Compare and Contrast health data and information. List Factors that lead to improvement in patient care healthcare quality and outcomes

Transcription

1 Developing World Class Health Information What Are the Factors That Lead To Improvement in Patient Care, Healthcare Quality and Outcomes? The Role of Electronic Health Records, Teamwork and Coordination of Care Dr Nigel Umar Beejay MB BChir, MA (Cantab), FACP, CPE, Dip (Med Hyp) Cert (Biomedical Informatics) Advanced Center for Daycare Surgery Harley Street London

2 Learning Objectives Compare and Contrast health data and information List Factors that lead to improvement in patient care healthcare quality and outcomes Outline the role of EHRs in improving documentation Describe the key elements of teamwork and coordination of care

3 How Does Physician Documentation Impact Coding Improvement?

4 Who are the Physicians?

5 Who are the Physicians? Physician are very smart people Do not think that you can pull the wool over their eyes They are committed to a vocation that puts the patient first They need to see logic before they change They tend not to be team players by design

6 What is the Physician Perspective?

7 What is the Physician Perspective? Change has come hard and fast and from outside They are scared Lots of new terminology Lots of new concepts (E&M, IR-DRG, P4P, ICD9 and ICD 10 In SEHA hospitals roll of enterprise wide EHRs Rapidly changing teams Challenging learning Resistance to change

8 Where do Physicians Practice?

9 UAE Healthcare MENA region is fastest growing region in health care spend Health care model mix of US/Canadian and European models Hospital teams (Health Information Staff and Clinical Staff) heterogeneous Governmental adoption of the US system

10 Physicians are overloaded with information They are scared to learn a second language

11 What language do physicians speak now?

12 Physicians speak best to other Physicians They are not good at teamwork They are not great at communicating to other members of the team

13 Physicians do not have a clear understanding of the process?

14 What do Physicians need to learn?

15 What do Physicians need to learn? Teamwork Communication Other Health care teams members perspectives Outcome on patients Outcome for themselves (P4P) Outcome for any organization

16 What do Physicians need to learn? Complete Documentation Correct Medical Coding Appropriate Reimbursement

17 WYSIWYG What you see is what you get

18 Documentation Guidelines If it wasn t written, it wasn t done If you can t read it, it wasn t done If you can t find it, it wasn t done If it is not filed in the record, it wasn t done If it was not ordered, it wasn t necessary

19 The Game Coding Level Documentation Coding Level Documentation

20 Where do we want all want to be? Future State

21 Where do we want all want to be? We want to amalgamate and learn from the histories of more developed health care systems We want to adhere to best practice We want the safest and highest quality health system on the world that is affordable to all ( payers/payors/regulators) We want sustainability

22 Evaluation and Management Provider Setting Each Code Type of care HPI History Exam Medical Decision Making HX HPI ROS PFSH PF Brief None None EPF Brief 1 None ROS PFSH DET Ext 2-9 1/3 COMP Ext 10 3/3 Ex Bullets MDM DX Data Risk PF 1-5 No of systems examined EPF 6-11 DET 12 COMP 18 SF 1 1 Min Low 2 2 Low Diagnosis Data Risk Mod 3 3 Mod High 4 4 HIgh

23 E & M broken down Provider Setting Each Code Type of care History Exam Medical Decision Making HPI ROS PFSH No of systems examined Diagnosis New/Established Work up Stable/worsening Data Extent of review/order Tests/Rad/ Records Risk 4 levels

24 MDM Levels and Components 4 levels Complexity Straightforward Low Moderate High 3 Components Diagnosis/Problems Data reviewed Risk

25 3 Components of MDM Number of Diagnosis and Management Options Self-limited or minor Established problem, stable or improved Established problem, worsening New problem, no additional workup New problem, additional workup planned Extent of Patient Data Review and/or order clinical lab tests 1 Review and/or order radiology tests 1 Review and/or order medicine tests 1 Discuss diagnostic test results with performing physician 1 Independent review of an image, tracing or specimen 2 Decision to obtain old records 1 Review and summarize old records 2 What is the risk of morbidity/mortality? Refers to patient s level of risk at the visit Sources of risk Presenting problem Diagnostic procedures ordered Management options selected Summate to give one of 4 MDM levels (Straightforward, low, mod, high)

