Unleashing the Power of Data Analytics to Improve Clinical Documentation

Gwen Blackford, BS, RHIA Coding/CDI Manager

Yvonne Karolski, RN, RHIT Clinical Documentation Specialist

Objectives / Contents

• Overview of Clinical Documentation Improvement Program

• Data Collected / Changes to HDM fields

• Application of metrics:

– Impact of Metrics on key services

– Utilization of UHC comparison data

– Creation of EPIC Smart text

• Additional metrics for review

• “This presentation has been reviewed and contains no Protected Health Information (PHI)”.

2

University of Michigan Health System

• Facts & Figures:

– 3 hospitals- 1,000 beds

• University Hospital

• C.S.Mott Children’s

• Von Voigtlander Women’s

– 40 outpatient locations

– More than 120 clinics

– 1.9 million outpatient visits a year

– 50,000 inpatient admission a year

3

Clinical Documentation Improvement Program (CDIP)

• CDIP has been operational since 2006

• 21 Clinical Documentation Specialists (CDS)

– 7 former coders (coding experience 15-25 years)

• One lead CDS

– 7 RN background without RHIT/RHIA

– 5 RN background and RHIT/RHIA

– 2 with physician background

• One Physician Advisor- 60% appointment

4

CDIP Review Process

• CDS are assigned by clinical service

• All payers are reviewed with death, hospice and Medicare as a priority

• Services not reviewed:

– OB

– Normal Newborn

– Psych

– Rehab

– Some Pediatrics

5

CDIP Review Process Goals

• CDS review all documentation and query for diagnoses that impact the following: – Reimbursement – Risk of mortality scores (ROM) – Severity of illness scores (SOI) – Present on admission diagnoses – Hospital acquired conditions – Patient safety indicators – SOI/ROM scores for hospice discharges and deceased patient’s

• ROM scores increased from 74% to 92%

– Complications – Death and hospice reviews a priority

6

CDS Clinician Education

• Face to face rounding on a few key services – Cardiology, General Medicine, Trauma/Burn/Surgery,

etc. • Tip cards … • Smart phrases … • Ten minute meetings monthly with rotating residents • Most meeting are with mid-level providers • Vascular surgery has monthly meetings with

Department Chair • Provide on going education as needed

7

CDIP Clinician / I10 Support

EMR Clinical Documentation Tools, Templates and Calculator

Online ICD-10 Education

MiChart New Provider Training

Clinical Documentation Specialists

Departmental Presentations Documentation Tip Cards

8

Driver for Enterprise CDIP Physician Interest

• US News & World Report (USNWR) ranking – UMHS ranking is trending in the wrong direction:

» Ranked 9 in 2003 » Ranked 17 in 2012 » Dropped off the ranking 2013 and 2014

– Coding/Documentation has a small part in hospital ranking, but is a easy target

– Committee formed to identify ranking issues

• Physician leadership (all Chiefs and Chairs)

• CMO, CEO and CFO

• Me!

9

Driver for Physician Interest Cont’d

• Many Chairs wanted data on how to improve the USNWR scores

• Utilized a contract person and financial analysts to generate metrics

• University Health System Consortium (UHC) comparison data outcomes by clinical service

• Clinical services reached out to ask for help on improving scores

10

DATA CAPTURE

11

Capturing CDI Metrics

• Identified metrics to capture:

– Working and baseline admit and discharge SOI/ROM scores

– Multiple queries, clinicians, and responses

– Initial and secondary reviews

– CDS secondary review findings

• Created additional fields, tables and chapters to allow for the capture of CDI metrics

12

Data Capture – CDS Reviews

13

Data Capture - Admit/Discharge SOI/ROM

14

Baseline admit /D/C scores

Working admit /D/C scores

15

Secondary CDS Review Screen

Missed query opportunity and impact

16

CDS Metrics- What are we Measuring?

• Case mix index trends

• MCC/CC capture rates

• Clinician query response rates:

– Action rates

– Rates by recipient roles

– Query reason trends

• CDS specific metrics:

– Coverage rates

– Review rates

– Query rates

17

PROOF IS IN THE PUDDING!

18

Lets take a closer look at 3 key

services

• Cardiology Service

• Orthopaedics Service

• Vascular Surgery Service

19

Cardiology Challenges

• Cardiology Structure-3 separate services with attendings and residents that rotate every 15-30 days

• Lack of understanding and engagement in the CDS program

• Query response rate of 63%

20

Cardiology Pilot

• Cardiology Chair became concerned with low SOI/ROM scores

• In December, 2014 two CDS were given workstations in Cardiology physician department to allow for more accessibility

• Changed rounding process to only meeting as needed

21

Cardiology Pilot

• Goal of the pilot was to keep CDS engaged with Cardiology Department

• Increase visibility on the unit

• Physician Assistants more accessible to CDS

• CDS can seek out attendings as needed

• One Cardiologist now works closely with CDS on Present-on-Admission SOI/ROM scores and will review all cases with score < 4

• Metrics have shown improvements

22

CARDIOLOGY PILOT CDS METRICS

09/1/14 - 11/30/14 Query Report Service Case Count

Verbal Query Count

Written Query Count

Cases Queried

DCA/Coder Queried

Queries Responded

(Any per case)

Non-Responses

Response Rate New CC New MCC

From CC to MCC

Cases with ↑$ Impact

MC - Medicine Cardiology = MW, MJ, PITT 464 15 95 105 16 97 8 92% 10 19 14 43 41%

HFT - Heart Failure/Transplant 134 5 26 28 7 26 2 93% 1 2 8 11 39%

598 20 121 133 23 123 10 92% 11 21 22 54 41%

4%

12/1/14 - 02/30/15 Query Report Service Case Count

Verbal Query Count

Written Query Count

Cases Queried

DCA/Coder Queried

Queries Responded

(Any per case)

