CDI 2021: Transforming Health Care was the inaugural CDI conference held in Australia and took place at the Royal Randwick Racecourse Sydney in May of this year.
The event was an absolute success. Comments from delegates include:
“Fantastic conference. The sessions were very interesting and well presented.”
“I enjoyed the conference immensely and have renewed energy for CDI initiatives.”
“Wonderful Conference!! Thank you all! A lot of learning and insights.”
This innovative hybrid event brought together both virtual and in-person speakers and delegates from around the globe.
We have complied questions from the virtual audience and sent them to the relevant speakers. They have kindly responded to share their expertise with the CDIA community.
CDI at Ballarat Health Services – Let’s Be Specific
Kylie Holcombe, Debra Pearce, and Joanna Forteath – Ballarat Health Services
How did you go about getting medical staff to attend discharge summary reviews at a dedicated time? Did you identify the cases to discuss beforehand?
We actually piloted the meetings with our Cardiology Unit - the head of Cardiology was very engaged and keen to improve his documentation. Other units saw the benefit of these meetings and asked to be included - this has kept the program growing.
On average, how many concurrent reviews are conducted in a day?
About 10- 12 concurrent reviews a day per CDS depending on meetings and availability of clinicians. Our CDSs work 4 x 6-hour days.
Queries/clarification have to be part of the record for coders to use them to inform coding decisions. Are CDS notes included and signed by the clinician?
CDS notes are scanned into our digital record but are not considered part of the patient notes. They are visible only to the coding staff and are not to be used for code assignment, therefore they are not signed by medical staff.
The expectation is the clinician will include the updates in their progress notes or summary. If this does not occur, then the coder can generate a query based on the information provided by the CDS.
How is setting a financial target for CDS in line with the clinical coding practice framework?
Although we have a set target to work to for CDI, we always exceed it without targeting specific DRG's/codes. Good documentation is our goal, the target is easy to meet. Our queries and CDI interactions are done ‘blind’, that is, without knowing or looking into what the financial impact of the exchange could be. In some instances, it does result in a reduction in funding.
We are required to have targets for our various audits and coding initiatives. While we are mindful of these targets we think that the targets are reasonable and achievable. We apply all of the IHPA rules around ethical querying and stay within the coding rules and standards.
An example of this is ‘urosepsis’ - while the index in the coding books implies that you can code ‘UTI’ and ‘sepsis’, we ALWAYS query this to establish if the term means ‘UTI’ or ‘generalised sepsis due to UTI’. We are keen to capture the clinical truth and have data that reflects our true patient complexity.
How do you measure 'definite' CDS impact on funding? Arguably coders could have identified, queried, and coded the same conditions.
We look at CDS input separately to coding queries. Usually where CDS' are involved, coding query is not required - or the coder will query something different. Interestingly there has not been any real impact on the number of coding queries generated since the implementation of our program. The coders are learning from the CDS notes how to target gaps and generate queries. Leaving all the queries to be generated by the coders retrospectively would lose the improvement in quality and safety for the patient while they are still in the bed, so we aim to do as much concurrently as possible.
How do you measure the CDI impact?
We keep two spreadsheets, one lists the CDS reviews the other our discharge summary reviews. I review the episodes once they have been coded and measure the impact of CDS and/or discharge summary queries. I deduct the conditions that would not have been coded without the interaction/query from CDI and recalculate the funding.
It is not an exact science but it is a close as we can get. We also know that there is an unmeasured ‘ripple effect’ as the medical staff learn more about good documentation they are more inclined to document without prompting and this will also have a financial impact that is not captured by the above measures.
From CDI to Revenue Assurance
Regan Dent, Mater Health Queensland
How do you allocate workloads etc to your CDS team - is it based from reports? Can you describe the average day for your CDS?
Our Central Qld and North Qld facilities have small bed numbers so the CDS can cover all the wards.
In our SEQ facilities, each CDS tends to have their own wards. This has some pros and cons, but has worked for us well for the last few years.
What DRG version(s) are you using? Do you know when you will be switching to a new version, which one will it be, and what have you done to prepare?
DRGs are funder specific. Our public pts are of course coded in V10.0 so we can filter our data by version. As we move into the different versions we learn from the data from other funders that have already been in that version.
If you would like any more information, please feel free to contact me. firstname.lastname@example.org.
Collecting and using Patient Reported Measures to Drive Improvements in Outcomes and Experiences of Care
Melissa Tinsley, NSW Agency for Clinical Innovation
Can you share your response rates please? (to SMS, tablets, email etc)
No formalised evaluation of the response rates in the platform – this will be completed in the upcoming financial year, with a report due June 2022.
