to look at the root cause of things such as denials. Even if you are measuring all the right things, if something is not happening at the front end (for example, the registration department is not verifying the patient insurance), you are going to get denials. UnityPoint Health in Des Moines, Iowa, is using data to get to the root cause of denials.
"We’re using data to drive that change by having the service providers focus on getting it correct at the beginning, versus always having to do it on the back end," says Renee Rasmussen, CPA, MBA, FHFMA, vice president of revenue cycle for UnityPoint Health.
Ensure ‘clean’ data
Organizations that can’t trust their data might run into problems with data standardization. Alternatively, organizations can fall into the trap of having too much data, but not enough accountability. The first step to ensuring clean data is to assemble a group of stakeholders to determine what data is necessary and where it will come from, says Tammy Thomlison, chief revenue cycle officer for the University of Mississippi Medical Center in Jackson.
Her organization has set up a team to look at the data warehouse generated by Epic and agree, organizationwide, where they will pull data from.
"As an organization, we had to decide where we would pull certain information from the data warehouse, so that when we’re pulling reports we all get the same results," says Thomlison. Her team also uses the Qlik software to provide reporting options on top of the data warehouse. Having data in multiple systems and managing various interpretations of that data is a challenge for many organizations.
Systems must also ensure the data is clean once they have it, says Don Shaw, vice president of revenue cycle for Baton Rouge (Louisiana) General Medical Center. "Once you start pulling information, you find that sometimes you have surprises that you have to fix."
Revenue cycle leadership must hold itself to the same accountability standards it hopes to see from other departments. Data transparency is one way to increase collaboration and trust between the revenue cycle and clinical departments.
"I think it goes back to making sure our data is as accurate as possible. If other departments find differences or errors, we acknowledge that and go back and make those adjustments," says Rasmussen.
Measure the right things
The University of Chicago Medicine focuses more on internal benchmarks than external.
"Your benchmark is what you did last week. Now do better than that," says Charlie Brown, MBA, vice president of revenue cycle for The University of Chicago Medicine. "To really set those individual targets, you’ve got to measure against your own internal performance."
UnityPoint also focuses on internal benchmarks, but supplements them with HFMA’s MAP App, says Rasmussen. "We look at the key performance indicator of net revenue yield for our nine regions to really compare different areas."
The most important thing is to set your own benchmarks and targets, adds Berkebile. "By looking at your data and seeing where you are, you see the opportunities and continually set targets to improve your own data. We don’t try to match somebody else’s number?we continually work on improving our own performance."
Organizations need to avoid the pitfall of measuring the wrong things or being so inundated with data that they can’t make a decision.
"There are an endless number of things we can measure, and you don’t want to be playing a game of whack-a-mole where every time something pops up, you hit it and then another thing pops up," says Brandt. "It’s important to find the balance and identify where we need to drill and what we need to focus on."
Using data to drive physician engagement
"You are your own best teacher," or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers’ own records.
With pay-for-performance and other quality initiatives underway as a part of healthcare reform, physicians need to see how they are performing in real time. Showing them this data in comparison to their peers demonstrates through real numbers how they stack up, says ACDIS Advisory Board member Robin Jones, RN, BSN, CCDS, MHA/Ed, system director for CDI at Mercy Health in Cincinnati.
Query responses
Until recently, most providers were not interested in seeing how unanswered clarifications or conflicting DRG assignment affected metrics, Jones says. CDI programs traditionally measure overall success by tracking items such as:
This data isn’t often shown to physicians, and yet, since queries represent the single most important tool for CDI programs, gleaning patterns of information from them often illuminates opportunities for improved physician support. For example, a lack of response from a particular physician might represent an opportunity for education or a change in approach, or the need for a new method of communication (e.g., notifying the physician of an outstanding query through a phone call rather than email).
Mercy’s CDI program lists physicians’ clarification response rates and places them in physician lounges for all to see, says Jones. To keep the information anonymous, the CDI team assigns each physician a number so they can quickly and safely gauge how they are performing in comparison to their peers.
"When physicians see their rate is lower than their peers, they hurriedly find our CDI supervisor," Jones says.
Mercy also provides physicians with an individualized list of DRGs assigned to their patients, so they can cross-reference that information to their own private billing.
Case studies
CDI programs can elevate the importance of data by tying it to case studies?real scenarios relevant to patient care, says ACDIS Advisory Board member Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP, director of education at Med- Partners based in Tampa, Florida.
Additional elements
Show providers an example of poor documentation, then compare it to the same case with improved documentation and show how the improvement affects a variety of metrics, Newhouser says. Collectively, members of the ACDIS Advisory Board suggest sharing information regarding the following data points:
Be transparent so physicians can see the benefits?both financial and quality-related?of precise documentation, Newhouser says.
"Physicians need to know that the money is important if they want to have a hospital to practice in, updated equipment, and a paycheck," she explains. But, "it is imperative to remind them that while money is important, it is quality that must come first."
For each metric, consider the data for the facility as a whole, and compare it to other facilities within the system or region, says Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford (California) Health Care. Sharing such information with the physicians illustrates how their documentation affects the larger hospital community.
Then, drill down into the data to identify individual metrics, comparing physicians against one another within the facility and within a particular specialty or service line, says McCormack.
External analysis
Beyond simply showing physicians the data, CDI teams must teach providers how documentation and coding affects their personal profile as well as their facility’s standing, says Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Phoenix. A host of consumer websites cull data and employ a variety of algorithms to rank physicians and hospitals?many of these are well known, such as CMS’ Hospital and Physician Compare sites, Healthgrades, and Leapfrog.
Understand how those practicing within your facility measure up in these reports and share important milestones as necessary, Schade says. When positive shifts occur that correlate with documentation improvement focus areas, tout those accomplishments and acknowledge the role the physicians play.
"Physicians will be engaged if they understand how documentation and coding impacts their personal profile," Schade says. "Physicians are by nature competitive, and so they aim to be high achievers." CDI programs can use this to their advantage.
Nuanced details of these reports need analysis, warns Paul Evans, RHIA, CCS, CCS-P, CCDS, manager for regional CDI at Sutter West Bay in San Francisco.
For example, The San Francisco Chronicle recently published raw mortality outcomes data for the region. Since the paper did not understand how observed versus expected mortality plays a role in telling the story of a patient’s care, its analysis left a tertiary care center in the Sutter family looking as though it had worse mortality rates than its competitors despite the fact that it treated extremely sick patients, Evans explains.
"You have to be careful to compare apples to apples," Schade agrees.
With internal data in hand, Evans showed the high-level ROM of that facility’s patients and demonstrated that the facility actually outperformed its competitors.
"Unfortunately, you can’t explain statistics and ROM to the typical layperson, but you certainly can communicate it to your staff and to your physicians," Evans says.
Data discretion
Some data discretion may be warranted. Choose data elements that are most relevant to the CDI program’s goals at the time, as well as targeted to the specific physicians in the audience. Remember to share success stories with data elements as they are reached.
"CDI managers should consider all data points and make sure the numbers they present to the physician accurately represents the message they need to convey and targets the needs of the physicians themselves," says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, director of CDI services at Enjoin.
For example, if a service line that has not been responding to queries begins to consistently increase its response rate, include the improvements in that response rate along with the other metrics you present, McCormack says.
"You want to select metrics that will allow you to see progress as well as areas of opportunity," she says.
It can be difficult to choose which data points to share, McCormack says, but sharing such concrete analysis leads to greater support from physicians overall.
Editor’s note: This article originally appeared in the CDI Journal. For any questions, contact editor Amanda Tyler at [email protected].
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