Becker's Hospital Review

85 Executive Briefing matters are measured by analytics and technical language, Dr. Oliva says. Physicians commonly find themselves in situations where they don't know the "magic words" that coding systems require to properly synchronize a diagnosis, treatment or other element of care with a bill or electronic health record (EHR). Clinicians may think they are doing an excellent job with clinical documentation by writing thorough notes, but they face a number of setbacks if they don't work within the confines of what the coding system will recognize. Nuance believes technology should work in service of people: instead of forcing people to adapt to machines, technology should adapt to the way people communicate. Through advancements in speech recognition and Clinical Language Understanding technology (CLU), the Nuance approach to accurate documentation enables physicians to document care through narrative dictation. These solutions capture the unique nature of each patient encounter and document physicians' decision-making processes without the rigidity and limitations of templates. CLU technology enables CDI Specialist efficiency by automating the review of physician documentation, which allows greater case coverage and more in depth chart analysis. EHR companies are realizing the benefit of embedding such tools into their solutions to further improve the physician and CDI Specialist experience. Dr. Oliva says he always had a hunch that clinical documentation improvement programs could affect care quality, but there were no tools to draw a line between the two — until now. Running numbers produced by tools that give a granular picture of hospital performance, such as ProPublica's Surgeon Scorecard, CareChex® and Healthgrades, against severity adjusted mortality — whether patients die or are discharged — demonstrates the impact on quality. "If you look at hospitals that used our program from 2011 to 2014, 37 percent of our hospitals are in the top 10 percent for severity adjusted mortality," Dr. Oliva says. "About 70 percent of them are in the top 25 percent, and about 90 percent are in the top 50 percent." It is very difficult to move the needle on quality without robust clinical acumen. Fortunately, Nuance's solution is rooted in clinical expertise, which is a large determinant of its effectiveness. The approach and supporting technology is developed by clinicians and continually updated to include the latest guidelines and strategies to support clinical decision- making. Tailored education programs and peer-to-peer training reinforce the continuing education and real-world clinical training often overlooked in clinical documentation. Now is the Time to Address Clinical Documentation If healthcare's second curve is the shift to a value-based system of care, healthcare providers must ensure their care teams have the proper tools and support for exemplary patient care, correct coding and accurate quality reporting. It is imperative for physicians to accurately describe patients and patient interactions so they get credit for all that they are doing, and that will in turn accurately reflect the hospital's financial and quality performance, Dr. Oliva says. "I call it the clinical revenue cycle, because we've so often lived in two worlds, but they're inextricably merging as we move forward," Dr. Oliva says. "Understanding that is vital, because every dollar you leave on the table today, you never get back. Are you capturing dollars and moving quality at the same time?" Reimbursement is quickly moving toward value- and outcomes- based payment, and commercial payers are following suit. An increasing percentage of healthcare claims will be measured in relation to performance, with reimbursement based on outcomes achieved. The way in which episodes of care are coded becomes more critical when there is a direct correlation to payment based on performance. This scenario will become increasingly problematic for those organizations who don't get it right over the coming years. Clinical Documentation Improvement with the appropriate methodology to engage physicians, CDI Specialists and coders with an emphasis on measuring outcomes and quality commensurately is at the center of a successful transition. "Sometimes we think just having the program is enough, but coding and documentation is a very complicated world," Dr. Oliva says. "You can't just give it lip service." n Sponsored by: Nuance has helped healthcare systems evaluate their clinical documentation practices so patient care, quality and reimbursement are accurately reflected. With more than 20 years of clinical documentation expertise backed by J.A Thomas (JATA) proven Compliant Documentation Management Program® methodology, we can help you mitigate risk while maximizing your potential.

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