Non-Responses

Response Rate New CC New MCC

From CC to MCC

Cases with ↑$ Impact

MC - Medicine Cardiology = MW, MJ, PITT 463 37 88 118 26 112 7 95% 6 10 20 36 31%

HFT - Heart Failure/Transplant 150 36 28 58 4 57 1 98% 2 10 13 25 43%

613 73 116 176 30 169 8 96% 8 20 33 61 35%

5%

Verbal queries increased by 78% Query response rate increased by 4%

23

Orthopaedic Challenges

• Structure of Services - with 9 distinct services, 9 service chiefs, 38 attending surgeons, 45 residents and 5 PA’s. Each functioning separately rather than as a team

• Belief that surgeons don’t need to document medical diagnoses

• Unaware of the role of CDS and importance of comorbid condition documentation

24

Orthopaedic Catalyst for Change

• USWNR

• Concern over decreasing CMI and increasing LOS.

• Attending and a resident working on a QI project found areas for improvement.

• Need to find revenue to hire another PA.

• Skeleton Dance Song

25

Orthopaedic Breakthrough

• Chief of Orthopaedics contacted us to set up a meeting to learn more about how we could assist them to meet their goals

• Chairman invited us to present at their departmental meeting

• Director of Resident program arranged for a mandatory in-service for residents to be educated on documentation

26

Effective tool to illustrate the importance of accurate documentation. Performed AKA with post-op respiratory complications, required SICU,

BiPAP and arterial line to monitor ABGs

DRG 474 Amputation for musculoskeletal system w/MCC. e.g. : acute resp failure

Reimbursement: $29,537.23

SOI/ROM: Scores: 3/3

DRG Weight/CMI: 3.6884

Average LOS: 11.2

DRG 475 Amputation for musculoskeletal system w/CC. e.g. : ac resp dx, acidosis

Reimbursement: $16,407.06

SOI/ROM Scores: 2/2

DRG Weight/CMI: 2.0488

Average LOS: 7.1 days

DRG 476 Amputation for musculoskeletal system w/o CC/MCC. e.g.: hypoxic

Reimbursement: $8582.32

SOI/ROM Scores: 1/2

DRG Weight/CMI: 1.0717

Average LOS: 3.9 days

27

Orthopaedic Results

• CMI has increased which has validated the LOS

• Capturing all valid CC’s and MCC’s which has also increased the SOI and ROM

• Query rate response has increased to 98%

• Hired an additional PA

• Understand the value of CDI program

• Contact person to ensure all queries are answered

28

Vascular Catalyst for Change

• This service was known for lack of engagement in CDI program, wanted to improve their comparison data

• UHC data was provided the Chair that showed we were missing many CC/MCC opportunities

• Had poor query response rate of <70%

29

Vascular Results

• Weekly meeting with the vascular team to go over queries

• Monthly orientation with residents to introduce CDS and purpose of the program

• Monthly meeting with the Chair of the department to review data and measure success of new process

• Increase in CMI and CC/MCC capture rate

• Better understanding of the CDI program

• Query response rate of 90%

30

Physician Query Response Rates

• Physician query response rates for 2014: – Congenital Heart

Center: 63% – Transplant: 66% – Vascular surgery:

70% – Orthopedic surgery:

77% – Family medicine:

76% – Cardiology: 63% – Gynecology: 79%

31

• Physician query response rates for 2015:

– Congenital Heart Center: 90%

– Transplant: 78%

– Vascular surgery: 90%

– Orthopedic surgery: 98%

– Family medicine: 99%

– Cardiology: 95%

– Gynecology: 100%

How Did We Do it?

• Provided data to department Chairs:

– UHC comparison secondary diagnoses data

– Their observed over expected rates

– Risk of Mortality results

– Department presentations

– Buy-in from physicians

– Physician Advisor involvement

32

UHC Data Analytics

• Director of Quality put a team together to analyze data

• Benchmarked UHC prevalence of secondary diagnoses that drive expected mortality within specific clinical services

• Took the top diagnoses where the UHC cohort was higher than ours. Examples include: – Renal disease – Severe malnutrition – Metastatic diseases – Electrolyte disorders

33

CDI Opportunities - Analysis

Examples of CDI Opportunities: Vascular Surgery

Vascular Surgery DRGs:

Mortality Model Pre-

Existing Diagnoses

Presence of Pre-Existing Diagnosis

in Hospital Discharge Records

USNWR Best

Hospitals

UMHS Vascular

Surgery

Renal Disease 34.1% 17.7%

Metastatic Cancer 5.10% 0.66%

Fluid & Electr Disorders 10.4% 2.2%

• In-hospital expected mortality rate is based on the University HealthSystem Consortium (UHC) mortality risk model

• Expected mortality rate driven by documentation of selected pre-existing (comorbid) diagnoses, which are found less frequently in UMHS hospital discharge records

• Improvements in clinical documentation of pre-existing diagnoses increase the expected mortality rate and thus reduce the UMHS observed-to-expected mortality ratio

34

Cardiac Surgery Improvement

Points of Interest

• 3 Key Services

• Similar Challenges

• Each service had improvement in metrics

• This was successful because we worked with each service individually to meet the needs of the team.

