Becker's Hospital Review

27 Executive Briefing For instance, a hospital's mortality ratio — the ratio of the total number of patient deaths observed to the total number of pa- tient deaths expected — is a key performance indicator often used to compare quality of care between hospitals. "Hospitals with a clinically focused CDI program outperform their peers in overall mortality ratings," says Dr. Oliva. This suggests docu- mentation methodologies that more accurately capture severity can reduce variability in a hospital's observed mortality metrics. Reactive versus proactive Clinical documentation improvement technology shifts the onus of process improvement from the back to the front of the documentation lifecycle. Typically, documentation improvement occurs retroactively, when coders or clinical documentation specialists identify a need to query the responsible physician for context during cod- ing. Because clinicians are typically absorbed in the demands of day-to-day patient care, few have the capacity to quickly re- spond to administrative requests. This makes completing query and documentation improve- ment processes from the back office both resource and time intensive. Some physicians may even interpret CDI queries as punitive or degrading, which can negatively impact employee collaboration. Technology deployed in the clinical setting can empower physicians to proactively improve documentation in real time. Speech recognition software responds in real-time, so physi- cians can improve specificity, accuracy and medical context be- fore saving it to the medical record. "Right there at the point of care, in real time, a physician is getting advice on how to make the notation easier for the coder," Dr. Coleman says. This can reduce time-intensive administrative processes downstream. Improved patient care By improving the quality of clinical documentation, clinicians can improve the quality of care they deliver. Speech recogni- tion technology gives physicians relevant, actionable informa- tion about their clinical documentation in real time, allowing clinicians to adjust patients' care management plans to better match medical necessity. Clinically integrated CDI technology also lends itself to quali- ty improvement initiatives by streamlining communication be- tween clinicians, nurses and ancillary staff. Speech recognition software enables physicians to create a narrative document that outlines medical decision making and defines the nuances of the episode of care. The output is composed in a readable note — important not only for the medical record and coding team, but also for communication with other physicians and patients. Nurses often see gaps in the clinical documentation from pro- viders and ancillary staff, the COO of a Chicago-based hospital system said during the roundtable discussion. "I see CDI technol- ogy as a vehicle to improve channels of communication between caregivers to make sure everyone is on the same page," she said. The shared understanding helps ensure continuity of care in the transition between on-duty nursing staff or care settings. Improved clinician experience An intuitive CDI solution that seamlessly integrates with clinical workflow can markedly improve physician satisfaction. More than 80 percent of physicians said it is disruptive and time con- suming when queries for information occur after they entered the note or after the patient is discharged, according to a 2014 survey from Nuance. "[Real time speech recognition technology] would help our physicians tremendously because currently we have coders trailing behind physicians, looking over their shoulder, trying to improve [physicians'] documentation," said Paul Mihalakakos, MD, an anesthesiologist and president of medical staff at Auro- ra Medical Center in Twin Rivers, Wis. Technology and process improvements can help reduce phy- sician frustration and support quality patient care by ensuring clinical information is complete and compliant from the start to eliminate rework. Conclusion Natural language processing programs infused with clinical- ly-based guidance engage physicians and reinforce CDI spe- cialists and coders while easing the administrative burden on clinicians in the transition to value-based care. Advancements in areas like computer assisted physician documentation (CAPD) — either front-end solutions or those or integrated with a hospital's electronic health record (EHR) — provide physicians and hospitals with powerful tools to drive timeliness, accuracy and clinical quality across an enterprise. "Technology should be simple and do work for physicians — not the other way around," Dr. Coleman says. "Through a more nat- ural approach to creating clinically -accurate information, every- one wins — the physician, the institution and most importantly, the patient." n Timely, accurate, and compliant clinical documentation is critical to generating successful financial and clinical outcomes. Nuance solutions help clinicians document patient care more naturally and efficiently— freeing them to focus on their true purpose: caring for patients. "I see CDI technology as a vehicle to improve channels of communication between caregivers to make sure everyone is on the same page." — COO of a Chicago-based hospital system

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