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 Clinical Documentation

Using technology-enhanced clinical documentation to improve ACC reporting

Utilizing the correct system can drastically increase data integrity and improve data collection and submission across the organization.

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   By Allison Errickson, CPC-H, October 2013

For cardiology service providers, a number of forces are driving the need to provide higher quality American College of Cardiology (ACC) data elements, including increased reporting requirements, heightened regulatory and reimbursement scrutiny, and the expansion of appropriate use criteria (AUC). 

As the need to collect and submit quality data increases, so too does the realization by many organizations that there are numerous challenges in doing so. Issues, such as access and integration, as well as questionable data integrity resulting from inaccurate, incomplete or inconsistent procedure documentation, have emerged as key challenges across cardiology service lines. 

As a result, many providers are struggling to comply with new regulations. Confidence in billing procedures has also been lost, as physicians, billers and coders are often left guessing whether the data they are utilizing is accurate and complete and, as a result, whether procedures are being billed at the highest appropriate rate. 

Clinical documentation improvement (CDI) strategies that leverage properly designed technologies are key to overcoming these challenges and improving ACC data reporting. 

 

ACC data integrity challenges 

 

The underlying problem with ACC data integrity is that many cardiology providers lack the resources necessary to automate data capture, analysis and reporting. Yet, even for those organizations with resources available, health IT solutions have done little to help.

In fact, KLAS reports that 45 percent of providers consider cardiology systems to be incomplete, with the majority of respondents citing clinical reporting as the missing link. In addition, many find that these systems lack the reporting functionality necessary to compile and validate data to their best ability.

As a result, many providers continue to rely on primarily manual processes to capture and report data points, which can be highly redundant and fraught with the potential for human error – thus impacting both quality and compliance. Traditional manual processes are also resource intensive, requiring up to four full-time equivalents to handle the department’s registry reporting. 

Interoperability issues also exist. That is because, when data is siloed in multiple disparate systems, the procedure-documentation and hemodynamic systems are not interfaced with the electronic medical record (EMR); the result is an incomplete patient record. Further, conflicting perspectives regarding what data is necessary for capture and reporting can also create tension between teammates, resulting in process inertia. 

Complicating the situation is the complex nature of cardiology documentation, which can lead to information gaps resulting in double-digit error rates, thus hindering the accurate, comprehensive capture of structured and compliant data. In fact, an internal audit conducted by one hospital found error rates as high as 90 percent in its cardiac catheterization lab, while another found an average error rate of 70 percent in cardiology peripherals.

The reality is that these documentation and record-keeping deficiencies ultimately result in incomplete and inconsistent data that does not advance the goals of quality initiatives or allow providers to validate data submitted to the National Cardiovascular Data Registry (NCDR).

 

Establishing a data integrity road map 

 

To overcome these data integrity challenges, cardiology providers must establish a road map that closes the gaps in their current data-collection and reporting processes, beginning by identifying and prioritizing data-improvement objectives. At the very least, these objectives should include minimizing manual data entry and eliminating redundant processes. Doing so will prevent bottlenecks and decrease the potential for error by HIM and quality staff who are typically charged with manually abstracting data and reformatting data elements for registry submission. 

Objectives should also enable the capture of trustworthy and comprehensive data that flows freely between systems and departments. This includes critical quality data required by NCDR registries, such as pre-procedural, intra-procedural and post-procedure information, which are traditionally documented and stored in multiple reports or systems. 

Identifying and communicating with key stakeholders is also critical to success. Unless leadership is engaged and sold on the process and technology changes necessary to achieve the desired state, it is unlikely that short- or long-term resources will be dedicated to improving data integrity. 

 

The role of technology 

 

Despite dissatisfaction with the documentation and reporting functionality of many cardiovascular information systems (CVIS), the right solutions can provide users with the tools they need to drive CDI and achieve organizational goals. Procedure-documentation and coding software capable of automating previously manual processes, for instance, can significantly improve data collection and reporting. 

By automating these processes, organizations can increase standardization and mitigate the risk of error. That is because intuitive procedure-documentation software allows many of the required data points to be collected directly from procedure notes, lessening the need for manual intervention and eliminating duplicate data entry. In addition, the best systems can gather information through the software’s interfaces and other IT systems to streamline registry reporting for numerous quality registries. 

These systems also enable resources to be focused on other core responsibilities, increasing productivity and potentially accelerating patient throughput. Finally, by improving documentation and quality data, cardiology departments can take the steps necessary to improve processes and organizational decisions that may lead to better patient care. 

In recognition of the growing emphasis on quality metrics, a small number of vendors have also introduced reporting tools that integrate with procedure documentation and coding software to further enhance data integrity and streamline reporting processes. 

The best solutions will also include registry reporting modules that extract registry data for multiple reporting registries. By guiding physicians through the process of capturing all required data elements, these tools allow data to be organized into specific formats that can be transmitted directly to the various registries, integrating data collection and reporting directly into the physician workflow. The result is increased reporting efficiency and reduced human errors that can lead to incomplete documentation and incorrect coding.


Making CDI work for you 

 

While cardiology providers can certainly address increased reporting requirements by modifying current processes to capture data more efficiently and effectively within their department, the best strategies will also include the implementation of automated cardiology procedure documentation and coding software. Utilizing the correct system can drastically increase ACC data integrity and improve data collection and submission across the organization.

 

About the author 

 

Allison Errickson, CPC-H, is director of coding compliance for ProVation Medical, part of Wolters Kluwer Health. 

For more on ProVation: click here



Tags:  Clinical Documentation