26 Quantifying the MDM Number of Diagnosis Data reviewed Level of Risk Level of MDM Minimal Minimal Minimal Straightforward Limited Limited Low Low Multiple Moderate Moderate Moderate Extensive Extensive High High Only need 2 out of three to reach level

27 Quantifying the MDM using points Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

28 Diagnosis/Problem Points Problems/Dif diagnosis No of Points Self Limited/Minor (max 2) 1 Established Problem (Stable) 1 Established Problem (Worsening) 2 New Problem no additional work up planned New Problem additional work up planned 3 4

29 Data Reviewed Points Problems/Dif diagnosis No of Points Review/Order Clinical Labs/Tests 1 Review/Order X Rays 1 Review/Order tests in medicine section (Echo/EKG/PFTs) Discussion of tests with performing MD 1 Independent review of image, tracing or specimen Decision to obtain old records 1 Review and summation of old records 2 1 2

30 Quantifying the MDM using points Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

31 Level of Risk Levels Minimal/Low/Moderate/High Presenting Problems Diagnostic procedures Management Options

32 Medical Decision Making Table of Risk : use highest level documented Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected Minimal * One self limited or minor problem, e.g. cold, insect bite *Lab tests requiring venipuncture *CXRs *ECG/EEG, U/A, echo * Rest * Gargles * Elastic bandages * Superficial dressings Low 2 or more self limited or minor problems 1 stable chronic illness Acute uncomplicated illness or injury, e.g. cystitis, sprain * Physiologic tests not under stress, e.g. PFTs * Non CV imaging with contrast, e.g. barium enema * Superficial needle biopsy * Clinical lab test requiring arterial puncture * Skin biopsies * OTC drugs * Minor surgery w/ no identified risk factors * PT, OT IV fluids w/out additives Moderat e * 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment * 2 or more stable chronic illnesses * Undiagnosed new problem with uncertain prognosis, e.g., lump in breast * Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis * Acute complicated injury, e.g. head injury with brief LOC * Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test * Diagnostic endoscopies with no identified risk factors * Deep needle or incisional biopsy * CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath * Obtain fluid from body cavity * Minor surgery with identified risk factors * Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors * Prescription drugs * Therapeutic nuclear medicine * Closed tx of fr* IV fluids w/ additives acture or dislocation without manipulation High * 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment * Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI * An abrupt change in neurological status, e.g. seizure * CV imaging studies with contrast with identified risk factors * Cardiac EP test * Diagnostic endoscopies with identified risk factors * Discography *Elective major surgery w/ identified risk factors * Emergency major surgery * Parenteral controlled substances * Drug therapy requiring intensive monitoring for toxicity * Decision not to resuscitate or to de escalate care because of poor prognosis

33 MDM Levels and Components Complexity 3 Components Straightforward Putting all components Problems Low together Data reviewed Moderate Risk High

34 Quantifying the MDM Number of Diagnosis Data reviewed Level of Risk Level of MDM Minimal Minimal Minimal Straightforward Limited Limited Low Low Multiple Moderate Moderate Moderate Extensive Extensive High High Only need 2 out of three to reach level

35 Example: Straightforward MDM Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

36 Straightforward MDM CC: Assessment/Plan: Common Cold Recommend Fluids and rest

37 Low Complexity MDM Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

38 Low Complexity MDM CC: Assessment/Plan: Arthritis pain Pt with osteoarthritis no longer controlled by paracetamol. Recommend OTC NSAID Problems/Dif diagnosis Self Limited/Minor (max 2) Established Problem (Stable) Established Problem (Worsening) No of Points New Problem no additional work up planned New Problem additional work up planned 3 4

39 Moderate Complexity MDM Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

40 Moderate Complexity MDM CC: Assessment/Plan: Uncontrolled dyslipidemia Pt with stable HTN but uncontrolled dyslipidemia not controlled on current meds. You increase simvastatin from 20mg od to 40 mg od Problems/Dif diagnosis Self Limited/Minor (max 2) Established Problem (Stable) Established Problem (Worsening) No of Points New Problem no additional work up planned New Problem additional work up planned 3 4 Level of MDM represents optimal labor Risk= 2 stable chronic or prescription drug Rx Problem points: 3 stable or 1 stable,1 suboptimal