What experience measures do you use? i.e. NPS, AHPEQS?
Questions are a relevant subset of our BHI Patient Experience survey questions – for use in real time to drive service improvement and service delivery.
The Health Economic and Patient Safety Implications of Data Issues Related to Hospital-Acquired Complications
Catherine Li, Fiona Stanley Hospital
What was the usual timeframe between discharge and contacting the clinicians for review of HACS? How was this undertaken, and by whom?
Coding completion is normally 4-6 weeks post discharge however with the database we set up on REDCap, we can do case review the day after it is coded. The process is that HACs Team conduct condition onset flag analysis as first step of data cleaning to remove HACs that are clinically present on admission; HACs Team will then send case review notifications to DC clinicians via REDCap for deeper review, with a focus on preventability and risk mitigation strategies. This is done on a daily basis.
DC clinicians are given 2 weeks to complete the review. Automatic reminder will be sent if no response received at the end of 2 weeks.
I was hoping to get some feedback from other hospitals whether the HAC reduction program and the CDI program are integrated or are separate entities
For us it is a separate entity at present but I do have my own CDI officer for HAC documentation.
What's your next project focus?
Using the HAC model as a driver to promote and implement evidence-based clinical care.
CDS Certification Pathway
Nicole Draper, CDIA
Can you explain again what the intention is of this certification?
With the emergence and rapid evolution of the CDS role in Australia, the industry demand has led to the formation of the first national credentialing platform for CDSs. The CDIA CCDS certification provides the opportunity for CDSs to demonstrate a commitment to the profession whilst building their confidence and knowledge of clinical documentation improvement.
The CDIA CCDS credential demonstrates that the holder has undertaken formal CDS training, time in the role of a CDS, and a comprehensive assessment process. Achieving the full credential recognises that a CDS possesses prerequisite educational requirements as well as proven, hands-on experience performing the functions of a CDS.
Who was involved in ascertaining the required competencies?
The required competencies were determined through consultation with experienced CDSs, doctors, and health information managers.
Is this likely to become an industry expectation?
The CDIA Certification provides future employers the reassurance that a CDIA CDS is ready to hit the ground running and have an immediate impact in their organisation.
Initially, the CDS Certification will make you stand out from the crowd for recruiters. However, it is possible that as more CDSs complete certification, employers might choose certified CDSs over non-certified CDSs, or even require certification as a minimum requirement to apply.
What are the job opportunities like after course completion?
The CCDS provides evidence that you have the skills and knowledge to work as a CDS in any country using ICD-10-AM.
Were HIMAA & IHPA involved in ascertaining the certification requirements? They are the peak coding related bodies nationally.
HIMAA and IHPA were not involved in developing the certification. While we agree that they are the national bodies for coders, this certification is for CDSs, which requires a different, though related, set of knowledge and skills.
Is there a minimum/maximum timeframe that you need to complete each level within?
You can complete assessments at your own pace once enrolled. CDIA expects candidates enrolled in Level 1 certification to have completed the assessment within one month of the enrolment date. Candidates in Level 2 or 3 certification are expected to complete all requirements and assessments within three months of the enrolment date.
We recognise that this may not be possible considering the requirements for arranging your examination and viva voce. We will contact you if you have not completed your assessment within this period of time to offer support. Special permission to continue with certification will be granted on a case-by-case basis. Certification fees will be refunded if you are eligible under our Refund Policy.
CDIA reserves the right to cancel the application if you have not completed all assessments within six months of your enrolment date and have not applied for special consideration.
Are there example exam questions available online?
There are not currently any example questions online. However, we have taken your feedback on board and are in the process of producing these to be published in the CCDS Reference Guide.
Sally Hart, Mayo Clinic, USA
In my experience, there is a greater than 2-month turnaround time for care episodes to be scanned and coded. Is this the case in your hospital? When you are presenting real cases to the physicians, are they useful given the significant delay?
Thank you for the question! In the US, inpatient accounts are usually coded within 2 -7 days post discharge. There are many reasons why there might be a delay before accounts are actually “dropped” (billed to the payer), but the industry generally aims to have cases final billed within 4 days to a week of discharge although sometimes it takes even longer to finalize queries, pathology reports, and other important documents. We hold those cases awaiting the missing documentation. This means some accounts may take 30 days or more, but this is not the norm.
Since we have a shorter turnaround time for accounts, we can potentially use the case examples within a month. In my experience, that is not an important point when working with providers. The reason? Providers remember their patients much longer than one would expect. If it is a unique case with unusual circumstances, they will remember details months later or even longer. It has happened over and over as I’ve worked with providers. I’m confident you will experience the same with your providers.