• We recognized that there is no “One Size Fits All”

Leveraging the EMR

37

Top Queried Diagnoses

• Severe protein calorie malnutrition

• Chronic kidney disease- stages

• Congestive heart failure- type

• Obesity with BMI

• Chronic liver disease

• Electrolyte abnormalities:

– Hyponatremia

– Hypernatremia

– Hyperkalemia

• Coagulopathy

• Acute blood loss anemia

38

SMART Text

• Physician advisor (PA) created dot phrase/SMART text in MiChart (EHR) for common comorbidities:

– Used in H&P, progress notes and D/C summary

• Created dot phrase for nutrition diagnoses

– Up to clinician to utilize

• Dot phrase have been implemented by specific clinical services

39

40

Comorbid SMART Text

Provider create their notes and type in “ .nutritiondx ” it displays as:

Progress note

Future of SMART Text

• We will be working on more SMART Text phrases for ICD-10: – Specific operative reports to prompt the following;

• Laterality

• Root operation

• Body part

• Approach

• Device used

• Specifics of lymph node removal (full or partial chain)

• Path report findings

42

Clinician Education

• Created a voice over power point in M-Learning system for clinician education: – Mandatory for all mid-level providers and

residents yearly and at time of hire

• PA talked to House Office Association which requested very small documentation tip cards

• Updated full documentation tip cards for ICD-10

43

Contributions to Improve Documentation

• Ability to capture metrics and provide to clinical departments

• Utilizing UHC comparison data

• Physician Advisor (60% appointment) involvement with clinicians

• Creation of SMART Text in EHR

• Increased CDS involvement in their clinical departments

44

Outcome of Utilizing CDS Metrics

• Share metrics with staff to encourage process improvements and accountability

• CDS/PA presents service specific metrics to their departments for continued clinician buy-in

• Management will be reviewing metrics for the following:

– Determine the need to quit covering services with low review rates

– Look at creating CDS teams to cover key services to assure 100% coverage

– Drill down on services with high action query rates to identify the issues

45

Thank you!! Questions or Comments?

Gwen Blackford gmbford@med.umich.edu 734-936-7597

Yvonne Karolski ykarolsk@med.umich.edu 734-936-7717

46

Additional Metric Slides for Review

47

Additional Metric Slides for Review

Case Mix Index – Current Quarter

Case mix has fallen in FY15Q3 due to shorter stays and less surgical cases.

FY1415 FY15Q2 FY15Q3

FY15Q3

v FY1415

FY15Q3

v

FY15Q2

Cases 81,989 12,669 5,538

ActualCMI 1.867 1.888 1.809 (0.058) (0.079)

AvgOfPredictedCMI 1.866 1.879 1.778 (0.088) (0.101)

Length of Stay 5.97 6.05 5.68 (0.29) (0.37)

TotalChgs $56,103 $58,112 $53,009 ($3,094) ($5,103)

Group SubGroup Variable Coeff Vars Vars Vars Vars Vars

Intercept (1.693) (1.693) (1.693) (1.693) (1.693) (1.693) (1.693) 0.000 0.000 0.000 0.000

non-Psych LOS 01 (0.287) 15.6% (0.045) 15.2% (0.044) 17.0% (0.049) 1.4% (0.004) 1.8% (0.005)

non-Psych LOS 02 (0.217) 21.1% (0.046) 20.8% (0.045) 22.6% (0.049) 1.5% (0.003) 1.8% (0.004)

non-Psych LOS 03 (0.162) 14.8% (0.024) 14.7% (0.024) 14.4% (0.023) -0.3% 0.001 -0.3% 0.000

non-Psych LOS 04 (0.074) 10.6% (0.008) 10.7% (0.008) 9.7% (0.007) -0.9% 0.001 -1.0% 0.001

non-Psych LOS 10-11 0.098 3.1% 0.003 3.0% 0.003 3.1% 0.003 0.0% 0.000 0.1% 0.000

non-Psych LOS 12-13 0.171 2.0% 0.003 2.0% 0.003 2.0% 0.003 -0.1% (0.000) -0.1% (0.000)

non-PsychLOS 14-15 0.055 1.7% 0.001 1.8% 0.001 1.5% 0.001 -0.2% (0.000) -0.3% (0.000)

non-Psych LOS16-17 0.181 1.1% 0.002 1.2% 0.002 1.1% 0.002 0.0% (0.000) -0.1% (0.000)

non-Psych LOS 1819 0.132 0.9% 0.001 0.9% 0.001 0.7% 0.001 -0.2% (0.000) -0.2% (0.000)

non-Psych LOS 20-24 0.462 1.6% 0.007 1.6% 0.007 1.4% 0.007 -0.2% (0.001) -0.2% (0.001)

non-Psych LOS 25-29 0.691 0.8% 0.006 0.8% 0.006 0.9% 0.006 0.0% 0.000 0.0% 0.000

non-Psych LOS 30-39 0.454 0.9% 0.004 0.9% 0.004 0.6% 0.003 -0.3% (0.001) -0.3% (0.001)

nonPsychLOS 40 plus 0.064 1.2% 0.001 1.3% 0.001 1.1% 0.001 -0.1% (0.000) -0.1% (0.000)

Psych LOS 04 0.169 0.4% 0.001 0.4% 0.001 0.3% 0.001 -0.1% (0.000) -0.1% (0.000)

Psych LOS 05 0.173 0.3% 0.001 0.4% 0.001 0.3% 0.001 0.0% 0.000 0.0% (0.000)

Psych LOS 06 0.154 0.3% 0.001 0.3% 0.000 0.3% 0.000 0.0% (0.000) 0.0% 0.000

Psych LOS 18 plus (0.234) 0.3% (0.001) 0.4% (0.001) 0.3% (0.001) 0.0% 0.000 -0.1% 0.000

ICU Usage 0.491 18.3% 0.090 18.2% 0.089 15.7% 0.077 -2.6% (0.013) -2.4% (0.012)

Total Charges 0.000002 $56,103 0.119 $58,112 0.123 $53,009 0.112 ($3,094) (0.007) ($5,103) (0.011)

Log Total Charges 0.213 $10.256 2.181 $10.298 2.189 $10.196 2.168 ($0.061) (0.013) ($0.102) (0.022)

Baby (NonNewborn) 0.164 3.0% 0.005 3.1% 0.005 2.9% 0.005 -0.1% (0.000) -0.2% (0.000)