41 High Complexity MDM Number of Diagnosis/ Problems (Points) Data reviewed (Points) Level of Risk Level of MDM 1 1 Minimal Straightforward 2 2 Low Low 3 3 Moderate Moderate 4 4 High High Only need 2 out of three to reach level

42 High Complexity MDM CC: Assessment/Plan: Uncontrolled CHF Pt with CAD and DM presents with CHF exacerbation requiring IV diuretics Problems/Dif diagnosis Self Limited/Minor (max 2) Established Problem (Stable) Established Problem (Worsening) New Problem no additional work up planned New Problem additional work up planned No of Points Acuity of Care is high Risk= severe acute or chronic illness Data points: add up quickly

43 Evaluation and Management Provider Setting Type of care Each Code MDM drives the level of care and hence the code HPI History Exam Medical Decision Making HX HPI ROS PFSH PF Brief None None EPF Brief 1 None ROS PFSH DET Ext 2-9 1/3 COMP Ext 10 3/3 Ex Bullets MDM DX Data Risk PF 1-5 No of systems examined EPF 6-11 DET 12 COMP 18 SF 1 1 Min Low 2 2 Low Diagnosis Data Risk Mod 3 3 Mod High 4 4 HIgh

44 ER Case 1 Unconscious Hit by car No ROS documented Altered mental status Sudden, severe, hit by car Unable to get ROS Unable to get PFSH Altered mental status Sudden, severe, hit by car Unable to get ROS Unable to get PFSH Case 1 25yr old male. Pedestrian hit by car. Pt brought by EMS Unconscious. No additional history available. No past medical history or Social history available. Vital signs 120/80, Heart Rate 80, RR 16, Temp 37, Pulse Ox 97%.Contusion on parietal scalp. Eyes, Ears face normal. Neck immobilize with C-collar. Chest, CVS, abdomen, pelvis, -inspected, palpated, auscultated - no findings. Back examined- Normal. CNS- GCS Eyes 2, Verbal 3, Motor 5 = 11 Management. Oxygen, IV s x 2. Chest XR + ECG normal. Trauma CT - only finding is cerebral contusion. Neurosurgery is consulted for admission. Diagnosis Cerebral Contusion VSS Contusion HEENT Chest, CVS, Abdomen, Pelvis, Back CNS GCS done Cerebral Contusion CXR and EKG Consult Code Not enough exam documentation or ROS VSS 1 Pupils 1 Ears/Nose 1 Neck 1 Lungs auscultated 1 Heart auscultated 1 No mass/tender/l/s 2 Inspection/ROM/Stability spine ribs and pelvis 1 New problem, needs Ix (4) Ordered Labs/CXR/EKG/CT (4) An abrupt Change in neuro status High Risk = HIGH risk MDM Code Hx: OK Exam: low level MDM: High Code History PE MDM Vital signs Well developed medium stature RS: dull percussion, CTA CVS HS NAD/pedal pulses NAD GI: No mass/tender/l/s LN: No neck/submental LN Eyes: Lids/Conjunctivae NAD/PERLA Neck: Normal/Thyroid Normal ENT: Ears/Nose/Otoscopy N M/S: Spine ribs and pelvis N M/S: Digits/Nail No clubbing M/S: Head and Neck New problem, needs Ix (4) Ordered Labs/CXR/EKG/CT (4) An abrupt Change in neuro status High Risk = HIGH risk MDM To go to highest billing in 9 systems Code Hx: unchanged Exam: 2 by 6 MDM: High CC/HPI 1-3/No PFSH/1 ROS >6 Problems Limited/Data limited/risk Low CC/HPI 1-3/1 PFSH/1 ROS >6 Problems Multiple/Data mod/ Risk Mod (3+3 + mod) CC/HPI >4/1 PFSH/2-9 ROS 2 by 6 Problems Multiple /Data mod / Risk Mod (i.e

45 References Towers, Adele L. "Clinical Documentation Improvement A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs" Journal of AHIMA 84, no.7 (July 2013): El-Kareh R, Hasan O, Schiff G. Use of health information technology to reduce diagnostic error. BMJ Quality and Safety ii: p Clinical Documentation Improvement: Principles and Practice By Pamela Hess MA, RHIA, CDIP, CCS, CPC Health Information Management Technology: An Applied Approach / Edition 4 Nanette B. Sayles