- Well before the implementation deadline for ICD-10 last October, clinical documentation improvement was a well-established aim of healthcare organizations and providers seeking gains in both clinical efficiency and data integrity.
Now with the federal government looking to implement value-based care initiatives tying reimbursement to quality, health systems have even more reason to improve clinical documentation to avoid losses stemming from a lack of specificity in the electronic record.
CHRISTUS Health in Texas recently undertook an initiative to improve the quality of clinical documentation by implementing health IT from Nuance — both a quality reporting system for radiologists with speech recognition and natural language processing technology for providers in ambulatory and inpatient settings.
The Catholic health system comprising more than 40 hospitals in the United States and abroad has only just begun the implementation, CMIO Luke Webster recently told EHRIntelligence.com.
“We’re fairly early in the journey,” he explained. “We have been in implementation mode for the last few years in terms of our clinical information systems for the physician-facing components and the last piece of that is the documentation.”
The current attention to clinical documentation improvement would have come sooner were it not for budgetary or resource-related constraints that saw functionalities such as computerized physician order entry take greater precedence considering its benefits to patient safety. The delay came with an advantage — the opportunity to take a measured approach to improving clinical documentation.
“We chose that opportunity to take an enterprise-wide look at all of our documentation needs,” Webster continued, “not just in the traditional sense from a clinic perspective or inpatient workflow perspective but across radiology and looking also at our traditional backend dictation transcription methodology and workflows as well as the frontend documentation needs for the inpatient and ambulatory clinics.”
The health IT implementation required for the improvement project began six months ago with radiologists for two reasons.
“We have one region without a sophisticated radiology reporting system in place, so they were essentially doing the old-fashioned read the image and dictate the report to be transcribed and so forth,” the CHRISTUS CMIO stated. “The other piece is that radiologists tend to be pretty tech-savvy these days. They moved into the digital arena many years ago with PACS deployments. They tend to be a fairly receptive audience, so that was a part of this.”
More recently the focus has shifted to the dictation and transcription side of the health IT initiative. The use of natural language processing is pegged first and foremost to reduce the costs associated with traditional dictation and transcription workflows.
“We do provide some dictation rooms, dedicated stations, but the great bulk of it occurs just by use of the regular telephone,” Webster noted. “They have a dedicated number they dial into and then using the keypad, voice prompts, etc., they dictate into the system and that’s stored digitally. Interestingly enough, most providers don’t really know this, but those voice files are first run through a voice recognition engine and then a human transcriptionist does the final polishing very quickly.”
The implementation of natural language processing is now underway and Webster and his team are keeping a close eye on physician uptake.
“We’re monitoring that very closely, moving through our physician population in segments. Right now, for example, we’re focusing on hospitalists. We’re looking at their pre- and post-dictation patterns,” he added.
“One of the things we’ll do is circle back with our physicians, in particular focusing on those who have by our reporting demonstrated less-than-ideal adoption curves and do some optimization training, troubleshooting to try to understand what it is that is a barrier to adopting the tool,” he further elaborated.
In the long run, the plan is to leverage these improvements to clinical documentation for secondary and tertiary purposes. The current efforts simply lay the foundation for these long-term gains.
“One of the hopes (and obviously the plans that we have in place) is to leverage that foundational technology to improve clinical documentation real-time, such as prompting providers as they document,” said Webster.
“For example, if you state that you have a patient with congestive heart failure and you don’t qualify what type or condition, then the system can prompt you real-time for more specificity, which obviously benefits us in terms of clinical quality but also downstream billing and collection rates,” he detailed. “With the capture of much more discrete data, then that helps us with secondary uses of that data in terms of research and iterative improvements in care processes, etc.”
With radiologists, CHRISTUS Health is already seeing the benefits in reducing turnaround times and quality reporting such as reducing the duration for issuing an imaging order and receiving an official sign-off from providers. “That has improved substantially,” said Webster.