Newborn 0.577 8.8% 0.051 8.3% 0.048 9.0% 0.052 0.2% 0.001 0.7% 0.004

5_14_YRS 0.051 5.3% 0.003 5.4% 0.003 4.7% 0.002 -0.6% (0.000) -0.7% (0.000)

Discharging Service Avg CMI 0.336 1.807 0.607 1.817 0.610 1.756 0.590 (0.051) (0.017) (0.061) (0.021)

Surgery (NonOB) 1.149 31.3% 0.360 31.5% 0.361 29.0% 0.333 -2.3% (0.027) -2.5% (0.029)

OB 0.291 8.6% 0.025 8.0% 0.023 8.8% 0.026 0.3% 0.001 0.8% 0.002

MDC Transplant Heart 17.197 0.16% 0.028 0.14% 0.024 0.14% 0.025 -0.02% (0.003) 0.00% 0.000

MDC Transplant Hrt Asst 7.931 0.99% 0.079 0.96% 0.076 0.99% 0.079 0.00% 0.000 0.03% 0.002

MDC Transplant NonHeart 4.021 0.2% 0.008 0.2% 0.007 0.2% 0.007 0.0% (0.001) 0.0% (0.001)

MDC Transplant BMT 3.648 0.5% 0.019 0.5% 0.017 0.4% 0.014 -0.1% (0.005) -0.1% (0.003)

MDC Burns Surg 1.237 0.1% 0.001 0.1% 0.002 0.1% 0.002 0.0% 0.000 0.0% (0.000)

Expired 0.014 2.0% 0.000 2.0% 0.000 2.2% 0.000 0.2% 0.000 0.2% 0.000

Home Health 0.154 17.8% 0.027 19.2% 0.030 18.9% 0.029 1.1% 0.002 -0.2% (0.000)

Transfer To Facility 0.172 10.0% 0.017 9.9% 0.017 10.1% 0.017 0.1% 0.000 0.2% 0.000

Hospice 0.252 1.4% 0.004 1.6% 0.004 1.3% 0.003 -0.1% (0.000) -0.2% (0.001)

Retro Actioned Query 0.225 5.6% 0.013 6.5% 0.015 6.8% 0.015 1.1% 0.003 0.3% 0.001

Concurrent Actioned Query 0.293 5.9% 0.017 6.5% 0.019 5.9% 0.017 0.0% (0.000) -0.6% (0.002)

CCECPos 0.070 1.9% 0.001 2.4% 0.002 2.2% 0.002 0.3% 0.000 -0.2% (0.000)

CCECNeg (0.249) 1.0% (0.003) 1.3% (0.003) 1.2% (0.003) 0.2% (0.000) 0.0% 0.000

1.866 1.866 1.866 1.879 1.879 1.879 1.778 1.778 1.778 (0.088) (0.088) (0.088) (0.101) (0.101) (0.101)

Wt Wt Wt

FY1415 FY15Q2 FY15Q3

Patient

Mix

General

Acuity0.604

Demographics 0.058

Care

Disposition 0.049

HIM 0.0310.031

1.837

1.126 1.122 1.074

0.029 0.032

1.747

0.056 0.059

0.050

0.618

1.847

0.563

0.002 (0.001)

HIM Reviews 0.029 0.032

0.051

0.002 0.002 (0.001) (0.001)

FY15Q3 v FY1415 FY15Q3 v FY15Q2

Wt Wt

(0.041)

(0.091)

(0.055)

(0.100)

0.001 0.004

(0.052) (0.048)

Updated 2/11/15

48

49 Case Mix Index Trends

49

CC/MCC capture rates continue to increase

50

51

CDS reviews are concentrated on specific services. Cases with DRG payers are reviewed more frequently, but a significant proportion of non-DRG payer cases are also reviewed.