My advice: Be sure to quote the provider’s documentation so they will recognize the language they use in their day to day work. Provide all the evidence available within the record (clinical indicators) that shows they had access to information to document more specificity. Finally, demonstrate the original outcomes and the “potential” outcome with more specificity (or whatever the needed documentation was). I like to show the DRG, relative weight, GMLOS, SOI, ROM, and other important quality risk methodologies (depending on your industry).
Questions: Ink the Link: Using Problem-Oriented-Plans
Joevin Vincent and Roxanne Carroll, Gold Coast University Hospital
Do you have clinical coders help you with your decisions in developing your CDI program?
Yes, we have an ongoing collaboration with our Clinical Coding Service as they are one of our key stakeholders.
Did you have challenges with buy-in from the unit's Senior Clinical-Leads and how did you move through these?
Yes, we have had challenges. However, persistence and clear communication has been key. Actively seeking out feedback and involving clinical teams in the development of any proposed solution was very helpful.
What conditions increased the complexity of the stroke DRG?
We did not have an agenda to get the medical officers to document certain diagnoses. We supported to clinicians to clearly ‘ink’(document) the problem/diagnosis that they were actively managing. It could be anything like AF, aspiration pneumonia, diabetes, HTN, alcohol related issues, delirium, conjunctivitis, deconditioning, etc.
Is POP used to add information to the discharge summary?
Discharge summaries were not included in the scope of our study, and unfortunately, we are unable to answer that question.
Can we use the term ‘Ink the Link’?
We are pleased to hear that you would like to use the term “ink the link”. It is a tag line that we coined at Gold Coast University Hospital and are quite proud of as it has caught on really quickly. We are happy for services to use the term locally for their CDI program, and as long as it is not trademarked/copyrighted.
CDI Through the Eyes of a Junior Doctor
Dr Kelsi Marris and Dr Felicity Sinclair-Ford, CDIA
Do junior doctors feel more intimidated if a CDS is a medical doctor offering input to improve the clinical documentation?
We think junior doctors would react positively to a CDS being a medical doctor! While junior doctors can be intimidated by more senior doctors, it’s usually more to do with the behaviour of the senior than the actual job title. If CDSs are friendly and are offering input to improve, we think junior doctors will be co-operative and grateful!
Do the junior Doctors have a general awareness of why someone may be asking to improve documentation especially for coding?
At hospitals we’ve worked at, and from talking to others, junior doctors have some basic awareness that documentation is important for coding and funding. However, we often have no understanding of how the reimbursement system works or the limitations of the Australia Coding Standards. So any request to improve documentation needs to be accompanied with education, so that junior doctors understand the need for change.
Do you have proper training/study for clinical documentation at university?
For us, the answer to that is a resounding no! We were given some sense that documentation is important for medicolegal purposes, but this wasn’t taught formally and was something we gradually picked up. The main way I (Felicity) learned to document was a junior doctor thrusting the notes at me and saying “write SOAP (subjective, objective, assessment, plan)”. They then signed my notes after hardly glancing at them!
The Science Behind CDI
Dr David Tralaggan, CDIA
How soon will we see automated designs and AI in the coding environment, in Australasia?
Artificial intelligence is already used to assist coding. It goes by the term CAC or Computer Assisted Coding. These technologies use natural language processing to review an electronic record to assign possible codes. These technologies are already widely used in the United States to highlight potential codes to the coder and then coder can accept or reject these findings based on their human knowledge of the coding rules.
There is no doubt that artificial intelligence is coming into the coding realm in a major way. When it will completely remove the role of the coder is subject to conjecture.
I remember going to conference five years ago where a speaker claimed that “95% of all accounts will be redundant in five years”. Futurists love to make these claims. The reality is that things take much longer than we think. So, yes, at some certain point in the future there will be a reduced need for human clinical coders. However, I don’t think that is as near as some make it out to be.
To put it all in perspective, most private hospitals in Australia don’t even have an electronic medical record and are still on a paper record. For many hospitals there are major milestones that need to be achieved to allow these technologies to be implemented.
Artificial intelligence is an exciting and evolving space that we continue to watch closely.
So what is your advice if it's been a slow start with the program you are involved in?
If your program has had a slow start, my single most important piece of advice that I think I can offer is to get help. There’s no need to reinvent the wheel. Get an external party like CDIA to help you kickstart the program and create a successful overarching program structure.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact email@example.com to learn more.