Recent CDS Coverage by Service Status/Payer

Discharging

Service

Status

DRG

Payer

From

Discharge

Date

To Discharge

Date Financial Class No Review Review Review %

Covered N 02-Jul-14 29-Mar-15 COMMERCIAL 4,141 3,490 46%

Covered N 03-Jul-14 28-Mar-15 Military 128 132 51%

Covered N 03-Jul-14 29-Mar-15 NO INSURANCE PER PT 96 102 52%

Covered N 07-Jul-14 28-Mar-15 WORKER'S COMPENSATION 53 54 50%

4,418 3,778 46%

Covered Y 02-Jul-14 30-Mar-15 BCBS 4,811 6,636 58%

Covered Y 02-Jul-14 29-Mar-15 MEDICAID 572 767 57%

Covered Y 02-Jul-14 29-Mar-15 MEDICARE 2,859 6,665 70%

8,242 14,068 63%

12,660 17,846 58%

Not Covered N 02-Jul-14 29-Mar-15 COMMERCIAL 2,130 24 1%

Not Covered N 08-Jul-14 29-Mar-15 Military 23 1 4%

Not Covered N 02-Aug-14 27-Mar-15 NO INSURANCE PER PT 33 - 0%

Not Covered N 02-Jul-14 23-Mar-15 WORKER'S COMPENSATION 12 - 0%

2,198 25 1%

Not Covered Y 02-Jul-14 30-Mar-15 BCBS 4,538 22 0%

Not Covered Y 02-Jul-14 29-Mar-15 MEDICAID 732 8 1%

Not Covered Y 02-Jul-14 29-Mar-15 MEDICARE 331 1 0%

5,601 31 1%

7,799 56 1%

6,616 3,803 37%

13,843 14,099 50%20,459 17,902 47%

All non-DRG Payer

All DRG PayerAll

Subtotal

Subtotal

Subtotal

Subtotal

All Covered

All Not Covered

51

52 CDS Coverage, Staffing, and Productivity

52

Case Review Intensity

LOSGroup Cases Reviewed % 2009 2010 2011 2012 2013 2014

01 3,070 5% 1.7 1.7 1.7 1.8 1.6 1.7

02 7,027 11% 1.9 1.9 1.8 1.8 1.7 1.7

03 8,492 13% 1.9 2.0 1.9 1.9 1.7 1.8

04 7,810 12% 2.1 2.1 2.0 1.9 1.9 1.8

05 6,462 10% 2.3 2.4 2.2 2.0 2.0 2.1

06 5,326 8% 2.4 2.4 2.3 2.1 2.2 2.1

07 4,557 7% 2.7 2.5 2.5 2.3 2.3 2.3

08 3,412 5% 2.8 2.9 2.7 2.5 2.6 2.4

09 2,607 4% 3.1 3.3 2.8 2.6 2.7 2.4

10 2,162 3% 3.3 3.2 2.9 2.6 2.8 2.7

11-15 6,579 10% 3.4 3.5 3.2 3.1 3.1 2.8

16-20 2,932 4% 4.2 3.9 3.6 3.5 3.7 3.3

21 plus 5,167 8% 4.6 4.7 4.7 5.1 5.0 4.7

53

CDS Reviews and Queries-by Service Reviews

New

Service Group

From

Discharge

Date

To

Discharge

Date

Discharged

Cases

Total CDS

Reviews

CDS

Reviewed

Cases Avg LOS

Avg Total

Charges

Avg MS-

DRG CMI

Total

CDS

Querie

s

CDS

Queried

Cases

Actioned

Cases

Review

Rate

Reviewed

Case

Query

Rate

Action Rate

Per Queried

Case

Action

Rate Per

Reviewed

Case

Action Rate

per

Discharged

Case

PEDIATRICS - CRITICAL CARE MEDICINE 7/1/14 3/22/15 112 171 60 6.6 $114,246 2.42 59 29 28 54% 48% 97% 47% 25%

CARDIAC SURGERY - ADULT 7/1/14 3/22/15 1,224 2,703 908 10.0 $151,855 5.85 589 342 273 74% 38% 80% 30% 22%

PEDIATRICS - PULMONOLGY 7/1/14 3/22/15 407 828 279 10.1 $103,244 1.81 149 103 79 69% 37% 77% 28% 19%

INTERNAL MED - CARDIOVASCULAR MEDICINE 7/1/14 3/22/15 1,948 3,936 1510 7.2 $71,254 2.03 691 492 378 78% 33% 77% 25% 19%

SURGERY - VASCULAR SURGERY 7/1/14 3/21/15 530 1,239 424 5.2 $74,972 2.63 186 113 73 80% 27% 65% 17% 14%

PEDIATRIC CARDIOVASCULAR 7/1/14 3/22/15 582 631 260 12.2 $161,504 4.71 209 112 79 45% 43% 71% 30% 14%

OTLARYNGOLOGY - ADULT 7/1/14 3/22/15 437 600 224 5.4 $62,195 2.47 91 67 59 51% 30% 88% 26% 14%

INTERNAL MEDICINE - GASTROENTROLOGY 7/1/14 3/22/15 858 1,262 684 5.3 $42,022 1.43 183 145 115 80% 21% 79% 17% 13%

UROLOGY 7/1/14 3/21/15 949 2,612 770 3.7 $45,191 1.82 259 152 117 81% 20% 77% 15% 12%

SURGERY - GENERAL SURGERY 7/1/14 3/22/15 1,793 2,641 1127 6.3 $73,387 2.42 529 293 217 63% 26% 74% 19% 12%

INTERNAL MED - HEMATOLOGY/ONCOLOGY 7/1/14 3/22/15 1,448 1,346 743 8.7 $89,850 2.47 206 156 134 51% 21% 86% 18% 9%

SURGERY - THORACIC SURGERY 7/2/14 3/22/15 525 856 333 6.1 $71,755 2.80 144 79 48 63% 24% 61% 14% 9%

FAMILY MEDICINE 7/1/14 3/22/15 1,420 1,291 512 3.3 $20,526 0.94 215 160 129 36% 31% 81% 25% 9%

SURGERY - PEDIATRIC SURGERY 7/1/14 3/22/15 629 742 298 8.5 $82,270 2.23 124 79 57 47% 27% 72% 19% 9%

SURGERY - ACUTE CARE SURGERY 7/1/14 3/22/15 1,533 2,311 930 7.7 $89,917 2.43 389 211 135 61% 23% 64% 15% 9%

INTERNAL MEDICINE - GENERAL MEDICINE 7/1/14 3/23/15 7,496 9,427 4319 5.7 $45,424 1.41 1,187 822 634 58% 19% 77% 15% 8%

PEDIATRICS - GASTROENTROLOGY 7/2/14 3/21/15 241 161 67 7.2 $42,606 1.26 56 33 20 28% 49% 61% 30% 8%

PEDIATRICS - NEPHROLOGY 7/2/14 3/22/15 138 208 84 8.6 $76,750 1.58 29 18 11 61% 21% 61% 13% 8%

SURGERY - PLASTIC SURGERY 7/1/14 3/22/15 442 366 209 5.0 $51,585 1.84 42 30 26 47% 14% 87% 12% 6%

SURGERY - MAXILLOFACIAL SURGERY 7/3/14 3/21/15 273 228 101 3.2 $52,394 2.43 28 17 15 37% 17% 88% 15% 5%

PEDIATRICS - HEMATOLOGY/ONCOLOGY 7/1/14 3/22/15 683 508 279 6.1 $59,543 1.80 74 53 37 41% 19% 70% 13% 5%

PEDIATRICS - GENERAL PEDIATRICS 7/1/14 3/22/15 1,401 618 242 6.7 $41,188 1.49 167 85 73 17% 35% 86% 30% 5%

ORTHOPAEDIC SURGERY- SPORTS MEDICINE 7/1/14 3/19/15 78 41 34 2.1 $50,005 2.22 6 4 4 44% 12% 100% 12% 5%

NEUROLOGY 7/1/14 3/22/15 1,193 1,363 717 4.5 $36,452 1.34 120 78 53 60% NA NA NA 4%

NEUROSURGERY 7/1/14 3/22/15 1,484 1,837 834 5.0 $87,185 3.06 115 84 65 56% NA NA NA 4%

ORTHOPAEDIC SURGERY - ADULT 7/1/14 3/22/15 932 911 679 3.0 $52,780 2.40 69 44 38 73% 6% 86% 6% 4%

INTERNAL MEDICINE - PULMONOLGY 7/2/14 3/20/15 338 157 86 13.8 $151,095 3.13 33 19 12 25% 22% NA 14% 4%

ORTHOPAEDIC SURGERY - PEDIATRIC 7/1/14 3/22/15 247 129 105 2.8 $57,921 3.10 10 8 6 43% 8% 75% 6% 2%

PEDIATRICS - ENDOCRINOLOGY 7/2/14 3/21/15 101 35 20 2.7 $19,958 0.76 5 3 2 20% 15% 67% 10% 2%

OBSTETRICS GYNECOLOGY 7/1/14 3/22/15 3,725 1,064 428 2.8 $19,576 0.83 102 75 59 11% 18% 79% 14% 2%

PHYSICAL MEDICINE 7/1/14 3/20/15 473 75 22 18.1 $110,552 1.59 16 9 7 5% NA NA NA 1%

OTLARYNGOLOGY - PEDIATRIC 7/4/14 3/19/15 99 53 27 3.1 $39,340 1.48 6 3 1 27% 11% NA 4% 1%

PEDIATRICS - NEONATOLOGY 7/1/14 3/22/15 2,606 91 53 3.5 $20,816 0.94 33 15 15 2% 28% 100% 28% 1%

Anesthesia 3/21/15 3/21/15 1 0 0 1.0 $1,987 NA 0 0 0 0% NA NA NA 0%

Emergency 9/12/14 1/6/15 3 0 0 1.3 $9,994 0.79 0 0 0 0% NA NA NA 0%

Ophthalmology 9/30/14 9/30/14 1 0 0 1.0 $23,702 0.82 0 0 0 0% NA NA NA 0%

PEDIATRICS - GENETICS 7/3/14 1/28/15 9 1 1 4.2 $44,012 1.14 0 0 0 11% 0% NA 0% 0%

PEDIATRICS - RHUEMATOLOGY 7/4/14 3/18/15 34 2 1 4.1 $27,899 1.39 0 0 0 3% 0% NA 0% 0%

PSYCHIATRY - ADULT 7/1/14 3/21/15 648 0 0 9.7 $27,235 0.93 0 0 0 0% NA NA NA 0%

PSYCHIATRY - CHILD AND ADOLESCENT 7/1/14 3/20/15 327 0 0 9.4 $22,897 0.92 0 0 0 0% NA NA NA 0%

RADIOLOGY - ADULT 7/23/14 3/21/15 10 2 1 2.4 $55,008 1.89 0 0 0 10% 0% NA 0% 0%

37,378 40,446 17,371 6,121 3,933 2,999 46% 23% 76% 17% 8%

54

CDS Queries-by ServiceQueries

Requestor

Role

Fiscal

Year Query Report Service Chief Queries Responded Actioned

Response

Rate

Action

Rate

Response

& Action

Rate

CDS 2015 Anesthesia 1 1 1 100% 100% 100%

CDS 2015 ORTHOPAEDIC SURGERY - PEDIATRIC 9 9 7 100% 78% 78%

CDS 2015 ORTHOPAEDIC SURGERY- SPORTS MEDICINE 4 4 4 100% 100% 100%

CDS 2015 OTLARYNGOLOGY - PEDIATRIC 4 4 2 100% 50% 50%

CDS 2015 PEDIATRICS - ENDOCRINOLOGY 4 4 2 100% 50% 50%

CDS 2015 PEDIATRICS - NEONATOLOGY 19 19 15 100% 79% 79%

CDS 2015 NEUROLOGY 98 96 62 98% 65% 63%

CDS 2015 OBSTETRICS GYNECOLOGY 83 81 65 98% 80% 78%

CDS 2015 OTLARYNGOLOGY - ADULT 75 73 67 97% 92% 89%

CDS 2015 INTERNAL MED - HEMATOLOGY/ONCOLOGY 183 178 152 97% 85% 83%

CDS 2015 PEDIATRICS - HEMATOLOGY/ONCOLOGY 69 67 46 97% 69% 67%

CDS 2015 SURGERY - PLASTIC SURGERY 30 29 25 97% 86% 83%

CDS 2015 PEDIATRICS - CRITICAL CARE MEDICINE 54 52 46 96% 88% 85%

CDS 2015 ORTHOPAEDIC SURGERY - ADULT 50 48 39 96% 81% 78%

CDS 2015 SURGERY - MAXILLOFACIAL SURGERY 22 21 17 95% 81% 77%

CDS 2015 FAMILY MEDICINE 185 176 142 95% 81% 77%

CDS 2015 PEDIATRICS - NEPHROLOGY 20 19 11 95% 58% 55%

CDS 2015 PEDIATRICS - GENERAL PEDIATRICS 127 120 100 94% 83% 79%

CDS 2015 INTERNAL MEDICINE - GENERAL MEDICINE 1,017 955 732 94% 77% 72%

CDS 2015 INTERNAL MED - CARDIOVASCULAR MEDICINE 620 581 442 94% 76% 71%

CDS 2015 CARDIAC SURGERY - ADULT 524 490 377 94% 77% 72%

CDS 2015 PEDIATRIC CARDIOVASCULAR 157 146 91 93% 62% 58%

CDS 2015 INTERNAL MEDICINE - GASTROENTROLOGY 169 157 124 93% 79% 73%

CDS 2015 UROLOGY 219 202 156 92% 77% 71%

CDS 2015 PHYSICAL MEDICINE 10 9 7 90% 78% 70%

CDS 2015 SURGERY - THORACIC SURGERY 108 97 55 90% 57% 51%

CDS 2015 PEDIATRICS - PULMONOLGY 121 107 83 88% 78% 69%

CDS 2015 NEUROSURGERY 93 81 68 87% 84% 73%

CDS 2015 SURGERY - PEDIATRIC SURGERY 89 77 62 87% 81% 70%

CDS 2015 PEDIATRICS - GASTROENTROLOGY 43 37 23 86% 62% 53%

CDS 2015 SURGERY - VASCULAR SURGERY 164 141 90 86% 64% 55%

CDS 2015 INTERNAL MEDICINE - PULMONOLGY 28 24 16 86% 67% 57%

CDS 2015 SURGERY - GENERAL SURGERY 436 365 271 84% 74% 62%

CDS 2015 SURGERY - ACUTE CARE SURGERY 303 240 168 79% 70% 55%

Total 5,138 4,710 3,568 92% 76% 69%

55

CDS Queries- Response Intervals

56

HIM has recently started to collect information on the role of the query recipient, and has subsequently refined this to distinguish resident from attending physicians.

CDS Queries- Recipient Roles

Provider Role Description 3/31/2014 4/30/2014 5/31/2014 6/30/2014 7/31/2014 8/31/2014 9/30/2014 10/31/2014 Average %

Resident 225 386 273 300 331 385 396 328 38%

Attending 142 207 237 274 222 208 234 218 25%

Physician 582 194 3 2 195 23%

Mid-level Provider(PA, NP, CNM) 141 140 125 111 101 112 101 99 116 13%

Nutritionist/Dietician 2 6 3 1 2 2 5 1 3 0%

Other 1 4 1 3 1 1 1 2 0%

Nurse(Wound care, etc.) 2 1 2 0%

Practice Management(Discharge Planning) 1 1 1 1 1 0%

728 712 725 625 681 670 700 731 864 100%

57

CDS Queries

58

Just 5 clinical conditions (malnutrition, CHF, renal failure, anemia, and respiratory failure) account for, anemia, and respiratory failure) account for about half of all the CDS queries issued.

CDS Query Reasons

Query Reason Group 4/30/2014 5/31/2014 6/30/2014 7/31/2014 8/31/2014 9/30/2014 10/31/2014 11/30/2014 12/31/2014 1/31/2015 2/28/2015

3/31/2015

to date Average %

Malnutrition 117 125 98 126 124 127 141 117 141 177 125 113 128 18%

Other, Secondary Diagnosis Clarification 132 119 102 97 116 133 133 115 88 123 103 115 115 16%

Congestive Heart Failure, type and/or severity 105 85 63 64 56 58 69 79 66 78 56 61 70 10%

Renal Failure 77 56 70 64 65 55 54 56 56 69 61 57 62 9%

Anemia 52 43 43 39 44 51 49 38 67 34 55 52 47 7%

Respiratory Failure 40 44 36 33 40 45 56 24 30 44 46 53 41 6%

Sepsis 30 43 32 29 31 32 48 26 26 28 27 37 32 5%

Other, Principal Diagnosis Clarification 32 18 20 30 30 39 37 37 28 35 30 35 31 4%

Pathological Diagnosis /Result 10 13 14 26 12 35 26 13 12 13 17 11 17 2%

Encephalopathy; acute,chronic,unspecified; w/wo coma 9 18 14 20 18 11 10 17 12 18 23 26 16 2%

Acidosis 12 27 18 24 17 12 16 7 9 12 13 11 15 2%

Shock 5 17 10 12 13 8 8 7 9 11 16 18 11 2%

Pneumonia 4 7 6 18 13 11 10 2 15 24 8 9 11 1%

Alkalosis 13 20 11 9 8 8 12 12 12 6 4 7 10 1%

UTI 11 10 10 10 12 4 9 5 8 6 6 7 8 1%

Complication 15 5 4 9 11 7 11 9 4 7 5 8 8 1%

Hypotension 9 15 9 5 6 15 5 7 4 9 5 5 8 1%

Brain Compression 4 7 5 6 4 3 6 8 6 7 19 11 7 1%

Cerebral Edema 4 5 8 6 8 6 9 4 4 3 15 11 7 1%

Neoplasm 6 9 6 7 4 3 3 9 11 8 1 3 6 1%

BMI 4 8 3 5 10 5 6 1 5 2 4 6 5 1%

Pressure Ulcer, Site and Stage 1,2,3,4 6 7 5 1 2 4 3 5 8 8 5 1%

Respiratory Distress Syndrome, Acute 3 6 5 4 8 7 5 4 4 2 4 2 5 1%

Myocardial Infarction 4 4 2 7 3 1 2 3 5 5 5 4 1%

Diabetes with manifestation 2 1 3 1 5 6 2 1 7 7 4 3 4 0%

ADT 1 1 3 10 3 1 4 3 0%

Quadriparesis 4 2 2 2 1 3 6 1 6 4 3 0%

Liver failure 1 6 4 2 5 2 1 3 0%

Ulcer Type and Site 4 1 4 5 1 1 2 1 2 2 6 4 3 0%

Endocarditis 4 1 3 0%

Pulmonary Embolism 1 2 6 1 2 1 2 4 2 0%

Underlying Cause - Symptom 1 2 2 4 2 0%

Bacteremia 2 2 1 3 1 3 1 3 2 2 2 0%

Urosepsis 2 1 5 1 2 2 2 2 1 2 0%

Coma 3 4 2 3 1 1 1 1 1 1 2 0%

Disseminated Intravascular Coagulation 1 2 2 3 1 2 2 1 2 2 0%

Wound Infection 2 1 3 1 2 1 2 2 2 0%

Wound Debridement 1 1 4 2 1 2 1 1 2 2 2 0%

Cachexia 2 1 1 1 1 1 4 2 2 2 0%

Other, Procedure Clarification 2 1 2 2 1 2 1 1 2 2 2 0%

Chest Pain 2 1 1 1 1 1 1 0%

Atrial Flutter 1 1 0%

Tumor Lysis Syndrome 1 1 1 1 1 0%

Total 721 726 629 685 676 703 752 627 645 760 695 703 707 100%

59

60

CDS Queries-Versus Coder Queries

Fiscal

Year Cases

Service

Status

Review

Status

CDS Query

Status

Coder Query

Status

No Query 9,265 93%

Query 703 7%

No Query 5 56%

Query 4 44%

No Query 11,613 92%

Query 980 8%

No Query 3,270 92%

Query 279 8%

No Query 10,340 98%

Query 206 2%

No Query 1 100%

Query 0 0%

No Query 1,207 92%

Query 109 8%

No Query 455 93%

Query 35 7%

Cases Cases Cases Cases

2015 38,472

Covered 26,119 68%

No

Review9,977 38%

No Query 9,968 100%

Query 9 0%

No Query 12,593 78%

Query 3,549 22%

85%

Review 1,806 15%

Review 16,142 62%

No Query 10,546 100%

Query 1 0%Not

Covered12,353 32%

No

Review10,547

No Query 1,316 73%

Query 490 27%

60

Dashboard Executive Summary Dashboard

61

Group Metric FY13 FY14 FY14Q4 FY15Q1 FY15Q2 FY15Q3*

CY14Q2 CY14Q3 CY14Q4 CY15Q1*

Overall Outcomes

CMI (MS-DRG) current weights 1.83 1.88 1.87 1.84 1.89 1.86 CMI (APR-DRG) current weights 1.66 1.66 1.64 1.60 1.63 1.63 Adult Subset CMI (MS-DRG) current weights 2.02 2.07 2.05 2.07 2.08 2.07 LOS 6.03 6.03 6.01 5.80 6.05 5.90 SOI 2.23 2.28 2.29 2.27 2.31 2.35 ROM 1.76 1.80 1.81 1.79 1.83 1.84

Clinical Documentation Improvement

CDS Coverage – All Services 34% 36% 42% 41% 47% 53%

CDS Coverage – Covered Svcs, DRG Payers 47% 55% 63% 60% 66% 70%

Deployed Staff (average per day) 11.6 13.7 15.0 15.7 16.8 16.7

Finalized Cases per CDS per Day 5.6 5.2 5.6 5.3 5.6 6.3

% Review Utilization 82% 75% 75% 80% 83% 84%

Reviewed Case Query Rate 24% 27% 26% 25% 22% 21% Query Response Rate 91% 89% 88% 91% 93% 91% Query Action Rate Per Response 82% 80% 79% 76% 78% 75% Actioned Query Case Rate 5.9% 7.3% 8.3% 7.7% 8.2% 8.2% Quality NA NA NA NA NA NA

Coding

Average Turnaround Time (Days) 7.4 6.8 8.7 8.2 5.8 4.8 Coding Staff - Coding Utilization 91% 80% 87.1% 86.0% 86.7% 90.4% Coding– All Actual Cases per Hour NA 1.21 1.21 1.25 1.26 1.26 Query Rate 5.3% 6.3% 6.3% 6.0% 6.1% 6.4% Query Response Rate 84% 83% 82% 88% 93% 86%

Query Action Rate Per Response 71% 69% 70% 69% 74% 75%

Actioned Query Case Rate 3.1% 3.6% 3.8% 3.7% 4.3% 4.4% DRG Impact Rate (All Audits) NA 21% 18% 15% 23% 17%

Quality Assurance Review Rate NA 16% 12% 21% 16% 23% * To cases discharged/coded by 3/30/15 3pm

61

62

CDS Executive Dashboard

Group Metric FY14Q2 FY14Q3 FY14Q4 FY15Q1 FY15Q2 FY15Q3*

CY13Q4 CY14Q1 CY14Q2 CY14Q3 CY14Q4 CY15Q1*

Capacity & Coverage

CDS Coverage – All Services 32% 41% 42% 41% 47% 53%

CDS Coverage – Covered Services, LOS>2 49% 63% 64% 61% 69% 76%

CDS Coverage – Covered Svcs, DRG Payers 46% 56% 60% 57% 63% 70%

Deployed Review Staff (average per Day) 12.7 15.0 15.0 15.7 16.8 16.7

Productivity

Finalized Cases per CDS per Day 4.9 5.3 5.6 5.3 5.6 6.3

% Review Utilization 66% 78% 75% 80% 83% 84%

Reviewed Case Query Rate 26% 26% 26% 25% 22% 21%

Total Queries Issued 1,430 1,959 2,137 2,028 2,048 2,235

Provider Response

Query Response Rate 92% 88% 88% 91% 93% 91%

Query Action Rate per Response 82% 81% 79% 76% 78% 75%

Query Action Rate per Query 76% 71% 69% 68% 72% 68%

Quality

DCA CDS Reviews 0 6 1 0 1 0

TBD TBD TBD TBD TBD TBD TBD

TBD TBD TBD TBD TBD TBD TBD

Impact Actioned Query Case Rate (% all cases) 6.6% 8.0% 8.3% 7.7% 8.2% 8.2%

Estimated Query Contribution ($millions) TBD TBD TBD TBD TBD TBD

ICD-10 Dual/Practice Coded/Queried Cases NA NA NA NA NA 0

Dual/Practice Coded/Queried Case Reviews

NA NA NA NA NA 0 * To cases discharged 3/30/15 9am 62